Introduction to Obstetric Procedures

Obstetric procedures encompass a range of medical interventions performed during pregnancy, labor, and delivery to ensure the safety and well-being of both the mother and the fetus. These interventions become necessary when spontaneous labor and delivery pose risks, are unduly prolonged, or when specific maternal or fetal conditions require assistance to achieve a safe birth. The significance of these procedures lies in their potential to prevent maternal and neonatal morbidity and mortality, improve outcomes in complicated pregnancies, and facilitate vaginal delivery, thereby avoiding Cesarean sections where appropriate. Understanding these Obstetric Procedures for Nursing Students is paramount, as nurses play an indispensable role in various capacities. This guide aims to provide nursing students with a comprehensive, evidence-based understanding of three key obstetric procedures: forceps delivery, vacuum-assisted delivery (ventouse), and version procedures (External Cephalic Version and Internal Podalic Version). The focus will be on imparting essential knowledge required for safe, effective, and compassionate nursing care.

The relevance of mastering these Obstetric Procedures for Nursing Students cannot be overstated. Nurses are integral members of the peripartum care team, involved in patient advocacy, meticulous pre-procedure preparation, providing crucial assistance during the procedures, and vigilant post-procedure monitoring and care. A thorough grasp of indications, contraindications, techniques, potential complications, and nuanced nursing interventions enables nursing students to anticipate needs, support informed decision-making, ensure patient safety, and contribute significantly to positive maternal and neonatal outcomes. This document serves as a foundational resource, preparing students to navigate the complexities of these obstetric interventions with competence and confidence. The intricate nature of Obstetric Procedures for Nursing Students demands a robust knowledge base to support clinical judgment and patient-centered care.

Forceps Delivery

Forceps delivery is a type of operative vaginal delivery that has been utilized for centuries, albeit with significant refinements over time. While its frequency has declined with the rise of Cesarean sections and vacuum extraction, it remains a vital skill in modern obstetrics when specific conditions are met. For nursing students, comprehending the nuances of forceps delivery is essential for providing safe and effective care. A deep dive into Obstetric Procedures for Nursing Students regarding forceps use is critical.

Definition, Purpose, and Types of Forceps

Definition: Forceps delivery is an operative vaginal delivery procedure where specifically designed instruments, known as obstetric forceps, are used to assist in the birth of the fetus by applying traction to the fetal head. This intervention is performed by a skilled obstetrician during the second stage of labor (Medscape Emedicine; StatPearls – Forceps Delivery).

Purpose: The primary purpose of forceps delivery is to expedite the delivery of the fetus for either maternal or fetal benefit, particularly when the second stage of labor is prolonged or complicated. It aims to achieve a vaginal birth and potentially avoid a Cesarean section when conditions are favorable for such an intervention (StatPearls – Forceps Delivery; Cleveland Clinic).

Anatomy of Forceps

Obstetric forceps generally consist of two mirror-image metal branches that are articulated. Each branch has four main components:

• Blades: These are the curved portions that cradle the fetal head. Each blade has two curves:
  • Cephalic Curve: Designed to fit snugly around the fetal head, minimizing pressure on delicate structures.
  • Pelvic Curve: Designed to conform to the curve of the maternal birth canal (Carus’s curve).
  Blades can be fenestrated (with an opening) to provide a better grip and reduce slippage, or solid (smooth), which may cause less pressure marking.
• Shanks: These connect the blades to the handles. Shanks can be parallel or overlapping (crossed). The length of the shanks varies among different types of forceps.
• Lock (Articulation): This is the mechanism that joins the two branches of the forceps. Common types include:
  • English Lock: A simple lock where one shank has a socket and the other a pivot. It does not allow for full rotation.
  • Sliding Lock (e.g., Kielland forceps): Allows for movement and adjustment of the blades, facilitating rotation of the fetal head.
• Handles: These are gripped by the operator to apply traction and, if necessary, rotation. (Medscape Emedicine; StatPearls – Forceps Delivery)

Types of Forceps

Numerous types of forceps have been developed, each designed for specific obstetric situations. They can be broadly classified based on their intended use (outlet, low, mid-forceps) and their design features (e.g., for rotation). Some common types include:

• Simpson Forceps: Characterized by an elongated cephalic curve and parallel, separated shanks. They are typically used when there is significant molding of the fetal head (long, molded head). These forceps have an English lock and are generally used for non-rotational or outlet deliveries (StatPearls – Forceps Delivery; Healthline).
• Elliot Forceps (or Tucker-McLane Forceps): These have a more rounded cephalic curve and overlapping shanks. They are preferred when the fetal head is round and unmolded. Tucker-McLane blades are smooth without fenestrations. Like Simpson forceps, they typically have an English lock and are used for non-rotational deliveries (StatPearls – Forceps Delivery; Contemporary OB/GYN).
• Kielland Forceps: These are specialized rotational forceps. They have a minimal pelvic curve and a sliding lock, which allows for disengagement and full rotation of the fetal head (e.g., from occiput posterior or transverse positions to occiput anterior). Their use requires considerable skill and is associated with higher rates of maternal and fetal complications if not applied correctly (StatPearls – Forceps Delivery).
• Piper Forceps: Specifically designed for the aftercoming head in breech deliveries. They have longer shanks with a pronounced pelvic curve to protect the fetal head and maintain flexion during extraction (StatPearls – Forceps Delivery; Medscape Emedicine).

The choice of forceps depends on the clinical situation, including fetal head position, station, degree of molding, and the operator’s experience. Understanding these different types is crucial for nurses to anticipate equipment needs and potential procedural nuances. Obstetric Procedures for Nursing Students should emphasize the importance of skilled application for these instruments.

Indications for Forceps Delivery

Forceps delivery is considered when specific maternal or fetal conditions arise during the second stage of labor that necessitate expedited delivery. The decision to proceed is always based on a careful risk-benefit analysis, ensuring that the potential benefits outweigh the risks for both mother and baby. No indication is absolute (StatPearls – Forceps Delivery).

Maternal Indications:

• Prolonged Second Stage of Labor: This is one of the most common indications. Definitions according to the American College of Obstetricians and Gynecologists (ACOG) are (StatPearls – Forceps Delivery; ACOG – Operative Vaginal Birth):
  • Nulliparous women: Lack of progress for 3 hours with regional anesthesia, or 2 hours without regional anesthesia (ACOG guidelines updated these to 4 hours with and 3 hours without, respectively, if maternal and fetal conditions permit and progress is being made).
  • Multiparous women: Lack of progress for 2 hours with regional anesthesia, or 1 hour without regional anesthesia (ACOG guidelines updated these to 3 hours with and 2 hours without, respectively, under similar conditions).
  These definitions imply adequate maternal pushing efforts with contractions.
• Maternal Exhaustion: When the mother is too fatigued to continue effective pushing efforts, despite adequate labor progress earlier in the second stage.
• Maternal Medical Conditions: Certain pre-existing maternal medical conditions may make prolonged pushing efforts dangerous or contraindicated. In such cases, shortening the second stage of labor with forceps assistance can be beneficial. Examples include (StatPearls – Forceps Delivery; Medscape Emedicine):
  • Certain cardiac diseases (e.g., aortic stenosis, pulmonary hypertension) where Valsalva maneuver increases cardiovascular strain.
  • Certain neurological conditions (e.g., intracranial aneurysm, some neuromuscular disorders).
  • Severe respiratory disease.

Fetal Indications:

• Non-reassuring Fetal Status: This refers to signs of potential fetal compromise, typically identified through fetal heart rate (FHR) monitoring. If a non-reassuring FHR pattern (e.g., persistent bradycardia, recurrent late decelerations, or severe variable decelerations unresponsive to conservative measures) occurs when the fetal head is low enough in the pelvis (vertex well below ischial spines) and delivery is imminent, forceps can expedite birth and potentially avert further fetal hypoxia (StatPearls – Forceps Delivery; ACOG – Operative Vaginal Birth).
• Malposition of the Fetal Head: Certain fetal head malpositions, such as occiput posterior (OP) or occiput transverse (OT), can arrest labor progress. Specific types of forceps (e.g., Kielland) can be used by experienced operators to rotate the fetal head to a more favorable occiput anterior (OA) position and then effect delivery. However, rotational forceps deliveries are associated with higher risks and require significant expertise (StatPearls – Forceps Delivery).
• Delivery of the Aftercoming Head in Breech Presentation: Piper forceps are specifically designed to assist in the delivery of the aftercoming head in a vaginal breech birth, helping to maintain flexion and minimize trauma to the fetal neck (StatPearls – Forceps Delivery).

For Obstetric Procedures for Nursing Students, recognizing these indications helps in anticipating the need for intervention and preparing accordingly.

Contraindications for Forceps Delivery

While forceps can be a valuable tool, their use is not appropriate in all situations. Recognizing contraindications is crucial for preventing maternal and fetal harm. These contraindications can be absolute (procedure should not be performed) or relative (procedure may be considered with caution, weighing higher risks).

Absolute Maternal Contraindications:

• Cephalopelvic Disproportion (CPD): If the maternal pelvis is too small for the fetal head, or if there is a significant mismatch in size, attempting forceps delivery can lead to severe trauma for both mother and fetus. This is a primary contraindication (StatPearls – Forceps Delivery).
• Unengaged Fetal Head: The leading bony part of the fetal head must be engaged in the maternal pelvis (at or below the level of the ischial spines, station 0 or lower). Applying forceps to an unengaged head is extremely dangerous and associated with high rates of failure and complications (StatPearls – Forceps Delivery).
• Incompletely Dilated Cervix: The cervix must be fully dilated (10 cm) and fully retracted (effaced) to allow passage of the forceps and the fetal head without causing cervical lacerations (StatPearls – Forceps Delivery).
• Unknown Fetal Position or Presentation: Accurate knowledge of the fetal head’s position (e.g., occiput anterior, posterior, transverse) and presentation (must be vertex for most forceps, except Piper for breech) is essential for correct forceps application. If the position cannot be determined with certainty (even with ultrasound), forceps application is contraindicated (ChildbirthInjuries.com; StatPearls – Forceps Delivery).
• Operator Inexperience: Forceps delivery is a skilled procedure. If the operator is not adequately trained or experienced with the specific type of forceps required or the clinical situation, the procedure should not be attempted (StatPearls – Forceps Delivery).
• Refusal by the Patient: After being fully informed, if the patient refuses the procedure, it is an absolute contraindication.

Relative Maternal Contraindications:

• Certain Maternal Connective Tissue Disorders: Conditions like Marfan syndrome or Ehlers-Danlos syndrome may increase the risk of pelvic tissue damage or vascular injury, warranting careful consideration and potentially favoring Cesarean section (StatPearls – Forceps Delivery).
• Severe Maternal Pelvic Deformity: While CPD is absolute, lesser deformities might make forceps delivery more challenging and risky.

Absolute Fetal Contraindications:

• Known Fetal Bleeding Diathesis: Conditions like hemophilia, von Willebrand disease (in the fetus), or severe fetal thrombocytopenia pose a high risk of hemorrhage with forceps application (StatPearls – Forceps Delivery; ChildbirthInjuries.com).
• Known Fetal Bone Demineralization Disorder: Conditions such as osteogenesis imperfecta make the fetal skull highly susceptible to fracture with forceps pressure (StatPearls – Forceps Delivery; ChildbirthInjuries.com).
• Fetal Head Not Yet Descended Sufficiently: Attempting forceps when the head is too high (e.g., above +2 station for low forceps, or not engaged for mid-forceps) is contraindicated (ChildbirthInjuries.com). The American College of Obstetricians and Gynecologists (ACOG) has specific criteria for outlet, low, and mid-forceps applications, with high forceps being contraindicated.

Relative Fetal Contraindications:

• Prematurity: While not an absolute contraindication for all forceps applications, extreme prematurity (often cited as <34 weeks gestation) increases the fragility of fetal tissues and the risk of intracranial hemorrhage. The risks versus benefits must be carefully weighed (StatPearls – Forceps Delivery). Some sources suggest vacuum is more strongly contraindicated in prematurity than forceps, but caution is advised for both.
• Macrosomia: An estimated fetal weight significantly above average (e.g., >4000g or >4500g) increases the risk of shoulder dystocia and failed forceps delivery. While no strict weight limit is universally agreed upon, caution is warranted (StatPearls – Forceps Delivery).
• Suspected Fetal Compromise Not Requiring Immediate Delivery: If fetal status is concerning but allows time for Cesarean section, and if forceps delivery is anticipated to be difficult, C-section may be a safer option.

Understanding these contraindications is fundamental for Obstetric Procedures for Nursing Students to ensure patient safety and advocate effectively.

Pre-procedure Preparation for Forceps Delivery

Meticulous preparation is paramount before attempting a forceps delivery to maximize the chances of success and minimize risks to both mother and baby. Adherence to established prerequisites, often guided by ACOG criteria, is essential. Nursing staff play a vital role in this preparatory phase.

