Instrumental vaginal delivery (vacuum / forceps)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• failure of the instrument and need for caesarean section
• perineal tear including anal sphincter injury
• vaginal, cervical or periurethral tears and haematoma
• postpartum haemorrhage
• urinary retention
• scalp bruise, chignon, cephalhaematoma (vacuum)
• subgaleal or intracranial haemorrhage in the baby (rare)
• facial marks or facial nerve palsy (forceps)
• shoulder dystocia

Pre-operative details for this operation

1. IndicationSuspected fetal compromiseProlonged second stageMaternal exhaustionMaternal medical condition (to shorten second stage)for fetal indication, write the CTG finding; for prolonged second stage, write the duration of passive and active second stage
2. Abdominal examinationhead palpable in fifths (must be 0/5 or 1/5), contractions per 10 min, estimated fetal weight
3. Vaginal examinationcervix fully dilated, membranes ruptured, liquor colour, station of bony vertex relative to spines, position, caput (0 to +++), moulding (0 to +++), asynclitism, descent with pushing
4. ClassificationOutletLow (< 45 degree rotation)Low (> 45 degree rotation)Mid-cavity
5. BladderEmptied by catheterVoidedNot palpable
6. ConsentVerbalWrittenexplained reason, alternatives and possible move to caesarean
7. Operator and supervisornames and grades; senior present for mid-cavity or rotational
8. Paediatrician informed / present

Anaesthesia and position

1. AnalgesiaPerineal infiltrationPudendal blockEpidural top-upSpinaldrug, strength, volume; perineal sensation tested if regional
2. PlaceLabour roomOperation theatre (trial of instrumental delivery)
3. PositionLithotomy
4. Fetal heart monitoring during the procedureContinuous CTGIntermittent auscultation

Operative findings

1. Position and station confirmed just before application
2. Descent with each pullyes / no, for each pull
3. Babylive / stillborn, sex, time of birth, weight, APGAR at 1 and 5 min, scalp or face marks
4. Cord blood gasesarterial and venous pH and base excess, if taken
5. Perineum, vagina and cervix after deliveryepisiotomy, tears and degree, cervical tear, periurethral tear

Procedure (steps)

1. Instrument checked before usevacuum holds pressure / forceps blades form a matching pair
2. Instrument usedVacuum: Kiwi (rigid disposable)Vacuum: silastic / soft cupVacuum: metal anterior cupVacuum: metal posterior cupForceps: Wrigley's (outlet)Forceps: Neville-Barnes / Simpson's (non-rotational)Forceps: Kielland's (rotational)
3. Vacuum: cup placementcentre of cup on flexion point (sagittal suture, 3 cm in front of posterior fontanelle), no maternal tissue trapped under the cup
4. Vacuum: pressureworking pressure (e.g. 0.8 kg/cm2), raised quickly or stepwise
5. Forceps: applicationleft blade first, then right; locked without force; checks: sagittal suture midway and perpendicular to shanks, occiput about 3 cm above shanks, no more than one finger between heel of blade and head
6. Rotation (if any)NoneDigitalManualKielland's forcepsAutorotation with vacuumfrom which position to which
7. Tractionnumber of pulls for descent and for crowning, with contractions and maternal effort, direction along the pelvic curve, force (gentle / moderate / strong)
8. Cup detachments (pop-offs)number, reason, scalp checked before reapplication
9. Timingtime instrument applied, time of birth; total application time
10. EpisiotomyRight mediolateralLeft mediolateralNot givengiven at crowning
11. Second instrument / abandonedNot neededSecond instrument usedAbandoned: caesarean sectiontime of decision, reason, who decided
12. Delivery of shoulders and babyshoulder dystocia yes / no; baby handed to paediatrician
13. Third stageControlled cord tractionManual removaluterotonic drug, dose, route, time; placenta complete?

Closure, drains and dressing

1. Examination after deliveryvulva, vagina, cervix and perineum inspected; rectal examination
2. Repair of episiotomy / tearsdegree, suture used; for 3rd / 4th degree use the perineal tear repair note
3. Rectal examination after repair
4. Vaginal packNonePack left: remove at (time)
5. Swab and needle countCorrect
6. Uterine tone and bleeding at end

Specimens and implants

1. Cord blood gases sentArterial and venousNot sent
2. Placenta sent for HPEYesNo

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals, uterine tone and vaginal bleedingevery 15 min for the first hour
2. Bladder caretime and volume of first void; catheter if unable to void, palpable bladder, or tear near urethra
3. Analgesiadrug, dose, frequency
4. Antibioticsingle IV dose after assisted birth if unit policy, drug and time
5. ThromboprophylaxisVTE risk assessed, low / medium / high, measures ordered
6. Babypaediatric review of scalp, face and head circumference; watch for signs of subgaleal bleed after vacuum
7. Debriefoperator to explain indication, events and any injuries to the woman before discharge

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery