Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 9.5 Operative Vaginal Deliveries
We discuss the pressing issues surrounding operative vaginal deliveries, including trends in their usage and the disparities impacting delivery outcomes. Join us as we navigate these critical insights with expert guests Jamie Perry and Howard Herrell, revealing the complexities and nuances surrounding forceps and vacuum deliveries.
• Examining the historical context of operative vaginal deliveries
• Analyzing the decline in forceps and vacuum usage since the 1990s
• Discussing the rise of cesarean deliveries as an alternative
• Revealing racial disparities adjacent to delivery practices
• Outlining effective techniques for both forceps and vacuum-assisted deliveries
Learn more about this pressing topic and gain valuable insights by listening to our episode.
00:00:00 ntroduction and Overview of the Episode
00:01:18 The Decline in Operative Vaginal Deliveries
00:05:24 Forceps
00:24:21 Vacuums
00:49:30 Advice For Trainees
00:55:38 Four Tips for Forceps and Vacuums
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Welcome to Thinking About OB-GYN. Today's episode features Jamie Perry and Howard Harrell discussing operative delivery.
Speaker 2:Howard.
Speaker 3:Jamie.
Speaker 2:What are we thinking about on today's episode?
Speaker 3:Well, we're going to talk about operative vaginal deliveries. Exciting Well we're going to talk about operative vaginal deliveries. Exciting, yeah Well, it'll be up to you to make it exciting. But for the listeners, let me introduce again Jamie Perry, an old friend of mine and of the show you actually co-hosted once before years ago, back on episode 5.9.
Speaker 2:I did. I think we talked about lactation cookies.
Speaker 3:Among other things. Yeah, we also talked about lactation cookies, Among other things yeah, we also talked about virgin births. Among other things.
Speaker 2:yes, Well, any fans can go check out that episode if they need more.
Speaker 3:Yeah, well, yeah, okay, something like that. Anyway, you like forceps, or do you like vacuums?
Speaker 2:Yes.
Speaker 3:Yes to both.
Speaker 2:Yes.
Speaker 3:Okay, all right, unbiased, I see. Well, we're going to talk about both and at the end of the episode, remember, we need to come up with four tips for vacuums Maybe I'll do that and four tips for forceps.
Speaker 2:Sounds great.
Speaker 3:Okay, well, first let's talk about, just for a second sort of the state of affairs for operative vaginal delivery, the Just for a second sort of the state of affairs for operative vaginal delivery. The rates of both forceps and vacuum deliveries have been declining, but certainly since the 90s, while the rates of cesarean, of course, have been increasing. These numbers have been going down. These declining rates have had the biggest impact on the rate of primary cesarean delivery, because in theory, an operative delivery probably saves a primary cesarean not always, but then of course the number of primary cesareans also affects the total cesarean rate. So as we've seen a declining operative vaginal delivery rate since the 1990s, we've seen an increase in both the primary and total C-section rates.
Speaker 2:Right. If you can prevent the primary cesarean, you'll also likely prevent a subsequent future repeat cesarean delivery, since the rate of vaginal birth after c-section is so low. So for every primary cesarean delivery that you prevent, it's very reasonable to think that you save two or so total cesareans, given the birth rate. And that means for every percentage point drop you see in the operative vaginal delivery rate, you may be increasing the total cesarean delivery rate by two percentage points. Of course, that's assuming that every operative vaginal delivery would prevent a cesarean, which isn't always the case, but it's clear that cesarean delivery is replacing operative vaginal deliveries.
Speaker 3:Yeah, to put some numbers on it, in the 1990s a little bit over 5% of all deliveries were forceps deliveries and about 4% were vacuum deliveries. So about 9% to 10% total were operative vaginal deliveries. But by the 2000s forceps had declined to only about 2% of deliveries, with a slight increase in vacuum deliveries to nearly 5%. So still not quite 7% total but operative deliveries. But in the last decade or so these rates have declined to less than 1% of deliveries are forceps deliveries and less than 3% of deliveries are vacuum deliveries. Our most recent numbers from 2022 shows that only about half a percent of deliveries are forceps deliveries and only about 2.4% are vacuum deliveries. So that gives a total operative vaginal delivery rate of just under 3%.
Speaker 2:And if you think about that, then that's a 7% point decline in operative vaginal deliveries since the 1990s, which, if you buy my premise that you're preventing 2% points of the total cesarean delivery rate, then that's as much as a 14% increase in the total cesarean delivery rate that could be related to this decline.
Speaker 3:Yeah, and there's definitely some assumptions in there, like, of course not every operative delivery is going to prevent a cesarean. That's an assumption, but as it turns out, of course, over that same time the total cesarean rate in the 90s was about 20 to 21% and now the total cesarean rate has risen and it hovers around 33 or 34%. So that is a magnitude of nearly 14 percentage points. And the decline in operative vaginal deliveries isn't the only issue for certain, but it clearly has contributed significantly to the rise in cesareans.
Speaker 2:And the rates in the United States of operative vaginal deliveries are much lower than in comparable European countries. In France or Ireland or England, for example, the national operative vaginal delivery rate is around 12 to 13% for each of those. We also see a racial disparity in the use of vacuum and forceps in the United States. The most recent data from 2022 shows an operative vaginal delivery rate of 2.9% for white women, but only 2.3% for black and Hispanic women. We know that black women have a higher cesarean rate than white women and again, this women have a higher cesarean rate than White women and again, this is part of the issue. I do think it's also interesting to note how vacuum has become a much more popularly used instrument in the United States than forceps about five times more commonly used. So why has this happened?
Speaker 3:Well, a lot of it, I think, is related to the medical legal crisis that obstetrics began to face in the 1980s and 1990s, and obviously a big impact is what's happening in our training programs and the experiences our graduates are getting. We're just not training residents to do these sorts of deliveries as well as we perhaps once did, maybe, and they don't feel comfortable. So we can get into that a little bit some of the reasons for that. But why don't we start with forceps for a few minutes?
Speaker 2:Let's do it.
Speaker 3:All right. Well, I'm going to ask some questions then. So, in very broad terms, what types of forceps are at our disposal and what are some quick pros and cons of those different types? I know there are just gosh. There's probably hundreds of different forceps over the years. So what are the big ones we need to think about in the broad differences?
Speaker 2:So you're right that there are lots of different types, but only a few that are very frequently used. But in general categories are forceps used for cephalic presenting fetuses and ones used for breech vaginal deliveries. We have forcep categories for molded fetal heads and ones better, for an unmolded head, and then also can be categorized by the type of blade solid, an unmolded head and then also it can be categorized by the type of blade solid, fenestrated or pseudofenestrated.
