Instrumental delivery

• Types:

  • Ventouse (vacuum)
  • Forceps
• A single dose of co-amoxiclav is recommended after instrumental delivery to reduce the risk of maternal infection.
• Some key indications are:

  • Failure to progress
  • Fetal distress
  • Maternal exhaustion
  • Control of the head in various fetal positions
• There is an increased risk of requiring an instrumental delivery with an epidural
• Having an instrumental delivery increases the risk to the mother of:

  • Postpartum haemorrhage
  • Episiotomy
  • Perineal tears
  • Injury to the anal sphincter
  • Incontinence of the bladder or bowel
  • Nerve injury (obturator or femoral nerve)
• The key risks to remember to the baby are:

  • Cephalohaematoma with ventouse
  • Facial nerve palsy with forceps
• Rarely there can be serious risks to the baby:

  • Subgaleal haemorrhage (most dangerous)
  • Intracranial haemorrhage
  • Skull fracture
  • Spinal cord injury
• Ventouse:

  • Suction cup on a cord
  • Different types - silastic cup, metal cup, kiwi omnicup
  • Cup goes on baby's head and careful traction applied
  • Main complication is a cephalohematoma - collection of blood between the skull and the periosteum (membrane covering skull)
• Forceps:

  • Cradle the foetal head - gentle pulling during a contraction
  • Rotational or non-rotational
  • Main complication is facial nerve palsy with facial paralysis on one side
• Rarely an instrumental delivery may result in nerve injury for the mother. This usually resolves over 6 – 8 weeks. The affected nerves may be:

  • Femoral nerve
  • Obturator nerve
• Femoral nerve injury:

  • Compressed against the inguinal canal during forceps delivery
  • Weakness of knee extension
  • Loss of the patella reflex
  • Numbness of the anterior thigh and medial lower leg
• Obturator nerve injury:

  • May be compressed by forceps during instrumental delivery or by the foetal head during normal delivery
  • Weakness of hip adduction and rotation
  • Numbness of the medial thigh
• Subgaleal haemorrhage:

  • Serious complication of instrumental delivery
  • Bleeding between the potential space between the skull periosteum (membrane covering skull) and the scalp galea aponeurosis (dense fibrous tissue surrounding skull)
  • Can lead to haemorrhagic shock due to the volume of blood that can be lost in this potential space