Chapter 45: Operative Vaginal Delivery

BACKGROUND

Operative vaginal delivery (VD) remains an essential component of labor management, accounting for 3% to 6% of all deliveries, and includes forceps and vacuum-assisted births. Operative VD is used to expedite safe VD for maternal and/or fetal indications.^1,2

• Maternal indications:

  • Maternal exhaustion

  • Ineffective pushing in the second stage of labor

  • Need to avoid pushing in the second stage due to maternal cardiac or neurologic disease

  • Prolonged second stage

• Fetal indications:

  • Non-reassuring fetal heart rate during the second stage of labor

Operative VD can cause significant maternal and fetal morbidities.^3-5 These should be compared to cesarean delivery (CD) outcomes, and maternal and fetal complications should be considered for both prior to operative VD.

COMPLICATIONS

Maternal complications from operative VD include increased rates of the following:

• Third- and fourth-degree perineal tears

• Anal sphincter injury

• Fecal incontinence

• Vaginal and cervical lacerations

• Postpartum hemorrhage

• Urinary retention

• Urinary incontinence

Newborn complications from operative VD vary somewhat based on the device used. They include increased rates of the following:

• Scalp laceration

• Cephalohematoma

• Subgaleal hemorrhage⁶

• Cerebral hemorrhage

• Skull fracture

• Brachial plexus injury

• Facial nerve palsy

• Facial lacerations

• Corneal abrasions

• External ocular injury

• Retinal hemorrhage

CONTRAINDICATIONS

Specific criteria must be met prior to operative VD. This includes fetal vertex presentation, fully dilated cervix, known fetal head position, obstetrician’s familiarity and experience with an instrument, and ability to perform an emergency CD if needed, to name a few.

Operative VD is contraindicated in the following instances:

• Fetal head is not engaged.

• The position of the head is not known.

• Fetus has a known or suspected bone demineralization condition.

• Fetus has a known or suspected bleeding disorder.

ANESTHETIC MANAGEMENT

In order to perform an operative VD, a parturient has to have adequate anesthesia. The anesthesiologist should be alerted and present, and should assess the epidural level and functional status prior to obstetricians initiating operative VD. We recommend a 5- to 10-mL bolus of 3% bicarbonated chloroprocaine epidurally to aid maternal comfort for operative VD without hampering maternal pushing effort. An anesthesia provider should stay with the patient to ensure adequate anesthesia and be ready for an emergent CD, anticipating and managing any subsequent postpartum hemorrhage.

REFERENCES