Speaker 3:Fenestrated means having a window. It's a Latin word. I got your Latin words Very good, smarty. Yes.
Speaker 2:The Simpson forceps are commonly used, probably the most common. They have a complete window, so they are fenestrated. This allows a little bit firmer grip on the fetal head. Pseudofenestrated forceps have an indentation on the fetal side of the blade that provide slightly more grip than the fully smooth ones but are smooth on the maternal side and we think that this helps with prevention of vaginal lacerations. So that would be the Leucard modification to the Simpsons forceps, having that pseudo-fenestration. And then there are the smooth on both side type forceps. Most common is going to be Tucker-McLean forceps.
Speaker 3:And these names can all be so confusing because so many people have come along and just changed one thing and thrown their name on it. So, for example, there's a Leucard-Tucker-McLean that's actually a pseudo-fenestrated forcep, but then when you see these things through prep and pack, they have all sorts of the wrong names on them and mislabeled, and then, I think, culturally different people call forceps by the wrong name. So, whatever your forceps look like, just Google the picture and find out what they really are, because I think there's just a lot of confusion about which ones are which.
Speaker 2:Absolutely. I went on a miniature rampage on a slow morning at the hospital a few months ago, unwrapped all 40 pairs of forceps and laser engraved each of them to the appropriate name, hoping it would help us with identification. But you're right, the difficulty with them all being named after people makes it challenging too, instead of what their purpose or indication is. So the pictures do help quite a bit. We didn't mention that there are some forceps that can be used for rotation of the fetal head, such as Keelan's. Most forcep types do have a lock, either an English lock or a sliding lock, and then big differences in them also are the cephalic curves and the pelvic curves. That might make them easier to use in specific situations.
Speaker 3:Like a Elliott type forceps for Skanzonis.
Speaker 2:Correct.
Speaker 3:Yes, should we spend the next to the rest of the hour on the Skanzoni maneuver?
Speaker 2:Absolutely not.
Speaker 3:That's a different episode, okay, well, I do think rotational forceps are probably beyond the scope of what we're going to talk about here today.
Speaker 2:Fully agree with that, but it is worth mentioning that Piper forceps, which are used for aftercoming breech heads, are a completely different design than the rest of the types that we've mentioned.
Speaker 3:Yeah. So I also think you probably need to be good, you probably need in your inventory two or three types of forceps if you're doing this and develop your expertise, and you don't have to have all these forceps at your disposal. And so for most of us that's going to be the ones you've mentioned. Maybe it's Simpsons, which there's a lot of and so they're all over the place, or the modified Simpsons that are not fenestrated, something like that. They're also useful for cesareans.
Speaker 3:I prefer if I have a difficult cesarean, I prefer to use forceps rather than a vacuum. And then, of course, piper forceps. I think you have to have both for maybe the unexpected vaginal breach that walks through the door, or maybe that second breach, twin, that is anticipated or unanticipated. But also, again, at the time of C-section you've got an entrapped fetal head and piper forceps can come in useful there. And also, by the way, a good time to practice using them with your resident and learning how to use them, because those 3 am unexpected breach deliveries happen when they happen. So maybe Simpsons, pipers, tucker, mclean's pick your three that you're going to have in your inventory is my thoughts about it. Keep it simple and work on understanding those and how they work. Okay, so let's talk about the indications for using forceps.
Speaker 2:Absolutely. There's really not much difference between indications for using forceps and the indications for using a vacuum for delivery. We essentially treat it as the same list but we divide it into maternal versus fetal indications. I would guess that the most common maternal indication for an operative vaginal delivery is a prolonged second stage, but these can also be offered to shorten the second stage when needed, maybe for patient exhaustion or if she has an inability to effectively push. Less commonly, but importantly, some patients have medical comorbidities that might make pushing dangerous, with the cardiovascular changes that can come with Valsalva. That could be some particular heart structural abnormalities or if they had had a history of retinal detachment. And then we have the fetal indications as well, really, that's if there's any suspicion for fetal compromise present. That may be concern found with fetal heart tracings, but also for malposition, as you mentioned with the breached vaginal deliveries. We'll use operative vaginal delivery to expedite delivery when we see fetal distress in the second stage.
Speaker 3:Often and we're not going to spend a lot of time, or any time, talking about rotational forceps. We've done an episode of the podcast before talking about manual rotation and for a lot of people my age and younger that's the rotations we're doing. We're not doing the rotational forceps, so we don't need to spend much time on that. But you mentioned malpresentation, so by that we mainly mean not rotating misrotated heads, but breach after coming breaches and things like that. Okay, what about contraindications to forceps?
Speaker 2:Sure. Contraindications are an inexperienced provider or a provider who does not have the ability to perform an emergent cesarean section if the procedure fails. Other contraindications include an unengaged fetal head, an unknown fetal position and for the fetus, if we have suspicion that the fetus has a bone demineralization disorder or a bleeding disorder. I'll also add that a common question I get from my residents is if hepatitis C is a contraindication to instrumented delivery, which it isn't. However, we know that maternal HIV infection is a relative contraindication, even without having a positive viral load.
Speaker 3:Okay, let's go over the important sort of anatomical considerations when we choose to do forceps, or a vacuum, for that matter. Again, these issues are basically the same for both. What do we need to know about the maternal and the fetal anatomy? What do we need to be thinking about?
Speaker 2:So the first obvious consideration is fetal presentation.
Speaker 2:If a provider is planning a breech vaginal delivery, then Piper forceps should be brought into the room open and available.
Speaker 2:But for most of these we're going to be talking about cephalic presentation.
Speaker 2:A very clear understanding of the fetal position and the station is absolutely essential for success.
Speaker 2:I really encourage my residents to take their time evaluating this with thorough palpation and confirming with ultrasound if they need or desire. Certainly there's going to be times when an operative vaginal delivery needs to be performed urgently, such as in cases of fetal bradycardia, and a more rapid assessment is going to suffice. But in general, I advocate for even before attempting or offering an operative vaginal delivery, a thorough exam should be performed so the provider can get a really accurate understanding of not just the position but also the degree of the head rotation, how much asynclitism is present, how flexed is the fetal head. The provider needs to carefully evaluate the station, particularly with those arrest of descent cases, and know how much cap is present, how much fetal molding is present as well. Certainly we have to know the estimated fetal weight to ensure that the patient is even a candidate for an operative vaginal delivery, taking note of the risk for shoulder dystocia with suspected macrosomic neonates, and this is particularly if we're considering using forceps for a prolonged second stage, as we don't want to cause a shoulder dystocia.
