Care of the Woman Experiencing Operative Vaginal and Cesarean Birth
Donna R. Frye
Sarah Branan
Objectives
As you complete this module, you will learn:
Indications for operative vaginal and cesarean birth
Indications and contraindications for operative vaginal birth (vacuum-assisted and forceps-assisted)
Risks and benefits of vacuum-assisted and forceps-assisted birth
Nursing considerations for operative vaginal and cesarean birth
The most common types of forceps and their uses
Types of cesarean births
Guidelines for identifying appropriate VBAC candidates
Indications for and risks of cesarean birth
Roles of the nurse during the preoperative, intraoperative, and postoperative period
Ways to promote family-centered care for the woman experiencing operative birth
Key Terms
When you have completed this module, you should be able to recall the meaning of the following terms. You should also be able to use the terms when consulting with other health professionals. Terms are defined in this module or in the glossary at the end of this book.
cephalopelvic disproportion (CPD)
cesarean birth
cesarean delivery upon maternal request
cesarean hysterectomy
classic incision
dystocia
emergency cesarean birth
elective birth
forceps-assisted birth
low-segment transverse incision
low-segment vertical incision
neuraxial anesthesia
operative vaginal birth
primary cesarean birth
repeat cesarean birth
shoulder dystocia
trial of labor (TOL) or trial of labor after cesarean (TOLAC)
vacuum-assisted birth (vacuum extraction)
vaginal birth after cesarean (VBAC)
Part 1 Operative Vaginal Birth
Although most women desire and set a goal for spontaneous vaginal birth, complications may arise, necessitating consideration of other options to facilitate birth such as application of forceps or vacuum, or cesarean section. Operative vaginal birth, assisted by vacuum or forceps, is a modification in the mode of delivery implemented by the primary care provider in certain circumstances in order to reduce maternal or fetal risk. While the overall rate of operative vaginal birth has decreased (3.5% of all births), vacuum-assisted births have increased. Vacuum-assisted births account for 4% of all vaginal births, while forceps-assisted births represent 1%.1
Vacuum-Assisted Birth (Vacuum Extraction)
Vacuum-assisted birth is achieved by the use of a vacuum cup attached to the fetal head (occiput). Suction is used to create negative pressure developing an artificial caput (chignon), and ensuring a snug fit of the cap onto the head (Fig. 15.1). The birth attendant uses gentle traction while the woman actively pushes with contractions to help the fetal head descend and shorten the second stage of labor.
 FIGURE 15.1 Vacuum extraction. (From Pillitteri, A. (2007). Maternal & child health nursing: Care of the childbearing & childrearing family (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.) |
Why is vacuum used to assist birth?
Vacuum may be used in a variety of situations. Some of the most common scenarios are summarized in Display 15.1.
The fetus must be in a vertex (cephalic) presentation, engaged, with the head position known
The membranes must be ruptured to ensure proper placement
The woman’s cervix should be completely dilated to avoid potential lacerations
Display 15.1 Indications for Operative Vaginal Birth
Prolonged second stage of labor:
Nulliparous women—lack of continuous progress for 3 hrs with neuraxial anesthesia or 2 hrs without neuraxial anesthesia
Multiparous women—lack of continuous progress for 2 hrs with neuraxial anesthesia or 1 hr without neuraxial anesthesia
Fetal compromise
Immediate or potential which may include, but is not limited to, abruption, category III EFM pattern
Maternal benefit
Poor pushing effort (secondary to exhaustion, neuraxial anesthesia)
Cardiac, pulmonary, cerebrovascular, or neurologic disease
From American College of Obstetrics and Gynecologists. (2002; reaffirmed 2012). Practice Bulletin No. 17. Operative vaginal delivery. Obstetrics & Gynecology, 95(6).
face or breech presentation
evidence of CPD as determined by the obstetric provider
fetal osteogenesis imperfecta
gestational age less than 34 weeks
estimated fetal weight less than 2,500 g or greater than 4,000 g
live fetus with a known bleeding disorder
What are the risks of vacuum-assisted birth?
The newborn commonly experiences cup marks, bruising, and minor lacerations (Fig. 15.2). These effects are lessened with the use of a soft cup.3,4
 FIGURE 15.2 Caput succedaneum. (From Pillitteri, A. (2007). Maternal & child health nursing: Care of the childbearing & childrearing family (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.) |
cephalohematoma
subgaleal hematoma
retinal hemorrhage
intracranial hemorrhage
skull fractures
NOTE: Scalp avulsions, abrasions, blistering, bruising, and other trauma are more likely to occur when the vacuum is applied for a prolonged period of time (longer than 20 minutes) or with excessive suction (maximum pressure force should not be longer than 10 minutes).5,6
BE PREPARED: Shoulder dystocia may be more frequently encountered with mid pelvic vacuum extraction and has a higher risk of brachial plexus injury than forceps-assisted or cesarean births.1
Maternal complications are rare, but may include pain, bladder trauma, perineal lacerations, and soft tissue injuries to the vulva, vagina, cervix, and anal sphincter.2,5 Perineal wound infections, vaginal bleeding, uterine atony, and anemia may also result from vacuum-assisted birth.1,7
What is the nurse’s responsibility in a vacuum-assisted birth?
