Vakum & Forseps

7/25/2019 Vakum & Forseps

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Malang,14Maret 1967

Staf Fetomaternal,Departemen Obstetri &GinekologiFKUI/RSUPNCipto Manukusumo

Pelatih Basic

FasilitatorAdvanced

Labour And

Pelatih/Advanved Trainer

Jaringan Pelatih

AnggotaPOKJAHIV/AIDS&

Pelatih

PesertaInternational

Course

SurgicalSkillPOGI,tahun

2004

RiskManagemen

t(ALARM)

as onaPelatihan

Klinik

Kesehatan

esus asNeonatusPerinasia,

tahun 2004

PMTCTKementerian

Kesehatan

exuaReproductiveHealthand

Right,. ,

2005sekarang

Reproduksi,tahun 2005

sekarang.

sekarang.Indonesia,

tahun 2007sekarang.

Swedia,Pebruari

2009


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dr. Yudianto Budi Saroyo, SpOG

Divisi Fetomaternal

Departemen Obstetri & GinekologiRSUPN dr. Cipto Mangunkusumo/

Fakultas Kedokteran Universitas Indonesia


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Goal 4: Reduce child mortality

Target 4a: Reduce by two thirds the mortality rate among children

un er ve

Goal 5: Improve maternal health

Target 5b: Achieve, by 2015, universal access to reproductive health

Goal 6: Combat HIV/AIDS, malaria and other diseases

Target 6a: Halt and begin to reverse the spread of HIV/AIDS

Target 6b: Achieve, by 2010, universal access to treatment forHIV/AIDS for all those who need it

other major diseases


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Force s & Vacuum E ui mentForce s & Vacuum E ui ment

Pitkin J, Peattie AB, Magowan BA. Operative delivery. In: Pitkin J, Peattie AB, Magowan BA, editors. Obstetrics and

Gynecology- An Illustrated Colour Text. Edinburgh: Elsevier Science; 2003. p. 54-7.


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Syarat

Anatomi

Klasifikasi

e o e ap as an ra s

Dokumentasi


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Syarat

Anatomi

Klasifikasi

e o e ap as an ra s

Dokumentasi


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IndikasiIndikasi Mempercepat Kala Dua

Kala Dua Memanjang

Kasus Khusus :

Ibu lelahIndikasi hipertensi dalam kehamilan, PEB,penyakit jantung, bekas SC

Per alanan Kala Dua tidak

a erna

memuaskan

Gawat janin

Malposisi

Asinklitismus

Vakum saat SCJanin

e a r an an n e ua pa a geme


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Indications for VacuumIndications for Vacuum--

Assisted Vaginal DeliveryAssisted Vaginal Delivery

Prolonged second stage of

labor

In nulliparous women, this is defined as lack of

progress for 3 hours with regional anesthesia or 2ours w ou anes es a.

In multiparous women, it refers to lack of

progress for 2 hours with regional anesthesia or 1

hour without anesthesia.

Nonreassuring fetal testing Suspicion of immediate or potential fetalcompromise (nonreassuring fetal heart rate

pattern, abruption) is an indication for operative

vag na e very w en an expe ous e very can

be readily accomplished.

Elective shortening of the

second sta e of labor

Vacuum can be used to electively shorten the

second sta e of labor if ushin is contraindicated

because of maternal cardiovascular or neurologic

disease.

Maternal exhaustion Largely subjective and not well defined.


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Contraindications for VacuumContraindications for Vacuum--

Absolute Contraindications

Underlying fetal disorder

Fetal bleeding disorders (eg, hemophilia, alloimmune thrombocytopenia)

Fetal demineralizing diseases (eg, osteogenesis imperfecta)

Failure to fulfill all the requirements for operative vaginal delivery

Incomplete dilatation of the cervix

Intact fetal membranes

Unen a ed vertex

Abnormalities of labor Fetal malpresentation (eg, breech, transverse lie, brow, face)

Suspected cephalopelvic disproportion

st mate gestat ona age < wee s or est mate eta we g t < g

Failure to obtain informed consent from the patient

Relative Contraindications Suspected fetal macrosomia (defined as an estimated fetal weight of > 4500 g)

Uncertainty about fetal position

Inadequate anesthesia

Prior scalp sampling or multiple attempts at fetal scalp electrode placement


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KondisiKondisi yang memyang memprediksiprediksi

kesulitan atau kegagalankesulitan atau kegagalan tindakantindakan

Perabaan abdomen :Kepala teraba1/5

ag an presen as se ngg sp na s a a.

Posisi occi ito- osterior.

Molase kepala yang luas dan tebal.

an n esar.

Perjalanan persalinan yang lambat. IMT >30.

Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-

55.


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Syarat

Anatomi

Klasifikasi

e o e ap as an ra s

Dokumentasi


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Prerequisites for Forceps orPrerequisites for Forceps or

Engaged fetal vertex

Ruptured membranes

Fully dilated cervix

Assessment of maternal pelvis reveals adequacyfor the estimated fetal wei ht

Adequate maternal analgesia is available Bladder drained

Knowledgeable operator

Willingness to abandon the procedure, if

Informed consent has been obtained

Necessar su ort ersonnel and e ui ment

are present


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Prerequisites for operativePrerequisites for operative

Preparation Essential

Full abdominal

and vaginal

examination

Head is 1/5 palpable per abdomen

Vertex presentation

Cervix is fully dilated and the membranes ruptured

Exact position of the head can be determined so proper placement of

t e nstrument can e ac eve

Pelvis is deemed adequate

Mother Informed consent must be obtained and clear explanation given

Appropriate analgesia is in place, for mid-cavity rotational deliveries this

will usually be a regional block

A pudendal block may be appropriate, particularly in the context ofurgent delivery

Maternal bladder has been emptied recently

Indwell ng catheter should be removed or balloon de lated

Aseptic techniques

Staff Operator must have the knowledge, experience and skills necessary to

use the instruments Adequate facilities and back-up personnel are available

Back-up plan in place in case of failure to deliver

Anticipation of complications that may arise (e.g. shoulder dystocia,

postpartum haemorrhage)

Personnel present who are trained in neonatal resuscitation

SOGC, 2004 & RANZOG 2002


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Prerequisites for OperativePrerequisites for Operative

Maternal Criteria Fetal Criteria Uteroplacental

Criteria

Other Criteria

Adequate analgesia

Patient in the

lithotomy position

Vertex presentation

The fetal head must

be engaged in the

Cervix fully dilated

Membranes ruptured

No placenta previa

An experienced

operator who is fully

acquainted with the

Clinical pelvimetry

must be adequate in

dimension and size

the fetal head must

be known with

certainty The station

instrument

Ability to monitor

fetal well-being

to facilitate an atrau-

matic delivery

Verbal or written

of the fetal head

must be 0/+ 5

The estimated fetal

continuously

The capability to

perform an

documented (ideally

2500-4500 g)

The attitude of the

delivery if required

fetal head and the

presence of caput

succedaneum and/or

-

noted

Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics & Gynecology. 2009;2(1):1-16


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Syarat

Anatomi

Klasifikasi

e o e ap as an ra s

Dokumentasi


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PAP : Promontorium tak teraba CV > panjang jari

pemeriksa -1,5. Bila teraba harus disebutkan ukuran

Linea inominata : semakin sedikit teraba semakin luas


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Diameters of the MaternalDiameters of the Maternal

PelvisPelviseg on o e e v s easuremen en me ers

Brim (Inlet)

AP 11.5

Transverse 13.0

Midpelvis

AP 12.0Transverse 10.5

ut et

AP 12.5

.

AP, anteroposterior.

Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics andGynecology: Lippincott Williams & Wilkins; 2008.


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Pintu tengah panggul :

in ing samping se ai nya urus

Spina tajam agar sebagai tempatpu aran pa s a am poros

defleksi kepala

konkaf


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PBP :

Arcus Pubis > 900

Intertuberositas > 8 cm


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StationStation


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The pure types of maternal pelves andThe pure types of maternal pelves and

the conver ence and diver ence of theirthe conver ence and diver ence of their

sidewalls.sidewalls.

Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and

Gynecology: Lippincott Williams & Wilkins; 2008.


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ntero-poster or o r m

(Obstetric conjugate) 12 cmTransverse of brim 13 cm

Ischial bispinous 10,5 cm

Antero-posterior of outlet 10,5 cmSub-pubic angle 850

de Jong P. Vacuum Delivery Procedures. 3rd ed. Gothenburg: Cascade Publications; 2007


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Bony anatomy, sutures, andBony anatomy, sutures, and

skullskull




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Diameters of the fetal head.Diameters of the fetal head.




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Diameter

(Centimeters)

Suboccipital-Bregmatic 9.5

Submental-Bregmatic

Below chin to center of bregma9.5

-

Point of chin to above posterior fontanelle

14.0

Basal-Vertical

Base of skull to most distant oint of vertex9.0

Occipital-Frontal

Root of nose to occipital protuberance11.5

Bi arietalBetween the two parietal eminences

.

Bitemporal

Greatest distance between two halves of coronal suture8.5




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Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Fetal Growth and Development: The McGraw-Hill

Companies; 2010. Available from: www.accessmedicine.com.

Ci f f F l H dCi f f F l H d


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Circumferences of Fetal HeadCircumferences of Fetal Head

Circumferenceeasuremen

(Centimeters)

- Well-flexed vertex

Occipital-Frontal Biparietal 33.0

Deflexed vertex, OP positionMentum-Vertical Biparietal 35.5

row presen a on

OP, occiput posterior.




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Metoda Stewart untuk menentukanMetoda Stewart untuk menentukan



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Syarat

Anatomi

Klasifikasi

e o e ap as an ra s

Dokumentasi

T f P d d Cl ifi ti fVT f P d d Cl ifi ti fV


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Type of Procedure and Classification of Vacuum orType of Procedure and Classification of Vacuum or

Force s Deliver accordin to Station and RotationForce s Deliver accordin to Station and Rotation

Outlet forceps/Vacuum

Scalp is visible at the introitus without separating the labia.

e a s u as reac e e pe v c oor.

Sagittal suture is in the AP diameter or right or left OA or OP position.

Fetal head is out or on the perineum.

Rotation does not exceed 450

Low forceps/Vacuum

Leading point of fetal skull is at station +2 cm and not on the pelvic floor.0

Rotation is >450

.Midforceps/Vacuum

a on s cm pa pa e u e a ea s engage .

Rotation is 450

Rotation is >450

Not included in classification

AP, anteroposterior; OP, occiput posterior. Adapted from American College of Obstetricians and Gynecologists.

Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and Gynecology: LippincottWilliams & Wilkins; 2008.

Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55

. . , .


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Syarat

Anatomi

Klasifikasi

e o e ap as an ra s - a um

Dokumentasi


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..

The original vacuum extractor developed in the 1950s by the Swedish obstetrician Dr. Tage


, , ,

device.


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Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Forceps Delivery and Vacuum Extraction: The McGraw-Hill Companies; 2010.

Available from: www.accessmedicine.com.


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Desain Man kuk Vakum.Desain Man kuk Vakum.

A: Tipe umum berbentuk lonceng dengan pompa tangan. B: Versi sekali pakai

terbuat dari plastik (versi Bird) dengan perangkat pompa tangan sekaligus penarik.


: ang u r . : pe se a pa a er en u amur.


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en s u ama perang a

vakum genggam sekali pakai

ini : (A) mangkuk yang lembutyang entur an er entulonceng. (B) mangkuk kaku,yang kokoh dan berbentukseperti jamur mang u .Alat tersebut dapat terbuatdari plastik, polietilen atausilikon. Batang bebas berputarperangkat genggam ini

mencegah torsi (rotasi) darimangkuk dan cederasayat/lecet ke kulit kepalaanin.


Dua perangkat vakum kiwiDua perangkat vakum kiwi--pompapompa


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Dua perangkat vakum kiwiDua perangkat vakum kiwi--pompapompa

en am dan eran kat en ukuren am dan eran kat en ukur

tekanantekanan..

Berbeda dengan mangkuk dalam B, batang pada mangkuk di A, OmniCup bersifat

fleksibel dan dapat diletakkan mendatar terhadap mangkuk.(From Vacca A:

an oo o acuum e very n s e r c rac ce. on, us ra a, acca

Research Pty. Ltd., 2003.)Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia: Churchill Livingstone Elsevier; 2007.


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PenempatanPenempatan Mangkuk VakumMangkuk Vakum

Correct placement of the suction cup on the fetal scalp is shown. The suction cupshould be placed symmetrically astride the sagittal suture at the median flexion point


a so nown as t e pivot point , w ic is cm anterior to t e posterior ontane e or

cm posterior to the anterior fontanelle.