The following criteria and preparations must be met (StatPearls – Forceps Delivery; Medscape Emedicine; Cleveland Clinic):

1. Informed Consent: This is a critical first step. The obstetrician must explain the indication for the forceps delivery, the procedure itself, potential risks and benefits to both mother and fetus, and available alternatives (e.g., continued observation, vacuum-assisted delivery, Cesarean section). The discussion should include the possibility of failed forceps delivery and the subsequent need for a Cesarean section. The patient’s questions must be answered, and written consent obtained. Nurses often reinforce this information and ensure the patient understands.
2. Cervix Fully Dilated and Retracted: The cervix must be 10 cm dilated and completely effaced (retracted) to prevent cervical injury during forceps application and delivery.
3. Ruptured Membranes: The amniotic membranes must be ruptured. If intact, an amniotomy will be performed.
4. Fetal Head Engaged: The leading bony part of the fetal skull must be engaged in the maternal pelvis. For outlet forceps, the fetal skull is on the pelvic floor. For low forceps, the leading point of the fetal skull is at station +2 cm or lower. Forceps are not applied to an unengaged head.
5. Known Fetal Position, Presentation, and Station:
   • Presentation: Must be vertex (cephalic), unless Piper forceps are planned for the aftercoming head of a breech.
   • Position: The exact position of the fetal head (e.g., occiput anterior, occiput posterior, occiput transverse, asynclitism) must be accurately determined by vaginal examination. Ultrasound confirmation is advisable, particularly if there is any uncertainty or if a rotational forceps delivery is contemplated (RCOG Green-top Guideline No. 26). Incorrect assessment of position can lead to improper blade application and trauma.
   • Station: The level of the fetal head in relation to the maternal ischial spines must be precisely assessed.
6. Adequate Maternal Analgesia/Anesthesia: Forceps delivery can be painful. Effective pain relief is necessary. This typically involves a functioning epidural analgesia. If an epidural is not in place or not working adequately, a pudendal nerve block combined with local perineal infiltration may be used. General anesthesia is rarely used for forceps delivery but may be necessary in emergent situations if regional anesthesia is contraindicated or fails.
7. Empty Maternal Bladder: A full bladder can obstruct fetal descent and increase the risk of bladder injury. The bladder should be emptied, usually by straight catheterization, immediately before the procedure.
8. Adequate Maternal Pelvis: Clinical pelvimetry should confirm that the maternal pelvis is adequate for the estimated fetal size, with no suspicion of cephalopelvic disproportion.
9. Availability of Personnel and Facilities:
   • An obstetrician skilled in forceps delivery must perform the procedure.
   • Nursing staff knowledgeable in assisting with operative vaginal deliveries.
   • Personnel skilled in neonatal resuscitation (e.g., pediatrician, neonatal nurse practitioner) should be present or immediately available, especially if there are concerns about fetal well-being.
   • An operating room and anesthesia personnel must be readily available for an emergency Cesarean section should the forceps delivery fail or complications arise.
10. Equipment Ready: The appropriate type of forceps, correctly assembled and functioning, should be readily available. Suturing materials for perineal repair and neonatal resuscitation equipment should also be prepared.
11. Consideration of Prophylactic Antibiotics: The World Health Organization (WHO) recommends routine antibiotic prophylaxis for women undergoing operative vaginal birth to prevent maternal peripartum infections (WHO Recommendation 2021). While practice varies, this is an important consideration based on current evidence. StatPearls notes this topic is debated but points to limited evidence for significantly lower endometritis rates.

These preparatory steps are crucial components of safe Obstetric Procedures for Nursing Students to understand and participate in.

Forceps Application and Delivery Technique (Outlet, Low, Mid-Forceps)

The technique for forceps delivery varies based on the station of the fetal head and the type of forceps used. ACOG classifies forceps deliveries to standardize definitions and assess risks associated with different levels of application (Medscape Emedicine; StatPearls – Forceps Delivery).

Classification of Forceps Deliveries (ACOG):

• Outlet Forceps:
  • The fetal scalp is visible at the introitus without separating the labia.
  • The fetal skull has reached the pelvic floor.
  • The sagittal suture is in the anteroposterior diameter, or in the right or left occiput anterior or posterior position (i.e., fetal head is at or on the perineum and rotation required does not exceed 45 degrees).
• Low Forceps:
  • The leading bony point of the fetal skull is at station +2 cm or lower, but not on the pelvic floor.
  • Low forceps deliveries are further divided based on rotation:
    • Rotation < 45 degrees: (e.g., from LOA/ROA to OA, or LOP/ROP to OP).
    • Rotation > 45 degrees: (e.g., from OT to OA).
• Mid-Forceps:
  • The station is above +2 cm, but the head is engaged (biparietal diameter has passed the pelvic inlet).
  • Mid-forceps deliveries, especially those involving significant rotation, are associated with higher rates of maternal and fetal morbidity and are rarely attempted in contemporary practice. Cesarean delivery is often preferred in these situations.
• High Forceps:
  • The fetal head is not engaged.
  • This procedure is not included in the current ACOG classification and is contraindicated due to unacceptably high risks.

General Technique Principles:

The operator, typically sitting, performs the following steps (StatPearls – Forceps Delivery; Medscape Emedicine):

1. Re-assessment: A final check of fetal position, station, and cervical dilation is performed.
2. Blade Application:
   • The left blade is usually introduced first, guided by the operator’s right hand into the left side of the maternal pelvis, along the fetal head.
   • The right blade is then introduced, guided by the operator’s left hand into the right side of the maternal pelvis.
   • The application should be gentle to avoid trauma.
3. Articulation (Locking): Once both blades are correctly positioned, they are articulated (locked). If the blades do not lock easily, they are likely misapplied and should be removed and reapplied.
4. Checking Application: After locking, the application is meticulously checked:
   • Symmetric Placement: The blades should be applied symmetrically to the sides of the fetal head, ideally over the biparietal diameter and cheeks (biparietal-bimalar application). This minimizes pressure on vulnerable areas.
   • Sagittal Suture: Should be midway between the shanks of the forceps if the head is OA. If the head is in an OP or transverse position, this will differ but symmetry must be maintained.
   • Posterior Fontanelle: Should be palpable one_fingerbreadth above the plane of the shanks if correctly applied for flexion.
   • Fenestrations (if present): Should not admit more than one fingertip between the blade and the fetal head, indicating a snug but not overly tight fit.
   • No Maternal Tissue: Ensure no maternal soft tissues (cervix, vaginal walls) are caught between the blades and the fetal head.
5. Rotation (if indicated): If a rotational delivery is planned (e.g., with Kielland forceps for an OT or OP position), the rotation is performed gently and slowly between contractions, before traction is applied.
6. Traction:
   • Traction is applied only during uterine contractions, synchronized with maternal pushing efforts.
   • The traction should be steady, intermittent, and generally in a downward and outward direction, following the curve of the maternal pelvis (J-shaped maneuver or Saxtorph-Pajot maneuver). The direction of pull changes as the head descends and extends.
   • Force should be generated from the forearms and wrists, not the entire body, to maintain control and gentleness.
   • Avoid rocking motions or excessive force.
7. Episiotomy (if necessary): While not routine, an episiotomy (commonly mediolateral) may be performed when the perineum is distending if it is thought to facilitate delivery or prevent a more severe, uncontrolled tear. The evidence supporting routine episiotomy with operative vaginal delivery is lacking, and it is generally reserved for specific indications (StatPearls – Forceps Delivery; AAFP – Vacuum-Assisted Vaginal Delivery, notes episiotomy no longer recommended routinely).
8. Delivery of the Head: As the head crowns, traction is typically reduced, and the head is delivered slowly and controlled to minimize perineal trauma.
9. Removal of Forceps: Once the biparietal diameter (BPD) has passed the vulvar ring (head is crowning significantly) and the jaw is reachable, the forceps are disarticulated and removed in the reverse order of application. The remainder of the delivery proceeds as usual.
10. Assessment for Abandonment: The procedure should be abandoned if:
    • There is undue difficulty in applying or articulating the blades.
    • The fetal head does not descend with appropriate traction after a few pulls (e.g., 2-3 pulls, or as per operator judgment and institutional guidelines). Most cases progress with the first or second pull and deliver with the third or fourth (StatPearls – Forceps Delivery).
    • Delivery is not imminent after a reasonable period of attempts.
    If abandoned, a Cesarean section is usually performed. Sequential use of forceps after failed vacuum (or vice versa) is generally discouraged due to increased risk of fetal trauma (StatPearls – Forceps Delivery).

Mastery of these classifications and techniques is vital for obstetricians, and awareness is important for nursing students involved in Obstetric Procedures for Nursing Students to understand the flow of the procedure and anticipate needs.

Potential Complications of Forceps Delivery

While forceps delivery can be a crucial intervention, it is not without risks. Complications can affect both the mother and the fetus/neonate. The likelihood and severity of complications depend on factors such as the indication for forceps, the station and position of the fetal head, the type of forceps used (especially rotational vs. non-rotational), the operator’s skill, and underlying maternal/fetal conditions. It is important for those studying Obstetric Procedures for Nursing Students to be well-versed in these potential adverse outcomes.

Maternal Complications

• Perineal Lacerations: This is one of the most common maternal complications. Forceps deliveries are associated with a higher incidence of third-degree (involving anal sphincter) and fourth-degree (involving rectal mucosa) perineal tears compared to spontaneous vaginal deliveries or vacuum-assisted deliveries (StatPearls – Forceps Delivery; Cleveland Clinic; NHS).
• Vaginal and Cervical Lacerations: Tears in the vaginal walls or cervix can occur, leading to increased bleeding (StatPearls – Forceps Delivery).
• Hematomas: Vulvar, vaginal, or paravaginal hematomas can form due to vessel injury. These can be painful and may require drainage.
• Anal Sphincter Injury (Obstetric Anal Sphincter Injuries – OASIS): A significant concern, potentially leading to short-term and long-term fecal incontinence or flatus incontinence (PMC10601252 – Maternal complications associated with assisted vaginal delivery).
• Urinary Tract Injury: Injury to the bladder or urethra can occur, potentially leading to urinary retention, fistulas (rare), or stress incontinence (Cerebral Palsy Guide; NHS).
• Increased Blood Loss / Postpartum Hemorrhage (PPH): Due to lacerations, uterine atony, or retained placental tissue.
• Infection: Increased risk of endometritis, wound infection, or urinary tract infection.
• Pain: Significant perineal pain is common post-procedure.
• Long-term Sequelae:
  • Pelvic organ prolapse (POP)
  • Dyspareunia (painful intercourse)
  • Chronic perineal pain
  • Persistent urinary or fecal incontinence
  (StatPearls – Forceps Delivery)
• Blood Clots (Deep Vein Thrombosis – DVT / Pulmonary Embolism – PE): Operative delivery can increase the risk of thromboembolic events (NHS).
• Psychological Distress: A difficult or traumatic forceps delivery can contribute to postpartum psychological distress or PTSD.

Fetal/Neonatal Complications

Risks to the baby are generally mild and temporary, with serious complications being rare (Cleveland Clinic). However, the potential does exist.

Common/Mild (Often Transient):

• Facial Bruising, Abrasions, or Lacerations (“Forceps Marks”): These are common and usually resolve within a few days. They occur where the forceps blades contacted the baby’s head and face (Cleveland Clinic; UTSW MedBlog).
• Cephalohematoma: A collection of blood under the periosteum of a skull bone. It is well-defined, does not cross suture lines, and usually resolves in weeks. It is less common with forceps than with vacuum extraction (StatPearls – Forceps Delivery).
• Temporary Facial Nerve Palsy: Weakness of facial muscles on one side, due to pressure from a forceps blade on the facial nerve. This usually resolves spontaneously within days to weeks but can affect feeding initially (StatPearls – Forceps Delivery).
• Scalp Edema or Swelling: Minor swelling at the application site.
• Subconjunctival Hemorrhages: Small hemorrhages in the white of the eyes, typically harmless and resolve.

Rare/Serious:

• Skull Fracture: A rare but serious complication that can occur with excessive or improper force. Linear fractures are more common than depressed fractures (StatPearls – Forceps Delivery; ChildbirthInjuries.com).
• Intracranial Hemorrhage (ICH): Bleeding within the skull, such as subdural, subarachnoid, or intraventricular hemorrhage. This is a very serious complication but rare with proper technique (StatPearls – Forceps Delivery).
• Ocular Trauma: Injury to the eyes, though uncommon.
• Subgaleal Hematoma: Bleeding into the loose connective tissue space beneath the epicranial aponeurosis. While more typically associated with vacuum extraction, it can occur with forceps. This can be a life-threatening emergency as a large volume of blood can accumulate (StatPearls – Forceps Delivery).
• Brachial Plexus Injury: Injury to the nerves supplying the arm, potentially occurring if there is associated shoulder dystocia during the delivery, rather than a direct result of forceps to the head.
• Hyperbilirubinemia (Jaundice): Indirectly, due to the breakdown of extravasated blood from cephalohematomas or significant bruising (StatPearls – Forceps Delivery).
• Cerebral Palsy or Long-term Neurological Sequelae: While often a concern, the direct causal link between appropriately performed forceps delivery and long-term neurodevelopmental issues like cerebral palsy is complex and often related to the underlying reasons for the operative delivery (e.g., fetal distress) rather than the instrument itself, provided no direct trauma occurred. However, traumatic forceps application can lead to such outcomes (ChildbirthInjuries.com).
• Fetal Death: Extremely rare with modern obstetric practice and skilled operators (StatPearls – Forceps Delivery).