The nurse’s role in a vacuum-assisted birth is twofold: educating the woman and family about the procedure and assisting the provider. Nursing actions are summarized in Display 15.2.
Display 15.2 Nursing Actions: Operative Vaginal Birth
Provide the woman and her support person(s) with education about the procedure and prepare her for vaginal birth.
Verify informed consent for instrument use (vacuum, forceps).
Place the woman in lithotomy position to provide for optimal traction.
Empty the woman’s bladder to decrease risk of trauma.
Instruct the woman that she will actively push with uterine contractions.
Explain to the woman that the baby will probably have a finding of caput succedaneum (Fig. 15.2). This is considered a normal finding and generally resolves within 24 hrs of birth).
Prepare the room for the procedure and assemble necessary equipment and team members.
Assure equipment for neonatal resuscitation is available and in working order.
Assure that the provider’s preferred instrument is available.
Anticipate the need for pain management and have the anesthesiology provider at birth.
Alert the neonatal resuscitation team for attendance at birth.
Perform a Time Out
Interprofessional participation to confirm informed consent, provider roles, and fetal positioning.
Attempt assessment of the fetal heart rate (FHR) throughout the procedure and document findings.
Remove internal monitoring devices (fetal scalp electrode, IUPC).
If continuous EFM is not used or the tracing is uninterpretable, the FHR should be auscultated and documented every 5 min.
Alert the provider to abnormal FHR characteristics.
Be prepared and have a contingency plan for a failed operative vaginal birth.
Alert the charge nurse that the physician is attempting an operative vaginal birth.
Determine the capability to perform a cesarean section, if necessary.
Note and document the time of the first application of the vacuum/forceps.
While cup detachment may occur, best practice recommendations state a maximum of 2–3 detachments before the procedure is abandoned.
The maximum total time of vacuum application should not exceed 20 minutes, the time of maximum pressure force should not be longer than 10 minutes, and manufacturer’s recommendations should be observed.
Help the provider maintain situational awareness of time elapsed with discrete prompts regarding time.
Steady traction should only be applied during contractions while the woman is actively pushing. The birth should be accomplished without rocking or torque movements by the provider.
Assess the neonate after birth for signs of trauma at the site of the device application.
Continue to observe the infant during the newborn transition period for signs of trauma.
Assess the immediate postpartum woman for signs of perineal trauma, lacerations, or increased bleeding.
Document all nursing interventions during the birth. (See Module 20 for additional information regarding documentation)
From American College of Obstetrics and Gynecologists. (2002; reaffirmed 2012). Practice Bulletin No. 17. Operative vaginal delivery. Obstetrics & Gynecology, 95(6); Nichols, C. M., Pendlebury, L. C., Jennell, J. (2006). Chart documentation of informed consent for operative vaginal delivery: Is it adequate? Southern Medical Journal, 99(12), 1337–1339.
What are the advantages of vacuum-assisted birth?
Vacuum is generally preferred to forceps for operative vaginal birth because it is easier to apply and there is less associated maternal trauma. Provider preference training and frequency of use are also considerations.5,6
Forceps-Assisted Birth
Obstetrical forceps are metal blades designed to curve around the fetal head and help to facilitate birth. Forceps are shaped to fit the fetal head and maternal pelvis using blades that are curved to provide the best traction in a variety of situations. The blades are joined with a locking pin, screw, or groove to limit compression of the fetal skull.2,7,8
Incidence of forceps-assisted birth varies according to birthing facility and the skill and experience of the provider. The incidence has decreased in the last few decades as providers opt for the use of the vacuum or cesarean section.7,9
Why are forceps used?
Forceps are used for a variety of situations, similar to the indications for use of the vacuum (Display 15.1). Forceps may also be used in cases of malpresentation for rotation of the fetal head. Other indications for use of forceps instead of the vacuum are listed in Display 15.3. Under these conditions, forceps are considered safer than vacuum-assisted birth.2,6,10,11
Display 15.3 Specific Indications for Forceps-Assisted Birth
Assisted delivery of the head in a breech delivery
Face presentation
Maternal conditions (e.g., cardiac, cerebrovascular, or neurologic conditions)
Instrumented birth with the woman under general anesthetic
Cord prolapse in the second stage of labor
From American College of Obstetrics and Gynecologists. (2002; reaffirmed 2012). Practice Bulletin No. 17. Operative vaginal delivery. Obstetrics & Gynecology, 95(6).