Speaker 3:Well, and for vacuum-assisted deliveries, that list is the same essentially. The only stage is we don't want to cause a shoulder dystocia. Well, and for vacuum assisted deliveries, that list is the same essentially. The only thing we do have a more clear cut. I say clear cut, not everybody agrees about it, but generally texts will say that vacuums are contraindicated in gestational ages less than 34 weeks. For forceps we don't have such a clear cut. There'll be institutional policies that vary. They actually even make smaller forceps for preemies, things like that. But before 34 weeks we worry about the increased risk of bleeding with vacuums. But keep going. I interrupted you.
Speaker 2:Also, when performing my exam, I'm noting the maternal level of comfort because that may help me decide which instrument is going to be most appropriate to use and pay attention to the shape of her pelvic outlet and the length of her perineum. Okay, so, after all of this and doing this really thorough evaluation, the provider then has to decide which forceps are the most appropriate and what they're going to request. The goal when we're thinking about right forcep type is choosing the shape that's going to allow the blades to lie very closely and evenly against the head. Most providers are going to use the degree of molding as their decision tree at this point for what forcep type to request.
Speaker 2:So if we have an unmolded fetal head, we're thinking about the forceps that have blades that are more round and shorter to give the best fit. So that can be Elliott's or Tucker McLean's if you want a solid blade. But if you try to apply Elliott's, for example, to a very elongated or a very molded head, it would be a challenging application to get the ends or the toes of the blade all the way below the malar eminences. So that's going to create some serious pressure points along the face. We may also see blade slipping and more risk to the fetus. So when we have a very molded or elongated fetal head, we're thinking about the forcep types that have longer blades and more tapered cephalic curves, such as the Simpsons or the Leucar Simpsons, to give us a better fitting application.
Speaker 3:And in general, would you say that the fenestrated blades typically lead to more bruising and facial marks?
Speaker 2:They do. We certainly see increased facial marks with them. They do provide a tighter grip. I'm not certain that fenestrated blades are necessary for the amount of force that they can provide against the fetal head in our current obstetric practices.
Speaker 3:Yeah, yeah, okay. Well, pretend that I'm your resident and walk me through the proper technique for applying forceps and how we're going to do this delivery.
Speaker 2:Okay. So we are assuming that full consent has already been obtained from the patient. I want the patient to be in lithotomy position with a recently drained bladder. I like to pick my forceps up, articulate them together once and then I pull them back apart just to assess the level of tightness of the lock. So I know what to expect when I'm articulating. Something I remember to be helpful when I was learning and I still say in my head now is left, left, left, left. So this applies to any variation of the occiput anterior positions, but essentially it's the left blade is held in my left hand, goes on the left side of her pelvis, at the left fetal ear.
Speaker 2:Especially when you're doing these middle of the night deliveries and we're trying to affect a rapid delivery, sometimes we'll open the blades and there's a high adrenaline and you panic and forget things that you know really well. So those little tricks were helpful for calming me down sometimes. As far as which blade to insert first, there is some difference among provider opinion. The lock of most commonly used forcep types is on the left handle and the right blade slides in and then lays on top. So with a direct OA position the left blade is going to be placed first and then the right, for a really natural and easy articulation. If you did it the opposite, then the handles would have to be pulled apart, crossed over one another so that the right would be on top, and that's okay to do when you need. But it can be a little awkward to perform and provide stretch at the perineum and even shift your blade positioning a little bit. So because of that, some providers will always place the left blade first, regardless of fetal position.
Speaker 3:That's the English lock style forceps.
Speaker 2:Yes, correct, okay. Alternatively, many providers will prefer to place whichever is the posterior blade first for any oblique position. So let's imagine this with right occiput anterior, for example. In that situation, your blades are going to be placed at something like two o'clock and eight o'clock, so in that case your right blade would actually be inserted first, because it's going to be the most posterior or around eight o'clock. The reason for this is that posterior blade acts as a splint and prevents the head from further rotation to transverse while you're trying to place the anterior blade. But, as I mentioned, with this technique, before being able to articulate, the handles would have to be pulled apart and cross in order to facilitate locking For ease, though, let's say the patient in question is direct occiput anterior, and I'm order to facilitate locking For ease, though, let's say the patient in question is direct occiput anterior, and I'm about to place my first blade.
Speaker 2:So I have the resident hold the blade in the left hand very loosely, just by one finger and thumb, or two fingers and thumb. The opposite hand will take the index and middle finger and put it in the vagina on the left side of the fetal head. So the hand with the blade is driving the direction of the blade but not the force. Instead, the thumb of the vaginal hand is going to be applying all the force needed and it's against the heel of the blade and that helps to safeguard against that natural tendency to push when we meet resistance and provides a safety mechanism. So, starting with the toe of the blade flush against the fetal head, the handle is then going to take a wide arc towards the maternal thigh until it's about parallel with the floor and then brought towards the midline and that's going to take the toe of the blade in the correct position right along the fetal head and face. If resistance is encountered at any part of that, we reverse those exact movements and then try again. I usually have an assistant hold the handle of the first blade while I'm placing the second, but I do ask them to make sure that that handle isn't rotating or sliding up and down while I'm placing the second blade in the same manner, and then I articulate the blades.
Speaker 2:Now if they can't easily articulate, we have to assume that there's incorrect placement. Big mistake would be to try to force the lock together against resistance, because it usually means that one of the blade, probably the anterior one, needs to be advanced a little bit further so that the toe is curving down around the cheek and not at the brow, and that's a fairly easy adjustment, okay. So, once articulated, we do three checks before providing any traction to make sure that we have a good placement. First is finding the posterior font now, and we make sure it's right in the center of the blades and about one finger breadth above the level of the shanks. If that posterior fontanelle is much higher than a finger breadth, then that's going to be like pulling against a deflex head and so traction is only going to worsen that head extension and may prevent us from being able to deliver the fetus. So in that situation I would unlock the handles, just very basically lift the blades up one at a time without taking them out, and relock.
Speaker 2:The second check is running a finger along the whole length of the sagittal suture and confirm that it's perpendicular to the plane of the shanks.
Speaker 2:And third, we want the blades to lie very flat against the fetal head and face symmetrically, and shouldn't allow the provider to place more than a full finger between either blade and the head.