Nurses play a crucial role in monitoring for, identifying, and managing these complications, making a thorough understanding vital for Obstetric Procedures for Nursing Students.

Nursing Care in Forceps Delivery

Nurses play a multifaceted and critical role throughout the process of a forceps-assisted vaginal delivery. This involves meticulous assessment, thorough preparation, active assistance during the procedure, and vigilant post-procedure monitoring and care for both the mother and the neonate. Effective nursing care contributes significantly to patient safety, comfort, and positive outcomes. Understanding these nursing responsibilities is a cornerstone of learning about Obstetric Procedures for Nursing Students.

Pre-procedure Nursing Care

• Comprehensive Assessment:
  • Verify that all prerequisites for forceps delivery are met (e.g., full cervical dilation and effacement, ruptured membranes, engaged fetal head, known fetal position and station, adequate pelvis). Document findings.
  • Assess maternal vital signs, pain level, coping mechanisms, and anxiety.
  • Assess fetal heart rate (FHR) pattern for reassurance or signs of distress that may be an indication for the procedure.
  • Confirm patient allergies and Rh status.
• Patient Education and Consent Verification:
  • Reinforce the information provided by the obstetrician regarding the rationale for forceps, the steps of the procedure, potential risks and benefits, and alternatives.
  • Ensure the patient’s questions are answered and that informed consent has been obtained and is documented. Address any anxieties or fears expressed by the patient or her support person(s).
  • Explain the nurse’s role during the procedure.
• Environmental and Equipment Preparation:
  • Ensure a well-lit environment, typically a delivery room equipped for emergencies.
  • Confirm that emergency equipment is readily available and functional, including neonatal resuscitation equipment (warmer, oxygen, suction, intubation supplies) and a setup for an emergency Cesarean section if needed.
  • Prepare the specific type of forceps requested by the obstetrician, ensuring they are sterile and in good working order.
  • Have supplies for perineal cleansing, local anesthesia/pudendal block (if applicable), episiotomy (if planned), and laceration repair readily accessible.
• Maternal Preparation:
  • Assist the patient into the lithotomy position, ensuring comfort and proper alignment. Use leg supports and padding as needed.
  • Administer prescribed analgesia or assist the anesthesia provider with regional anesthesia (e.g., topping up an epidural, preparing for a pudendal block).
  • Ensure the maternal bladder is empty. Perform straight catheterization if the patient is unable to void or if indicated by the obstetrician (StatPearls – Forceps Delivery).
  • Establish or ensure patent intravenous (IV) access for fluids and potential emergency medications.
  • Cleanse the perineum according to hospital protocol.
• Team Communication:
  • Notify the pediatric team (pediatrician/neonatologist, neonatal nurse) of the impending forceps delivery so they can be present or immediately available for neonatal assessment and resuscitation if required.
  • Communicate effectively with the obstetrician and other team members to ensure coordinated care.

Intra-procedure Nursing Care

• Continuous Monitoring:
  • Fetal Monitoring: Continuously monitor the fetal heart rate (FHR) and pattern, typically with electronic fetal monitoring (EFM) or by frequent auscultation if EFM is not feasible. Report any significant changes (e.g., bradycardia, severe decelerations) to the obstetrician immediately.
  • Maternal Monitoring: Monitor maternal vital signs (blood pressure, pulse, respirations) regularly. Assess pain level and effectiveness of analgesia. Observe for signs of distress, excessive bleeding, or other complications.
• Patient Support and Coaching:
  • Provide continuous emotional support and reassurance to the mother and her support person(s). Maintain a calm and professional demeanor.
  • Clearly explain what is happening during each step of the procedure.
  • Coach the mother on breathing techniques and coordinate her pushing efforts with contractions and forceps traction as guided by the obstetrician.
• Assistance to the Obstetrician:
  • Position lighting effectively.
  • Provide instruments and supplies as needed in a sterile manner.
  • Help document key aspects of the procedure, such as the time of forceps application, type of forceps used, ease of application, number of pulls, duration of traction, and any difficulties encountered.
  • Observe for and report any observed complications during the application or traction (e.g., maternal tissue entrapment, significant bleeding).
• Advocacy: Act as a patient advocate, ensuring her comfort, dignity, and safety are maintained throughout the procedure. If concerns arise about maternal or fetal well-being, communicate these promptly to the obstetrician.

Post-procedure Nursing Care

Immediate Maternal Assessment and Care (Fourth Stage of Labor):

• Perineal and Genital Tract Assessment:
  • Carefully inspect the perineum, vagina, and cervix for lacerations immediately after delivery of the placenta. Assist the obstetrician with the repair of any tears or episiotomy. Document the degree of any lacerations.
  • Assess for the formation of hematomas (vulvar, vaginal). Note any unusual swelling, discoloration, or severe, localized pain.
• Monitoring for Postpartum Hemorrhage (PPH):
  • Frequently assess uterine tone (fundal massage as needed), lochia (amount, color, consistency, clots), and maternal vital signs (especially BP and pulse) for signs of PPH. Forceps delivery is a risk factor.
  • Administer uterotonic medications as prescribed.
• Pain Management:
  • Assess perineal pain regularly using a validated pain scale.
  • Administer prescribed analgesics (e.g., NSAIDs, opioids if necessary).
  • Offer non-pharmacological comfort measures such as ice packs to the perineum to reduce swelling and discomfort.
• Bladder Care:
  • Monitor for spontaneous voiding within a few hours post-delivery. Assess for bladder distension.
  • Measure first few voids to ensure adequate bladder emptying and rule out retention. Difficulty voiding or hematuria may indicate urinary tract injury.
• Vital Signs and General Well-being: Monitor vital signs per protocol or more frequently if concerns arise. Assess overall maternal condition, including level of consciousness and emotional state.

Immediate Neonatal Assessment and Care:

• Comprehensive Examination (by pediatrician/neonatal nurse):
  • Thoroughly examine the neonate for any signs of trauma related to forceps application:
    • Inspect the head and face for bruising, abrasions, lacerations (forceps marks), or swelling.
    • Assess for facial asymmetry, which could indicate facial nerve palsy (e.g., drooping eyelid or mouth on one side, especially when crying).
    • Gently palpate the skull for signs of fracture (e.g., depressions, crepitus) or significant cephalohematoma.
  • Assess Apgar scores at 1 and 5 minutes.
  • Evaluate respiratory effort, heart rate, muscle tone, and reflexes.
  • Monitor for neurological signs such as irritability, lethargy, seizures, or abnormal cry, which could indicate intracranial injury.
• Thermoregulation: Ensure the neonate is kept warm (e.g., skin-to-skin contact with mother, radiant warmer).
• Feeding Support: Facilitate early skin-to-skin contact and breastfeeding initiation, as appropriate and if the mother and baby are stable. Offer assistance if facial nerve palsy affects sucking.

Ongoing Postpartum and Neonatal Care:

• Maternal Care:
  • Continue to monitor for PPH, infection (fever, foul-smelling lochia, perineal wound infection signs), and DVT.
  • Provide perineal care instructions: gentle cleansing, sitz baths (if ordered), use of peri-bottle.
  • Educate on signs and symptoms of complications to report (e.g., excessive bleeding, fever, severe pain, difficulty voiding, signs of wound infection).
  • Manage constipation with stool softeners and dietary advice as needed.
  • Provide psychological support. Allow the mother to discuss her birth experience. Screen for postpartum mood disorders.
  • Discuss activity, rest, and nutrition.
  • Provide contraceptive counseling before discharge if desired.
• Neonatal Care:
  • Continue to monitor for signs of hyperbilirubinemia (jaundice), especially if significant bruising or cephalohematoma is present.
  • Observe for resolution of minor injuries like bruising or facial nerve palsy. Educate parents on expected timelines and when to seek further medical advice.
  • Ensure regular feeding and monitor output (urine and stool).
  • Reinforce parental education on newborn care and signs of illness. Schedule follow-up appointments.
  (General postpartum care principles adapted from Mayo Clinic – Postpartum Care)

Thorough nursing care is integral to successful outcomes in Obstetric Procedures for Nursing Students and these skills are crucial for practice.

Mnemonic Device for Forceps Delivery Criteria

Mnemonics can be helpful learning tools for nursing students to remember the essential criteria and prerequisites for a safe forceps delivery. One common mnemonic is FORCEPS (Radiopaedia, with adaptations from Contemporary OB/GYN and general obstetric principles):

This mnemonic serves as a quick checklist but should always be supplemented by a thorough understanding of the underlying principles and guidelines for Obstetric Procedures for Nursing Students.

Vacuum-Assisted Delivery (Ventouse)

Vacuum-assisted delivery, also known as ventouse delivery, is another form of operative vaginal delivery used to assist the mother in birthing her baby during the second stage of labor. It involves applying a suction cup to the fetal scalp and using traction to facilitate delivery. While sharing similar indications with forceps delivery, there are distinct differences in equipment, technique, and associated risks that are crucial for understanding these Obstetric Procedures for Nursing Students.

Definition, Purpose, and Types of Vacuum Extractors

Definition: Vacuum-assisted delivery (VAD) is an obstetric procedure where a specially designed cup (vacuum extractor or ventouse) is applied to the fetal scalp, and negative pressure (suction) is generated. Traction is then applied to the cup to aid in the delivery of the fetal head (StatPearls – Vacuum Extraction; Cleveland Clinic).

Purpose: The primary purpose of VAD is similar to that of forceps delivery: to expedite vaginal delivery when indicated for maternal or fetal reasons, thereby potentially avoiding a Cesarean section. It aims to shorten the second stage of labor when progress is inadequate or when rapid delivery is necessary.

Components of a Vacuum Extractor:

A typical vacuum extractor system includes:

• Cup: The part applied to the fetal scalp. Cups vary in material, size, and shape.
• Pump: A device (manual hand pump or electric pump) used to create negative pressure.
• Handle: Attached to the cup (directly or via tubing/chain), which the operator uses to apply traction.
• Tubing: Connects the cup to the pump and sometimes to a pressure gauge.
• Pressure Gauge: Displays the amount of negative pressure being applied.

Types of Vacuum Cups:

Vacuum cups are broadly categorized into soft cups and rigid cups, each with its own advantages and disadvantages (StatPearls – Vacuum Extraction; AAFP – Vacuum-Assisted Vaginal Delivery):

• Soft Cups:
  • Made of flexible materials like silastic (silicone) or plastic.
  • Examples include bell-shaped or mushroom-shaped cups.
  • Advantages: Generally easier to apply, associated with a lower risk of causing significant scalp trauma (lacerations, abrasions) to the neonate. More commonly used.
  • Disadvantages: Higher rate of detachment from the fetal scalp (“pop-offs”) compared to rigid cups. May have a slightly lower success rate in achieving delivery, especially if significant traction is required.
• Rigid Cups:
  • Made of metal (e.g., Bird, O’Neil cups) or rigid plastic.
  • Examples include Mityvac M-cup (rigid plastic) or metal O’Neil or Bird cups. Some are designed with a flatter profile which can be useful for occiput posterior positions.
  • Advantages: Tend to provide a more secure attachment to the scalp, lower detachment rate, and may be more effective when greater traction is needed or for certain malpositions (e.g., occiput posterior).
  • Disadvantages: Associated with a higher risk of neonatal scalp injuries such as lacerations, abrasions, and potentially cephalohematomas. Requires more precise application.
• Hand-held, Disposable Devices:
  • Some modern vacuum extractors are single-use, handheld devices that integrate the cup, pump, and handle into one unit (e.g., Kiwi OmniCup). These can be convenient and reduce concerns about sterilization (AAFP – Vacuum-Assisted Vaginal Delivery). The Kiwi OmniCup features a rigid plastic cup.

The choice of cup depends on the clinical scenario, fetal head position, expected traction force, and operator preference and experience. Familiarity with these types is key for Obstetric Procedures for Nursing Students preparing for clinical practice.

Indications for Vacuum-Assisted Delivery

The indications for vacuum-assisted delivery are generally the same as those for forceps delivery. The primary goal is to expedite delivery in the second stage of labor for maternal or fetal well-being (StatPearls – Vacuum Extraction; AAFP – Vacuum-Assisted Vaginal Delivery).

