Essay 351

A. I would inform the woman that this is  a prolonged second stage and, Ideally we have to achieve delivery in 4 hours after being confirmed she is fully dilated as it is associated with higher morbidity in it goes beyond that, I would ascertain that epidural is effective. Fluid intake as women tend to drink less and I would ask for urine to be tested for presence of ketones and i.v fluids given accordingly.  I would assess the woman using mneomnic of 3Ps(power, passanger, passage). I would start with abdominal palaption to assess babies size clinically, how m any fifths of the fetus's head are palpable abdominally and that the bladder is empty(full bladder can prevent descent). I would feel for the contractions for their strength, frequency and duration and recommend oxytocic infusion if contractions felt inadequate and CTG is normal. I would ask for permission  to assess her vaginally as this will reveal the most important  information. by VE I would assess the quality of liquor( meconium stained suggesting fetal distress). I would assess the position of the fetus head by feeling the sutures to ascertain vertex presentation suitable for instrumental delivery and that not a malposition is the cause of prolonged stage. I would feel for caput which might give a false impression of the heads station which will be assessed in report to maternal ischial spines. Presence of moulding not reducible( Stewart 3) might suggest cephalo- pelvic disproportion. If the head is engaged pelvic inlet assumed adequate and I would assess the pubic arch openning for outlet adequacy. I would inform the woman with the findings and involve her in the decision.

b) I would take into account all the factors known to lead to less successful operative delivery and if present I would decide for undertaking the procedure in theatre as it will facilitate easier recourse to C/S and avoiding delay which might lead to fetal compromise and also the panic which might put the mother under huge stress. 

 maternal BMI(>35) is an important factor for instrumental failure,  Prolonged first or second stage are important factors. Being in labour for more than 12hr. Cephalic presentation  not in OA  and the need for rotation( OP, OT positions).  Secondary arrest in labour. Presence of any will lead to a trial of instrumental in theatre. 

c) My skills and familiarity with a certain instrument is  the most important factor on deciding which instrument I will use. Woman's wishes as ventouse use is associated with more fear about babies wellbeing. Presence of contraindication for ventouse such as prematurity(<34weeks), presence of blood dycrasia or tendency for bleeding( maternal immune thrombocytopenia, haemophillia with unknown fetal status make ventouse out of choices.  If no contraindications for use of any instrument I will take into consideration  maternal efforts  to push as if ineffective ventouse will likely to fail. if OP or OT position I will use a rotational ventouse or use a manual rotation and then a lift out forceps. The likelihood of any instrument success has to take priorty as using sequential instruments will add on morbidity and C/S in second stage after failed instrument has even a hihger morbidity and mortality for mother and fetus.

A.

Patient’s observations like pulse, temperature, blood pressure, and hydration status ,urine testing will help in getting info about general condition, hydration status as prolonged second stage will make patient exhausted, dehydrated & tachycardia. IV Fluids may be given if needed.

Abdominal examination will include the lie of the baby, position if identifiable (ROA/LOA), presentation vertex/breech. Breech/ transverse lie will need individualized plan of care as per presentation.

No of contraction in 10 minutes, frequency & duration will help in determining the adequacy of contractions. If power is poor or contractions inadequate then oxytocin augmentation (30 U in 5oo mls Normal saline as per protocol) if no other contraindication can be needed.

Palpation to assess how many fifths (0/5, 1/5, 2/5 or more) palpable abdominally because if more fetal head is palpable (2/5 or more) then it’s a contraindication for vaginal instrumental delivery.

Clinical estimation regarding the size of baby because if clinically big baby then consider chances of failure of instrumental delivery.

Ensure bladder is not full &/or palpable because full bladder can be cause of prolonged labour.

Fetal heart rate pattern and CTG trace to be noted. Normal trace can allow continuing of further plan. Suspicious/ pathological trace and time before for which the trace was suspicious/pathological needs attention (see later below).

Vaginal examination to assess cervical dilation to ensure full dilation, position of presenting part below/above ishcial spines (-2, -1) as high presenting part of fetal head will increase chances of failure of instrumental delivery.

Moulding is suggestive of obstruction in the passage.

Presence of caput increases chances of failure of ventouse delivery.

Patient and her birthing partner should be informed about current status and further plan should be discussed sensitively and sympathetically. Patient should be counseled regarding the type of instrumental delivery needed its procedure, pain relief(Epidural working in this case)and its complications which includes vaginal tears, ¾ degree vaginal tears, PPH, injury to baby and complications like cephalo-hematoma, nerve injuries, and admission to SCBU (nursery). Any long term implications like fecal/flatus incontinence to be discussed. Chignon, forceps marks also to be discussed. Any questions or doubts clarified honestly.

 Fetal blood sampling to be considered if pathological trace or suspicious trace + other abnormal features on CTG trace (NICE guidelines). PH below 7.20 may need delivery within 30 minutes.

B.

High BMI has high chances of failed instrumental in room so trial in theatre should be considered.

Vaginal delivery in theatre is indicated if clinical suspicion of big baby so that trial of instrumental delivery +/_ emergency LSCS can be done.

Occipito-posterior presentation may need manual rotation or rotational instrumental delivery.

If transverse arrest and station at -1 0r 0 then Keilland forceps can be done in theatre provided appropriate operator experience is there.

Inadequate pain relief or epidural not working properly is also an indication for trial in theatre under spinal anesthesia.

Spontaneous descent may occur if high presenting part after adequate anesthesia in theatre secondary to maternal tissue relaxation is also possible.

C.

Patient’s and couple’s preferences against not using any particular instrument should be taken into consideration.

Availability of appropriate instrument is a pre-requisite.

Fetal gestational age (ventouse contraindicated in premature infants before 34 weeks) or any contraindications like skeletal/hematological abnormalities (platelet disorders) precluding the ventouse use must be taken into account.

Operator experience in using either ventouse/forceps should be considered. Back- up plan in case of failure i.e consultant availability must be ensured.

If the fetal head is quite low 0 to +1, +2 then ventouse cup (metal/silastic) can be used. Fetal head at +2, +3 the simple kiwi cup can also be used.

Neville Barne’s forceps can also be used if occipito anterior presentation or manual roation from OP and then forceps application can be done.

a) I will check her obsteric records for SFH chart and ultrasound estimated fetal weight to check the possibility of big baby.Signs of dehydratin like dry coated tongue will give indication of prolonged active labor. Her pulse and BP will be checked for hpotension and tachycardia in case of maternal exhaustion and dehydration, urine is examined for ketones( for exhaustion) and concentarted urine suggestive of dehydration. Abdominal examination is done for palpation of fetal pole as how many fifth palpable .the uterine contractions is assessed by the number, frequency ,duration and intensity for its adequacy.if palpable bladder per abdominally,to be emptied as it can delay descent of presenting part.I will check for adequacy of analgesia by enquiring the woman. Vaginal examination is performed to check for status of membranes and color of liquor if meconium stained or not as it indicates chances of fetal distress.The cervical dilatation and effacement to be confirmed. The presentation is confirmed as vertex as brow or mentoposterior cannot be possible to deliver vaginally.presence of caput and irreducible moulding will indicate CPD. the fonanelles are palpated for rotation and malpositions like OP and OT which may delay delivery. The station of presenting part confirmed as if 0 or +1less likely to be CPD.  CTG to be commenced if not yet started and assessment to be done and any pathological or persistent suspicious trace needs fetal blood PH. If PH < 7.2, delivery should be within 30 minutes.