Speaker 2:If you can place more than a fingertip in that space, that should be a red flag for us that we have a short application, meaning that the toe of the blade is probably digging in at the brow and not all the way down under the cheek. If we were to put traction in that position, the blades can easily slip off and cause pretty serious injury to the fetus. So once all three of those checks are done, we verbally prep the patient in the room. We're ready to attempt delivery. The very last thing I have, or the very last thing that I do at this point, is have the nurse drop the bed low. It always surprises my residents early in their training how much the vector force changes as that head descends Right before disarticulation and removal of the blades. The handles are usually about 45 degrees above the horizontal, which would put me way up on my tippy toes if the bed's not all the way down.
Speaker 3:Yeah, and you take the blades off before the head's delivered.
Speaker 2:Yes, correct.
Speaker 3:Okay, what are some pitfalls or potential pitfalls or complications of a forceps-assisted vaginal delivery?
Speaker 2:So the first pitfall or mistake that I see is providers trying to apply the blades in a generic way every time, instead of modifying it based on the way that fetal head is particularly situated within the maternal pelvis. I know I keep saying it, but truly having a very clear awareness of the fetal head position is such a crucial key to success with forceps. The second is providers getting frustrated if the blades aren't articulating or applying very easily. I think it's pretty common to need to make small adjustments to get that correct placement, and sometimes I'll see providers try to make those adjustments by maneuvering the handle, twisting at the handle instead of having fingers inside, and making those small modifications to the blade itself. Here's another challenge or pitfall. This is particularly with our forceps types that are more narrow, such as Simpsons or Leucard Simpsons In a term fetus. I expect there to be a small gap at the distal end of the handles when my blades are fully articulated.
Speaker 2:A common error that I'll see providers do is grasping those handles and squeezing them hard together when applying traction. That's going to put some unnecessary compression on the head Instead. If we hold up at the finger guards, we can prevent that. And then the last challenge. This is a hard one to learn, but it's applying efficient and correct traction.
Speaker 2:I think it's easy for providers to intuit that it's going to take both downward and outward force to guide the head under the pubis and then out, but how to effectively apply that balance is challenging. I think it's easiest to do if your dominant hand is holding the forceps, palm up and at the finger grips, and that's providing your outward force, and the non-dominant hand using the palm will provide the downward pressure at the shanks. We have to remember to continually change the vector, though, and raise the handles once we see that biparietal diameter passing under the pubic symphysis. If we do that too soon, however, we're driving the toes of the blade into the vaginal walls and risking deep lacerations. A helpful pearl that I remember from residency is with our occiput posterior positions. It does require more outward than downward traction than in OA positions, because we're trying to promote that head flexion to affect delivery.
Speaker 3:All right. Well, by letting you go first with this forceps conversation, I don't now have to answer all these questions about indications and contraindications and prerequisites and all that stuff about operative vacuum deliveries, because, as we said, with a couple of exceptions, this is going to be the same for vacuums.
Speaker 2:Exactly.
Speaker 3:That's my cleverness is making you do all the hard work.
Speaker 2:I see it now. Well, you're welcome. You know we didn't really talk yet about criterias specifically, so why don't you go over that?
Speaker 3:Yeah, so by criteria we mean for forceps. So this applies to vacuums too the outlet, or low or mid. So for outlet for forceps or vacuum deliveries, this is when the scalp is visible at the introitus without having to separate the labia with your hand. It implies that the fetal skull has reached the pelvic floor and it's on the perineum, and the amount of rotation shouldn't exceed more than 45 degrees, meaning that the sagittal suture is in an anterior to posterior direction and it's slightly to the right or the left, but not by more than 45 degrees. Then there are low forceps where the fetal skull and the skulls.
Speaker 3:We talk about the fetal head, but we mean the skull, not the swelling. That might be three or four centimeters long sometimes, but when the fetal skull is at plus two station, meaning at least two centimeters beyond the ischial spines, and then that's subdivided into with and without rotation. So without rotation means that again, less than 45 degrees of rotation off the midline and with rotation meaning more than 45 degrees. And then there are mid forceps where the head's engaged, so it's at least at zero station, but it's still higher than plus two. It might be plus one, for example, and with mid forceps. If you needed rotation, that would essentially make it a high forceps, which is a delivery we wouldn't do. So if you were doing these rotations, if it was more than 45 degrees, that wouldn't be an option for a mid forceps delivery, whereas it might be an option for a low forceps delivery.
Speaker 2:Okay, can we talk about station for a moment? I bet I was at least three years into residency before I recognized people were using two different systems sometimes to describe station.
Speaker 2:So historically plus one or plus two was out of three, where plus three meant the leading edge was at the introitus and zero was at the ischial spines. So essentially the space from the spines to the introitus was just divided into thirds. But when we see plus two we mean two centimeters beyond the level of the ischial spines. And so in that scenario for a normal weight patient when the head is at the introitus it's typically plus five. But again, that's not to imply that we're dividing the total length into fifths but that the bony part of the head is five centimeters beyond the ischial spines.
Speaker 3:Yeah, and this change, I think in 1984 is when the criteria were redone, and so even in our own literature prior, in our textbooks and stuff, the idea of just measuring this with an objective measurement of centimeters was post 1984, essentially. But it creates a lot of confusion, as you said, and there's then there's cultural variation in which system nurses in particular use, and so, just like you, I definitely have noted that the fetal head was plus three and then been looked at by the nurse like I was crazy man because you couldn't see the fetal head at the introitus. But that's a difference in which system we're using, and she was using the three out of three system and thought it should be crowning. Essentially. So in our literature, in our terminology, we're speaking specifically of how many centimeters beyond the ischial spines the fetal head is and specifically the bony part of it, not the swollen part that she's been pushing with for two hours, which can be very confusing.
Speaker 2:Yes, absolutely. And just to be explicit about the remaining prerequisites for either type of delivery that we've not mentioned yet, we do require there to be a fully dilated and retracted cervix, ruptured membranes, engagement of the fetal head. We have to know the fetal head position, have the estimation of the fetal weight and we need to clinically believe that the mom's pelvis is adequate for vaginal delivery. We have to be able to confirm adequate anesthesia We'll talk more about what that means have the maternal bladder drained and, of course, have full informed consent, including the ability to abandon the procedure and quickly proceed with a cesarean if necessary.
Speaker 3:Yeah, another fun historical fact, and you have to look this up. People don't even believe it, but in the nineties in a lot of our textbooks they talked about vacuums as something you could use when you were eight or nine centimeters dilated, and forceps you had to be completely dilated for. So this stuff's interesting because when you get back you're reading a study from the 90s or a textbook from the 90s or you go back in the 80s and they're using the terminology differently, but you they're using the terminology differently but you need to be completely dilated for both. All those prerequisites that you just listed, which a good resident will document in the note, will be fulfilled, the same for both forceps and vacuums.
