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.