**6. Types and classification of operative vaginal delivery procedures**

Forceps and vacuum delivery are the most common procedures employed for assisted vaginal delivery. Others like symphysiotomy and fetal destructive operations are rarely if ever performed in developed countries. The ACOG developed a classification system that takes into account the station and position of the fetal head in the maternal pelvis (ACOG, 1992). (Figure 3 and Table 2)


Table 2. Classification for operative vaginal deliveries adapted from ACOG

### **7. Guidelines and indications**

The invention of obstetrical forceps may have been driven by the search for a way to address one of the tragic outcomes of pregnancy of those days; prolonged obstructed labor with a dead fetus. With no luxury of ability to perform a caesarean section, the dilemma faced by the birth accoucheur was undoubtedly formidable. As the tools of the trade grew in number and design, the indications also multiplied. Some institutions like the Royal College of Obstetricians and Gynaecologists (RCOG) UK, The American Congress of Obstetricians and Gynaecologists and the Society of Obstetricians and Gynaecologists of Canada have helped to clearly define the indications for operative vaginal delivery (Table 3). There are several indications for assisted vaginal delivery; these could be due to fetal compromise, maternal indications to avoid Valsalva or inadequate progress in labour. No indication is absolute and each case should be considered individually.


\*New York Heart Association classification

262 From Preconception to Postpartum

Forceps and vacuum delivery are the most common procedures employed for assisted vaginal delivery. Others like symphysiotomy and fetal destructive operations are rarely if ever performed in developed countries. The ACOG developed a classification system that takes into account the station and position of the fetal head in the maternal pelvis (ACOG,

**6. Types and classification of operative vaginal delivery procedures** 

**Outlet** Fetal scalp visible without separating the labia

and not on the pelvic floor

(a) rotation of 45 degrees or less (b) rotation more than 45 degrees

(a) rotation of 45 degrees or less (b) rotation more than 45 degrees

Table 2. Classification for operative vaginal deliveries adapted from ACOG

indication is absolute and each case should be considered individually.

Two subdivisions:

**Mid cavity** Fetal head is 1/5 palpable per abdomen

the ischial spines Two subdivisions

**High** Not included in classification

**7. Guidelines and indications** 

Fetal skull has reached the pelvic floor

occiput anterior or posterior position (rotation does not exceed 45 degrees) Fetal head is at or on the perineum

**Low** Leading point of the skull (not caput) is at station plus 2 cm or more

The invention of obstetrical forceps may have been driven by the search for a way to address one of the tragic outcomes of pregnancy of those days; prolonged obstructed labor with a dead fetus. With no luxury of ability to perform a caesarean section, the dilemma faced by the birth accoucheur was undoubtedly formidable. As the tools of the trade grew in number and design, the indications also multiplied. Some institutions like the Royal College of Obstetricians and Gynaecologists (RCOG) UK, The American Congress of Obstetricians and Gynaecologists and the Society of Obstetricians and Gynaecologists of Canada have helped to clearly define the indications for operative vaginal delivery (Table 3). There are several indications for assisted vaginal delivery; these could be due to fetal compromise, maternal indications to avoid Valsalva or inadequate progress in labour. No

Sagittal suture is in the antero-posterior diameter or right or left

Leading point of the skull is above station plus 2 cm but not above

1992). (Figure 3 and Table 2)

**Term Definition** 

Table 3. Indications for operative vaginal delivery (no indication is absolute and each case should be considered individually)

The safe use of both the vacuum extractor and obstetric forceps require prerequisites one of which is that "the operator must have the knowledge, experience and skills necessary to use the instrument" (ACOG, 1994). A list of the essential pre-requisites for operative vaginal delivery is presented in Table 4.


Table 4. Prerequisites for operative vaginal delivery

Operative Vaginal Deliveries in Contemporary Obstetric Practice 265




Blood-borne viral infections of the mother e.g HIV are not a contraindication to operative vaginal delivery. However, it is sensible to avoid difficult operative delivery where there is an increased chance of fetal abrasion or scalp trauma and to avoid fetal scalp clips or blood

While the role of operative vaginal deliveries using instruments like forceps and vacuum extractor has received wide acclaim, complications, sometimes of profound severity have been documented for both mother and child. These undesired outcomes have made

operative vaginal delivery an object of great scrutiny by the medical and lay press.

**Complication Vacuum Forceps** 

8 (42.1) 0 (0)

0 (0) 3 (15.8) 4 (21.1) 0 (0) 4 (21.1) 20

Table 6. Complications observed with instrumental/operative vaginal deliveries in Zaria

While a diverse number of complications have been ascribed to these procedures causality

16 (44.4) 7 (19.4)

10 (27.8) 0 (0) 2 (5.6) 1 (2.8) 0 (0) 36


sampling during labour.

Genital tract laceration Postpartum haemorrhage

has been difficult to establish.

**8. Complications** 

*Maternal* 

*Fetal* 

Skin bruises Neonatal jaundice Cephalo haematoma

Erb's palsy Fetal death Total

Nigeria

subgaleal and intracranial haemorrhage.

delivered abdominally from deep in the pelvis.




Facility-based studies from several countries show that indications for operative vaginal delivery procedure fall easily within these categories. Indications for vacuum and forceps delivery in 3 large hospitals in 3 countries are shown in table 5 below.

Table 5. Indications for vacuum and forceps delivery in health care facilities