Speaker 3:I do think that there's maybe a difference in what exactly adequate anesthesia means. It's not ever defined exactly what it means in different situations, and different situations might require you to do slightly different things. But for a vacuum delivery, I think you're okay with a pedendal block or maybe even just infiltration of the perineum with a local anesthetic. In a lot of cases, especially for going natural, you're probably good or maybe you have time to inject lidocaine. But for forceps, when we say adequate anesthesia we're usually talking about an epidural.
Speaker 2:Agree, I think that's such an important point. Okay, well, how about you walk us through a vacuum placement and assisted?
Speaker 3:delivery. Well, nowadays there are different products still on the market, but nowadays mostly what you see are the soft cup vacuums. They've replaced older metal cups, which is how these started. We've had vacuums actually quite a long time and there's some subtle differences in the products that are out there.
Speaker 3:But in general, whichever product you have and it's probably the small cup you want to place that vacuum cup over the sagittal suture and the posterior edge of the cup should lie just in front of the posterior fontanelle.
Speaker 3:This is what people call the flexion point. This placement is really important and it will help the head flex correctly to present the smallest diameter of the head to the pelvis. When you apply traction, when you put it on, spend some extra time to make sure that there's no maternal tissue in the application. Just take your finger after you've sort of partially inflated it just very minimally inflated it to where it's sitting, and then run your finger around the full circumference of the cup to make sure there's no vaginal tissue, no cervix or anything else in between the cup and the fetal head. The vacuums that have a disc cup are a little easier to place correctly or in their correct place, I should say, if there happens to be some asynclism where the size of the bell-shaped devices just becomes a problem. So one of the criticisms that I think forceps operators have of vacuum enthusiasts like me or if I was British Hoover enthusiasts, you think they say Hoover.
Speaker 2:Absolutely not.
Speaker 3:Okay, never mind then. Mind, then, is that many people have taken a laissez-faire approach with vacuums, that they wouldn't do with forceps, meaning that they don't know the exact position of the head and they just put it on whatever swollen part is, presenting as if that's the part where that's the flexion point. That's where it should be. But this is wrong, and this is why you see failures and disengagements with the vacuum and maybe even some of the traumas if they're put somewhere other than the flexion point. You need to know exactly where you're placing this in order to minimize complications and maximize your success and chance of delivery.
Speaker 2:Yes, and so the problem with either type of procedure can be how much swelling is present and make it difficult to actually determine the fetal position. So never be afraid to utilize ultrasound during your placement or when you're trying to confirm which instrument you want to use, so that you know you're placing it in the correct manner.
Speaker 3:Yeah, and I'll talk a little bit more about ultrasound in a couple of minutes.
Speaker 3:But I do use ultrasound not all the time but not infrequently either as part of both my decision making to proceed with operative vaginal delivery and also, of course, to understand the head position, if I'm uncertain from my exam.
Speaker 3:And then, just like with forceps, the angle at which you apply the traction will change as the head descends into the pelvis. So the higher the fetal head is positioned when you start to pull, the more posterior your vector of traction should be. And as the fetal head descends and starts to come around the pubic bone and crown out, your hand will move up towards the ceiling. So one way I think about this and teach it is to imagine that your hand is going to draw out the capital letter J, where the hook of the J is pointed upwards towards the ceiling. So you pull with a posterior angle of traction for a while and you're making the large downstroke of the J, and then, as the head starts to come around the pubic bone, your hand moves up and it draws that hook at the end of the J up into the air. And that's how I think about the relative shape that I'm making as that changes as the head comes out.
Speaker 2:So J like Jamie, is that why you didn't do this episode with Antonia? Because A is pretty hard to write that letter during a vacuum delivery.
Speaker 3:Well, you found me out. You found me out. That's your purpose now. So J for Jamie.
Speaker 3:Okay, we never do rotations intentionally with these devices. There's lots of things that in the past people have talked about. Once the vacuum is applied, like rocking it, don't do that. Or, yeah, even thinking I need to rotate this. So I'm going to turn the handle of the vacuum device to rotate it. So that's also a thing you don't do. But if the fetal head needs to rotate, it'll do so on its own while you apply traction, if you're doing this in the correct way. And actually there's videos on YouTube of babies and if you've done enough of these, you've seen it where babies will turn, rotate almost all the way around just under the normal traction of the vacuum, and so that will happen on its own if it's going to happen. But we don't do anything to force it and we don't rock our hands back and forth with a vacuum or turn it.
Speaker 3:I put two fingers on the cup of my non-dominant hand to monitor its position and monitor for any impending detachment and kind of monitor, fight myself with the traction I'm placing and I say non-dominant hand I also will switch hands sometimes. So if I, if my. If I'm using my right hand and I'm right-handed and it's tired because I've been pulling and my left hand is stronger, I'll switch hands. But I do keep two fingers of the other hand on the cup. Your goal is to have the cup placed correctly and then to always have the traction exactly perpendicular to the cup at all times. So when you get just off of perpendicular, that's when you may start to have these disengagements. But those disengagements too could lead to scalp lacerations if you're angling off because of the shearing force you're applying, and so you really want to be perpendicular to the cup at all times.
Speaker 3:And of course that's changing as the fetal head descends and that vector is changing. And of course you're not trying to apply so much force that you cause a disengagement even though you've remained perpendicular. So the two fingers are there to help you monitor and have a sense of that and monitor that you are perpendicular to the cup. And then you leave the cup attached until the head is delivered. So, unlike forceps where you said take this off before the head comes out, you can leave the cup attached until you've completely delivered. And a lot of times I actively protect the perineum so I can do that You're not using much force at all at that last bit, so I'll go ahead and protect the perineum. I know with forceps, sometimes for me it's useful to have somebody else protect the perineum as I'm doing that, but people figure out different tricks for that.
Speaker 2:Okay, so what are some pitfalls for using the vacuum extractor?
Speaker 3:I think one big pitfall is just the sort of attitude I mentioned earlier that vacuums are easier and you need less information than forceps. I'm going to use the vacuum in a lower information situation, and so you end up using it perhaps incorrectly or placing it inappropriately. And so you end up using it perhaps incorrectly or replacing it inappropriately. I think personally that it's just as hard or in some ways more difficult than with forceps, like the ability to maintain that exactly perpendicular application as you go through in the vector changes and not have disengagements is more, frankly, sort of a nuanced touch and feel than just having forceps once placed correctly and just pulling. And so I think that the pitfall is thinking that this is an easier substitute for forceps and not respecting it just as much as forceps. So you've got to know just as much.