Common Indications Include:

• Prolonged Second Stage of Labor:
  • Failure of the fetal head to descend or rotate despite adequate maternal effort. Definitions of prolonged second stage are similar to those for forceps (refer to ACOG guidelines for nulliparous/multiparous women with/without regional anesthesia).
• Maternal Exhaustion:
  • When the mother is unable to continue effective pushing due to fatigue.
• Maternal Medical Conditions:
  • Conditions where prolonged pushing or Valsalva maneuver is contraindicated or needs to be minimized (e.g., certain cardiovascular or neurological diseases, severe respiratory conditions). In these cases, shortening the second stage can relieve maternal strain.
• Non-reassuring Fetal Status:
  • Evidence of fetal compromise (e.g., concerning fetal heart rate patterns like persistent bradycardia or recurrent late/severe variable decelerations) that necessitates rapid delivery, provided the fetal head is sufficiently low in the pelvis for safe vacuum application.

Recognizing these indications is vital for Obstetric Procedures for Nursing Students to anticipate potential interventions and assist in timely and appropriate care.

Contraindications for Vacuum-Assisted Delivery

While vacuum-assisted delivery (VAD) is a valuable tool, its use is inappropriate in certain clinical situations due to increased risks to the mother or fetus. Many contraindications overlap with those for forceps delivery, but some are specific to vacuum use (StatPearls – Vacuum Extraction; AAFP – Vacuum-Assisted Vaginal Delivery; Cleveland Clinic).

Absolute Fetal Contraindications:

• Gestational Age < 34 Weeks: This is a significant contraindication widely cited. The premature fetal scalp is more fragile, and the skull is less ossified, increasing the risk of severe scalp trauma, cephalohematoma, subgaleal hemorrhage, and importantly, intraventricular hemorrhage (IVH) (StatPearls – Vacuum Extraction; ACOG FAQ). Some guidelines may suggest caution even up to 36 weeks.
• Known Fetal Bleeding Disorder: Conditions such as hemophilia, fetal thrombocytopenia (e.g., neonatal alloimmune thrombocytopenia), or von Willebrand disease in the fetus, as these increase the risk of severe hemorrhage (e.g., cephalohematoma, subgaleal, or intracranial hemorrhage).
• Known Fetal Bone Demineralization Disorder: Conditions like osteogenesis imperfecta, where fetal bones are fragile and susceptible to fracture.
• Non-Vertex Presentation: Vacuum extraction is contraindicated for breech, face, or brow presentations. The cup is designed for application to the occiput of a vertex-presenting fetus.
• Fetal Head Not Engaged: The leading bony part of the fetal skull must be engaged in the maternal pelvis. Applying vacuum to an unengaged head is unsafe.
• Prior Scalp Trauma or Sampling: If the fetal scalp has been recently traumatized, for example, by multiple attempts at fetal scalp blood sampling or a previously failed forceps attempt, vacuum application is generally contraindicated due to increased risk of further injury.

Absolute Maternal/Procedural Contraindications:

• Incompletely Dilated Cervix: The cervix must be fully dilated (10 cm) and retracted. Applying the vacuum cup through an incompletely dilated cervix can cause cervical lacerations or entrapment of cervical tissue under the cup.
• Suspected Cephalopelvic Disproportion (CPD): If the maternal pelvis is deemed inadequate for the size of the fetal head, VAD should not be attempted.
• Inability to Achieve Correct Cup Placement: If the operator cannot accurately identify fetal landmarks (fontanelles, sagittal suture) or properly position the cup at the flexion point, the procedure should not proceed.
• Operator Inexperience: The operator must be trained and experienced in vacuum-assisted delivery techniques.
• Patient Refusal: A fully informed patient’s refusal of the procedure.

Understanding these contraindications is a crucial aspect of safe practice in Obstetric Procedures for Nursing Students.

Pre-procedure Preparation for Vacuum-Assisted Delivery

Proper preparation before a vacuum-assisted delivery (VAD) is crucial for ensuring maternal and fetal safety and optimizing the chances of a successful outcome. The preparatory steps are largely identical to those for a forceps delivery, emphasizing a systematic approach (StatPearls – Vacuum Extraction; AAFP – Vacuum-Assisted Vaginal Delivery).

Key prerequisites and preparatory actions include:

1. Informed Consent: The obstetrician must discuss the indication for VAD, the procedure itself, potential risks (including scalp trauma, cephalohematoma, subgaleal hemorrhage, ICH), benefits, alternatives (e.g., continued labor, forceps, Cesarean section), and the possibility of failed VAD leading to Cesarean section. Patient understanding and written consent are mandatory. Nursing staff often help reinforce this information.
2. Assessment of Prerequisites:
   • Cervix: Must be fully dilated (10 cm) and retracted.
   • Membranes: Must be ruptured.
   • Fetal Presentation: Must be vertex.
   • Fetal Position and Station: Accurately determined. The fetal head must be engaged, ideally at station +2 cm or lower for a low-vacuum procedure. The flexion point for cup application needs to be identifiable.
   • Cephalopelvic Disproportion (CPD): No suspicion of CPD.
   • Gestational Age: Fetus should ideally be ≥34 weeks gestation (preferably ≥36 weeks) due to risks to premature infants.
3. Maternal Analgesia: Adequate pain relief is necessary. A functioning epidural is common. If not available, a pudendal block or local perineal infiltration may be considered, though VAD can sometimes be performed with less anesthesia than forceps.
4. Empty Maternal Bladder: Catheterize the bladder to create more room for fetal descent and prevent bladder injury (StatPearls – Vacuum Extraction).
5. Personnel and Facilities:
   • An obstetrician skilled in VAD.
   • Knowledgeable nursing staff.
   • Neonatal resuscitation team (pediatrician or neonatal nurse) present or immediately available.
   • Operating room and anesthesia personnel readily available for emergency Cesarean section.
6. Equipment Check:
   • Select the appropriate vacuum cup (soft or rigid, correct size).
   • Inspect the vacuum device: ensure the cup, tubing, pump, and pressure gauge are functioning correctly. Check for cracks or leaks. Ensure suction can be generated and released properly.
   • Have backup equipment available if possible.
   • Prepare supplies for perineal cleansing and laceration repair.
7. Team Briefing (Huddle): A brief discussion among the obstetric, nursing, anesthesia, and pediatric teams to review the plan, roles, and potential complications can enhance safety and coordination.
8. Prophylactic Antibiotics: Consider prophylactic antibiotics as recommended by WHO for operative vaginal deliveries to reduce maternal infection risk (WHO Recommendation 2021).

These preparatory steps are fundamental knowledge for Obstetric Procedures for Nursing Students, underpinning safe and effective assistance during VAD.

Vacuum Application and Delivery Technique

The correct application of the vacuum cup and appropriate traction technique are critical for the success of a vacuum-assisted delivery (VAD) and for minimizing maternal and fetal trauma. The procedure demands skill and adherence to established guidelines (StatPearls – Vacuum Extraction; Cleveland Clinic).

Cup Placement – The Flexion Point:

Correct cup placement is paramount for effective traction and to promote flexion of the fetal head, which presents the smallest diameter for delivery.

• Location: The ideal placement is called the “flexion point” (or “pivot point”). This point is located on the fetal scalp, centered over the sagittal suture, approximately 2 cm anterior to the posterior fontanelle (or about 6 cm posterior to the anterior fontanelle). This placement ensures that when traction is applied, the fetal head flexes, and the suboccipitobregmatic diameter presents at the pelvic outlet.
• Avoidance: The cup should not be placed directly over the anterior or posterior fontanelles or significantly off-center from the sagittal suture, as this can lead to deflexion, ineffective traction, increased scalp trauma, or cup detachment.
• Cup Size: An appropriately sized cup should be chosen.

Application Steps:

1. Final Assessment: Before application, quickly reconfirm fetal position, station, and full cervical dilation.
2. Cup Insertion: The cup is gently introduced into the vagina and applied to the identified flexion point on the fetal scalp.
3. Check for Maternal Tissue: Crucially, before applying suction, the operator must sweep a finger around the entire rim of the cup to ensure that no maternal tissues (cervix, vaginal wall, or labia) are trapped between the cup and the fetal scalp. Trapped tissue can cause severe lacerations or hematomas.
4. Application of Suction:
   • Negative pressure is gradually increased to the recommended level, typically between 500-600 mmHg (0.6-0.8 kg/cm²), often indicated by a “green zone” on the pressure gauge of many devices. Rapid application of high pressure can increase scalp trauma.
   • Once the desired pressure is reached, the seal should be checked.
5. Application of Traction:
   • Traction is applied steadily and gently along the axis of the pelvic curve (Carus’s curve). Initially, traction may be directed downwards, then horizontally, and finally upwards as the head crowns.
   • Traction should be coordinated with maternal pushing efforts during uterine contractions. The mother should be encouraged to push effectively.
   • The operator’s other hand can be placed on the cup to monitor its position, ensuring it doesn’t slip or detach, and to help guide the direction of pull. Some practitioners exert counter-pressure on the cup with this hand to maintain the seal.
   • Avoid any twisting, rocking, or torqueing motions on the cup, as this can increase scalp injury and does not aid delivery. Pull should be perpendicular to the plane of the cup.
6. Limits on the Procedure: Adherence to established limits is vital to prevent excessive trauma:
   • Duration of Application: Total time of vacuum application should generally be limited, often to no more than 15-20 minutes (some sources say up to 30 minutes, but shorter is preferred). Prolonged application increases risks (StatPearls – Vacuum Extraction).
   • Number of Pulls: The number of traction attempts (sets of pulls) should be limited. If there is no descent or progress after 2-3 effective pulls, the procedure should be reassessed and likely abandoned.
   • Cup Detachments (“Pop-offs”): The number of times the cup detaches from the scalp should be limited, typically to no more than two or three. Frequent pop-offs suggest incorrect placement, excessive force, or an unsuitable case for VAD (StatPearls – Vacuum Extraction: “Manufacturers discourage more than two to three attempts (or pop-offs)”).
7. Release of Suction and Cup Removal: Once the fetal head is delivered to a point where the vacuum is no longer needed (typically when the head is crowning sufficiently and the widest diameter has passed the perineum, or the jaw is reachable), the suction is released, and the cup is gently removed from the fetal scalp.
8. Completion of Delivery: The remainder of the delivery (shoulders and body) proceeds as with a spontaneous vaginal birth.
9. Abandonment: If any of the above limits are reached, or if there is no progress, or if maternal/fetal compromise occurs, the VAD attempt should be abandoned, and consideration given to proceeding with a Cesarean section. Sequential use of forceps after failed vacuum (or vice versa) raises the risk of fetal/maternal injury and is generally discouraged (StatPearls – Vacuum Extraction).

A comprehensive understanding of this technique is essential for Obstetric Procedures for Nursing Students who will assist in and monitor these deliveries.

Potential Complications of Vacuum-Assisted Delivery

Vacuum-assisted delivery (VAD), like any operative procedure, carries potential risks for both the mother and the neonate. While often considered less traumatic for the mother than forceps, it has specific neonatal risks, particularly related to the scalp. Awareness of these complications is essential for nurses involved in Obstetric Procedures for Nursing Students to ensure vigilant monitoring and timely intervention.

Maternal Complications

Maternal complications with VAD are generally less frequent or severe compared to forceps, especially regarding severe perineal trauma, but they can still occur (Cleveland Clinic; StatPearls – Vacuum Extraction; AAFP – Vacuum-Assisted Vaginal Delivery):

• Perineal, Vaginal, or Cervical Lacerations: Although typically less extensive than with forceps, tears can still happen. The risk of third and fourth-degree tears is lower with vacuum than with forceps.
• Perineal Pain and Discomfort: Common after any vaginal delivery, but can be exacerbated by operative procedures.
• Hematomas: Vulvar or vaginal hematomas may occur.
• Postpartum Hemorrhage (PPH): Can result from lacerations or, less commonly, uterine atony.
• Urinary Difficulties: Temporary urinary retention or incontinence can occur.
• Infection: Risk of wound infection or endometritis, although generally low.
• Psychological Impact: An assisted delivery can sometimes be a stressful experience for the mother.

Fetal/Neonatal Complications

Neonatal complications are primarily related to the application of the vacuum cup to the fetal scalp (StatPearls – Vacuum Extraction; ChildbirthInjuries.com; Healthline):

Common/Usually Benign:

• Caput Succedaneum (“Chignon”): This is a diffuse swelling or edema on the fetal scalp directly under the vacuum cup. It is caused by the suction and traction, crosses suture lines, and typically resolves within 24-48 hours. It gives the baby a “cone-head” appearance at the site of cup application.
• Scalp Abrasions or Lacerations: Minor breaks in the skin can occur where the cup was applied, especially with rigid cups or if there was excessive friction or torque. These usually heal without issues but require good hygiene to prevent infection.
• Cephalohematoma: A collection of blood beneath the periosteum of one of the skull bones, caused by the rupture of small blood vessels. Unlike caput, a cephalohematoma is confined by suture lines and feels fluctuant. It appears within hours to days after birth and usually resolves over several weeks to months. Cephalohematomas are more common with vacuum than with forceps and are a significant risk factor for neonatal jaundice (StatPearls – Vacuum Extraction).
• Retinal Hemorrhages: Small hemorrhages in the retina of the eye are relatively common after VAD (and even spontaneous vaginal delivery). They are usually asymptomatic and resolve without any long-term visual impairment (AAFP – Vacuum-Assisted Vaginal Delivery).
• Neonatal Jaundice (Hyperbilirubinemia): An increased risk due to the breakdown of extravasated blood from cephalohematomas or significant scalp bruising. This may require phototherapy (Cleveland Clinic).

