Obstetric forceps delivery

Obstetric forceps delivery

a forcep is a metal device  that enables gentle rotation and/or traction of the fetal head during vaginal delivery

Types

Kielland: enables rotation and traction of the fetal head

Simpson: only enables traction of the fetal head

Barton: used for occiput transverse position of the fetal head

Piper: used to deliver the fetal head during breech delivery

Classification

Outlet: fetal head lies on the pelvic floor
Low: fetal head is below +2 station (not on the pelvic floor)
Mid: fetal head is below 0 station (not at +2 station)
High: fetal head is not engaged

Indications

Prolonged second stage of labor

Breech presentation

Nonreassuring fetal heart rate

To avoid/assist maternal pushing efforts

Prerequisites

Clinically adequate pelvic dimensions (see “Mechanics of childbirth”)

Full cervical dilation

Engagement of the fetal head

Knowledge of exact position and attitude of the fetal head

Emptied maternal bladder

No suspicion of fetal bleeding or bone mineralization disorders

Advantages
Scalp injuries are less common

Cannot undergo decompression and “pop off”

Complications

Maternal: obstetric lacerations (cervix, vagina, uterus)

Fetal: head or soft-tissue trauma (e.g., scalp lacerations, injured ears), facial nerve palsy

 

Related Questions Neonatology and Recent Advances

a forcep is a metal device  that enables gentle rotation and/or traction of the fetal head during vaginal delivery

Types

Kielland: enables rotation and traction of the fetal head

Simpson: only enables traction of the fetal head

Barton: used for occiput transverse position of the fetal head

Piper: used to deliver the fetal head during breech delivery

Classification

Outlet: fetal head lies on the pelvic floor
Low: fetal head is below +2 station (not on the pelvic floor)
Mid: fetal head is below 0 station (not at +2 station)
High: fetal head is not engaged

Indications

Prolonged second stage of labor

Breech presentation

Nonreassuring fetal heart rate

To avoid/assist maternal pushing efforts

Prerequisites

Clinically adequate pelvic dimensions (see “Mechanics of childbirth”)

Full cervical dilation

Engagement of the fetal head

Knowledge of exact position and attitude of the fetal head

Emptied maternal bladder

No suspicion of fetal bleeding or bone mineralization disorders

Advantages
Scalp injuries are less common

Cannot undergo decompression and “pop off”

Complications

Maternal: obstetric lacerations (cervix, vagina, uterus)

Fetal: head or soft-tissue trauma (e.g., scalp lacerations, injured ears), facial nerve palsy

 

Umbilical cord prolapse

acute, life-threatening emergency for the fetus, in which a part of the umbilical cord lies between the antecedent part of the fetus (mostly head) and the pelvic wall, causing rupture of membranes


Epidemiology: rare (0.5% births)

Etiology: often seen in presentation anomalies (e.g., breech presentation, transverse fetal position), multiple pregnancy, long umbilical cord, or abnormal fetal movement (polyhydramnios, premature birth)


Clinical features: -
- an abrupt change from a previously normal CTG to one with fetal bradycardia or recurrent,
- severe decelerations,
- occuring after the rupture of membranes


Diagnostics: vaginal palpation → thick, pulsating cord is palpable


Treatment: Trendelenburg position; fetus is pushed back into the uterus; immediate tocolysis using β2-mimetics (e.g., fenoterol) → emergency cesarean section

 

ENDOMETRIOSIS

The proliferation and functioning of endometrial tissue outside of the uterine cavity

Incidence: - 15-30% of all premenopausal women, -mean age at presentation: 25-30 years
 
Etiology - unknown

theories

- retrograde menstruation theory of Sampson
- Mullerian metaplasia theory of Meyer
- endometriosis results from the metaplastic transformation of peritoneal mesothelium under the influence of certain unidentified stimuli
- lymphatic spread theory of Halban
- surgical transplantation
- deficiency of immune surveillance


Predisposing Factors

- nulliparity
- age > 25 years
- family history
- obstructive anomalies of genital tract

Sites of Occurrence

ovaries  most common location, 60% of patients have ovarian involvement
broad ligament
peritoneal surface of the cul-de-sac (uterosacral ligaments)
rectosigmoid colon
appendix


Symptoms

there may be little correlation between the extent of disease and symptomatology

pelvic pain - due to swelling and bleeding of ectopic endometrium, unilateral if due to endometrioma

dysmenorrhea (secondary) - worsens with age, suprapubic and back pain often precede menstrual flow (24-48 hours) and continue throughout and after flow

infertility - 30-40% of patients with endometriosis will be infertile, 15-30% of those who are infertile will have endometriosis

dyspareunia  on deep penetration

premenstrual and postmenstrual spotting
bladder symptoms - frequency, dysuria, hematuria

bowel symptoms - direct and indirect involvement diarrhea, constipation, pain and hematochezia

Diagnosis

truly a surgical diagnosis

history - cyclic symptoms - pelvic pain, dysmenorrhea, dyschezia

physical examination

- tender nodularity of uterine ligaments and cul-de-sac
- fixed retroversion of uterus
- firm, fixed adnexal mass (endometrioma)

laparoscopy

- dark blue or brownish-black implants (mulberry spots) on the uterosacral ligaments, cul-de-sac, or anywhere in the pelvis
- chocolate cysts in the ovaries (endometrioma)
- powder-burn lesions
- early white lesions and blebs


Treatment

pseudopregnancy - cyclic estrogen-progesterone (OCP) or medroxyprogesterone (Provera)

pseudomenopause - danazol (Danocrine) = weak androgen, s/e:  weight gain, fluid retention, acne, or hirsutism, leuprolide (Lupron) = GnRH agonist (suppresses pituitary GnRH)

s/e: hot flashes, vaginal dryness, reduced libido, and osteoporosis with prolonged use .these can only be used short term because of osteoporotic potential

surgical

- laparoscopic resection and lasering of implants
- lysis of adhesions
- use of electrocautery
- unilateral salpingo-oophorectomy
- uterine suspension
- rarely total pelvic clean-out
- follow-up with 3 months of medical treatment