Labor Stage 2: Operative Delivery

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.