Rare but Potentially Serious:

• Subgaleal Hemorrhage (SGH): This is the most serious potential complication of VAD. It involves bleeding into the subaponeurotic (subgaleal) space, which is a large potential space beneath the scalp aponeurosis, extending from the orbital ridges to the nape of the neck and laterally to the ears. SGH is not limited by suture lines, and a significant volume of blood can accumulate, leading to hypovolemic shock, coagulopathy, and even death if not recognized and treated promptly. Signs include diffuse, boggy scalp swelling that increases after birth, pallor, tachycardia, and poor perfusion. Incidence is estimated at 1 in 650 to 1 in 850 live births following operative vaginal delivery, but higher with VAD, especially after prolonged or difficult attempts (StatPearls – Vacuum Extraction; AAFP – Figure 1B illustrates SGH).
• Intracranial Hemorrhage (ICH): Bleeding within the skull (e.g., subdural, subarachnoid, intraventricular). The risk is higher in preterm infants (hence the contraindication for VAD <34 weeks) but can occur in term infants, especially with difficult or prolonged vacuum application, or pre-existing fetal vulnerability. This is a very serious complication (StatPearls – Vacuum Extraction).
• Skull Fracture: Rare with modern vacuum devices and proper technique, but possible if excessive force is applied or if the cup is placed over a fontanelle with a rigid cup (ChildbirthInjuries.com).
• Shoulder Dystocia: Operative vaginal delivery in general is a risk factor for shoulder dystocia. This is not a direct result of the vacuum cup but can occur during the delivery of the shoulders after the head is born (AAFP – Vacuum-Assisted Vaginal Delivery).
• Neurological Injury: Rare, but can be associated with ICH or severe asphyxia if delivery is unduly traumatic or delayed despite fetal distress.

Understanding these specific complications is vital for Obstetric Procedures for Nursing Students ensuring comprehensive and safe neonatal care post-VAD.

Nursing Care in Vacuum-Assisted Delivery

Nursing care for a patient undergoing vacuum-assisted delivery (VAD) is comprehensive, spanning the pre-procedure, intra-procedure, and post-procedure phases. Nurses are pivotal in ensuring patient safety, providing support, assisting the obstetrician, and monitoring for complications. A thorough understanding of these responsibilities is critical for Obstetric Procedures for Nursing Students.

Pre-procedure Nursing Care

This phase focuses on assessment, preparation, and ensuring all safety checks are complete:

• Verification of Prerequisites: Confirm that all criteria for VAD are met, similar to forceps delivery: full cervical dilation, ruptured membranes, vertex presentation, engaged head, known fetal position, adequate analgesia, empty bladder, and informed consent obtained. Specifically, confirm gestational age is appropriate (typically ≥34 weeks, ideally ≥36).
• Patient Education and Support: Reinforce the obstetrician’s explanations about VAD, answer questions, and alleviate anxiety. Ensure the patient understands the procedure and potential sensations.
• Maternal and Fetal Assessment: Baseline maternal vital signs, pain assessment, and FHR monitoring to establish fetal well-being prior to the procedure.
• Equipment Preparation:
  • Select and prepare the appropriate vacuum extractor (cup type and size as indicated by the obstetrician).
  • Test the vacuum device to ensure it generates and releases suction correctly and that the pressure gauge is functional.
  • Ensure all emergency equipment, including neonatal resuscitation supplies and a setup for Cesarean section, is readily available.
• Team Communication: Notify the pediatric team of the impending VAD for neonatal attendance. Ensure clear communication within the obstetric team.
• Maternal Preparation: Assist with positioning (lithotomy), ensure adequate analgesia (e.g., functional epidural), and confirm bladder emptying (catheterize if needed).

Intra-procedure Nursing Care

During the VAD, the nurse’s role involves continuous monitoring, support, and assistance:

• Fetal Heart Rate Monitoring: Continuous EFM is crucial during VAD. Monitor the FHR closely for any adverse changes (e.g., bradycardia, severe decelerations) and communicate immediately to the obstetrician.
• Maternal Monitoring: Monitor maternal vital signs, pain levels, and coping.
• Tracking Procedural Limits: Actively assist in tracking:
  • Time of Cup Application: Note the start time.
  • Number of Pulls: Keep count of traction attempts.
  • Number of Cup Detachments (“Pop-offs”): Document each pop-off.
  • Total Duration: Monitor the overall time the vacuum is applied. Communicate these to the obstetrician to ensure adherence to safety limits (e.g., maximum 2-3 pop-offs, 2-3 pulls without progress, total application time < 20-30 minutes) (StatPearls – Vacuum Extraction).
• Vacuum Pressure Levels: If visible, note the pressure levels being used.
• Patient Support: Provide encouragement and coaching for pushing efforts, synchronized with contractions and traction. Offer emotional support and keep the patient informed.
• Assistance to Obstetrician: Hand instruments, adjust lighting, and assist as required. Document the procedure details accurately in the patient’s record, including cup type, placement, duration, number of pulls, pressures used, and any complications.

Post-procedure Nursing Care

This phase is critical for early detection and management of complications for both mother and neonate.

Immediate Maternal Assessment and Care:

• Assess for Trauma: Inspect perineum, vagina, and cervix for lacerations. Assist with repair. VAD generally has lower rates of severe tears than forceps but tears can still occur.
• Monitor for PPH: Assess uterine tone, lochia, and vital signs.
• Pain Management: Provide analgesia and comfort measures (e.g., ice packs).
• Bladder Care: Monitor for spontaneous voiding and signs of retention.

Immediate and Ongoing Neonatal Assessment and Care (Crucial Focus):

• Scalp Assessment: This is a priority.
  • Inspect thoroughly for abrasions, lacerations, bruising, and swelling.
  • Differentiate between Caput Succedaneum (diffuse edema, crosses suture lines, resolves quickly) and Cephalohematoma (blood under periosteum, limited by suture lines, slower resolution, risk for jaundice). Document findings precisely.
  • Vigilantly monitor for Subgaleal Hemorrhage (SGH): This is a life-threatening emergency. Look for:
    • Diffuse, boggy scalp swelling that progressively enlarges and crosses suture lines (may feel like a fluid wave).
    • Increasing head circumference (serial measurements may be indicated if SGH is suspected).
    • Signs of hypovolemia/shock: pallor, tachycardia, hypotension (late sign), poor perfusion, irritability changing to lethargy. Immediate pediatric/neonatal consultation and aggressive management are required if SGH is suspected (StatPearls – Vacuum Extraction).
• Neurological Assessment: Assess for signs of ICH (irritability, lethargy, seizures, bulging fontanelle, abnormal cry).
• Jaundice Monitoring: Observe for developing jaundice, especially if cephalohematoma is present. Transcutaneous bilirubin screening or serum bilirubin levels may be needed.
• Parental Education:
  • Explain normal scalp findings (e.g., caput, minor bruising) and expected resolution.
  • Crucially, educate parents on the signs of SGH (e.g., increasing scalp swelling, pallor, lethargy) and the importance of seeking immediate medical attention if these occur after discharge.
  • Provide information on care for minor scalp abrasions.
• General Neonatal Care: Support feeding, thermoregulation, and bonding.
(Key aspects of neonatal care, especially SGH monitoring, are highlighted in StatPearls – Vacuum Extraction which notes “the care of the newborn is usually by a nurse” and lists complications to monitor for).

Proficiency in these nursing care aspects is vital for students focusing on Obstetric Procedures for Nursing Students.

Mnemonic Device for Vacuum-Assisted Delivery Steps

The Advanced Life Support in Obstetrics (ALSO®) course provides a useful mnemonic, ABCDEFGHIJ, to remember the critical steps and considerations for performing a vacuum-assisted delivery safely (AAFP – Vacuum-Assisted Vaginal Delivery; UI Health Care ALSO Cards; ALSO Scandinavia PDF). This mnemonic can be a valuable tool for Obstetric Procedures for Nursing Students.

This mnemonic helps structure the approach to VAD, emphasizing key safety checks and procedural steps essential for students learning about Obstetric Procedures for Nursing Students.

Version Procedures

Version procedures in obstetrics involve maneuvers designed to change the presentation of the fetus in utero, typically from a malpresentation (like breech or transverse lie) to a cephalic (head-first) presentation. The goal is usually to enable a vaginal cephalic delivery and avoid a Cesarean section indicated for malpresentation. The two main types are External Cephalic Version (ECV) and, much less commonly in modern practice, Internal Podalic Version (IPV). Understanding these interventions is an important part of comprehensive Obstetric Procedures for Nursing Students.

External Cephalic Version (ECV)

Definition and Purpose of ECV

Definition: External Cephalic Version (ECV) is a non-invasive obstetric procedure where a healthcare provider (typically an obstetrician) manually attempts to turn a fetus from a breech or transverse lie to a cephalic presentation by applying pressure to the mother’s abdomen externally (StatPearls – External Cephalic Version; Cleveland Clinic).

Purpose: The primary purpose of ECV is to increase the chances of a vaginal cephalic delivery for women whose fetuses are in a non-cephalic presentation near or at term. By successfully converting the fetus to a head-down position, ECV aims to reduce the rate of Cesarean sections performed due to fetal malpresentation (StatPearls – External Cephalic Version; Evidence Based Birth). This is particularly relevant given that breech presentation is a common indication for Cesarean delivery.

Indications for ECV

ECV is typically considered for:

• Singleton Fetus in Breech Presentation: This is the most common indication. ECV is usually offered at or near term, typically between 36 0/7 weeks and 37 6/7 weeks of gestation. Performing it earlier might lead to spontaneous reversion to breech, while later attempts (after 38 weeks) may have lower success rates due to reduced amniotic fluid and a larger fetus relative to uterine space (StatPearls – External Cephalic Version; RCOG Green-top Guideline No. 20a).
• Singleton Fetus in Transverse or Oblique Lie: If the fetus is in a persistent transverse or oblique lie near term, ECV can be attempted to correct the presentation to cephalic.
• Patient Desire for Vaginal Delivery: The procedure is offered to women who wish to attempt a vaginal delivery and are suitable candidates for ECV.
• No Contraindications to Vaginal Delivery or ECV: The patient must otherwise be a candidate for vaginal birth.

Contraindications for ECV

Careful patient selection is crucial to minimize risks. Contraindications can be absolute or relative (StatPearls – External Cephalic Version; Cleveland Clinic; Medscape – ECV Overview):

Absolute Contraindications:

• Any contraindication to vaginal delivery (e.g., placenta previa, vasa previa, active genital herpes outbreak where C-section is planned).
• Multiple gestation (for antepartum ECV attempts; it may be considered for the second twin intrapartum under specific circumstances, though this usually involves internal version).
• Non-reassuring fetal status (e.g., abnormal non-stress test (NST) or biophysical profile (BPP) prior to the procedure).
• Significant (severe) oligohydramnios (insufficient amniotic fluid to allow safe fetal movement).
• Ruptured membranes (significantly increases risk and decreases success, generally considered a contraindication).
• Recent, unexplained significant vaginal bleeding.
• Major uterine anomaly that restricts fetal movement or increases risk of rupture (e.g., clinically significant bicornuate uterus).
• Hyperextended fetal head (can indicate underlying issues or increase risk of spinal cord injury during version).
• History of classical Cesarean delivery (due to increased risk of uterine rupture).
• Known or suspected placental abruption.

Relative Contraindications (Factors that may decrease success rates or increase risks, requiring careful consideration):

• Maternal obesity (can make manipulation more difficult).
• Engaged presenting part (breech deeply engaged in the pelvis).
• Anterior placenta (may make manipulation harder and pose a slightly higher theoretical risk of abruption, though evidence is mixed).
• Fetal growth restriction (FGR), especially if associated with abnormal Doppler studies.
• Maternal hypertension or preeclampsia (may increase risk of placental insufficiency).
• Previous uterine surgery, such as a low transverse Cesarean section (LTCS). While not an absolute contraindication, success rates are reported between 50-84% in some studies, with no uterine ruptures in those trials (StatPearls – External Cephalic Version), but requires careful assessment.
• Tense uterus or uterine irritability.

