Treatment
Efforts should be made to achieve vaginal birth where appropriate. Amniotomy should be offered if the membranes are intact. Adequate pain relief should be provided, available options must be discussed with the woman prior to the onset of labour and offered according to her wishes and using health facility protocols and norms.
Operative interventions are unlikely to be required when maternal and fetal conditions are satisfactory and there is evidence of descent of the presenting part. On the other hand, if thick meconium is evident or fetal distress is suspected, it is necessary to have a medical review for a plan of care in the presence of multiple abnormalities, to decide the mode of birth. Management of thick meconium-stained amniotic fluid is described in another manuscript in this series. 27If obstructed labour or cephalopelvic disproportion is suspected, a medical review is needed to consider delivery by C-section and preparations should be made for neonatal resuscitation.
Safe assisted vaginal birth requires a careful assessment of the clinical situation, clear communication with the woman and healthcare providers, and expertise in the chosen procedure. The health provider should choose the instrument most appropriate to the clinical circumstances and their level of skill and they should be aware that the use of forceps or vacuum extraction have different benefits and risks. Failure to complete the birth with a single instrument is more likely with vacuum extraction, but maternal perineal trauma is more likely with forceps. Soft cup vacuum extractors have a higher rate of failure but a lower incidence of neonatal scalp trauma.28Instrumental delivery should only be attempted by care providers who are trained and qualified to recognize the indications, and are skilled and equipped to perform the procedure safely for mother and baby.17More information on indications, conditions to perform, precautions and supervision of assisted delivery can be found in a recent published guideline.28