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Pemasangan di atas sutura

-

kecil

Penempatan terhadap KepalaPenempatan terhadap Kepala


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Penempatan terhadap KepalaPenempatan terhadap Kepala


ALARM (VACUUM MNEMONIC)ALARM (VACUUM MNEMONIC)


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ALARM (VACUUM MNEMONIC)ALARM (VACUUM MNEMONIC)A ANAESTHESIA

ASSISTANCE

Adequate pain relief

Neonatal support

B BLADDER Bladder empty

u y a e , mem ranes rup ure

D DETERMINE Position, station and pelvic adequacy

Think possible shoulder dystocia

E E UIPMENT Ins ect vacuum cu um tubin and check ressure

F FONTANELLE Position the cup over the posterior fontanelle

Sweep finger around cup to clear maternal tissue

G GENTLE 100 mmHg initially and between contractions

pu w t contract ons on y as contract on eg ns:

o increase pressure to 600 mmHgo prompt mother for good expulsive effort

o traction in axis of birth canal

H HALT (Rule of 3s) no progress with three traction aided contractions

vacum pops-off three times

no significant progress after 30 minutes of assisted vaginal

e very

I INCISION Consider episiotomy if laceration imminent

J JAW Remove vacuum when jaw is reachable or delivery assured

Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-

55.

Penempatan MangkukPenempatan Mangkuk


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Penempatan MangkukPenempatan Mangkuk

Placement of the OmniCup with flexible stem at the point of flexion of a fetal head in the

occiput posterior position, which is otherwise difficult to accomplish with the traditional

. . ,

Australia, Vacca Research Pty, Ltd., 2003.)

Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia: Churchill Livingstone Elsevier; 2007.


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The three other abnormal positions are much less likely to lead to a successful vaginal delivery

and are more associated with fetal trauma.

Pitkin J, Peattie AB, Magowan BA. Operative delivery. In: Pitkin J, Peattie AB, Magowan BA, editors. Obstetrics and

Gynecology- An Illustrated Colour Text. Edinburgh: Elsevier Science; 2003. p. 54-7.

P t M k k & P i iP t M k k & P i i


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Penempatan Mangkuk & PosisiPenempatan Mangkuk & Posisi

Jari OperatorJari Operator

Pitkin J, Peattie AB, Magowan BA. Operative delivery. In: Pitkin J, Peattie AB, Magowan BA, editors. Obstetrics andGynecology- An Illustrated Colour Text. Edinburgh: Elsevier Science; 2003. p. 54-7.

Vacuum extraction with JVacuum extraction with J--shapedshaped


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pp

direction of traction similar to force sdirection of traction similar to force s

delivery.delivery.


Berbagai Tipe Vakum dengan MangkukBerbagai Tipe Vakum dengan Mangkuk


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dan ukurann adan ukurann aPerangkat Ukuran Bahan Material

Soft Cups

, ,

Kiwi ProCup (Clinical Innovations, Murray, UT) 65 mm Soft plastic

Mityvac MitySoft Bell (Cooper-Surgical, Trumball,

CT)60 mm Soft silicone

Secure Cup (Utah Medical, Midvale, UT) 63 mm Rubber

Silc Cup 50-60 mm Silicone rubber

Soft Touch (Utah Medical) 60 mm Soft polyethylene

en er ouc a e ca mm o s cone

Vac-U-Nate (Utah Medical) 65 mm Soft siliconeRigid Anterior Cups

Flex Cu Utah Medical 60 mm Pol urethane

Kiwi OmniCup (Clinical Innovations) 50 mm Rigid plastic

Malmstrm (Dickinson Healthcare, Hungerford, UK) 40-60 mm Metal

Mityvac M-Style (CooperSurgical) 50 mm Rigid polyethylene

Rigid Posterior Cups

Bird posterior cup 40-60 mm Metal

Kiwi OmniCup (Clinical Innovations) 50 mm Rigid plastic

Greenberg JA. Procedure for vacuum assisted operative vaginal delivery. UpToDate Web site. http://www.uptodate.com/patients/content/topic.do?topicKey=~cWABY9RJfJlwne. Accessed February 3, 2009. In :Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics &

Gynecology. 2009;2(1):1-16

B b i K iT k N tifB b i K iT k N tif


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Berbagai Konversi Tekanan NegatifBerbagai Konversi Tekanan Negatif

VakumVakumk /cm2 kPa mmH in H cm H 0 Ib/in2

0,23 13 100 3,9 134 1,9

0,27 27 200 7,9 268 3,90,41 40 300 11 ,8 402 5,8

0,54 53 400 15,7 536 7,7

, , ,

0,82 80 600 23,6 804 11,6

, ,

1,03 101 760 29,9 1018 14,7

Vacca A. The place of the vacuum extractor in modern obstetric practice. Fetal Med Rev 1990;

2:103. Reprinted from MJ Lucas, The role of vacuum extraction in modern obstetrics [Review],Clinical Obstetrics & Gynecology,Vol. 37, No. 4, pp. 794805, 1994, with permission


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D

(cm)

r =

(1/2 D)

Luas Lingkaran

MangkukTekanan Negatif (kgf/cm2)

, , ,4 2 12,6 7,5 8,8 10,1

5 2,5 19,6 11,8 13,8 15,7, , , ,

Ke a alanVakumKe a alanVakum aturan 3aturan 3


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Ke a alan VakumKe a alan Vakum aturan 3aturan 3

, ,

kemajuan

3 kali lepas: setelah satu kjali gagal, nilai

-

memasang kembali

Setelah 30 menit pemasanan tanpa

Vakum Le asVakum Le as SebabSebab sebabsebab


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Vakum Le asVakum Le as SebabSebab--sebabsebab

Perlen aka an an salah/ enutu an burukmenyebabkan kebocoran vakum

tak dikenali adanya CPD

presentasi OP

Sudut traksi yang kurang tepat menyebabkan

ro e an

Terkenanya jaringan lunak ibu pada introitus

Fetal scalp injuries associated withFetal scalp injuries associated with


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eta sca p ju es assoc ated w teta sca p ju es assoc ated w t

vacuum ex rac onvacuum ex rac onCa ut succedaneum scal edema isa normal finding, but may beexaggerated by vacuum-assisteddelivery. Use of a vacuum device can

refers to bleeding into the fetal scalpthat is located in the subperiostealspace and, as such, is contained

a subgaleal hematoma (bleeding into

the fetal scalp which is subaponeuroticand therefore not confined to a single

.complication is an intracranialhemorrhage, which includessubarachnoid, subdural,

,hemorrhage.


Gynecology: Lippincott Williams & Wilkins; 2008.Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics & Gynecology. 2009;2(1):1-16


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Syarat Anatomi

Klasifikasi e o e ap as an ra s - orsep

Dokumentasi

Indications for forceps deliveryIndications for forceps delivery


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Relative indications (vacuum extraction or

caesarean section may be an alternative

o tion Delay or maternal exhaustion in the second stage of

Dense epidural block with diminished urge to push

Rotational instrumental delivery for malpositioned

fetus Suspected fetal distress

Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ. 2004;328:1302-5.



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Specific indications (forceps delivery is usually superior

circumstances)

Delivery of the head at assisted breech delivery (singleton ortwin

Assisted delivery of preterm infant ( < 34 weeks gestation)

Assisted delivery with a face presentation

thrombocytopenia in fetus

Instrumental delivery for maternal medical conditions thatprec u e pus ng

Instrumental delivery under general anaesthesia


Anatomi ForseAnatomi Forse


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Anatomi ForseAnatomi Forse


Forceps DeliveryForceps Delivery--Instrument TypeInstrument Type


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p yp y ypyp

Procedure InstrumentOutlet delivery Classical forceps

mpson or ot type

Laufe divergent forceps

Low-forceps delivery45-degree rotation Classical forceps

Kielland

Tucker-Mclane

Bailey-Williamson

Hawks-Dennen

Breech delivery Piper

a ey- amsonCesarean section Vectis blade-Murless type

Classical forceps

Laufe forceps

Gilstrap-III LC, Cunningham FG, VanDorsten JP. Forceps Delivery. In: III LCG, Cunningham FG, VanDorsten JP, editors. Operative Obstetrics. 2nd ed. New

York: The McGraw-Hill; 2002. p. 89-122.