Speaker 3:All the things you went through about the fetal position and the maternal pelvis and stuff are just as important. And then, if you do have suboptimal placement or poor technique, you'll see these more violent disengagements, or people call them pop-offs, which then increase your rate of neonatal morbidity. Or even you can have these lateral pop-offs that cause shearing and cause scalp lacerations, things like that too, let alone the cephalohematomas and the bleeds and the things like that that are going to be more associated with disengagements. And then the other thing is cervical lacerations or vaginal lacerations caused by getting some of that tissue trapped between the cup and the fetal head.
Speaker 2:So when you're performing these, do you release the suction of the vacuum in between your pools and contractions and do you have a certain time limit that you follow or a certain number of contractions that you would continue trying?
Speaker 3:Yeah. So releasing the pressure in between contractions or in between pulls used to be a fairly popular thing, but we have lots of studies now that feel pretty confident that releasing the vacuum pressure doesn't appear to be associated with any improvement in neonatal or maternal outcomes. So I don't release it. I think that for the most part, most people have stopped doing that. So I don't release it. I think that for the most part, most people have stopped doing that.
Speaker 3:The truth is we don't have good data to talk about how many pulls or with forceps, or how many pop-offs or detachments with the vacuum, or how many minutes. When is it a failed forceps or a failed vacuum delivery? Is it a certain number of pulls? Is it a certain time limit? So people have some conventional wisdom about that, but not a lot of it is very evidence-based about when you should abandon the trial of operative vaginal delivery and proceed to cesarean.
Speaker 3:I do think for pop-offs, in terms of number of pop-offs, there's a difference in a mild, non-traumatic sort of disengagement and then the sort of violent disengagements that literally just pops off in terms of what that's going to do, potentially for neonatal hemorrhages and scalp hemorrhages and things like that.
Speaker 3:But in most circumstances and again, you're not going to find people write this down necessarily as a hard fast guideline but in most circumstances it's not recommended to continue a trial of a vacuum delivery or ventus delivery I should use that word at least once after you've had three disengagements and as far as a certain time limit again, we don't really have an established time, but if you've had it applied for more than five minutes from you know when you first put it on to when the delivery is affected, you do see about a little bit over a quarter I think it's 28% of newborns will have cephalohematomas, but most of those aren't that significant and five minutes is not a time where you should say it's been five minutes and we've not delivered, so we should give up. But keep in mind the longer you have it applied, the more cephalohematomas and things like that you're going to see.
Speaker 2:Okay. So now that we've gone through both of these types, I think the question probably everyone wants to know is what are we recommending to use then, forceps or vacuums, and is one better than the other? You use both, but more often utilize the vacuum, and I know Antonia predominantly uses forceps, so it sounds like I was brought here to break the tie and answer this.
Speaker 3:Well, you were brought here because your name starts with a J, oh, yeah, right, okay. Yeah.
Speaker 2:Fair enough, but what is the answer? Vacuum or forceps?
Speaker 3:Yeah Well, I think we'll both have different answers maybe a little bit to this question, and I think that just gets to how much personal preference and experience and comfort levels with things matter, and so this is one of those things where they both have pros and cons. Studies have shown that forceps are more likely to affect a vaginal delivery they're more likely to result in a vaginal delivery but vacuums are more likely to not cause third and fourth degree lacerations and a severe laceration. So I think for me, I like the aspect of not increasing my risk of lacerations and also in many cases I can get by with local anesthetic or a pedendal block is all I need for the patient, and I have a large percentage of patients who are not epiduralized. So I tend to favor vacuums more than forceps by a good margin. You said what? Five to one or something like that. I'm probably better than five to one, but I also think that if I need to deliver this fetus right now, I've got terminal bradycardia and I need this kid out now, not in five or eight or 10 minutes. Or if the mother can't participate, maybe, as you said, she shouldn't push for medical reasons, or she can't push because she just had an amniotic fluid embolism or something, and so if I can't rely upon her efforts, then I'm going to use forceps and rely upon my efforts. I need her to participate to make the vacuum delivery successful, and maybe she's just not a good pusher for that matter and hasn't really done what I've asked.
Speaker 3:I also prefer forceps. I think, as I said earlier, at the time of cesarean. I see that varies a lot too and I've looked before there are no good studies that say vacuum or C-section at forceps. It's just a thing. It's not really been studied. But as much as I like vacuums for vaginal deliveries, I do prefer forceps for the difficult cesareans because, well, I'm not worried about third or fourth degree tears, so that goes by the wayside. But I also worry about the ability with a vacuum to maintain that perpendicular traction with the cup as I'm pulling the head out because of the angles involved are difficult. So I actually prefer them for that too.
Speaker 2:Yeah, physician comfort level is so much of this. And your point about anesthesia is good, because forceps obviously require more anesthesia and obviously patient has a choice here. As someone who routinely performs both methods, I start with the discussion with the patient, giving the pros and cons of both and making sure she hears those in the context of her particular clinical situation. If there's a fetus at the outlet, yes, I am more likely to use a vacuum, especially if I think that our reason for delayed delivery is poor pushing efforts or something like that. But in the end, as far as choosing which instrument, it's often going to be which one we're most comfortable with and in that particular situation in that time. So there's lots of variables and not a clear cut right and wrong answer. Ideally, providers would be able to perform both methods proficiently.
Speaker 3:And that's going to require some volume in order to keep up your skill set in both of them too. But, as we said when we started the episode, we find ourselves as a community increasingly not very good at using both, and then our residents are seeing lower volumes, and it's just like route of hysterectomy If you only get so many uteruses in a residency program, you're probably going to come out most comfortable with one route of hysterectomy and not really have all of these options at your disposal, and so the same thing is true here, where we're not maybe getting the volumes and the kind of education we need for our residents. So maybe that segues us into and this is something that you're obviously passionate about how do we change that? How do we make the next generation better than us?
Speaker 2:Simulation is such a big part of this and that's nothing new. Anyone who loves forcep deliveries has probably read Denon's forceps and use that as our gold standard for understanding history Of these type of deliveries. In 1955, dr Denon said the intern, before being allowed to perform a forceps operation, should be giving a series of painstaking lectures on the subject. He or she should be drilled in detail repeatedly on the mannequin and should assist at numerous operations which should then be reviewed on the mannequin. When the instructor is satisfied that the training is properly prepared, the intern is allowed to do an easy case under direct supervision. So from that regard Nothing really has changed.
