Assisted vaginal delivery

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English: Medio-lateral episiotomy illustration...

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 Episiotomy , forceps and ventouse

Operative vaginal delivery refers to any operative procedure designed to expedite vaginal delivery.
The choice depends largely on obstetrician’s preference and expertise.



  • It is a surgical incision made in the perineum to facilitate the delivery.
  • It reduces the pelvic floor trauma , bleeding , infections and genital prolapse.

Types of episiotomy


  • It extends from the posterior vaginal forchette towards rectum in the midline.
  • Disadvantages are that it may involve external anal sphincter.

Mediolateral episiotomy

  • It extends 45 degree to the posterior forchette on right or left side.
  • Mediolateral episiotomy on the right side is the most common type of episiotomy given.

Stitching of episiotomy

It is stitched in three layers
  1.  Vagina with continuous non locking sutures using chromic catgut 1 or 0 or vicryl , vicryl rapide can also be used, depending upon the choice of the surgeon.Be sure that you have caught the apex of the cut vaginal wound.
  2.  Muscle is stitched with interrupted sutures
  3.  Skin with mattress sutures.




  • Maternal exhaustion
  • Prolonged second stage of labour
  • Need to avoid expulsive forces as in cardiovascular diseases or spinal cord injuries.

Fetal indications

  • fetal distress
  • They were introduced by chamberlain family in 18 th century.

Types of forceps are

Classical type

Simpson’s forceps
Which have a pelvic curve , a cephalic curve and locking handles.
Rotational forceps
Which lack a pelvic curvature and have sliding shanks
Piper’s forcep
Which lack a pelvic curve and has a long handle on which body of breech can be kept while delivering the head.

Criteria to be fulfilled for forceps application

  • Adequate analgesia
  • Written consent
  • Bladder should be empty
  • Adequate pelvimetry should be done
  • Vertex presentation
  • Head should be engaged.
  • Position , station of the head , amount of the caput should be assessed.
  • Cervix should be fully dilated.
  • No placenta previa should be there.
  • Cesarean section preparation should be kept ready.
Now a days nobody wants to wait for such a long and choose cesarean section over forceps and ventouse.
But if head is at outlet and obstetrician has the patience and skill then baby can be delivered within no time,
till one starts shifting the patient to OT , calling an anesthetist and giving spinal which will take minimum 15 minutes to half an hour.If proper consent is there one should go ahead , never get afraid of the forcep injury.


  • Prematurity
  • fetal macrosomia
  • Suspected fetal coagulation disorders.


  • Increased perineal injury
  • fetal brusing
  • Lacerations
  • facial nerve palsy
They are usually seen with rotational forceps.If simple outlet forceps like simpson’s are applied with experienced hands , morbidity is less.


Malstrom in 1954 introduced ventouse.
It was a metal cup.
Current ventouse cups are made of plastic , polyethylene or silicone.

Application of ventouse

To promote the flexion of the head , cup is placed over median flexion point.
Low suction 100mm of Hg is applied , after ensuring that no cervical tissue is entrapped between the cup nad head , pressure can be increased upto 500-600 mm of Hg.
Suction is released in between the contractions and applied with uterine contractions in the direction of pelvic curve.
If no descent occurs after applying it three times , procedure should be abandoned.
Episiotomy should not be applied as the pressure of perineum helps in flexion and descent. But if required can be applied after the descent of head.


  • Failed delivery with very soft cup.
  • Cephalhaematoma
  • Scalp lacerations
  • Maternal perineal injuries are less with vacuum.


Comments RSS
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    • bhagia

      Thanks , which bottom line ?

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