I will inform the woman that there is a delay in the progress of labor and the possible reasons as per examination finding can be explained to her. she should be cpunselled that further delay will increase maternal and fetal morbidityOperative  Vaginal delivery by forceps or vacuum should be informed. It should be counselled that forceps is asociated with increased maternal perineal trauma , PPH, anal sphincter injury, possbility of fecal incontinence later. regarding vacuum should be explained that it is associated with increased risk of fetal trauma , cephalhematoma, jaundice and admission to SCBU but has less maternal trauma.She should be informed regarding emergency LSCS at this stage of labor and that it is also associate with high morbidity like PPH, postop infection, injury to surrounding structures, higher chances of repeat CS in future pregnancy but no perineal trauma.maternal wishes should be respectec before deciding mode of delivry.

b) High station of 0 or -1 with palpable fetal pole ( 1/5) is asociated with high failure of instrumental delivery so to be done in OT. instrumenta delivery in incomplete rotated head also shoud be done in operation theatre as more chances of failure. MIDcavity rotation forceps by expert senior obstretician to be done inOT. women wih high BMI and suspected big baby with shoulder dystocia has high chances of failure so trial to be given in OT.Fetalscalp ph < 7.2 or pathologhical CTG trace is better done in OT as immediate conversion to LSCS can be done without loss of time in case of failure. I n case of inadequate analgesia, instrumental delivery to be done in OT with additional spinal anesthesia.

c) Maternal wishes to be considered after proper counselling regarding choice of instrument. the obsterician's expertise and familiarity of a prticular instrument is a factor for choice of forceps vs vacuum. if high station or incomplete rotation , vacuum is preferred over forceps.Prematurity of <34wks is achoice for forceps than vacuum. Presence of caput or risk of hemorrhage in baby as in ITP,low fetal platelet count if known, forceps is preferred over vacuum.

A)       Assessment includes previous obstetric/gynaecological history and current pregnancy to find out the risk factors for maternal and fetal wellbeing. Estimated weight, fundal height chart, fetal and placental abnormalities?  BMI and age needs to be checked.

Social history: expectations for the delivery and patients thoughts on the progress in the labour would be helpful information for discussion on the further intervention if required.

With regards the current labour, I would check gestational age, find out whether labour was augmented, review the partogram: any secondary arrest?, poor progress may indicate malposition or cephalopelvic disproportion. Also if contractions are hypotonic or discoordinate it can contribute to slow progress.

It is important to review a CTG as delivery should  be expedited in the presence of fetal compromise; and this  would influence the way how counselling is performed.

I would ask about epidural analgesia and whether the patient is comfortable, check observations as maternal infection could be a contributory factor to slow progress.

Abdominal examination would include lie, presentation and engagement (cephalic; less than 1/5 palpable are favourable for vaginal delivery), frequency and strength of contractions, ? palpable bladder.

Vaginal examination performed with consent to assess presentation, engagement, dilatation, position, caput and moulding. Cervix should be fully dilated, no membranes felt with cephalic presentation and station at or below ischial spines.

When counselling patient it is essential to ask about her wishes and discuss the progress of the labour, risks, possible options taking into account fetal heart rate pattern if there is any signs of fetal distress. Explaining to the woman that prolonged second stage is associated with maternal morbidity such as haemorrhage, increased risk of caesarean section, potential bladder problems is important; also the risks of vaginal delivery versus caesarean section at the full dilatation.

b) To achieve safe delivery there are a few factors indicate a high risk of failure such as BMI more than 30, big baby on clinical examination, EFW more than 4kg, midcavity delivery and occipito-posterior position; and if there is 1/5^th or more head palpable per abdomen. Also if difficulty is anticipated and vaginal delivery fails, the theatre would be an appropriate place for performing caesarean section to avoid unnecessary delay as delay may be responsible for fetal injury. Also the skills and the experience of the operator would  influence on the outcome.

c) Forceps and vacuum extraction are associated with different risks and benefits.

For non rotational deliveries: if the baby in DOA position, gestation of less 36 weeks, excessive caput; if there is a maternal exhaustion; or maternal effort not possible (eg cardiac disease),  foceps are particularly useful.

Rotational delivery depending on expertise or experienced operator available by Kielands forceps with or without manual rotation, vacuum rotational delivery can be performed.

Ventouse is associated with higher failure rate, therefore preferable when there is a good maternal effort with low or outlet delivers on babies after 36 weeks with no medical problems such as bleeding disorders etc as ventouse is associated with less perineal trauma.

Forceps are useful instrument in experienced hands; however is associated with “ tocophobia” postdelivery; and perineal tears; therefore all of this should be taken into consideration. It is crucial though to avoid double instrumentation and be ready to abandon the delivery if there is no descent of the head with pulls.

Enquiry is made if pain relief is adequate. If she is pushing, time since pushing is noted. History is taken if she had been suggested that baby being big during antenatal assessment while measuring fundal height. Maternal records are reviewed to note any indication of big baby by clinical assessment or in the ultrasound. Partogram is reviewed as slow progress can suggest CPD.

Pulse and blood pressure are recorded. Raised temperature, tachycardia, and sunken eyes suggest dehydration. Bladder is emptied. Abdominal examination is performed to assess the uterine height and to identify subjective assessment of big baby. The palpable fifths of the head should be assessed.

Vaginal examination is carried out to detect vulval edema suggesting prolonged labour. Assessment is done to identify the colour of the liquor and station of the head in relation to ischial spines. significant caput and irreducible moulding suggests cephalopelvic disproportion.

Fetal heart is monitored may be assessed by intermittent auscultation for 1 minute after a contraction at least every 5 minutes or by CTG.

Considerable distress is expected in this woman and support is provided with sympathetic approach. continuous support from a family member or partner is ensuredClear explanation about the finding of examination should be provided to the woman. A plan should be agreed with the woman to ensure that will have occurred with in 4 hours from the diagnosis of full dilatation. Her wishes are taken in to consideration.

During assessment, if high risk of failure is anticipated, operative vaginal delivery should be considered as a trial and conducted in the operation theatre where immediate recourse to CS can be undertaken. High rates of failure are associated with maternal BMI over 30, or if the estimated fetal weight over 4000g or a clinically big baby. Operative vaginal delivery in operating room is also indicated if the position of the head is occipito posterior or if the head is 1/5^th palpable per abdomen where the head is still in midcavity.

The factors that influence the choice of the instrument include operator's level of skill and expertise.Use of Keilland forceps carries additional risks and requires specific skills and training.

In case of high risk of failure, forceps is preferable to vacuum as vacuum especially soft cup is more likely to fail. Maternal wishes are another factor to decide the type of instrument as vacuum is associated with maternal worries.  

a)  I will inform the women that she is in prolonged 2^ndstage of labour.Now we have to examine her and assess either she will progress vaginally or needs intervention.All women should be advised about continuous support during labour.

During observation I will order for hourly pulse , blood pressure cheking and 4 hourly temperature checking.Uterine contractions  should be documented every half hourly.If contractions are inadequate we can start oxytocin by intravenous drip or IM.As she in prolonged labour her level of dehydration,mental condition and strength of pushing should be assessed properly.As she is with epidural analgesia we have to check it is effective or needs top up.

With the help of partogram we can assess her progress in labour.             

I will check her history from the file about any medical disease like heart disease that needs to shorten the 2^nd stage.BMI should be measured because obesity can cause failure of operative delivery trial.Her bladder should be emptied with catheter because it can prevent descend.Gestational age during delivery also an important factor for decision making.

I will check her per abdominally about descends of foetal head.If <1/5^th palpable she could be a candidate for operative vaginal delivery.I will also check lie and position of foetus.Pervaginally I will see membrane ruptured or not.If not ruptured I will perform amniotomy and check liquor either meconium stained or not.I will detect the presentation because in brow,face(mentoanterior) we cannot plan for normal delivery.If vertex we can continue vaginally.I will also check for caput and moulding stage if present.These will help to get an idea about cephalopelvic disproportion.I will check station of the foetus to decide for high or low cavity operative delivery.Clinical estimation of large baby,cause for nonprogress should be detected to avoid failure of trial of operative delivery.

Foetal condition I will assess by intermittent auscultation every 5 minutes.If any abnormality detected CTG should be done or continuous electronic foetal monitoring should be started if condition arises.Foetal blood sampling should be done if pathological tracing.PH<7.2 is an indication for delivery within 30 minutes.

Every step of progress and choice of treatment should be discussed with patient.Consent of patient is mandatory for operative vaginal delivery.Patient should be informed all the benefiets and side effects of forceps or ventouse if decide for operative delivery.Cephalhaematoma,retinal haemorrhage more likely with ventouse and perineal  trauma more common with forceps.Increased chance of SCBU admission should be informed to mother.She should also be informed of chance of caesarean section if trial fails and consultant obstetrician should be available.

b)  Conditions where there is more chance of failure of operative vaginal delivery should be considered a trial.It should be in theatre where immediate caesarean section can be done.

Maternal BMI>30 is associated with high failure rate.So if the patient is obese better to make trial in theatre.From the antenatal ultrasound record if estimated foetal weight is more than 4 kg or if clinical suspicion of big baby then trial for instrumental delivery should be in theatre.

Occipito-posterior presentation may need manual rotation or rotational instrumental delivery.So it also an indication for O.T. trial.If head is >1/5^th palpable per abdominally or in case of mid cavity delivery trial should be in theatre.

c)     My choice of instrument will depend on my clinical experience and availability of instrument.

Patient’s choice is an important factor.If she has any preference we should respect that.She should be informed the advantages and disadvantages of both forceps and vacuum.

Gestational age during labour is another factor.If <34 weeks vaccum is contraindicated.

Vaccum is associated with more failure rate.Sequential use of instrument is sometimes preferable and should be valued against caesarean section.Rotational delivery should be conducted by experienced hand and kiellans forceps or rotational vacuum extractor can be used.Back up plan should be there in case of failure.

XXXX

A healthy 32 year old primigravida has been in spontaneous labour with normal progress during the first stage. She is using epidural analgesia. You are asked to see her 3 hours after full dilatation because delivery is not imminent. (a) Discuss your assessment and counselling of this woman [12 marks]. (b) Following assessment, you conclude that vaginal operative delivery is appropriate. Discuss the indications for undertaking the delivery in the operating theatre [4 marks] (c) Which factors will influence your choice of instrument? [4 marks]

　

A ) Will l look into her notes for any ultrasound or notation of fetal macrosomia and plan for delivery. Will ask of her comfort with the epidural pain relief and if this is working. Will ask if she feeling exhausted and willing any more to push. Will ask the midwife how long she has been pushing for.

Will assess her BMI and BP .Will examine her for signs of dehydration as dry mucous membranes and tachycardia. Will assess the frequency and duration of uterine contractions. Will do abdominal examination for number of fifths of head above brim ( no more than 1/5^th of head above brim to be engaged).

Will take verbal consent for vaginal examination.Will asses the presentation to exclude a brow presentation or direct mento postterior. Will asses the position to detect if occipito transverse position and exclude deep transverse arrest.Will detect the station of the head. Will detect if there is caput or moulding and degree of moulding, to detect if there is cephalo pelvic disproportion and obstructed labour. Will asses the colour and consistency of me conium stained liquor.

Will counsell her and her partner ,that there is a delay in the second stage of labour . Should she have brow malpresentation,mento posterior, or obstructed labour will consent her for cesarean section explaining the risks of c/s . Should she need operative vaginal deliveryOVD,Will obtain informed consent. Will explain instruments used for OVD. Ventouse is associated with less trauma to vagina and perineum but is more likey to fail or slip than forceps. In her situation as she is having an epidural and less likely to push ,forceps would be a better choice. Will tell her that OVD might fail to deliver the baby and that cesarean section would be needed. Would respect her choice if she refuses OVD and request a cesarean section from the start.

　

B) Rotational forceps deliveries are conducted in operating theatre OT. Mid forceps deliveries ,when I/5^th of head palpable above brim or leading bony part of presenting part is above +2 station but below Ischia spine,are better conducted in the OT. Should I find that her BMI is >35 ,delivery at OT is better , Should I find on vaginal examination that the head does not come down with the contraction ,I would conduct it at the OT. Should I find that it would be a difficult OVD I would inform the consultant on call and carry it at the OT ,as there might be a possibility of failed trial and difficult cesarean.

C) Maternal wishes for not having OVD or having which instrument after explaining the pros and cones of each should be respected. Presence of epidural analgesia and lack of good pushing will favour forceps . Should the epidural be not working , ventouse is favored. Ventouse is not recommended if the gestation is 34wk or less. Ventouse is associated with more worries in the mother regarding her newborn baby, so would not be recommended in a very anxious patient.

　

　

　

A)

History or review of notes for confirmation of gestational age, antenatal course, ultrasound scan for placental position and estimated fetal weight if available,  and body mass index is useful.  Maternal viral serology should also be reiview to rule out contra ndiactions to difficult deliveries.

General observations like pulse, blood pressure, urine analysis to exclude dehydration to assess maternal well being. Ensure that the epidural analgesia is working well with indwelling catheter in situ with no hematuria to exclude obstructe labour. Review of the partogram would help in knowing if augmentation was needed in the first stage,the frequency, duration and strength of contractions, colour of the liquor to rule out meconium staining, and confirm adequte progress during 1st stage. The duration of active pushing should be ascertained.

Abdomen should be examined to assess for fetal size, lie, presenting part and fifths palpable for engagement.

Vaginal examination should be undertaken with maternal consent and presence of a chaperone to confirm full dilatation, ascertain the presenting part, position of the presenting part and station in relation to the ischial spines. Presence of caput and moulding should be looked for to exclude cephalopelvic disproportion. Descent of presenting part on maternal pushing should be ascertained.

sympathetic approach and support is warranted and the findings should be explained in details. She should be informed about the increased risk of maternal morbidity (post partum haemorrhage) and fetal morbidity (admission to special care) should be explained. Aim to achieve delivery within 4 hours. Maternal views and wishes should be taken into consideration.

