Instrumental Vaginal delivery AUDIT Vacuum forceps Definition Operative

Instrumental Vaginal delivery AUDIT

Vacuum & forceps

Definition - Operative obstetrics • refers to any method used to deliver the fetus other than uterine contractions and maternal pushing efforts , It may include vaginal or cesarean routes

OBSTETRIC FORCEPS - Indications • Prolonged second stage. • Fetal compromise. • Avoid maternal pushing. • Breech presentation.

OBSTETRIC FORCEPS

OBSTETRIC FORCEPS- Prerequisites • Clinically adequate pelvic dimensions • Experienced operator • Full cervical dilation • Engaged fetal head • Orientation of fetal head is certain

OBSTETRIC FORCEPS- Complications • Maternal: lacerations to the vagina, cervix, perineum, and uterus. • Fetal-neonatal: soft-tissue compression or cranial injury caused by incorrectly placed forceps blades.

Forceps left this boy brain damaged facial palsy

VACUUM EXTRACTOR • These are cuplike instruments that are held against the fetal head with suction.

VACUUM EXTRACTOR • Advantages Over Forceps : • Fetal head orientation , Space required , Perineal trauma , Head rotation. • Disadvantages Over Forceps : • Cup pop-offs , Scalp trauma , others.

VACUUM EXTRACTOR- Prerequisites • Clinically adequate pelvic dimension • Experienced operator • Full cervical dilation • Engaged fetal head • Gestational age is >34 weeks

VACUUM EXTRACTOR - Complications • Maternal: vaginal laceration. • Neonatal: cephalohematoma and scalp lacerations , subgaleal hematoma or intracranial hemorrhage associated with vacuum duration >10 min.

Health annual report – Palestine 2014 • Reported Live Births: The total number of reported live births in Palestine was (121, 330); 65, 778 (54. 2%) in West Bank and 55, 552 (45. 8%) in Gaza Strip.

US operative delivery incidence • The incidence of an operative obstetric delivery in US ( 35% to 40%). • ( 10% to 15% ) are operative vaginal deliveries using either a forceps or vacuum device. • ( 25% to 30% ) cesarean births

According to the records in al Emarati hospital • Number of live births and instrumental delivery in 7 months. Month Births Instrumental 405 1 April 254 2 may 320 1 June 312 - July 455 1 august 466 - September 410 1 Total 2622 6 March Percentage 0. 22 %

Our audit

Aims & Objectives • Identify at least 25 audits ( vacuum or forceps ) • Compare with international standard for instrumental delivery and complication rates • Check adherence to local protocol • Check standard of documentation

Our audit • Vacuum deliveries only are performed on labour ward • Forceps deliveries are performed only in the operating room • This is neither recorded in the notes nor in the operations records book

• So we looked for the cases which is recorded as VAD in the labour ward and the results as Follow :

• 23 cases registered in 5 months in Birth registration book. • 20 out of 23 files found in the archive. • 7 out of remaining 20 files recorded as NVD in the files !.

• 10 out of 13 recorded as VAD but ! Eithere was no instrumental delivery form or it is empty. • So only 3 files were properly documented and contained the instrumental delivery form.

In the 3 files : • All of them were full term , and silastic vacuum used in all of them. • Number of pulls : n of pulls 1 to 3 4 to 5 33% 67%

• We couldn’t assess maternal tissue entrapment ? • Indication for instrumental delivery in the 3 cases Prolonged second stage of labour

• In the 3 cases : Fetal station in all cases was +1 the bladder was emptied the doctor who perform the delivery was Resident cervical dilatation was adequate

• One of the cases needed episiotomy , and 2 didn't. • No maternal or fetal complication occurred in 2 of the cases , while in the third one there was 4 th degree tear , without fetal complication.

Conclusions • protocols with too small sample (3 files !) • The documentation of the vaginal deliveries was significantly substandard.

Recommendations Improve Documentation system

Thanks