Speaker 2:Some of the medical legal atmosphere is different and cesarean delivery has certainly become the modern operative delivery. We just don't have a healthy respect anymore for the dangers of cesarean delivery, particularly with subsequent cesareans. So if a study shows that there's not really a difference between composite outcomes of operative vaginal deliveries and cesarean deliveries for the mother, let's say that observation is fundamentally flawed because all the women with cesareans have a scar on their uterus and that does compound future risks during pregnancy and even for future hysterectomy and other things.
Speaker 3:Yeah, definitely. Every second stage cesarean that's performed should at least have been an opportunity to think about the utility of an operative vaginal delivery for that patient. We see increasing rates of complications with cesareans performed on mothers who particularly have been pushing and they've been in the second stage for an hour or two or three and the fetus is at plus three or plus four and we're going back and doing cesareans and this is when you get those really increased risks of hemorrhage and cervical and vaginal lacerations and bladder and ureter injuries, even all those things that really make cesareans more complicated. And so the question for all of those patients should be was an operative vaginal delivery considered and what was the thought process there? Those are opportunities.
Speaker 2:Absolutely, and simulation is such an important way to increase our comfort level as a provider for these situations that are less commonly encountered.
Speaker 2:I'm such a firm believer in use of simulation and having just repetitive practice in a very low stress and low risk situation where you can work one-on-one with a provider to really focus on technique in a situation that has no chance of harming a patient and not really just for the technique purposes.
Speaker 2:But I find simulation with operative vaginal delivery to also be helpful for the purpose of having providers in my residence practice patient counseling, running through the prerequisite checklist, doing interdisciplinary simulation for the nursing staff to become more aware and more comfortable with these types of deliveries, doing the post-counseling, et cetera. So I think simulation is really important when we're having situations like this of less opportunity, seemingly high risk or sometimes scary for residents and providers to consider utilizing in their practice, just to increase their familiarity and comfort. Additionally, although it can be pretty cost prohibitive, there are delivery mannequins that can be purchased by hospitals and training centers that have traction measurement capability and that's useful then for training providers on how much force can be applied safely, helpful not just for operative vaginal deliveries but also for shoulder dystocia maneuvers.
Speaker 3:Yeah, that's one of the hardest things to train anybody, even for spontaneous vaginal deliveries, is how much force is appropriate and how much is inappropriate. So, yeah, the mannequins and our ability to train with modern teaching techniques and some of the technologies that have entered into it are much worse. But the legal landscape perhaps has worsened since Dr Denon gave that quote that you read, I think. The other thing for me that I'll just briefly mention is the role of ultrasound, and we don't have to go into great detail for that now. Back in episode 4.12, antoni andI talked about this concept of the angle of progression, and in episode 7.9, we talk more about cesareans for deeply impacted fetal heads, and so both of those are worth reviewing if you're interested in this subject. But with ultrasound today we can use ultrasound to know the exact bony position of the head, we can measure that angle of progression, and if you don't know what that is, go back again and listen and then use that to predict the likelihood of a successful operative vaginal delivery with very good precision, and we can definitely confirm fetal position, even in the face of significant swelling and other obstacles that limit us with our digital exam, and then just have much more confidence in proceeding.
Speaker 3:You can even place the blades of the forceps while you watch with ultrasound to confirm accurate placement and I certainly don't do these things on every single patient, but not by any means.
Speaker 3:But if someone's been pushing for a couple of hours and I'm nervous about what that means and I'm nervous about proceeding with an operative delivery or just can't tell what I'm feeling due to all the swelling, then I absolutely will measure the angle of progression, decide with the patient if that reveals a good certainty that we're going to be successful and then confirm, through all that swelling, exactly where my placement point is. So that's something else that Dr Denton didn't have at his fingertips and something we can be teaching residents because they need confidence and if they're uncertain in clinical practice about what they're feeling or whether or not this is dangerous to do, so that's a way of doing it. I haven't used angle of progression that much and maybe you and I don't need it as much, but teaching this to somebody going out into practice and they're one or two years out, if they can see the confidence or gain confidence from that, then that's wonderful. Okay, well, what advice would you give to trainees who are learning to perform these procedures?
Speaker 2:I think the first is to become expert in assessment of the descending fetal head, and that's not going to come if you're only trying to perform these very specific position evaluations on your prolonged second stage. Tons of cap it, very molded fetal heads. I'm sure I drive my residents crazy with this, but they know if they tell me a patient is completely dilated. My next question is what's our position? Even it's a grand multiple and she's crowning because they know that I expect that to be clearly evaluated and documented every time. It's just good practice.
Speaker 3:It's part of the exam.
Speaker 2:It is. And if that position is anything other than an OA variant, I have them, allow the patient to push for 20, 30 minutes and then review it again. And certainly don't hesitate to use ultrasound confirmation, just like you talked about, especially when you're new with this, and confirming if what you're feeling vaginally is what you see abdominally. And the next, like we've already mentioned, is doing your own simulation. We keep those bony pelvises around I'm sure most hospitals have them, and little mannequins and dolls as well, and I have them. Take forceps and place them inside the bony pelvis around the doll's head and really pay attention to how different small movements and manipulations at the handle maneuver the blades, so noticing what happens when you twist the handle a little bit and how that really dramatically changes the direction and angle of the blade. Watch what happens with the toe during disarticulation and also practicing how various incorrect placements can be adjusted easily.
Speaker 2:And the last piece of advice is that I would tell trainees is just stay prepared for the opportunity. Truly, my residents who actively seek out operative vaginal deliveries are the ones that find them and have higher numbers and that might look like closer monitoring and attention during second stage progress, instead of waiting for the nurse to pay you to tell her that the patient's been pushing for three hours. And it may look also like having the conversation early with patients to introduce that idea of a possible operative vaginal delivery, especially when you're in the room because of fetal heart tracing concerns. And certainly it means incorporating the nursing team, being willing to involve them in your decision-making, your counseling, being willing to provide them education and debriefing after an operative vaginal delivery, increasing their understanding and comfort level, getting them on your side with the importance of this procedure as a viable option for their patient. That goes such a long way in the patient's perception and even rates of being able to perform these.
Speaker 3:Yeah, I wanted to briefly mention something that Antonia and I have talked about before, online and offline, about how we should think about the rate of cesarean deliveries, ntsv rates, operative deliveries, things like that.
