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