Operative vaginal delivery is an essential part of obstetric practice. However, there has been a trend of escalatingmedico-legal cases related to operative vaginal delivery due to an increasing a wareness of the potential morbidity for both the mother and the baby.
a) Outline the measures that could help to reduce the need for operative vaginal delivery. (20 marks)
- Continuous support during labour
- Inform women that epidural analgesia provides good pain relief, but it may increase the need for OVD
- If not on epidural analgesia, adopt upright or lateral positions in the 2 nd stage.
- If on epidural analgesia, lying down lateral positions is preferable to upright positions in the 2nd stage.
All prerequisites for operative vaginal delivery should be met.
i. ≤ 1/5th of the head is palpable abdominally and Station ≥ 0 vaginally.
ii. Cervix is fully dilated
iii. Membranes absent.
iv. Exact position of the fetal head should be known for correct placement of the instrument.
v. Caput and moulding should be no more than moderate (or +2).
vi. Pelvis should clinically be adequate.
vii. Analgesia should be appropriate and effective
viii. Maternal bladder should be empty or remove Indwelling catheter or deflate balloon
ix. Aseptic technique ( 18 marks)
b) What steps would you adopt to avoid adverse fetal and maternal outcomes due to operative vaginal delivery? (40 marks)
- All prerequisites for operative vaginal delivery should be met.
i. ≤ 1/5th of the head is palpable abdominally and Station ≥ 0 vaginally.
ii. Cervix is fully dilated
iii. Membranes absent.
iv. Exact position of the fetal head should be known for correct placement of the instrument.
v. Caput and moulding should be no more than moderate (or +2).
vi. Pelvis should clinically be adequate.
vii. Analgesia should be appropriate and effective
viii. Maternal bladder should be empty or remove Indwelling catheter or deflate balloon
ix. Aseptic technique ( 18 marks) - Preparation of mother
i. Appropriate to the clinical situation obtain an informed consent detailing all possible
neonatal and maternal risks and document it in BHT
ii. Trust established and full cooperation sought and agreed with woman
( 4 marks) - Preparation of staff
i. Operator should have the knowledge, experience and skill necessary
ii. Anticipation of complications e.g., shoulder dystocia, perineal trauma, PPH
iii. Personnel present who are trained in neonatal resuscitation
iv. A senior obstetrician should be present if an inexperienced trainee is conducting the birth
( 8 marks) - Place of delivery and others
i. Adequate facilities are available (equipment, bed, lighting) and access to an OT
ii. Perform a trial of operative delivery in OT due to increased likelihood of failure.
iii. The choice of instrument according to the clinical situation and the operator’s experience.
iv. The decision to use sequential instruments needs senior input and clear documentation.
v. Paired cord gases should be taken.
vi. An operative delivery proforma should be completed immediately after delivery.
( 10 marks for any 5)
c) Discuss how you could reduce the risks of litigation related to operative vaginal delivery in your institution without jeopardizing the standard obstetric care. (40 marks)
- Failures to provide adequate explanation and consent are major contributors to litigation
I. May not be practicable in an emergency. So antenatal counselling about OVD
II. Counsel about all possible complications and why it can be safer than a 2 nd stage Em/LSCS
III. Consent should ideally be provided in written form ( 12 marks) - Inexperienced operator and allegations of excessive traction or multiple pulls are other reasons for litigation
I. Trainees should be supervised until they become competent
II. Practical training using simulators and mannequins with the help of computer-assisted visual feedback can be useful to enhance training and enables trainees to learn how to achieve the appropriate force
III. Regular labour ward skills and drills in instrumental delivery are needed to maintain these
skills. ( 12 marks) - Use of sequential instruments is another reason
I. Appropriate case selection with careful decision making by a senior is of paramount
importance.
II. Informed consent and completing an operative delivery proforma immediately after delivery ( 4 marks) - Fetal trauma, maternal trauma, evidence of a significant birth asphyxia following the delivery
I. Adopting the steps in b)
II. Careful fetal monitoring
III. The patient should be briefed of labour circumstances and of any morbidity and its implication on the short and long term.
IV. Postnatal follow-up should also be organized. ( 2 marks) - When morbidity arises from instrumental delivery, expedite Risk management process and implement actions arising from the report and monitor progress ( 6 marks)
- Regular review of cases of failed instrumental delivery and medico-legal cases is very useful to increase the awareness of all staff. ( 4 marks
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