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Labor Stage 2: Operative Delivery

by Veronica Gillispie, MD, FACOG
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    00:01 Now let's discuss Operative Delivery.

    00:03 We'll start with the case presentation.

    00:07 A 25 year old gravida 1 para 0 female at 38 weeks gestation and 2 days presents to labor and delivery in active labor.

    00:16 She is not at stage 2 of labor.

    00:19 She has an epidural in place and has been pushing for 3 and a half hours.

    00:23 How would you manage her delivery at this point? Let's go through the lecture to find the answer.

    00:29 So operative deliveries have 3 types that we can do operatively.

    00:34 A vacuum assisted vaginal delivery.

    00:37 Forcep delivery and cesarean section.

    00:40 Let's take the time to talk about each of these in a bit of detail.

    00:45 So the indications for any operative vaginal delivery, fetal tolerance of labor.

    00:49 So we're talking about a category 3 tracing.

    00:52 Arrest of the 2nd stage of labor.

    00:54 And if you remember the 2nd stage of labor is when mom is pushing the baby out.

    00:58 And if we had no descent over 2 hours then we now have an arrest for second stage.

    01:04 And then shortening of second stage of labor.

    01:06 So there's some maternal conditions where we do not want mom to exert.

    01:10 The force that it takes to push such as cardiac anomalies, intercranial issues.

    01:15 In those cases we will perform an operative vaginal delivery so that mom doesn't have to exert that force.

    01:23 Now, there is a criteria to perform the operative delivery as well as those indications.

    01:28 First is knowledge of the fetal position.

    01:30 And when we speak of fetal position, we're talking about the fetal occiput in relationship to the maternal spine.

    01:37 So you can see from our examples here.

    01:40 Occipit anterior is what we most commonly see and that's what we have here at the top.

    01:44 But you can also have occiput rotate in different positions.

    01:48 You have to know that position of the head to know where to apply the vacuum or the forceps when you're performing an operative vaginal delivery.

    01:57 Now the patient must be at least +2 station.

    02:00 If you remember from our previous lecture, the station refers to the leading edge at the level of the ischial spine or in relationship to the ischial spine.

    02:09 So we want that fetal head to be at +2 station or at least 2 centimeters below the ischial spine.

    02:17 Now the cervix must also be fully dilated so 10 centimeters.

    02:21 And the patient has to have adequate anesthesia.

    02:26 Now what are the indications for cesarean section.

    02:28 They are a little bit different than operative vaginal delivery.

    02:32 Fetal intolerance of labor.

    02:33 So again our Category 3 tracing.

    02:36 Arrest of dilation or descent in labor.

    02:38 So the cervix when it's stop dilating or if the baby stops coming down through the pelvis.

    02:43 Malpresentation such a breech presentation or a mentum posterior presentation.

    02:49 Placental abnormalities such as placenta percreta, increta.

    02:55 Or if we have a placenta previa or the patient has previous uterine surgery.

    03:01 Now this would be for example for our patients who have had a cesarean section and decline at trial of labor at the cesarean.

    03:07 Or if they had 2 or more C-sections.

    03:10 In those situations a vaginal delivery is contraindicated.

    03:16 So, let's talk about those complications of our operative vaginal deliveries.

    03:21 First with the vacuum assisted delivery.

    03:23 You can have fetal scalp lacerations, Cephalohematoma.

    03:27 As you can see here in this picture where we have the swelling or above the head.

    03:31 And we can also have intracranial hemorrhage.

    03:34 Now there is some debate specially with intracranial hemorrhage as to how much of this is caused by the operative delivery and how much of it happens intrapartum.

    03:43 With forceps delivery there are also complications.

    03:46 Facial laceration, injury to the facial nerve, skull fracture.

    03:52 And you can also have intracranial hemorrhage.

    03:57 So back to our patient.

    03:59 This 25 year old gravida 1 para 0 female at 38 weeks and 2 days that presented to labor and delivery in active labor.

    04:06 She is now in stage 2 with an epidural in place and she has been pushing for 3 and a half hours.

    04:11 We know from our normal stages of labor and our normal parameters that as a G1, having epidural in place, she should have completed stage 2 in 3 hours.

    04:21 So she's beyond that time.

    04:23 Now within this, if this is a situation where the head is at + 2 station, we can consider doing an operative delivery.

    04:30 That would either be operative vacuum delivery or an operative forcep delivery.

    04:35 Whether you choose to do a vacuum or choose to do a forcep, is really left up to the clinician and the clinician's experience.

    04:42 If that head is at less than +2 station, however, or if it's malpositioned, we would need to perform a cesarean delivery.


    About the Lecture

    The lecture Labor Stage 2: Operative Delivery by Veronica Gillispie, MD, FACOG is from the course Intrapartum Care. It contains the following chapters:

    • Operative Delivery
    • Complications of Vacuum of Operative Deliveries

    Included Quiz Questions

    1. Arrest of the second stage of labor with fetal head at least 2 cm past the ischal spines
    2. Arrest of the first stage of labor due to fetal intolerance of labor
    3. Arrest of the second stage of labor with fetal head at least at the level of the ischal spines
    4. Arrest of the second stage of labor due to fetal malpresentation
    5. Arrest of the first stage of labor due to uteroplacental insufficiency
    1. Cephalohematoma
    2. Facial laceration
    3. Skull fracture
    4. Facial nerve injury
    5. Fetal clavicular fracture
    1. She is in arrest of labor and operative vaginal delivery should be considered
    2. She should be encouraged to continue to push for spontaneous vaginal delivery since the fetus is tolerating labor
    3. She is in arrest of labor and cesarean section should be the next step
    4. She is in protracted labor and cesarean section should be the next step
    5. Although she is progressing well in labor, she should have an operational vaginal delivery due to fetal intolerance
    1. Fetal macrosomia
    2. Fetal intolerance of labor
    3. Arrest of the 2ⁿᵈ stage of labor
    4. Need to shorten or decrease maternal exertion due to pre-existing conditions such as heart failure or intracranial berry aneurysms
    5. Category 3 fetal heart tracing

    Author of lecture Labor Stage 2: Operative Delivery

     Veronica Gillispie, MD, FACOG

    Veronica Gillispie, MD, FACOG


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