B)

Operative delivery should be conducted in theatre if there is a high suspicion of failure and need to proceed to emergency casearean section. Factors such as BMI >30, Estimated fetal weight more than 4 kgs, presenting part 1/5th palpable, malposition such as occipito posterior positon, station at spines, significant moulding and caput, no descent with maternal pushing, presence of hematuria suggest increased risk of failure. Requirement for adequate analgesia might prompt the operatot to conduct the delivery in theatre.

C)

Research dont prove the benefit of one instrument over the other, hence its at the discretion of the operator to choose either ventouse or forceps depending on his experience, skills and training, of course after taking the clinical situation into consideration. Ventouse delivery is contraindiacted in prematurity <34 weeks and its use is controversial between 34 and 37 weeks. Face presentation is also a contraindication to ventouse delivery. Forceps would be preferred in the above scenarios and if there is minimal maternal effort due to exhaustion. If rotational delivery is anticipated, either rotational ventouse or keilland's forceps or manual rotation with direct application of forceps can be undertaken, depending ont he operator's experience. Quicker delivery can be achieved with forceps if fetal distress is suspected.

The decision should be made to avoid double instrumentation and minimise the maternal and fetal trauma for the best possible outcome.

Patient is Greeted and informed by the finding of her examination and asked for full assessment by complete history taking about her pregnancy, her medical condition Specially Diabetes, excessive  weight  gain during pregnancy  ,her BMI  and previous pelvic surgeries.

Her progress of labor is assisted from her chart by looking in her partogram,slow progress in first stage may point to a cause of non progress in the 2^ndstage .fetal ultrasound may be showing the weight of the baby, Chart also shows weight and height of the patient that may appoint CPD.

 General examination for, vitals, degree of satisfaction with her pain, urine output, and degree of hydration.

Abdominal Examination will assess the estimated fetal weight fetal lie, degree of flexion of the head and the degree of engagement of the fetal head by measuring the palpable fifth above the symphysis pubis.

When the head is not felt abdominally it means completely engaged

Vaginal examination after informing the patient will let me know the station of the presenting part , in relation to the Ischial spine , degree of moulding and caput formation excessive moulding with overriding of scalp bones  is an indication of cpd, pelvic capacity in relation to the baby size ,Also the position of dominator of the presenting part in relation to the symphysis pubis OA, OP, OT,Condition of the vagina dry or hot, assessment of the perineal muscles, the degree of the descent of the head with effective pushing.

Fetal tracing should be also looked after any non reassuring signs like bradycardia or prolonged deceleration should prompt fast delivery.

Patient is informed by the finding after complete assessment and examination. Options of intervention should be discussed with her; both instrumental delivery of cs and the risk and benefit of either of them will be explained to her in a clear way

B

Inducation of operative delivery in the theatre includes either Maternal cases which, include maternal disease like cardiac disease , hypertension not responding to medical treatment to shorten the second stage,  taught perineal muscles  and poor maternal effort towards pushing because of morbid obesity.

Fetal cases which may include fetal mal positioning OT or OP position of the head while engaged in the pelvis.

Non reassuring CTG with engaged head need fast delivery.

Causes that favor operative delivery in the theatre may includes  any of the above conditions that need short time to start CS if failed manuvoures where extra care for the mother is needed by expert anesthesia physician.

C

Choice of the instrument will be influenced by the cause of the instrumental delivery, the availability of the instrument, how familiar am I with the instrument my level of training, either forceps or ventose delivery, after informed consent from the patient. Where forceps was accompanied by high success rate of vaginal delivery than ventose, it is also accompanied by higher risk of vagineal, perineal tears and sphincter injury. While ventose is accompanied by excess maternal worries about her baby due to scalp hematoma, but less perineal injury. 

Full clinical assessment  of the patient includinga quick review of patients history to rule out any medical risk factors or fetal risk factors(maturity of the fetus,any suspicion of fetal growth restriction). Enquiry regarding the adequacy of the pain relief which in case inadequate can lead to maternal exhaustion.Maternal habitus noted,vital signs(pulse,B.P,temperature ) checked and documented which in the second stage will be done hourly except temperature which is recorded 4 hrly.Patients hydration status checked.On abdominal examination,size of the fetus assessed ,lie confirmed to be longitudnal and presentation to be cephalic.Palpable fifths of head is checked to find out the descent in the pelvic cavity..one fifth of the head or less is desirable.Frequency and strength othe uterine contractions noted ..,if found to be inadequate ,oxytocin augmentation can be considered.Intermittent f etal heart rate monitoring by pinnard stehtoscope or hand held doppler done for complete one minute after every 5 minutes in the second stage is recommended.If ther is any suspicion of fetal compromise,continuous fetal monitoring done....if found to be pathological i.e 2 or > nonreassuring features onCTG trace ...secondary tests of fetal wellbeing instituted ..fetal blood sampling to detect fetal acidosis.

On vaginal examination(carried out after taking consent from the patient) ensuring bladder is empty,cephalic presentation confirmed.Position of the head (occipitoanterior/occipitoposterior) by palpatin the anterior and posterior fontenelle dtermined Station of the head  in relation to ischial spines noted.Degree of moulding and caput formation looked for which can indicate cephalpelivic disproportion.All findings carefully documented in the clinical notes.Senior obstetrician informed about the assessment and possible need for vaginal delivery.Paedatrician informed  to be prepared with the necssary neonatal resuscitation facilities if the need arises.Anaesthetist should be called to assess the need to top up analgesia or to upgrade it to regionl anaestheis for operative vaginal delivery.

Patient informed  about the lack of continuing progress for 3 hours after full dilatation which can increase the maternal risk of exhastion and fetal risk to develop  lack of oxygen inside in case delivery is delayed to 4 hours and it will necessitate expediant delivery with the help of instrumentsFailure to achieve instrumental vaginal delivery could lead to caesarean section.Informed consent taken.

If there is a high risk of failure,i.e maternal BMI.30,clinically big baby.EFW.4kg ,midcavity delivery and occipitoposterior position. this should be as a trial in theatre so that in cse of failure time for caesarean section would be saved/

The choice of instrument will be according to the appropriateness of the clinical situation, my level of competence which should be  confirmed prior to independant deliveries as well as familiarity with the instrument.If the head is visible at the introitus without parting the labia and had reached the pelvic floor the outlet forceps would be appropriate.If the head is at+2 station low cavity forceps be indicated.Keilland s forcps carry additional risks and require specfic skills and training and will be carried out by a senior obstetrician with the expertise.Alternatives will be manual rotation followed by traction forceps or rotational vacuum extractor.Vacuum extractor is more likely to fail than forceps but more likely to have scalp trauma.Sequential instrument use is associated with more morbidity as compared to single instrument.

a.I would like to assess the power, passage and the passenger to determine the reason for prolonged second stage. The uterine contractions might be suboptimal or the mother maybe exhausted or dehydrated. The fetus might be macrosomic. There should be no contraindications to operative vaginal delivery such as fetal bleeding disorder or osteogenesis imperfecta. The pelvis might not be adequate resulting in cephalopelvic disproportion. Ensure CTG is reactive. On examination, she should be hemodynamically stable, not dehydrated. BMI is noted, if >30 would be prone for failure of instrumentation and high risk for PPH. Abdominal palpation to assess fetal size if suspected macrosomic. Fetal head should be less than 1/5 palpable. Bladder should not be palpable. On vaginal examination, the presence of gross vulval edema would indicate obstructed labour. The membranes should be absent, cervical os fully dilated, vertex presentation and able to make out the position. The station of presenting part to the level of ischial spines to assess if vaginal delivery is possible. Presence of moulding of grade 3 would suggest obstructed labour. Large caput would make vaccum an unlikely option if decide on operative vaginal delivery. The pelvis is assessed to be adequate and bladder is emptied using catheter under aseptic technique. After my assessment if the patient is suitable for an operative vaginal delivery, i would give the patient the option of  operative vaginal delivery or Caesarean section. For operative vaginal delivery, i would infrom the patient on the planned procedure, the complications such as failed procedure which would require an emergency Caesarean section, fetal scalp trauma, 3rd or 4th degree perineal tears, post partum haemorrhage. However, caesarean section at 2nd stage has higher morbidity due to extended tears which may result in hysterectomy, post partum haemorrhage, bladder, bowel injury, longer hospitalisation, wound infection, venous thromboembolism. If the assessment does not fulfill the prerequisites for operative vaginal delivery, then i would inform the patient that she requires an emergency caesarean section. I would then obtain her informed consent for the procedure opted.

b. The procedure would be under taken in OT if there is anticipated difficulty or high risk of failure and considered as a trial. These would be in cases where the patient has a BMI of >30 or clinically estimated macrosomic baby >4kg where the risk of shoulder dystocia is likely. In addition head of 1/5 palpable or occipito posterior position and anticipated difficult rotational or midcavity forceps.

c. If the fetus is preterm, less than 36 weeks gestation or face position then vaccum is contraindicated. Vaccum is more likely to fail if there is a large caput compared to forceps. If the fetus is in OP position, then an OP cup vaccum should be used. If any rotational maneuvre is needed for delivery a vaccum is more suitable as it would result in auto rotation compared to forceps which is prone to cause more maternal perineal and vaginal trauma. A silasctic cup has higher failure rate compared to metal cup but causes less scalp trauma. If mother is exhausted with poor effort then forceps would be more suitable to achieve vaginal delivery as it does not require much maternal effort.  

A healthy 32 year old primigravida has been in spontaneous labour with normal progress during the first stage. She is using epidural analgesia. You are asked to see her 3 hours after full dilatation because delivery is not imminent. (a) Discuss your assessment and counselling of this woman [12 marks]. (b) Following assessment, you conclude that vaginal operative delivery is appropriate. Discuss the indications for undertaking the delivery in the operating theatre [4 marks] (c) Which factors will influence your choice of instrument? [4 marks]

A review of history , including gestation, height weight , partogram to assess the labour progress and ultrasound findings like estimated fetal weight, location of the placenta should be undertaken. Knowledge of HIV status is important as forceps delivery is preffered over vaccum .

On examination her vital signs will be checked to assess her general condition, signs of exhaustion, dehydration and fetal heart sounds will be assessed. Assessment of pains their intensity and duration , presence oxytocin infusion will undertaken. On abdominal examination the estimated fetal weight, lie , presentation and position of the presenting part in terms of fifths palpable per abdominally will be performed. It should not be more than 1/5^th palpable if vaginal delivery is contemplated.

On vaginal examination the position of presenting part , caput , moulding , descent with pains , station in relation to ischial spines and degree of rotation of the head will be assessed eg transverse , occipitoanterior or oblique. As this will help in the decision making if the presenting part is high and there is high degree of moulding and caput formation then a caesarean section will be a better option. If the presenting part is low and degree of moulding and caput is also low than a choice of instrumental delivery should be considered.

The woman should be informed of the progress , assessment and the plan for delivery , if instrumental delivery is contemplated then the need for episiotomy, additional manouveres for shoulder dystocia , Need for caesarean section and additional procedure in case of  perineal tears 3^rd or 4^th degree, which are common require explanation. Neonatal risks of chignon, laceration, forceps mark, jaundice etc. need to be explained fully and keeping in view of her conscious level, and understanding. A verbal consent may be sufficient however written if permitted is better. The discussion needs to be documented. Place of delivery needs to be selected.

I t must be informed that the success of vaginal delivery is dependant upon the size of the baby, weight of the mother, degree of rotation and the skill of the operator.

B ) Fetal macrosomia or estimated fetal weight above 4000g is associated with higher failure rate of instrumental delivery in addition shoulder dystocia therefore operation theatre is recommended for such cases. If the maternal BMI is more than 30 Kg/m2 then the risk of caesarean section and failure of instrumental delivery is high. If the head of the fetus is high and abdominally 1/5^th palpable again risks failure, occiputo posterior position is also related to raised failure rate. All such deliveries should be conducted in the operation theatre.

c. Prematurity i.e gestation <34 weeks is an absolute contraindication for vaccum delivery , between 34-36 weeks caution needs to be excericised (Green top guideline) . In HIV positive mothers forceps are indicated if need be. Face presentation is a contraindication for vaccum delivery. Forceps for mento anterior position can be used. If rotational forceps are to be used than Kieland forceps can be used by highly skilled and trained operator and not a novice. Use of two instruments is discouraged and if need be than outlet forceps may be used after a vaccum application if delivery is imminent by experienced person.

Kiwi cups have a high failure rate , where as metal cups have low detachment rate and siliastic cups are safer for the maternal and fetal tissues.

1. A 32 yrs old primi with normal progress in first stage of labour with epidural, after 3hrs of full dilatation .Woman examined abdominally height of the uterus, head 1/5 or less palpable per abdomen, FHR,approximate weight of the baby whether big baby,.Examined vaginally assessed cervix fully dilated, membranes ruptured, the station of the head at plus 2 or more, any caput or moulding and position of the head(occipito anterior,transverse, posterior positions.)Pelvic adequacy reassessed.Irreducible moulding indicates cephalopelvic disproportion.Outlet delivery (scalp visible at perineum, fetal head below  plus2 reaching perineum, sagittal suture in anteroposterior direction or short of rotation <45 degrees),low forceps - fetal head at plus2 not reaching perineum, mid cavity-fetal head below the ischial spines, High forceps fetal head above the spines not advisable.

Mother explained the situation prolonged 2^nd stage of labour morbidity for mother and fetal is increased either verbal or if possible written consent taken inbetween contractions or after the procedure.Adequacy of analgesia, bladder catheterised.

Explained about operative vaginal delivery as to expedite the delivery to mimic vaginal delivery with minimal morbidity to mother and fetus.But it will be done in theatre so in case of failure immediate recourse to LSCS within 30 mts minimises the morbidity.Causes of failure are maternal BMI >30, baby weight >4000gms,mid cavity delivery head >2/5 palpable abdominally,occipito posterior position.

1. Indications for operative vaginal delivery

Fetal- probable fetal compromise

Maternal- medical conditions like cardiac disease class 111 or 1v,hypertensive crisis, myasthenia gravis,spinal cord injury patients to avoid autonomic dysreflexia, proliferative retinopathy.