Pre-procedure Preparation for ECV

Thorough preparation is key to conducting ECV safely and effectively (StatPearls – External Cephalic Version; Cleveland Clinic):

• Ultrasound Examination: Confirm fetal malpresentation (breech type, transverse lie), verify gestational age, estimate fetal weight, assess amniotic fluid volume (AFI), locate the placenta, and rule out fetal or uterine anomalies that might contraindicate ECV.
• Fetal Well-being Assessment: Perform a non-stress test (NST) or biophysical profile (BPP) immediately before the ECV attempt to confirm fetal well-being.
• Informed Consent: A detailed discussion with the patient covering:
  • The nature of the procedure and its purpose.
  • Likelihood of success (average around 50-60%).
  • Potential risks: transient fetal heart rate changes (common), rare but serious risks such as placental abruption, umbilical cord compression/prolapse, premature rupture of membranes, fetomaternal hemorrhage, and the need for emergency Cesarean delivery (overall serious complication rate ~1-2%).
  • Benefits: increased chance of vaginal cephalic birth, avoidance of Cesarean section for malpresentation.
  • Alternatives: planned Cesarean section, trial of vaginal breech delivery (if available and appropriate), or expectant management (small chance of spontaneous version).
  • Written consent must be obtained.
• Facility and Personnel: ECV should be performed in a hospital setting where facilities for continuous fetal monitoring, tocolysis, and emergency Cesarean delivery are readily available (e.g., on or near the labor and delivery unit). Obstetric, anesthesia, and neonatal personnel should be available.
• Tocolysis: Administration of a tocolytic agent (e.g., terbutaline 0.25 mg subcutaneously 15-30 minutes before the procedure) is commonly recommended to relax the uterus, which can significantly improve the success rate of ECV (StatPearls – External Cephalic Version; ACOG guidelines support this).
• Maternal Preparation:
  • May be advised to have an empty stomach (NPO for a few hours) in case of emergency C-section, though this varies by institution.
  • Establish intravenous (IV) access.
  • Confirm Rh status. If Rh-negative, Anti-D immune globulin should be available for administration after the procedure.
  • Ensure the patient has emptied her bladder.
• Pain Management Considerations: While ECV can be uncomfortable, routine regional anesthesia (epidural/spinal) is not standard, though it may be considered to improve success rates, especially if an initial attempt without it fails or if the patient is very anxious or has a tense uterus. Data on its routine use is inconsistent (StatPearls – External Cephalic Version). The patient should be counseled about potential discomfort.

ECV Procedure Steps

The ECV procedure itself involves skilled external manipulation (StatPearls – External Cephalic Version; Cleveland Clinic):

1. Positioning: The mother is usually positioned supine, often with a slight left lateral tilt (using a wedge under the right hip) to avoid supine hypotension. Some practitioners may use a slight Trendelenburg position.
2. Technique:
   • The obstetrician places their hands on the mother’s abdomen, using ultrasound gel or powder to reduce friction.
   • One hand is typically used to lift or disengage the breech from the maternal pelvis.
   • The other hand applies pressure to the fetal head to guide its movement.
   • The attempt is to perform either a “forward roll” (somersault, bringing the fetus’s flexed back forward) or a “backward roll” (backflip, extending the fetus slightly and moving the occiput posteriorly). The direction chosen depends on fetal lie, placental position, and operator preference.
   • The manipulation should be firm but gentle, avoiding excessive force.
   • Fetal heart rate is monitored intermittently during the procedure using a handheld Doppler or brief ultrasound scans between manipulative efforts. Any significant or sustained fetal bradycardia warrants stopping the attempt.
3. Duration and Attempts: An ECV attempt is usually brief, lasting several minutes. If the initial attempt is unsuccessful, one or two more attempts may be made after a short pause, perhaps trying a different direction if feasible. The procedure should be abandoned if:
   • It is not easily achieved.
   • It causes significant or persistent fetal bradycardia.
   • It causes excessive maternal pain or distress.
   • Multiple attempts have failed.
4. Post-Procedure Monitoring: After the ECV attempt (successful or unsuccessful):
   • Continuous fetal heart rate monitoring (NST) is performed for at least 30-60 minutes (or longer, per institutional protocol) to ensure fetal well-being.
   • Maternal vital signs are monitored.
   • The patient is observed for signs of uterine contractions, vaginal bleeding, or rupture of membranes.
   • If the mother is Rh-negative, Anti-D immune globulin is administered.

Success Rates and Factors Influencing ECV Success

• Overall Success Rate: The average success rate for ECV reported in the literature is around 50-60% (e.g., StatPearls quotes a mean of 60%; Cleveland Clinic notes “a little more than half the time”) (StatPearls – External Cephalic Version; Cleveland Clinic). Success means the fetus is converted to a cephalic presentation at the time of the procedure.
• Factors Positively Influencing Success (StatPearls – External Cephalic Version; Medscape – ECV Overview):
  • Multiparity (due to more lax abdominal and uterine muscles).
  • Non-frank breech presentation (e.g., complete or footling breech, as the feet/legs provide “handles”).
  • Unengaged presenting part (more mobile fetus).
  • Adequate amniotic fluid volume (AFI > 7-10 cm).
  • Posterior placenta (allows more room for anterior manipulation).
  • Palpable fetal head.
  • Use of tocolysis.
  • Experienced operator.
  • Later gestational age for the attempt within the recommended window (e.g., 37 weeks might be better than 39 weeks, but practice varies based on parity).
  • Transverse or oblique lie often has higher success rates than breech.
• Factors Negatively Influencing Success (often mirroring relative contraindications):
  • Nulliparity.
  • Frank breech with extended legs splinting the fetal body.
  • Engaged presenting part.
  • Oligohydramnios.
  • Anterior placenta.
  • Maternal obesity.
  • Tense uterus or inability to palpate fetal parts easily.
  • Low estimated fetal weight.
• Reversion: A small percentage of fetuses (around 5%) may spontaneously revert to a non-cephalic presentation after a successful ECV. Immediate induction of labor after successful ECV to prevent reversion is generally not recommended unless otherwise indicated (StatPearls – External Cephalic Version).

Potential Complications of ECV

While ECV is generally considered safe when performed on carefully selected patients by experienced practitioners, complications can occur. The overall rate of serious complications is low, estimated at 1-2% (StatPearls – External Cephalic Version; Evidence Based Birth – Grootscholten et al. study).

Common/Transient Complications:

• Transient Fetal Heart Rate Abnormalities: Bradycardia or decelerations are the most common complication, occurring in up to 4.7-20% of attempts. These are usually temporary and resolve once the manipulation stops (StatPearls – External Cephalic Version). Persistent abnormalities necessitate further evaluation and possibly emergent delivery.
• Maternal Discomfort or Pain: The procedure can be uncomfortable or painful for the mother.
• Uterine Contractions: Mild, transient contractions may occur.

Serious (Rare) Complications (typically <1% each):

• Placental Abruption: Premature separation of the placenta from the uterine wall.
• Premature Rupture of Membranes (PROM).
• Umbilical Cord Prolapse or Compression/Accident: This can lead to acute fetal distress.
• Vaginal Bleeding: May indicate abruption or other trauma.
• Fetomaternal Hemorrhage: Passage of fetal blood cells into the maternal circulation. This is why Rh-negative women receive Anti-D immune globulin post-ECV.
• Preterm Labor: Labor starting before 37 weeks (though ECV is usually done at/near term).
• Need for Emergency Cesarean Delivery: Due to acute fetal distress, abruption, or cord prolapse during or immediately after ECV (around 1 in 286 ECVs in one large review (Evidence Based Birth – Grootscholten et al. study)).
• Stillbirth: Extremely rare, and a direct causal link to the procedure is often difficult to establish definitively, as some stillbirths in studies occurred days or weeks later (StatPearls – External Cephalic Version).

It’s crucial for nursing students to appreciate these risks to facilitate informed patient counseling and vigilant post-procedure monitoring as part of training in Obstetric Procedures for Nursing Students.

Nursing Care in ECV

Nurses play a vital supportive and monitoring role during External Cephalic Version procedures.

Pre-procedure Nursing Care

• Verify Consent and Understanding: Ensure the patient has given informed consent and understands the procedure, risks, benefits, and alternatives. Reinforce information provided by the obstetrician and answer any questions.
• Administer Medications: Administer prescribed tocolytics (e.g., terbutaline) as ordered, typically 15-30 minutes prior to the procedure. Monitor for maternal side effects like tachycardia, palpitations, anxiety, or tremors.
• Baseline Assessments: Obtain and document baseline maternal vital signs. Ensure a reactive NST or reassuring BPP has been completed and documented prior to starting. Confirm Rh status.
• Maternal Preparation: Assist the patient to empty her bladder. Ensure IV access is patent. Assist with positioning.
• Equipment and Environment: Confirm that emergency Cesarean section capabilities are immediately available. Ensure fetal monitoring equipment (Doppler, ultrasound, EFM for post-procedure) and neonatal resuscitation equipment are ready. Create a calm and supportive environment.

Intra-procedure Nursing Care

• Fetal Monitoring: Assist the obstetrician with intermittent FHR monitoring (e.g., via Doppler or brief ultrasound check) between manipulation attempts. Be alert for and report any significant bradycardia or decelerations immediately.
• Maternal Monitoring: Continuously monitor maternal vital signs, assess her comfort level, and observe for any signs of distress or complications (e.g., pain, bleeding, uterine hypertonus).
• Support and Communication: Provide ongoing emotional support and reassurance to the patient. Explain what is happening and what sensations she might expect.
• Assistance: Be prepared to assist the obstetrician as needed. Document the start and end times of attempts, medications administered, and maternal/fetal responses.

Post-procedure Nursing Care

• Fetal Monitoring: Perform continuous electronic fetal monitoring (NST) typically for at least 30-60 minutes (or as per institutional protocol) after the ECV attempt, regardless of whether it was successful or not, to ensure fetal well-being (StatPearls – External Cephalic Version). The FHR should return to a normal baseline with reassuring variability.
• Maternal Monitoring: Monitor maternal vital signs. Assess for uterine contractions, vaginal bleeding, leakage of amniotic fluid, or abdominal pain/tenderness.
• Administer Anti-D Immune Globulin: If the mother is Rh-negative and unsensitized, administer Anti-D immune globulin as prescribed, due to the risk of fetomaternal hemorrhage.
• Education and Discharge Planning:
  • If ECV was successful and fetal/maternal status is stable: Review signs of labor, premature rupture of membranes, decreased fetal movement, or vaginal bleeding that should prompt her to contact her provider or return to the hospital. Discuss the plan for ongoing prenatal care and delivery.
  • If ECV was unsuccessful: Provide emotional support, as this can be disappointing. Discuss the options presented by the obstetrician (e.g., repeat ECV attempt at a later date if appropriate, planned Cesarean section, or, rarely, options for vaginal breech delivery if available and the patient is a candidate).
• Documentation: Thoroughly document the outcome of the ECV, all post-procedure assessments, interventions, patient education, and follow-up plan.

Mnemonic Device for ECV Contraindications

A mnemonic can help recall the contraindications for ECV. Expanding on the common “ABCDEF” idea (Medicowesome – ECV Overview was inaccessible, but this is a common structure for mnemonics), we can use MALPRESENTED (though a bit long, it covers many points for Obstetric Procedures for Nursing Students):

(Note: While some items in this mnemonic are relative contraindications or factors reducing success, they are important considerations included for completeness.)

Internal Podalic Version (IPV)

Internal Podalic Version (IPV) is an obstetric maneuver with a long history but very limited application in modern obstetrics due to its associated risks and the availability of safer alternatives like Cesarean section for most of its historical indications. It is crucial for Obstetric Procedures for Nursing Students to understand its historical context and very niche current uses.

Definition and Purpose of IPV

Definition: Internal Podalic Version is an intra-uterine obstetric procedure where the operator inserts a hand into the uterine cavity, grasps one or both of the fetus’s feet, and turns the fetus to a breech presentation (specifically, a footling breech). This is usually immediately followed by breech extraction (ScienceDirect Topics – Internal Podalic Version).

Purpose:

• Historically: IPV was used for various fetal malpresentations (e.g., transverse lie, shoulder presentation in a singleton fetus) when the cervix was fully dilated, as a means to achieve vaginal delivery before Cesarean section became a safer option. It was also used in cases of placenta previa before the modern era.
• Current Primary (Rare) Indication: The most common, albeit infrequent, indication for IPV in contemporary obstetrics is for the delivery of a non-vertex second twin after the vaginal delivery of the first twin, especially if the second twin is in a transverse or oblique lie, or sometimes even an unengaged vertex presentation when rapid delivery is needed and expertise is available (ScienceDirect Topics – Internal Podalic Version; Wikipedia – Podalic Version).
• Resource-Limited Settings: In extremely rare situations in resource-poor settings without immediate access to Cesarean section, IPV might be considered as a life-saving measure for an obstructed labor due to transverse lie with a fully dilated cervix, but this carries very high risks (MSF Medical Guidelines – page inaccessible, but general principle in such contexts).

Indications for IPV

• Delivery of a Non-Vertex Second Twin: If, after the vaginal birth of the first twin, the second twin is found to be in a transverse lie, oblique lie, or an unengaged vertex or breech presentation, and rapid vaginal delivery is desired/indicated (e.g., due to fetal distress or prolonged inter-twin delivery interval), IPV followed by breech extraction can be performed by an experienced obstetrician (ScienceDirect Topics – Internal Podalic Version). The cervix must be fully dilated, and membranes ideally intact or freshly ruptured.
• Obstructed Labor with Transverse Lie (Singleton – Historical/Resource-Poor Context): In modern practice with access to surgical facilities, Cesarean section is the standard of care for a singleton transverse lie in labor. IPV for a singleton is generally considered contraindicated due to high maternal and fetal complication rates (Wikipedia – Podalic Version, quoting Gabbe).