Classification of forcepsClassification of forceps


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pp


Berba aiTi e Forse CunamBerba aiTi e Forse Cunam


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Berba ai Ti e Forse CunamBerba ai Ti e Forse Cunam

A: Laufe divergent

forceps. B: Salinas

forceps. C: Elliot

forceps. D: Simpsonorceps. : ie an

forceps. F: Barton

forceps with a traction

ar. : per a er-

coming head forceps.




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T es of locksT es of locks


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T es of locksT es of locks

A: Sliding lock of the Kielland

.

many types of forceps. C:

French lock of the Tarnier

force s historical interestonly). D: Lock/handle of the

Salinas forceps. E: Pivot lock

of the Laufe diver ent

forceps.



ALARM (FORCEPS MNEMONIC)ALARM (FORCEPS MNEMONIC)


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ASSISTANCE

equate pa n re e

Neonatal supportB BLADDER Bladder empty

D DETERMINE Position, station and pelvic adequacy

Think possible shoulder dystocia

E EQUIPMENTF FORCEPS Phantom application

Left blade, left hand, maternal left side, pencil grip and

vertical insertion, with right thumb directing blade

, , ,

and vertical insertion with left thumb directing blade

Lock blade and support check application Posterior fontanelle 1 cm above plane of shanks

Fenestration no > fingerbreadth between it and scalp

Sagittal suture perpendicular to plane or shranks with

occipital sutures 1 cm above respective blades

TRACTION

H HANDLE

ELEVATED

Traction in axis of birth canal

Do not elevate handle too early

I INCISION Consider episiotomy

J JAW Remove forceps when jaw is reachable or delivery assuredEdozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.

Abdominal palpation and the determination of theAbdominal palpation and the determination of the

amount of the fetal head palpable above the pelvicamount of the fetal head palpable above the pelvic


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r m.r m.


Forsep RendahForsep Rendah


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pp

Arah tarikan : pertama ke arah belakang sehingga dengan simfisis sebagai

menyesuaikan ke arah depan.


Langkah Pemasangan ForsepLangkah Pemasangan Forsep


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Pemasan an Forse an BenarPemasan an Forse an Benar


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1.Ubun-ubun kecil di tengah antara batang forseps dan satu jari di atasbidang datar dari tangkai forseps dengan sutura lambdoid satu jari di atas

2.Masuknya tangkai harus nyaris tak terasa dan tidak lebih dari seujung jaridapat diselipkan antara tangkai forseps dengan kepala bayi

From O'Brien WF, Cefalo RC: Labor and delivery. In Gabbe SG, Niebyl JR, Simpson JL [eds]: Obstetrics: Normal and Problem Pregnancies, 3rd ed. New

York, Churchill Livingstone, 1996, p 377, with permission. In :Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia:

Churchill Livingstone Elsevier; 2007.

3.Sutura sagitalis tegak lurus terhadap bidang datar dari tangkai forseps

Application of forceps to fetussApplication of forceps to fetuss


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Application of forceps to fetuss head in occipito-anterior position followed by controlled

traction and assisted delivery of head


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Force s & The Pelvic AxisForce s & The Pelvic Axis


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e cav ty o t e

true pelvis is

compara e to anobliquely truncated,

ent cy n er w t ts

greatest heightpos er or y.

Note the curvature

of the pelvic axis, thecurve of Caruso

Gilstrap-III LC, Cunningham FG, VanDorsten JP. Forceps Delivery. In: III LCG, Cunningham FG, VanDorsten JP, editors. Operative Obstetrics. 2nd ed. NewYork: The McGraw-Hill; 2002. p. 89-122.

Methods of hand placement and physicianMethods of hand placement and physician

. .


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Syarat Anatomi

Klasifikasi e o e ap as an ra s

Dokumentasi

Forceps versus Vacuum Maternal


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neonatus yang bermakna

Lebih sedikit membutuhkan anestasire ional/umum

Lebih sedikit trauma terhadapvag na per neum u


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perdarahan subaponeurotik (subgaleal)

Perdarahan retina pada neonatus tidak jelas bermakna secara klinis

Cenderung gagal, perlu alternatif lain

Pasien harus dibuat waspada terhadap

resiko-resiko ini

Effect of Method of Delivery onEffect of Method of Delivery on


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Hemorrhage (ICH)Hemorrhage (ICH)

Delivery ICH

Vacuum and forceps 1:280

Forceps 1:664

Vacuum 1:860

Cesarean with labor 1:907

Spontaneous 1:1900

Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Forceps Delivery and Vacuum Extraction: The McGraw-Hill Companies; 2010.Available from: www.accessmedicine.com.