Inadequate progress – nulliparous no descent of head after 3hrs (active and passive 2^nd stage of labour) with epidural, or 2hrs without anaesthesia

Multiparous no descent of head after 2hrs ( active and passive 2^nd stage of labour) with epidural, 1hr without epidural

Maternal fatigue/exhaustion

1. Choices of operative vaginal delivery

For both forceps and vacuum delivery operator must have the knowledge,experience and skills, trained.With vacuum failure rates are more and also cephalhematoma, subgaleal haemorrhage, retinal haemorrhage, but perineal trauma less, cs rates low, improved apgar scores,less phototherapy.

With silastic cups scalp injury is less but failure is more.With forceps perineal trauma is more.Sequential method also causes more morbidity.Inadequate evidence for episiotomy and antibiotic use.Pain relief with paracetamol and diclofenac.Incident report documented.Neonatologist informed.

a)First,i have to take aquick history from the woman and ask her if she has any urge to push to know wheather the second stage is active or passive.Then i have to review her clinical records as it may indicate the cause of delay.As to review the last ulrasound results regarding estimated fetal weight,as fetal macrosomia is an important cause for delay.I have also check if there is any abnormal finding mentioned in the ultrasound report either in the mother or fetus.I have also to review her progress during first stage of labour to determine wheather there was a dely or not ,as delay during the first stag may indicate the cause as fetal macrosomia or inadequate uterine contractions.Then i have to assess fetal heart rate to ensure that there is no fetal distress.Then i will perform abdominal examination to assess fetal size, lie, presentation and if there is any palpable fifth of the fetal head per abdomen.I have also to assess frequency,strength and the duration of uterine contrations during abdominal palpation to determine its adequacy.Vaginal examination should be offered to confirm the cervical dilatation,position and station of the presenting part and codition of the membranes if it is intact or ruptured.If membranes are rupture,i have to ask about the time of rupture.If membrane are intact,i will offer amniotomy.If the uterine contractios are inadequate,oxytocin infusion should be started if i felt that vaginal delivery is possible.Continous electronic fetal monitorin should be advised.If uterine contractions are adequate,instrumental delivery may be indicated if there is fetal compromise or prolonged active second stage of labour.If vaginal delivery is not possible,caesarean section is a safe option.

b)Indications for undertaking the delivery in the operating theatre,if there is any of the factors that are associated with high rate of failure of the operative vaginal delivery such as;maternal body masss index (BMI)>30,estimated fetal weight >4000gm or clinically big baby,occipito-posterior position and one fifth of the fetal head is papable per abdomen.So in case of failled trial of operative vaginal delivery,caesarean section can be performed immediately.

c) The choice of the instrument depends on the clinical circumstances ,as vaccum extraction is more likely to fail so forceps delivery is preferable with the condions associated with high failure rate such as occipito-posterior position.Also,forceps delivery is preferable if maternal effort is impossible  or contraindicated as in severe matenal exhausion or mternal medical diseases such as cardiac diseases or hypertensive crisis.Vaccum extraction is contraindicated before 34 weeks gestation.If the clinicl circumstance allow both instruments to be used,the choice of the instrument will depend upon my experience and skills in using both of them.

I would get history and review the notes to find out if there are any risk factors for failure to progress. It is essential to find out how often she is contracting and how long is it lasting. I would also find out about the duration of pushing and if she is oushing effectively. If she has already pushed for 2 hours then delivery should be planned immediately. But if she has pushed for 1 hour then depending on the assessment and if it is safe another 1 hour of pushing can be allowed.

I would check how she is feeling whether she is exhausted. If she is exhausted and if she is not able to push effectively she is more likely to need instrumental delivery.

I would also get hostory to find out if she suffers from any medical conditions like diabetes,, hypertension, cardiac disease or any infection. Diabetes mellitus is arisk factor for shoulder dystocia. Maternal infection like HIV is a contraindiaction for difficult instrumental delivery.

Check the CTG to assess fetal well being. Check maternal observations like temperature, pulse rate and blood pressure.

I would do abdominal examination to check fundal height and to assess how many fifths head is palpable per abdomen. This will  help to decide about the mode of delivery.

I would check the colour of liquor. Do vaginal examination to confirm the full dilatation, to assess the station, position and if there are any caput and moulding.

Depending on the examination findings if she needs an instrumental delivery in the room, I would explain to her about the risks and benefits of doing instrumental delivery and get verbal cosent from her. I would also explain about the risks to the fetus. If indicated episiotomy has to be done and sutured after delivery. Explain about the risk of perineal trauma..

If she needs trial of instrumental delivery in theatre, I would explain about the risks of instrumental delivery and caesarean section. I would also explain that caesarean section might be difficult and there is a 1:1000 chance of needing hysterectomy in case of life threatening situations.

b. Indications of delivery in theatre:

1. If the vertex is at spines and per abdomen examination revealed 1/5th head palpable.

2. Rotational delivery: If the vertex is at +1 or above and if there is >45 degree rotation needed then delivery should be done in theatre.

3. If there are any risk factors for shoulder dystocia like big baby and diabetes mellitus.

4. If there is minimal descent of head with pushing delivery should be done in theatre.

c. Factors which influence choice of instrument:

1. Operator skill and experience with the type of instrument

2. If there are lots of caput, soft cups are more likely to fail

3. Preterm delivery <34weeks is a contraindication for vacuum delivery

4. Maternal infection like HIV or maternal thrombocytopenia is a contraindication for vacuum delivery.

I will review her antenatal notes to gather information regading growth and size of baby.I will assess uterine contractions for frequency, strength and duration and gather information if she is on oxytocin drip.If she is not having efficient contractions , vaginal operative delivery may not be appropiate. I will look for any signs of maternal distress and maternal pushing efforts. I will assess hydration status -look for colour of urine if already catheterised / when did she lass pass urine and whether or not she is on Iv fluids and at what rate.I will make sure that epidural analgesia is working effectively as it eill help to determineI will do abdominal examination to assess lie, presentation and engagement of head. I will do vaginal examination and notice any vulval swelling, oedematous cervix, determine postion, station of head and any caput, moulding to rule out cephalic pelvic disproportion clinically though mostly it is retrospective diagnosis.I will assess descent of head with pushing.I will confirm with midwife if fetal heart is normal on auscultation or if she is on CTG - review trace to make sure that it is Normal.I will consider maternal wishes in decision making. I will explain pros and cons of vaginal operative delivery and caesarean section and depending on my findings explain the possibility of failed trail of instrumental delivery and proceeding to caesarean section.

Indications for operative delivery in theatre will be high head at spines and any malposition which may need rotational delivery. This might be difficult delivery and may need caesarean section if failed.

Maternal wishes may influence choice of instrument if she declines use of any particular instrument. The position and station of head like OA can be delivered with both nevelle barnes forceps and ventouse but high head is more likely to be successful with forceps. Similarly if rotational delivery is needed either rotational ventouse or manual rotation then application of forceps may need to be done. Expertise of the opearting doctor can also influence the choice of instrument.