Contraindications for IPV

• Singleton Pregnancy with Transverse Lie (in settings with C-section access): Due to unacceptably high risks of maternal and fetal complications compared to Cesarean section (Wikipedia – Podalic Version).
• Ruptured Uterus or High Risk of Uterine Rupture: (e.g., previous classical C-section, significantly scarred uterus).
• Incompletely Dilated Cervix: The cervix must be fully dilated to allow the introduction of the operator’s hand and extraction of the fetus without severe cervical trauma.
• Contracted Maternal Pelvis or Cephalopelvic Disproportion (if head were presenting): Although the fetus is extracted as a breech, a significantly contracted pelvis can still complicate delivery.
• Significant Oligohydramnios: Insufficient amniotic fluid makes intrauterine manipulation extremely difficult and dangerous.
• Fetal Compromise Where Cesarean Section is a Quicker and Safer Option.
• Placenta Previa.
• Operator Inexperience: IPV is a highly skilled procedure that is rarely performed today, so finding experienced operators can be challenging. Lack of skill significantly increases risks.
• Tetanic Uterine Contractions: A relaxed uterus, often requiring deep general anesthesia or effective regional anesthesia with tocolytics, is essential.

IPV Procedure Steps (Brief Overview)

IPV is a complex procedure requiring significant skill (ScienceDirect Topics – Internal Podalic Version; DigitalCommons@UNMC – Historical PDF):

1. Anesthesia: Deep general anesthesia or profound regional anesthesia (epidural/spinal) is usually required to achieve adequate uterine relaxation and maternal comfort. Tocolytics may also be used.
2. Preparation: Standard aseptic technique. Ensure readiness for immediate Cesarean section if IPV fails or complications arise.
3. Hand Introduction: The operator, after lubricating their hand and arm, introduces the entire hand into the uterine cavity. The choice of hand may depend on the fetal position (e.g., hand opposite to the side of the fetal back).
4. Fetal Manipulation:
   • The presenting part (if any) may be gently pushed upwards (disengaged).
   • The operator identifies one or both fetal feet. Grasping one foot is often preferred if specific rotation is desired. The ankle is typically held between the operator’s fingers.
   • Gentle, steady traction is applied to the chosen foot/feet, drawing it/them downwards towards and through the cervix.
   • Simultaneously, the other hand may be placed externally on the maternal abdomen to guide the fetal head upwards (abdomino-uterine manipulation), facilitating the version to a footling breech.
5. Breech Extraction: Once the version is complete and a foot or both feet are at the introitus, the procedure transitions into a total breech extraction to deliver the fetus.

Potential Complications of IPV

IPV is associated with significant risks for both the mother and the fetus/neonate:

Maternal Complications:

• Uterine Rupture: A major and potentially life-threatening complication, especially if the uterus is scarred, manipulation is forceful, or contractions are not adequately suppressed.
• Cervical Lacerations: Extensive tears can occur if the cervix is not fully dilated or if extraction is traumatic.
• Postpartum Hemorrhage (PPH): Due to uterine atony, lacerations, or retained placental tissue.
• Maternal Infection (Puerperal Sepsis).
• Trauma to other pelvic structures.
• Anesthetic Complications.

Fetal/Neonatal Complications:

• Birth Trauma: Fractures (clavicle, humerus, femur), dislocations, nerve injuries (e.g., brachial plexus palsy), or soft tissue damage due to manipulation and extraction.
• Hypoxia/Asphyxia: Can occur due to cord prolapse during the version, prolonged extraction, or difficulty delivering the aftercoming head.
• Umbilical Cord Prolapse: A significant risk during the intrauterine manipulation before the breech is engaged.
• Increased Perinatal Mortality and Morbidity: Compared to Cesarean section for similar indications in modern settings with surgical access, IPV generally carries higher fetal risks.
• Entrapment of the Aftercoming Head: A critical emergency during breech extraction.

Nursing Care in IPV

Given its high-risk nature and infrequent use, nursing care during IPV focuses on emergency preparedness, vigilant monitoring, and intensive support.

• Pre-procedure:
  • Verify informed consent, ensuring the patient understands the high risks and rationale, especially if it’s an emergency.
  • Confirm full cervical dilation and adequate anesthesia/uterine relaxation.
  • Ensure immediate availability of a fully staffed operating room for emergency Cesarean section. Have blood products cross-matched and ready.
  • Prepare for intensive neonatal resuscitation; pediatric team must be present.
  • Establish large-bore IV access.
• Intra-procedure:
  • Continuously monitor maternal vital signs (risk of hemorrhage, shock, effects of deep anesthesia). Alert anesthesiologist and obstetrician to any instability.
  • Monitor fetal heart rate if possible prior to and immediately after manipulation, though intrauterine manipulation can make continuous monitoring difficult. Be prepared for signs of acute fetal distress.
  • Assist the obstetrician with positioning and supplies.
  • Anticipate potential complications like PPH or uterine rupture.
• Post-procedure:
  • Intensive Maternal Monitoring: Closely monitor for signs of PPH (uterine tone, lochia, vital signs). Assess for uterine tenderness or rigidity (signs of rupture). Manage pain effectively. Monitor for infection.
  • Intensive Neonatal Care: The neonate will require immediate and thorough assessment by the pediatric team for birth trauma, hypoxia, and other complications. Support resuscitation efforts.
  • Psychological Support: IPV is often performed in emergent or highly stressful situations. Provide compassionate support and debriefing opportunities for the patient and family.

Knowledge of IPV, even if rare, contributes to a holistic understanding of historical and specialized Obstetric Procedures for Nursing Students.

Holistic Nursing Considerations in Obstetric Procedures

Beyond the technical aspects of specific obstetric procedures like forceps delivery, vacuum-assisted delivery, and version maneuvers, nurses must adopt a holistic approach to care. This encompasses ensuring informed consent, managing pain, comprehensive monitoring, providing robust psychological support, collaborating effectively within the interprofessional team, and delivering thorough postpartum care. These elements are fundamental to safe and patient-centered Obstetric Procedures for Nursing Students education.

Informed Consent and Patient Education

Informed consent is a cornerstone of ethical medical practice and a critical nursing responsibility in the context of obstetric procedures.

• Nurse’s Role in Reinforcement and Advocacy: While the primary responsibility for obtaining informed consent lies with the obstetrician performing the procedure, nurses play a crucial role in:
  • Reinforcing Information: Ensuring the patient and her support person(s) understand the information provided by the physician. This includes the rationale for the procedure, the steps involved, potential benefits, common and serious risks to both mother and baby, alternative treatment options (including expectant management or Cesarean section), and the likelihood of success (StatPearls – Forceps Delivery notes counseling and consent as the first step).
  • Clarifying Misunderstandings: Answering questions within their scope of practice or facilitating further discussion with the obstetrician if complex medical queries arise.
  • Assessing Understanding: Gauging the patient’s comprehension of the information, often through teach-back methods or by observing her ability to articulate the key points.
  • Advocacy: Ensuring the patient has adequate time and information to make a voluntary decision, free from coercion. If the nurse believes the patient does not fully understand or is feeling pressured, they should advocate for further clarification or support.
  • Cultural Sensitivity: Recognizing and respecting cultural beliefs or values that may influence decision-making. Utilizing interpreter services if language barriers exist.
• Documentation: Verify that written informed consent is obtained and documented in the patient’s record before any non-emergent procedure begins. In emergencies, consent may be implied if the patient is incapacitated, but efforts should always be made to involve family if present and adhere to legal and ethical guidelines.
• Ongoing Education: Patient education is not a one-time event. Provide ongoing information and updates as the situation evolves, explaining what is happening and what to expect.

Pain Management Strategies

Effective pain management is essential for patient comfort, cooperation, and psychological well-being during obstetric procedures.

• Assessment: Regularly and systematically assess the patient’s pain using a validated pain scale (e.g., numeric rating scale, verbal descriptor scale). Consider non-verbal cues, especially if the patient has difficulty communicating. Assess the effectiveness of any analgesia provided.
• Pharmacological Interventions:
  • Epidural Analgesia: Often the preferred method for operative vaginal deliveries (forceps or vacuum) as it provides excellent pain relief and muscle relaxation. Ensure the epidural is functioning effectively. The anesthesia provider may “top up” the epidural if needed.
  • Spinal Anesthesia: May be used if an emergent procedure is needed and an epidural is not in place or suitable.
  • Pudendal Nerve Block: Provides anesthesia to the perineum and lower vagina. Can be used for forceps or vacuum delivery if epidural analgesia is unavailable or inadequate for perineal sensation. Nurses may assist in preparing for and positioning the patient for this block.
  • Local Infiltration: Injection of local anesthetic into the perineum, typically used for episiotomy and repair of lacerations.
  • Systemic Analgesics: Opioids may be used cautiously, considering potential neonatal respiratory depression if delivery is imminent. NSAIDs are commonly used postpartum.
  • Tocolytics for ECV: While not for pain, tocolytics like terbutaline for uterine relaxation during ECV can cause side effects like palpitations or tremors, which nurses should monitor and explain.
• Non-Pharmacological Interventions:
  • Support and Reassurance: A calm, supportive nursing presence can significantly reduce anxiety and perception of pain.
  • Breathing and Relaxation Techniques: Coach the patient in patterned breathing or other relaxation strategies.
  • Positioning: Ensure comfortable and appropriate positioning for the procedure, using pillows and supports to relieve pressure points.
  • Information and Control: Keeping the patient informed and involving her in decisions where possible can enhance her sense of control and reduce anxiety.
  • Presence of Support Person: Encouraging the presence of a chosen support person can be beneficial.
• Post-Procedure Pain Management: Crucial, especially after operative vaginal deliveries involving lacerations or episiotomy. Regularly assess pain, administer prescribed analgesics, and educate on comfort measures like ice packs and sitz baths.

Comprehensive Maternal and Fetal Monitoring

Vigilant monitoring of both maternal and fetal status is a core nursing responsibility before, during, and after any obstetric procedure.

• Maternal Monitoring:
  • Vital Signs: Blood pressure, pulse, respirations, temperature, and oxygen saturation should be monitored regularly and as indicated by the patient’s condition and the procedure. Be alert for signs of hemorrhage (tachycardia, hypotension), infection (fever), or adverse reactions to medications.
  • Pain Level: Continuously assess and manage pain.
  • Coping and Anxiety: Observe verbal and non-verbal cues indicating anxiety or distress.
  • Hydration Status: Ensure adequate hydration, especially if labor is prolonged or IV fluids are running.
  • Vaginal Bleeding: Assess amount and character of bleeding. Excessive bleeding requires immediate attention.
  • Uterine Activity: Monitor contraction frequency, duration, and intensity (if applicable). During ECV, monitor for uterine irritability or contractions.
  • Bladder Status: Ensure bladder is empty before operative vaginal delivery. Monitor for ability to void postpartum and for signs of retention or injury.
• Fetal Monitoring:
  • Baseline Fetal Heart Rate (FHR): Establish and document the baseline FHR.
  • Variability: Assess FHR variability (absent, minimal, moderate, marked). Moderate variability is reassuring.
  • Accelerations: Presence of accelerations is generally reassuring.
  • Decelerations: Identify type (early, late, variable, prolonged) and significance. Late or prolonged decelerations, or severe recurrent variables, are concerning and require prompt intervention.
  • Monitoring Methods:
    • Continuous Electronic Fetal Monitoring (EFM): Often indicated during operative vaginal delivery and post-ECV.
    • Intermittent Auscultation/Doppler: May be used during ECV attempts (between manipulations) or in low-risk situations following other procedures if EFM is not continuous.
  • Post-Procedure (e.g., after ECV or delivery): NST or continued EFM to confirm fetal well-being. For neonates, Apgar scores, vital signs, and specific assessments related to the procedure (e.g., scalp integrity after vacuum, facial symmetry after forceps).
• Monitoring Labor Progress (if applicable): Assess cervical dilation, effacement, and station of the fetal head. Monitor maternal pushing efforts.

Providing Psychological and Emotional Support

Obstetric procedures, especially if unplanned or emergent, can be a source of significant anxiety, fear, and stress for the patient and her family. Psychological and emotional support from the nurse is invaluable.

• Establish Rapport and Trust: Introduce yourself, explain your role, and build a therapeutic relationship.
• Active Listening: Listen attentively to the patient’s concerns, fears, and feelings. Validate her emotions.
• Clear and Calm Communication: Provide clear, concise, and honest information in understandable terms. Avoid medical jargon where possible. Explain procedures before they happen. Update the patient and her support person on progress.
• Maintain a Reassuring Presence: A calm, confident, and empathetic demeanor can significantly reduce patient anxiety.
• Involve Support Persons: Encourage the presence and participation of the patient’s chosen support person(s) as appropriate and desired by the patient. Provide them with information and support as well.
• Respect Dignity and Privacy: Ensure the patient’s modesty and dignity are maintained throughout all procedures.
• Empowerment: Involve the patient in decision-making whenever possible. Offer choices where available (e.g., in comfort measures). Reinforce her strengths and coping abilities.
• Debriefing: After the procedure, especially if it was difficult or traumatic, offer the patient an opportunity to discuss her experience. Clarify any misunderstandings and address residual concerns. This can be important for psychological recovery (ACOG – Optimizing Postpartum Care, emphasizes mental health).
• Cultural Competence: Be aware of and sensitive to cultural factors that may influence the patient’s experience and expression of pain, anxiety, or her preferences for care.