Although vacuum-assisted birth is now more common, forceps have some advantages, including:
decreased failure rate
expedites vaginal birth at a more rapid rate
allows the provider to rotate the fetal head to an occiput anterior position to facilitate birth
There are different classifications of forceps applications for use in various situations and are dependent on fetal station.
Outlet forceps are used when the fetal head is visible at the vaginal introitus without separating the labia to guide and control the birth.
Low forceps are used when the leading part of the fetal head is at least +2 station.
In midforceps application, the fetal head is engaged but above +2 station.
Figure 15.3 illustrates the application of outlet forceps on the fetal head. Midforceps application is not frequently done except in emergent situations due to increased maternal and newborn morbidity. However, it may be considered by the physician if it is determined to be a more rapid approach to birth than a cesarean section in an emergent situation.
NOTE: High forceps applications are no longer a part of current obstetric practice due to the incidence of maternal and fetal injury.2,12
There are a variety of forceps in use today. The more common types and their uses are found in Display 15.4. As with vacuum-assisted birth, for forceps to be safely attempted, the provider should be knowledgeable and experienced with the type of forceps and credentialed to perform the procedure and a cesarean birth if there is a failed attempt. In addition, the physician must verify the following:
membranes are ruptured
cervix is completely dilated
the fetal head is engaged (Note: this may be difficult if excessive caput is present)
the fetal head position is known
the fetal presenting part is vertex (if face presentation, chin should be anterior)
cephalopelvic disproportion should not be suspected by the provider
 FIGURE 15.3 Forceps-assisted delivery: application of the forceps to the fetal head. (From Orshan, S. A. (2008). Maternity, newborn, & women’s health nursing. Philadelphia, PA: Lippincott Williams & Wilkins.) |
In preparation for a forceps birth, the nurse should make sure the woman’s bladder is empty and she has adequate pain management/anesthesia. If the physician anticipates a potentially difficult attempt, an anesthesiology provider, surgical team, and individuals capable of neonatal resuscitation should be readily available.1,7,12,13 Nursing considerations in care of the woman undergoing a forceps-assisted birth are similar to those of vacuum-assisted birth. They are summarized in Display 15.2.
Display 15.4 Type and Use of Forceps
Simpson or Elliot forceps are used for outlet vaginal deliveries and are designed for application to the molded fetal head.
Kielland or Tucker-McLane forceps are used for rotational deliveries and are appropriate for application to the fetal head with little or no molding.
Piper forceps which have a reverse pelvic curve are used for breech deliveries.
From Wegner, K. A., & Bernstein, I. M. (2014). Operative vaginal delivery. Retrieved from: www.uptodate.com; Incerpi, M. (2010). Operative vaginal delivery. In Goodwin, T. A., Montoro, M. N., Muderspach, L., et al. (Eds.), Management of common problems in obstetric and gynecology (pp. 41–44). Blackwell Publishing; Simms, R., & Hayman, R. (2013). Instrumented vaginal delivery. Obstetrics, Gynaecology, and Reproductive Medicine, 23(9), 270–278.
Morbidity after forceps-assisted birth is associated with fetal station and the degree of rotation required to effect birth (the higher the station and degree of rotation increases maternal and fetal morbidity). Risks include:
Fetal/newborn
facial nerve palsy
intracranial hemorrhage
Maternal
lacerations—vagina, cervix, perineum
episiotomy extension
uterine atony and postpartum hemorrhage
hematoma formation
bladder dysfunction and urinary retention
fecal incontinence
NOTE: Notify the primary care provider if the woman develops complications from operative vaginal birth.5
The woman may require more analgesia in the postpartum period and a longer hospital stay than with a spontaneous or vacuum-assisted birth. For additional information regarding immediate postpartum care, review Module 17.
Clinical Considerations of Operative Vaginal Birth
If forceps birth is attempted but not achieved, then a cesarean section may be indicated.
While studies are limited, evidence appears to be against multiple attempts to deliver the baby vaginally with different instruments. A failed attempt at vacuum extractions followed by an attempt to deliver with forceps is often associated with an increase in maternal and newborn injury.1 However, the sequential use of instruments is a provider decision, balancing the risks and benefits of neonatal and maternal morbidity. Each hospital should develop an interprofessional plan of care that addresses when attempts at an operative vaginal birth should be discontinued. Best practice recommendations include2,12:
if the instrument does not apply easily
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