User:PharmD Student Kathryn/Operative vaginal delivery

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

Operative vaginal delivery is a risk factor for postpartum hemorrhage.

We acknowledge that not all people who give birth identify as female or prefer the term mother. However, we have used these terms here in order to clearly differentiate how operative vaginal delivery impacts the mother versus the baby.

Indications
When fetal distress occurs during the second stage of labor, operative vaginal delivery may be used in place of caesarean section which may pose additional risks after birth has progressed and the fetal head is deep in the birth canal. Maternal exhaustion and fetal distress would also be indications for appropriate use of operative vaginal delivery.

An analysis of multiple studies found that detecting the angle of the fetal head using an ultrasound is a reliable way to predict where uncomplicated operative vaginal delivery can be used, especially in first-time mothers.

Contraindications
This can be further divided into two categories- definite and relative contraindications. With relative contraindication, clinical judgement is required due to fetal complications, and the skill of the health care provider needs to be assessed.

Definite contraindication include non-engagement of fetal heads, the position of the fetal is unknown, cervix not fully dilated, known loss of minerals from fetal bone, and fetal disorders.

Relative contraindication include less than 34 weeks of pregnancy, and less than 2400 grams of the total fetal weight.

Benefits
Discharge from the hospital after operative vaginal delivery (2-3 days) is faster than after a caesarean section, which requires 4 days for discharge. It is suggested that this decrease in in-hospital recovery time reflects a decrease in pain and an increase in post-birth mobility for the mother. Using operative vaginal delivery avoids the risks associated with repeat caesarian sections or vaginal births after caesarian sections for women who want to have additional pregnancies.

Pelvic Floor Injury
The process of operative vaginal delivery can cause damage to the pelvic floor and anal sphincter. Obstetric anal sphincter injury (OASI) is a complication that can lead to short term morbidity and long term loss of bowel movement control. OASI is observed in about 5.7% of nulliparous of births and 1.5% in multiparous with no prior OASI. While there does not appear to be a difference in long-term bowel or pelvic floor-related symptoms, studies of deliveries using forceps appear to to show an association with being at an increased risk of long-term fecal incontinence. Studies also show that performing a episiotomy can reduce the risk of OASI in both forceps and vacuum-assisted deliveries.

When operative vaginal delivery is unsuccessful, another method such as second stage caesarean section, must be implemented. Additionally, operative vaginal delivery increases the risk for venous thromboembolism.

Post Traumatic Stress Disorder
While statistics specific to PTSD post operative vaginal delivery are not available, studies show that 3-4% of all women and 20% of women in high risk groups will develop post traumatic stress disorder after birth. Operative deliveries are recognized as a risk factor for PTSD.

Prevalence
There has been a decrease in use of operative vaginal delivery as second stage caesarean section has become more common. However, operative vaginal delivery is by no means a rare procedure; in the United Kingdom 12.7% of women and up to 25% of first time mothers undergo operative vaginal delivery. Globally, this percentage decreases to 2.6%.

Devices
The procedure relies primarily on either a pair of curved forceps blades or a vacuum extractor that applies negative pressure inside the womb. The forceps are designed to reach the top of the fetal head and create the necessary traction to pull and rotate the baby out. On the other hand, the vacuum extractor uses a small metal or silicon cap that exerts negative pressure on the fetal scalp to felicitate pulling of the infant. Since vacuum extraction can cause less anal injuries than forceps-assisted delivery, in some countries vacuum extraction is the preferred technique.

Post-Delivery Care
Injuries such as tears, cuts, or bruises to the birth canal, cervix, anus, or vaginal openings will be assessed and addressed. For example, tears to the vaginal openings will be stitched to prevent blood loss.

Antibiotics
Operative vaginal delivery presents an opportunity for infection due to trauma to the tissue, vaginal examination and instrumentation, and bladder catherization with 0.7-16% of operative vaginal births leading to infections. Guidelines from the World Heath Organization (WHO) support the use of intravenous antibiotics for the mother as soon as possible after birth up to within 6 hours. The recommended antibiotic combination would be amoxicillin and clavulanic acid, but if they are not available antibiotics with similar activity can be used.

History
50% of first-time mothers had forceps-assisted deliveries in the 1960s.