The Role of the Interprofessional Team

Optimal outcomes in obstetric procedures are achieved through effective collaboration and communication among all members of the healthcare team (StatPearls – Forceps Delivery highlights this).

• Team Members: Obstetricians, anesthesiologists, pediatricians/neonatologists, midwives, and nurses. Each member brings unique expertise.
• Clear Communication: Essential for safe and coordinated care. This includes:
  • Standardized communication tools (e.g., SBAR – Situation, Background, Assessment, Recommendation).
  • Team huddles before complex procedures (like ECV or anticipated difficult operative delivery) to discuss plans, roles, and potential contingencies.
  • Clear “call-outs” during emergencies.
  • Respectful and open communication channels.
• Shared Mental Model: Ensuring all team members have a common understanding of the patient’s status, the goals of the procedure, and potential risks.
• Defined Roles and Responsibilities: Each team member should understand their specific tasks and responsibilities, as well as how they support others.
• Mutual Respect and Support: A culture of respect and Psychological safety allows team members to speak up if they have concerns, contributing to error prevention.
• Simulation Training: Regular interprofessional simulation training for obstetric emergencies and complex procedures (e.g., operative vaginal delivery, shoulder dystocia) can improve teamwork, communication, and clinical skills, ultimately enhancing patient safety (StatPearls – Forceps Delivery).
• Nurse’s Role within the Team: Nurses often act as a central communication hub, patient advocate, and vigilant monitor. They coordinate care, anticipate needs, and ensure smooth transitions.

General Postpartum Care after Operative Vaginal Delivery

Postpartum care following an operative vaginal delivery (forceps or vacuum) requires attention to the general physiological and psychological recovery from childbirth, with added focus on potential issues related to the instrumental delivery (Mayo Clinic – Postpartum Care; ACOG – Optimizing Postpartum Care; StatPearls – Postpartum Care of the New Mother, which is no longer accessible but principles generally known).

• Perineal Care:
  • Provide detailed instructions on perineal hygiene: cleansing with a peri-bottle after voiding/defecation (front to back), patting dry.
  • Cold therapy: Apply ice packs or cold gel pads to the perineum for the first 12-24 hours to reduce swelling and pain.
  • Warmth: Sitz baths (warm, shallow baths) may be recommended 2-3 times a day after the first 24 hours to promote healing and comfort.
  • Change perineal pads frequently.
• Pain Management: Continue regular assessment and administration of prescribed analgesics (e.g., NSAIDs like ibuprofen, acetaminophen). Discuss medication schedule and potential side effects.
• Monitoring for Infection: Educate patient on signs of perineal wound infection (increased pain, redness, swelling, purulent discharge, warmth, fever, foul-smelling lochia) and endometritis. Emphasize importance of reporting these.
• Bladder Function: Encourage frequent voiding. Monitor for urinary retention, dysuria, or incontinence. If significant perineal edema or trauma, risk of retention is higher.
• Bowel Function: Prevent constipation by encouraging fluid intake, high-fiber diet, and ambulation. Stool softeners may be prescribed, especially if there are significant perineal lacerations or hemorrhoids. Pain from an episiotomy or tear can make women hesitant to have a bowel movement.
• Breast Care and Lactation Support: Assist with breastfeeding initiation and provide support for any challenges (e.g., positioning, latch). Manage breast engorgement.
• Activity, Rest, and Nutrition: Encourage a balance of rest and gentle activity (e.g., walking) to promote recovery and prevent DVT. Discuss nutritional needs for healing and lactation.
• Monitoring for Postpartum Mood Disorders: Screen for “baby blues,” postpartum depression, and anxiety. Provide information on resources and support. Emphasize that these are common and treatable.
• Contraception and Family Planning: Discuss contraceptive options and timing of future pregnancies. Interpregnancy intervals shorter than 6-18 months are associated with increased risks. This discussion should begin prenatally and be revisited postpartum.
• Postpartum Follow-up: Stress the importance of attending postpartum checkups (initial contact within 3 weeks, comprehensive visit by 12 weeks per ACOG). This allows for assessment of physical and emotional recovery, management of any complications, and ongoing health planning.
• Thromboembolism Prophylaxis: For women with increased risk factors for DVT/PE after operative delivery, appropriate prophylactic measures (e.g., early ambulation, compression stockings, anticoagulants if indicated) should be implemented.

These holistic considerations are integral to the comprehensive education of Obstetric Procedures for Nursing Students, ensuring they are prepared to provide high-quality, patient-centered care.

Visual Aids and Learning Tools

Visual aids and structured summaries are invaluable for reinforcing complex medical information related to Obstetric Procedures for Nursing Students. Below are tables and descriptions for diagrams to enhance understanding.

Comparative Table: Forceps vs. Vacuum Delivery

Table: Summary of Risks for Major Obstetric Procedures

Diagram: Correct Application of Obstetric Forceps

Diagram: Correct Placement of Vacuum Cup

Diagram: External Cephalic Version (ECV) Maneuver

AI-Generated Image: Assisting with Operative Vaginal Delivery

These visual aids are designed to complement the textual information, making it easier for students to grasp the core concepts of these important Obstetric Procedures for Nursing Students.

Conclusion

This comprehensive guide has meticulously explored three critical interventions in obstetric care: forceps delivery, vacuum-assisted delivery, and version procedures (External Cephalic Version and Internal Podalic Version). A thorough understanding of the definitions, indications, contraindications, procedural techniques, potential maternal and fetal/neonatal complications, and, most importantly, the nuanced nursing care associated with each, is indispensable for nursing students. These Obstetric Procedures for Nursing Students represent a vital component of maternal-child health education, preparing future nurses to contribute effectively to safe and positive childbirth experiences.

It is reiterated that these procedures, when utilized appropriately by skilled practitioners within established guidelines and after careful patient selection, can be crucial interventions for achieving positive maternal and neonatal outcomes, often mitigating the need for more invasive Cesarean sections. The decision to employ any operative vaginal delivery or version technique is complex, always balancing potential benefits against inherent risks.

The role of the nursing student, and subsequently the registered nurse, in the context of these procedures is multifaceted and profound. Nurses act as patient advocates, educators, skilled assistants, vigilant monitors, and compassionate support providers. Their ability to anticipate needs, prepare thoroughly, monitor astutely for complications, and intervene promptly is paramount to patient safety and the overall quality of care. By mastering the knowledge presented, nursing students will be better equipped to navigate the dynamic environment of the labor and delivery unit and contribute to a culture of safety and excellence.

Continuous learning is essential in the ever-evolving field of obstetrics. Nursing students are encouraged to stay updated with the latest evidence-based guidelines and recommendations from professional bodies such as the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the World Health Organization (WHO), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), and the International Federation of Gynecology and Obstetrics (FIGO). A strong foundation in these Obstetric Procedures for Nursing Students will serve them well throughout their careers, enabling them to provide exceptional care to mothers and newborns during one of life’s most significant events.

References

• NCBI StatPearls – Forceps Delivery. (Evanson SM, Riggs J. Updated July 10, 2023)
• Cleveland Clinic – Forceps Delivery: What to Expect, Risks & Recovery. (Reviewed June 12, 2022)
• Medscape Emedicine – Forceps Delivery Overview. (Ponder SW, Reddy UM, et al. Updated Sep 4, 2024)
• Lecturio Nursing – Forceps Delivery. (Accessed May 2025)
• NHS – Forceps or vacuum delivery. (Accessed May 2025)
• RCOG Green-top Guideline No. 26 – Assisted Vaginal Birth. (Published 2020, Updated June 2023)
• ACOG Practice Bulletin – Operative Vaginal Birth. (Published April 2020)
• UTSW MedBlog – What moms should know about forceps and vacuum deliveries. (Accessed May 2025)
• ChildbirthInjuries.com – Forceps Delivery Complications. (Accessed May 2025)
• Cerebral Palsy Guide – Forceps delivery complications. (Updated July 14, 2024)
• PMC10601252 – Maternal complications and risk factors associated with assisted vaginal delivery. (Published Oct 26, 2023)
• Contemporary OB/GYN – Anatomy of the forceps. (Published Dec 11, 2019)
• Healthline – Types of Forceps Deliveries. (Accessed May 2025)
• Wikipedia – Obstetrical forceps. (Accessed May 2025)
• NCBI StatPearls – Vacuum Extraction. (Tonismae T, Canela CD, Gossman W. Updated July 29, 2023)
• Cleveland Clinic – Vacuum Extraction Delivery: Procedure, Risks & Recovery. (Reviewed April 29, 2025)
• AAFP – Vacuum-Assisted Vaginal Delivery. (Hook CD, Damos JR. Published Oct 15, 2008)
• ChildbirthInjuries.com – Birth Injuries Caused by Vacuum Extraction Complications. (Updated April 2, 2025)
• Healthline – Risks of Vacuum-Assisted Delivery. (Accessed May 2025)
• NCBI StatPearls – External Cephalic Version. (Shanahan MM, Martingano DJ, Gray CJ. Updated Dec 13, 2023)
• Cleveland Clinic – External Cephalic Version (ECV): Procedure & Risks. (Reviewed May 11, 2022)
• Medscape Emedicine – External Cephalic Version: Overview. (Lappen JR, Rauk PN. Updated Feb 24, 2023)
• RCOG Green-top Guideline No. 20a – External Cephalic Version and Reducing the Incidence of Term Breech Presentation. (Reviewed March 16, 2017)
• Evidence Based Birth – Evidence on: Breech Version (ECV). (Dekker R. Updated March 29, 2021)
• ScienceDirect Topics – Internal Podalic Version. (Accessed May 2025, page was accessible during research)
• MSF Medical Guidelines – 7.8 Internal version. (Page was not accessible during final generation, referenced from initial search)
• DigitalCommons@UNMC – Internal podalic version and extraction (Historical Thesis). (Bush TC. January 23, 1964)
• Mayo Clinic – Postpartum care: What to expect after a vaginal birth. (Published Dec 27, 2023)
• ACOG Committee Opinion No. 736 – Optimizing Postpartum Care. (Published May 2018, Reaffirmed 2021)
• WHO recommendation on routine antibiotic prophylaxis for women undergoing operative vaginal birth. (Published June 18, 2021)
• Radiopaedia – Forceps delivery criteria (mnemonic). (Evangelou K. Updated Aug 9, 2021)
• Contemporary OB/GYN – Forceps delivery: Contemporary tips for a classic obstetric tool. (Published Dec 11, 2019)
• UI Health Care – ALSO Cards (including ABCDEFGHIJ mnemonic for vacuum). (Revised October 2017)
• ALSO Scandinavia – Assisted Vaginal Delivery ABCDEFGHIJ. (PDF, undated)
• Medicowesome – External Cephalic Version : An overview. (Published July 5, 2017 – page was inaccessible during final writeup but used for mnemonic structure)

Appendix: Key International Guidelines Overview

Staying current with guidelines from major professional organizations is crucial for evidence-based practice in obstetrics. Below is a list of key organizations and examples of their relevant guidance documents for Obstetric Procedures for Nursing Students to explore further:

• American College of Obstetricians and Gynecologists (ACOG):
  • Practice Bulletin: Operative Vaginal Birth (Link)
  • Practice Bulletin: External Cephalic Version (Link is indicative for ACOG’s ECV general page)
  • Committee Opinion: Optimizing Postpartum Care (Link)
  • FAQ: Assisted Vaginal Delivery (Link)
• Royal College of Obstetricians and Gynaecologists (RCOG):
  • Green-top Guideline No. 26: Assisted Vaginal Birth (Link)
  • Green-top Guideline No. 20a: External Cephalic Version and Reducing the Incidence of Term Breech Presentation (Link)
  • Full list of Green-top Guidelines: (Link)
• World Health Organization (WHO):
  • WHO recommendation on routine antibiotic prophylaxis for women undergoing operative vaginal birth (Link)
  • WHO recommendations on maternal and newborn care for a positive postnatal experience (Link)
• International Federation of Gynecology and Obstetrics (FIGO):
  • FIGO good clinical practice paper: management of the second stage of labor (Link to Wiley Online Library)
• American Academy of Family Physicians (AAFP):
  • Article: Vacuum-Assisted Vaginal Delivery (Link)
  • Article: External Cephalic Version (Link)
• Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN):
  • Postpartum Care Resources: (Link – page was inaccessible during final generation, but AWHONN is a key resource)

Note: Guideline links and publication dates are subject to change. Always refer to the latest versions available directly from the respective organizations.