Abstract
Routine use of a partograph is associated with a reduction in the use of forceps,
but is not associated with a reduction in the use of vacuum extraction (Level A).
Early artificial rupture of the membranes, associated with oxytocin perfusion, does
not reduce the number of operative vaginal deliveries (Level A), but does increase
the rate of fetal heart rate abnormalities (Level B). Early correction of lack of
progress in dilatation by oxytocin perfusion can reduce the number of operative vaginal
deliveries (Level B). The use of low-concentration epidural infusions of bupivacaine
potentiated by morphinomimetics reduces the number of operative interventions compared
with larger doses (Level A). Placement of an epidural before 3-cm dilatation does
not increase the number of operative vaginal deliveries (Level A).
Posterior positions of the fetus result in more operative vaginal deliveries (Level
B). Manual rotation of the fetus from a posterior position to an anterior position
may reduce the number of operative deliveries (Level C). Walking during labour is
not associated with a reduction in the number of operative vaginal deliveries (Level
A). Continuous support of the parturient by a midwife or partner/family member during
labour reduces the number of operative vaginal deliveries (Level A). Under epidural
analgesia, delayed pushing (2 h after full dilatation) reduces the number of difficult operative vaginal deliveries
(Level A). Ultrasound is recommended if there is any clinical doubt about the presentation
of the fetus (Level B).
The available scientific data are insufficient to contra-indicate attempted midoperative
delivery (professional consensus). The duration of the operative intervention is slightly
shorter with forceps than with a vacuum extractor (Level C). Nonetheless, the urgency
of operative delivery is not a reason to choose one instrument over another (professional
consensus). The cup-shaped vacuum extractor seems to be the instrument of choice for
operative deliveries of fetuses in a cephalic transverse position, and may also be
preferred for fetuses in a posterior position (professional consensus). Vacuum extraction
deliveries fail more often than forceps deliveries (Level B).
Overall, immediate maternal complications are more common for forceps deliveries than
vacuum extraction deliveries (Level B). Compared with forceps, operative vaginal delivery
using a vacuum extractor appears to reduce the number of episiotomies (Level B), first-
and second-degree perineal lesions, and damage to the anal sphincter (Level B). Among
the long-term complications, the rate of urinary incontinence is similar following
forceps, vacuum extraction and spontaneous vaginal deliveries (Level B). Anal incontinence
is more common following forceps delivery (Level B). Persistent anal incontinence
has a similar prevalence regardless of the mode of delivery (caesarean or vaginal,
instrumental or non-instrumental), suggesting the involvement of other factors (Level
B). Rates of immediate neonatal mortality and morbidity are similar for forceps and
vacuum extraction deliveries (Level B). It appears that difficult instrumental delivery
may lead to psychological sequelae that may result in a decision not to have more
children (Level C). The rates of neonatal convulsions, intracranial haemorrhage and
jaundice do not differ between forceps and vacuum extraction deliveries (Levels B
and C).
Rapid sequence induction with a Sellick manoeuvre (pressure to the cricoid cartilage)
and tracheal intubation with a balloon catheter is recommended for any general anaesthesia
(Level B).
Training must ensure that obstetricians can identify indications and contra-indications,
choose the appropriate instrument, use the instruments correctly, and know the principles
of quality control applied to operative vaginal delivery. Nowadays, traditional training
can be accompanied by simulations. Training should be individualized and extended
for some students.
Keywords
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Article info
Publication history
Published online: July 18, 2011
Accepted:
June 14,
2011
Received:
May 3,
2011
Identification
Copyright
© 2011 Elsevier Ireland Ltd. Published by Elsevier Inc. All rights reserved.