Assessment should start with reviewing of the notes to identify risk factors such as high BMI, fetal macrosomia by checking recent ultrasound reports if any and confirming gestational age of fetus. Check blood group and ensure no atypical bodies are found. If any atypical antibodies found, better to inform laboratory well in advance and request blood for cross matching as she is at risk of PPH. Assessment of fetal well being is done by reviewing CTG. Enquire if the woman has started pushing and for how long? Uterine activity can be assessed by palpating the contractions and reviewing CTG. It should be explained to her that prolonged second stage poses risk to her in terms of PPH, need for operative delivery and increased risk of vaginal trauma. It should be explained that fetus might start showing signs of stress and might not cope with prolonged labour; hence assessment is required to make plans for delivery. She should be explained the possible need for transferring to theatre and risk of PPH necessitating blood transfusion. After counselling abdominal examination be done to check presenting part, lie and assess fetal size. Bladder should be catheterized as full bladder can prevent the decent of head. Patient should be put in lithotomy position. Vaginal examination is done to confirm full dilatation, position and station of presenting part. Assess for moulding and caput and any meconium in liquor. Assess decent of head with contractions and pushing as this will give an idea whether vaginal delivery is possible or not. Patient should be explained and consent obtained for operative delivery either in room or operating theatre depending on assessment.

2) Poor maternal effort, high presenting part, malposition, presence of large caput and significant moulding, fetal macrosomia, CTG abnormalities and increased risk of caesarean section are all pre-requisites for delivery in theater.

3) Choice of instrument depends on factors such as malposition and station of head, presence of caput and moulding and maternal effort. If evidence of poor maternal effort and there is presence of moulding and caput, forceps would be ideal instrument. In case of malposition, ventouse cup should be used to do rotational delivery or in experienced hands keillands forceps can be used. 

a) Sympathetic  & supportive attitude towards laboring woman. I will ask her about effectiveness of  epidural analgesia & would she require top up. I will ask her if she feels anxious, distressed or dehydrated to see maternal exhaustion . I will ask her if she has bearing down sensation & since how long to see active stage of second stage labour.. I will go through her antenatal records to see if suspected macrosomia or any factor which obstructs progress of labour e.g. fibroid or ovarian mass. I will go through her partogram to reconfirm her normal progress & see the descent of presenting part. I will examine her & take her BMI(from records) as high BMI above 30 is associated with dysfunctional labour. & operative delivery. I will take her pulse, B.P, Temperature to see her general conditions. I will see her coindition of skin, mucus membranes & eyes for dehydration as this may lead to exhaustion & delay in progress. Per abdominal examination to see symphsiofundal height  to see macrosomia, I will ascertain presentation, position of the fetus. I will see for engagement of head perabdominally by palpating fetal head. If more than 1/5 palpable vaginal delivery would not be possible & may be risky.I will auscultate for fetal heart rate . I will do per vaginal examination to see if me,mbranes are still intact. I wilI seeif meconeum staining liquor. will palpate for sutures to see for moulding  to  ascertain its grades. I will see for the position like occipito posterior or occipitotransverse. I will assess pelvis to see any obvious fetopelvic disproportion.

                           Will counsel her in sympathetic manner . I will tell her about her progress in second stage labour. I will also tell her that second stage delay can be associated with epidural. I will tell her if spontaneous is not imminent she would require delivery by instruments like forceps or ventouse. I will offer membrane rupture of membranes if membranes still intact.

b)         Indications of operative delivery in operating theatre would be occipito posterior or occipito transverse where chance of failure are more . In cases where manual or instrumental rotation is required it is better to carry out operative vaginal delivery in theatre to avoid delay in transfer after failed instrument. If fetal compromise is suspected then to undertake instrumental deliver in theatre as failure of instrumental delivery can be immediately followed by grade I caesarean section.

c)   The choice of instrument depend upon clinical circumstances & also on operator’s expertise & preferences. If maternal exhaustion is there vacuum application may not be successful as maternal bearing down efforts are poor. Maternal wishes & fears for the particular instrument should be taken into account. If presenting part high with expert operator midcavity forceps delivery can be undertaken.

1. I start with abdominal palpation to assess the size of the baby clinically, the position and the presenting part should be cephalic and its relation to pelvis like 0/5 or 1/5 palpable per abdomen.  I will also feel for contractions, the frequency, the strength and how long it would last and prefer at least 3-4 contractions in 10minutes, strong on palpation and lasts 40-60seconds to be efficient. On vaginal examination, I would look for presenting part as cephalic, and its relation to spine whether above or below spine, whether there is any caput and moulding and the position such as occipital-anterior, occipital-posterior or occipital-transverse.  During my examination, I would also encourage the mother to push with contraction to assess the descent.  I simultaneously, review the CTG in view of any concern with fetal heart beats – making sure it is normal.  If it is suspicious or pathological, it requires appropriate intervention.  I start with reviewing her antenatal notes for her booking BMI and whether she had any GTT in the antenatal period, and any growth scan before, to  try to establish whether it could be big baby.   I review the the scan report in view of placental location.  I would also like to review the labour records and partogram to assess the progress.  I would like to assess the patient for adequate hydration and when she had passed urine last and whether it is clear or blood stained or concentrated.  Based on my assessment, I would decide either to perofrm instrumental delivery or Emergency Caesarean section.  Also, if it is appropriate for instrumental delivery, I would decide whether it could be performed in the labour room or in the theatre based on my findings.  I would explain to the patient, my assessment findings and the plan for delivery including the mode and place of delivery and do the written consent.  I will make sure the paediatrician to be present at the time of delivery.
2. The instrument delivery should take in the theatre if the maternal BMI is more than 30, the size of the baby if clinically feels large or from scan the estimated fetal weight more than 4kg or if the presenting part abdominally 1/5^th in relation to pelvis or  it would be midcavity instrumental delivery based on vaginal findings including the need for rotation upto 45degree to more than 45degree (ie) left or right occipital anterior or occipital transverse.
3. The choice of instrument depends on the clinical situation – like if rotation is required, I would go for vaccum cup to facilitate rotation and descent.  If there is no need for rotation, but the delay in delivery was due to poor maternal effort, I would go for forceps delivery.  It depends on the findings from my abdominal and pelvic examination and also based on my confidence.

A) I’ll review her partogram and note the rate of progress of labour in 1^st stage. I’ll note the progress in 2nd stage,duration of active pushing  and use of syntocinon and assess the maternal condition by noting her pulse and blood pressure and state of hydration. I’ll inquire from her the   effectiveness of analgesia. I’ll assess fetal condition by cardiotocogram. I’ll examine the mother by palpating her abdomen and assessing the fetal size and engagement of fetal head. I’ll perform vaginal examination and note the position and station of fetal head and note any caput or molding as these are signs of obstruction. I’ll discuss with the mother the mode of delivery according to clinical situation and inform her about the details of the procedure , the risks  and benefits of the procedure and serious and frequently occurring risks related to that procedure and alternative procedure and expectant management. If maternal and fetal condition is satisfactory and there is ongoing progress of labour without any signs of obstruction I’ll counsel her for spontaneous vaginal delivery as a safe method of delivery. If there are signs of obstruction or malpresentation such as brow presentation or deflexed head I’ll counsel her for abdominal delivery as safe method for her and for the baby as compared to expectant or operative vaginal delivery. In case there is fetal compromise and there is relative CPD or delivery is not feasible by forceps or ventouse due to head higher than ischial spines I’ll counsel her for abdominal delivery. In case the head is well engaged as assessed by abdominal and pelvic examination that is lower than ischial spines and fetal condition is satisfactory but mother is exhausted I’ll counsel her for operative vaginal delivery or if there is fetal compromise with well engaged head I’ll counsel her for operative vaginal delivery as a safe method of delivery at this stage as compared to emergency cesarean section. In case of malrotation such as persistent occipitoposterior position or deep transverse arrest I’ll counsel her for rotational operative vaginal delivery. The decision of mode of delivery should be based upon maternal wishes after explaining her clearly about the clinical situation and best method of delivery and alternatives.