Intelligence Test Scores at Age 17 for SubjectsIntelligence Test Scores at Age 17 for Subjects

orn n erusa em e ween anorn n erusa em e ween an


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Type of Delivery

Mean Intelligence

Score (SE)

na us e us e

Spontaneous (n = 29,136) 105.4 (0.1) 105.7 (0.1)

orceps n = . . . .

Vacuum extraction (n = 1207) 109.6 (0.5) 105.9 (0.4)esarean e very n . . . .

SE = standard error. aAdjusted by multiple regression for confounding effects of sex, birthweight, ethnic

origin, birth order, maternal age, and paternal and maternal education and social class.

.

Long-term effects of vacuum and forceps deliveries, pp. 15831585, Copyright 1991, with permission from

Elsevier.

Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Forceps Delivery and Vacuum Extraction: The McGraw-Hill Companies; 2010.Available from: www.accessmedicine.com.

Neonatal and maternal morbidity by mode ofNeonatal and maternal morbidity by mode of

delivery in New Jersey, 1989delivery in New Jersey, 1989--93.93.


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Unassisted

(n=327 373)

Forceps

(n=26 491)

Vacuum

(n=19 120)

Vacuum plusforceps

(n=1889)

Neonatal morbidity

Cephalohaematoma* 5457 (166,7) 1681 (634,6) 2135 (1116,6) 257 (1360,5)

Facial nerve injury 78 (2,4) 98 (37,0) 10 (5,2) 10 (52,9)

Intracranial haemorrha e 31 16 2Adjusted odds ratio (95%

CI)

122 (3,7)

0,29 (0,20 to 0,41)

45 (17,0)

1

0,96 (0,62 to

1,52)

5 (26,5)

1,35 (0,53 to 3,42)

Shoulder dystocia

Ad usted odds ratio 95% 1464 44 7 145 54 7

216 (113,0)

2 00 1 62 to 12 63 5

CI) 0,71 (0,59 to 0,85) 1

2,48) 1,10 (0,59 to 2,03)

Feeding difficultyAdjusted odds ratio (95%

CI

763 (23,3)

0 89 0 69 to 1 15

68 (25,7)

1

57 (29,8)1,15 (0,80 to

1 64

6 (31,8)

1 23 0 53 to 2 84

Mechanical ventilation

Adjusted odds ratio (95%

CI)

768 (23,5)

0,84 (0,66 to 1,06)

83 (31,3)

1

77 (40,3)

1,27 (0,92 to

1,74)

14 (74,1)

2,22 (1,24 to 3,97)


CI)

597 (18,2)

0,87 (0,65 to 1,18)

51 (19,3)

1

,

0,78 (0,50 to

1,24)

6 (31,8)

1,65 (0,71 to 3,86)

Maternal morbidity


CI)

12 359 (377,5)

0,39 (0,38 to 0,41)

3316 (1251,7)

1

,

0,78 (0,73 to

0,83)

295 (1561,7)

1,21 (1,06 to 1,38)

Fourth degree perinealDemissie K, Rhoads GG, Smulian JC, Balasubramanian BA, Gandhi K, Joseph KS, et al. Operative vaginal delivery and neonatal and infant adverseoutcomes: population based retrospective analysis. BMJ. 2004;329:1-6.

Advantages and disadvantages of forcepsAdvantages and disadvantages of forceps

delivery compared with vacuum extractiondelivery compared with vacuum extraction


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and emergency caesarean sectionand emergency caesarean sectionForceps delivery

Advantages Disadvantages

extraction in distress; lower failure rate;

reduced need for sequential use

analgesia needed; greater

maternal perineal trauma;

cephalohaematoma and retinal

haemorrhage

nerve palsy more common

mergency

caesarean

section

a or o s e r c aemorr age

and admission to neonatal

intensive care less common;

rauma o a y more

likely; perineal trauma,

dyspareunia, and urinary

shorter hospital stay; fewerreadmissions; subsequent

s ontaneous va inal deliver

incontinence morecommon


more likely


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Syarat Anatomi

Klasifikasi e o e ap as an ra s

Dokumentasi

INDICATIONS FOR ABANDONMENTINDICATIONS FOR ABANDONMENT


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.The attempt at instrumental vaginal

delivery should be abandoned if: there is difficulty in applying the

instrument; there is no descent with each pull; delivery is not imminent following

three pulls of a correctly appliedinstrument;

a reasona e me m nu es,depending on the local protocol) has elapsed

.

Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.

Examples of error in instrumentalExamples of error in instrumental


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Type of error Description Possible

consequence

Safe practice

A: Action

Operation omitted Abdominal palpation not

done

Level of

presenting part

Use of

proforma/checklistmisjudged

Operation mistimed Rotation done during a

contraction

Cervical spine

injury to the

Rotate only when

uterus is relaxed

e us

Operation too long or

too short

Prolonged traction Intracranial

injury

Stick to time limits

and number of pullsO eration in wron Traction directed forwards Third de ree Mind axis of traction

direction and upwards too soon; this

causes premature extension

of the head as a result of

perineal tear

w c a argercircumference of the head

emerges at the introitus

O eration too much Continuous traction Com ression of Onl a l traction

applied fetal head during a contraction




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consequence

Safe practice

B: Information

retrieval

Information not No assessment Prophylaxis not Incorporate this

thromboprophylaxis documentation proforma

History of diabetes

disre arded

Shoulder dystocia

not antici ated

Identify background risk

factors before offerin

instrumental delivery

Wrong informationretrieved

Mistaken head levelor position

Misapplication ofinstrument; trauma

Double check

n ng e cerv x s

fully dilated when it is

not

erv ca ear

Incom lete Failure to assess Traumatic deliver Ado t s stematic

information retrieved moulding brain injury approach to assessment

Omission of

equipment check

Delay in delivery;

stress and

mpa rment o

cognition




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consequence

Safe practice

C: Procedural checks

Check omitted or not

properly done

Failure to ensure cup

does not catch tissue

Training

Vaginal laceration

Check for proper

application of forceps

Trauma to babys

face and eye

Understand reason for

check

no one as escr e

in text

No check for descentwith ull

Undue tractiona lied

Beware of confirmationbias

PR not done at end of

procedure

Third degree tear

missed

Include VE, PR, swab

check in documentation

VE not done at end of Retained swab in

proce ure vag naSwabs not counted




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Type of error Description Possible consequence Safe practice

D: Communication

Failure to

communicate

With woman Valid consent not obtained Verbal and eye

contact; empathy

With midwife Patient iven conflictin Preo erativeinformation briefing

With senior colleague Required supervision not

provided

anaes e s na equa e ana ges a eam wor

With paediatrician Neonatal resuscitationdelayed

E: Selection (choosing

from a number of

options)

type ventouse

Ill-advised sequential

instrumentation

Neonatal handicap




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consequence

Safe practice

F: Cognition

Failure to anticipate Failure to anticipate

PPH in prolonged

Massive

haemorrhage

Have Syntocinon infusion

ready at delivery

labour

Failure to ask the

right

No descent despite

traction: is position

Trauma Situational awareness

ques ons correc y

determined? Is pulling

in the right direction?Force s have less Trauma Situational awareness

than secure grip of

head: is there

undiagnosed OP? Is

orceps app e overbabys face?


DOCUMENTATIONDOCUMENTATION


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indication for intervention; consent;

fifths palpable (abdominal examination);

position and station of the fetal head (vaginal examination);

de ree of mouldin and ca ut adequacy of maternal pelvis;

fetal heart rate;

assessmen o u er ne con rac ons;

ease of application of instrument; number of pulls;

number of detachments;

duration of instrumentation; condition of baby;

assessment of va ina and erineum after deliver

findings on rectal examination after delivery;

umbilical cord pH;

,



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setiap kasus

o umentasi ini arus memi i ipenjelasan terhadap intervensi operasiyang telah dilakukan

Termasuk ambaran tentan carapelaksanaan tehnik operasi dan indikasi-indikasin a

Kebutuhan untuk Intervensi harus:

convincin com ellin consented tocharted


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TERIMA KASIHTERIMA KASIH

Documents

Vakum & Forseps