Speaker 3:So, of course, we are full of data about our primary cesarean rate, our total cesarean rate or the NTSV rate or some modification of that, and then it's also easy to measure the operative vaginal delivery rate, and, as we said earlier, that's just a smidge under 3% now, it's not many. So I think I like to think about this in a different way. If you're the average OB in America and you have a 34% cesarean rate total rate and you have a 3% operative vaginal delivery rate, well, the inverse of that is, you have a 63% spontaneous vaginal delivery rate babies that weren't instrumented and weren't cesarean. But these are averages, they're descriptive, they're not necessarily the goals or the numbers that we should be aspiring to, and so one of the mistakes I think that happens is people today look and they see a provider who has a higher operative vaginal delivery rate and they think that there's something wrong with that. They're doing too many. So people with only a 3% rate, though, in truth, are probably not practicing their best obstetrics, which is a theme of this episode, and you can see that by how much it's dropped since the 1990s. The rate is.
Speaker 3:But on the other hand, in the bygone days, in the 40s and 50s, there were people with every delivery was an operative vaginal delivery. There was no indication for them, they were just prophylactic forceps deliveries from Joseph DeLee, I thought they were preventing cerebral palsy. Everybody got a proctoepisiotomy and everybody got forceps and the mothers were unconscious and that's wrong too. And so we recoiled against the prophylactic forceps delivery to a point where only half a percent of women now are getting forceps deliveries delivery to a point where only half a percent of women now are getting forceps deliveries, and so we've overshot the mark quite a bit at the expense of doing lots more cesareans.
Speaker 3:So I think we have to change our paradigm about how we think about this. I think we should have more focus on what our spontaneous vaginal delivery rate is. And so if your operative vaginal delivery rate was, say, 10%, but your total cesarean rate in relationship to that was, say, 18%, then you'd have a spontaneous vaginal delivery rate of 72%, with that 28% being some mix of cesarean and operative deliveries. So I think that we could contextualize this better if we focused more on what our spontaneous vaginal delivery rate is, because it encompasses all the areas that we need to independently maximize. And also, I've never liked the NTSV rate that much because it gives people a pass on not doing external cephalic versions for breaches and it gives people a pass on twins, and so, anyway, I think we should push the spontaneous vaginal delivery rate and we shouldn't view harshly our colleagues who might have an 8% or 10% operative delivery rate, as long as their patients are safe and they have a lower cesarean rate, to show that they're doing that with intent.
Speaker 2:Yeah, I think that's such a great point. Certainly we don't know what the ideal rate of operative vaginal deliveries in a practice is and it absolutely is going to vary by your patient population and who you're treating. So probably somewhere higher than 3%, but would guess less than 15% is the right number, with a lot of variation depending on your patient population, of a reasonable operative vaginal delivery rate for your practice.
Speaker 3:Yeah, and remember, some of those European countries you mentioned are in the 10 to 12% range. Okay, well, we're running out of time, so we've got to come up with four tips for both forceps deliveries and four tips for vacuum deliveries. So we plan on doing the history of some of these things too. We totally don't have the time for that. We'll do it later For you history buffs, when Antonia's back. Next episode, we're going to talk about the history of the birth control pill.
Speaker 2:But for now let's do our four tips. Okay, I'll do forceps. So tip number one is simulation. We can't drive that home enough.
Speaker 2:I feel like a pair of forceps should be kept in every call room just for that ease of practice and availability. Number two is confidence about the fetal position, and if you can't tell what it is, don't be afraid to utilize the ultrasound to help confirm your findings. Third tip is knowing when to abandon your attempt at a forcep delivery, excluding situations that require a silent second stage. I still tell patients before I utilize forceps that the majority of the work is coming from them. I can only add so much force safely. So if progress is not easily evident with every contraction that I'm applying traction with, then attempt should be discontinued and transition to cesarean.
Speaker 2:And fourth tip I do feel like performing forcep deliveries with an experienced assistant helps to reduce those higher degree perineal lacerations. The other provider can help provide perineal support or assist with the blade removal. So remember that removing the forceps is exactly the reverse motions that were used to place them. And if you do it in that manner, that moment where the head and baby are coming out quickly, it can stop those blades from lacerating the vagina, stretching the perineum too much in that quick moment. So certainly advocate for using an experienced provider as an assistant. Okay, your turn.
Speaker 3:All right. So vacuums, okay. Well, number one is easy Make sure the cup is placed at that traction point and run your finger around and make sure there's no maternal tissues involved with the cup, the application, and use ultrasound if you need to, but don't assume that the swelling that's presenting with the fetal head is where the traction point is. You've got to know where the traction point is and put it in the right place. So that's number one is to get the right application. Number two if you do have a disengagement or a pop-off, think about why. It might be due to poor application and you've got it not on the traction point and you may need to change the position. It might be due to poor traction, where you don't have it exactly perpendicular, or it might be that this isn't going to fit. This is not going to work. Not all disengagements are created the same and try to understand what the disengagement is telling you. If your technique is good and your placement is good, I personally don't tolerate more than two disengagements before moving on to cesarean, even if the book might say three.
Speaker 3:Number three make sure you're making progress, just like you said before Sips. Make sure you're making progress with every pool, with each contraction and there's not necessarily a time limit. But you should be making significant progress with each pool and in most cases that does mean that delivery is going to occur in five minutes or less. So if you're not making progress again, you probably should abandon what you're doing and proceed with cesarean. And number four is my J. That's why you're here. Remember to pull in a posterior vector for the longest stretch as you're making the long arm of the J, and then start to pull upward only near the very end. Again, imagine writing the letter J in the air with your traction hand. So I think one more thing we could throw in 10 seconds is unless you have a really good reason, don't attempt both. If your vacuum isn't working, don't try forceps and there might be some really good reasons where there aren't cesarean resources available or something like that. But you should not be doing both types of deliveries on the same patient. Absolutely All right.
Speaker 2:Well, we'll types of deliveries on the same patient, absolutely All right.
Speaker 3:Well, we'll have you back on later this year.
Speaker 2:Hey, thanks for letting me come hang out today Talk about one of my favorite topics.
Speaker 3:Well, hopefully you have some more favorite topics.
Speaker 2:Well, there's not a lot of topics that can incorporate the letter J, but I'll come up with a list for you.
Speaker 3:Yeah, we'll figure it out. We'll figure it out, we'll figure it out. Chat GPT can come up with a list of things to start with Jay.
Speaker 2:Perfect.
Speaker 3:All right, and for everybody else we'll see you in two weeks.
Speaker 1:Thanks for listening. Be sure to check out thinkingaboutobgyncom for more information and be sure to follow us on Instagram. We'll be back in two weeks.