(B) If there is need of rotational delivery I’ll prefer to deliver her in operation theater because it is associated with high risk of failure. Relative CPD or fetal macrosomia , that is fetal weight more than 4 kg, is also associated with high risk of failure or fetal and maternal morbidity therefore I’ll prefer to deliver her in operating theater. Need of delivery  with high head that is at the level of ischial spines requiring midcavity forceps or ventouse should also be delivered in operating theater. Maternal obesity,that is BMI more than 30 is also associated with high risk of failure, therefore  if the mother is obese it is more safe to deliver her in operation theater.

(C) My choice of instrument is the one in which I am well trained as it is associated with high chance of success and low risk of maternal and fetal morbidity. The instrument should suit the gestational age and fetal presentation also. For the fetus with face presentation or at the gestational age less than 34 weeks forceps should be used. For midcavity rotational forceps delivery the instrument of choice is keilland forceps if the appropriate expertise is available and for non rotational midcavity forceps delivery Neville barn forceps should be used.Ventouse can also be use for rotation,other option is to rotate the head manually and deliver by ventouse or nonrotational forceps.  The mothers choice need to be taken into account after explaining her risks and benefits of both methods and explaining her the expertise available and backup facilities.                            

hi please , explain the technique  better and please the answer keys because i seem to be loosing on each one of your questions

hi please , explain the technique  better and please the answer keys because i seem to be loosing on each one of your questions

A)  A brief history from the attending midwife and assessment of the partogram would inform me how long the patient had been in active second stage. Furthermore details from the antenatal history may indicate risk factors for obstructed labour; eg macrosomia secondary to diabetes and increased BMI.

An abdominal examination would reveal how many fifths of fetal head were palpable, an instrumental delivery would be contraindicated if more than a fifth was palpated. SFH measurement > 40cm may indicate macrosomia which could be why she has a delayed second stage. A palpable bladder may be felt as she has an epidural therefore she would loose sensation to pass urine. A catheter could be inserted as retention can obstruct labour and it would be needed if an instrumental delivery or C/S were needed.

Assessment of the CTG trace would provide information on fetal well being, if the trace was suboptimal delivery would have to be expedited either by OVD or C/S. Contraction frequency would be shown on the toco, the midwife would have assessed the strength of these. If contractions were poor and there were no signs of obstructed labour syntocinon could be considered.

During vaginal examination it would be important to assess for signs of obstructed labour including vulval oedema, caput and moulding. The position of fetal head could indicate the reason for delay; eg OP or assynclitism. Where the head is in relation to the ischial spines would help determine if delivery was imminent and if the baby was deliverable in the room.

When counselling the patient it would be important to remember that she may be tired and frustrated. If the CTG was normal I would reassure her that her baby was fine, however our current recommendations advise patients that this part of labour shouldn’t last more than 3 hours. Options for delivery would be given to the patient and her partner and her wishes respected.

 B) The decision to deliver with an instrument in the operating theatre would be because there may be a risk that the baby would not come vaginally in which case a caesarean section would need to be performed. Fetal factors influencing this decision include a high head (spines to +1), malposition of head (OP/ assyclitism) and caput and moulding indicating obstructed labour. Maternal factors include large maternal BMI and poor maternal effort. The decision to go to theatre for a “trial” needs to be discussed with the consultant on call, if the instrumental delivery is not successful it is likely to result in a difficult caesarean section.

 c) Choice of instrument is dependant on the users experience however in certain situations one instrument may be more appropriate than another. If significant caput or moulding was present forceps or a salistic ventouse cup could be used as they are more likely to be successful. If the baby was in an OA position a ventouse or forceps could be used however forceps would be a bester choice if there was poor maternal effort. Forceps however are associated with more maternal trauma compared with ventouse however the latter is more traumatic for the fetus therefore contraindicated in prematurity or if any potential bleeding disorders (haemophilia) If rotation was required this can be tried manually to OA and then either venouse or forceps can be used. If this is not successful a rotational ventouse cup can be used or kleillands forceps however extra training and expertise are needed in order to use the latter. Care should be taken to select the most appropriate instrument initially as sequential use of instruments is associated with greater morbidity to both the mother and fetus.

a) The lady should be assessed & counselled in a sensitive & encouraging manner. The adequacy of her analgesia is assessed & top-up given, if required.

Her case notes and partogram are reviewed. The gestation of fetus should be confirmed and fetal well being assessed by CTG. If CTG indicates fetal compromise, either FBS or immediate delivery is indicated and mother should be counselled accordingly.  Maternal well being is assessed by noting hourly BP, pulse and 4hrly temperature record, hydration & coping strategies. Frequency of emptying her bladder is also noted. History of rupture of membranes should be asked & date & time noted. Palpation of maternal abdomen will help in rough estimation of fetal size, lie, the fifth of head palpable & adequacy of uterine contractions, if any. Frequency of contractions are obtained from the partogram. A vaginal examination will confirm full dilatation of cervix, presence or absence of membranes, position and station of the presenting part. Presence of excess caput or moulding may suggest some disproportion. Any vaginal loss- clear, blood stained, meconium stained is noted.

The mother asked about her preferences for delivery. She & her birthing partner should be explained about the findings and options of delivery- operative vaginal delivery or caesarean section. The advantages and disadvantages of both are discussed before obtaining consent. If she opts for operative vaginal delivery, advantages and disadvantages of forceps and ventouse are discussed. Ventouse will cause less perineal trauma but more likely to fail in achieving vaginal delivery & more likely to cause cephalhematoma & retinal haemorrhage in the neonate. She should be informed that Caesarean section in second stage of labour can lead to increased risk of bleeding, prolonged hospital stay and admission of the neonate to SCBU. In presence of fetal compromise, counselling and action should go simultaneously to achieve quick delivery.

b) Operative vaginal deliveries which are anticipated to have high failure rates are undertaken in the operation theatre as immediate caesarean section can be done, if required. Failure rates are higher when maternal BMI is more than 30. When head is 1/5^thpalpable per abdomen, the biparietal diameter is still above ischial spines and hence vaginal delivery difficult. A big baby & occipito posterior position is also associated with higher failure rates, and hence should be delivered in operation theatre.

c) The choice of instrument depends on the expertise of operator and clinical situation.

Ventouse is contraindicated in face presentation.

Station & position of presenting parts influence choice of instruments. Outlet deliveries are performed with Wrigley’s forceps. Occipito lateral or occipito posterior positions requiring rotation are delivered using Keilland’s forceps or rotational ventouse. If maternal expulsive efforts are inadequate, forceps may be a better option than vacuum extraction. 

Dear paul,

                Hi, please mark my answer as well.It will be kind of you.

Dear paul,

                 Hi, I posted my answer on 26th july,I think it is missed from marking.Please mark it.