3.3 Operative Vaginal Delivery, Cesarean Birth & VBAC/TOLAC

3.3 Operative Vaginal Delivery, Cesarean Birth & VBAC/TOLAC

Operative vaginal birth and cesarean delivery represent major intrapartum interventions utilized to resolve labor dystocia, maternal medical compromise, or non-reassuring fetal status. Inpatient obstetric nurses must be skilled in operative delivery assistance, neonatal head trauma differentiation, perioperative surgical care, and risk stratification for trial of labor after cesarean (TOLAC).

---

Operative Vaginal Delivery: Forceps & Vacuum Extraction

Operative vaginal delivery involves applying forceps blades or a silicone/plastic vacuum cup to the fetal head to assist maternal pushing efforts during the second stage of labor.

Clinical Indications

• Prolonged Second Stage: More than 3 hours of pushing in a nulliparous patient or more than 2 hours in a multiparous patient, regardless of epidural use. Diagnose arrest and choose operative assistance only after individualized assessment of progress, rotation, descent, maternal condition, fetal status, preferences, and clinician skill.
• Non-Reassuring Fetal Status: Suspected fetal hypoxemia requiring urgent delivery in the second stage.
• Maternal Medical Indications: Maternal cardiac disease, severe hypertension, or neurological lesions where voluntary Valsalva pushing is medically contraindicated.

Mandatory Clinical Prerequisites

1. Cervix 10 cm dilated and completely effaced.
2. Membranes ruptured.
3. Fetal head engaged, with position and exact station documented; +2 describes a low procedure, not the universal definition of engagement.
4. Fetal head position, station, and rotation precisely determined.
5. Maternal bladder emptied (catheterized prior to application).
6. Adequate maternal anesthesia established.
7. Informed consent obtained after explaining the reason, alternatives, material maternal and neonatal risks, and possibility of failed assistance and cesarean.
8. Backup emergency cesarean capability available.

Vacuum Extractor Safety Rules

• The cup is applied over the pivot point / flexion point (mid-sagittal line, 3 cm anterior to the posterior fontanelle).
• Traction is applied only during uterine contractions while the patient pushes.
• Discontinuation Criteria: Stop for no progressive descent, repeated cup detachments, excessive time or pulls, worsening fetal status, or unsafe placement. Common limits such as three detachments or 15–20 minutes are guardrails, not substitutes for device instructions, policy, and earlier abandonment when descent is absent.

---

Differential Diagnosis of Neonatal Scalp & Cranial Trauma

Operative deliveries carry risk of fetal cranial trauma. Nurses must differentiate between caput succedaneum, cephalohematoma, and subgaleal hematoma.

CRITICAL CLINICAL ALERT: The subgaleal space can accommodate more than 250 mL of blood (over half an infant's blood volume). If a subgaleal hematoma is suspected following vacuum extraction, measure serial head circumferences, assess for boggy scalp swelling expanding past the ears and neck, and monitor for tachycardia, pallor, and hypotension.

---

Other Birth Procedures: Version, Episiotomy, Breech & Twins

External cephalic version (ECV) may be offered near term for a non-cephalic singleton when vaginal birth would otherwise be appropriate. Before the attempt, verify presentation and placental location by ultrasound, reassuring fetal status, informed consent, cesarean capability, and Rh status. Monitor FHR before and after; complications can include transient FHR changes, membrane rupture, bleeding, abruption, fetomaternal hemorrhage, or emergency cesarean. Give Rh immune globulin when indicated.

Episiotomy should be selective rather than routine. It may create space for an urgent procedure but does not relieve the bony obstruction of shoulder dystocia. After any vaginal birth, inspect and classify lacerations, assess pain and bleeding, and escalate concern for hematoma or anal-sphincter injury.

Planned vaginal breech birth and twin birth require carefully selected patients, skilled clinicians, immediate operative and neonatal support, and continuous reassessment. For twins, confirm presentation after the first birth because the second twin may change lie. A non-cephalic first twin or lack of experienced support commonly shifts the plan toward cesarean; local criteria and informed preference govern.

---

Cesarean Birth: Perioperative Nursing Management

Cesarean birth is the delivery of the fetus, placenta, and membranes through abdominal and uterine incisions.

Preoperative Nursing Care

• NPO Status & IV Access: Ensure NPO status and establish a large-bore (18-gauge) IV catheter.
• Aspiration Prophylaxis: Administer oral non-particulate antacid (Sodium Citrate / Bicitra 30 mL PO) 30 minutes preoperatively to neutralize stomach acid and reduce the risk of Mendelson syndrome (aspiration pneumonitis).
• Antibiotic Prophylaxis: Administer IV Cefazolin (2 g or 3 g depending on body weight) within 60 minutes before skin incision.
• Thromboembolism Prevention: Apply Sequential Compression Devices (SCDs) prior to surgery.
• Uterine Displacement: Position the patient on the operating table with a left lateral tilt (wedge under right hip) to prevent inferior vena cava compression and supine hypotensive syndrome.
• Bladder Decompression: Insert an indwelling Foley catheter with a urimeter after regional anesthesia is placed.

Surgical Incisions & Uterine Scar Implications

• Skin Incisions: Pfannenstiel (low transverse "bikini cut") vs. Vertical midline.
• Uterine Incisions:
  • Low Transverse: Most common; safest uterine scar with <1% risk of rupture in subsequent pregnancies.
  • Low Vertical: Uncommon; lower segment vertical incision.
  • Classic Vertical: Incision into the contractile upper fundus of the uterus. ABSOLUTE CONTRAINDICATION to future TOLAC/VBAC due to high uterine rupture rate (~4–9%).

---

Trial of Labor After Cesarean (TOLAC) & VBAC

Trial of Labor After Cesarean (TOLAC) refers to a planned attempt to labor by a patient with a prior cesarean birth, leading to a Vaginal Birth After Cesarean (VBAC) if successful.

Candidate Eligibility & Selection Criteria

• Eligible Candidates:
  • One or two prior low transverse cesarean deliveries.
  • Clinically adequate maternal pelvis.
  • No other uterine scars, prior uterine ruptures, or transfundal surgical procedures.
  • In-house obstetric physician and anesthesia staff immediately available to perform emergency C-section if needed.
• Strongest Predictor of VBAC Success: History of a prior successful vaginal delivery (success rate exceeds 80–90%).
• Absolute Contraindications:
  • Prior classic vertical or T-shaped uterine incision.
  • Prior transfundal uterine surgery (e.g., extensive myomectomy entering endometrial cavity).
  • Previous history of uterine rupture.
  • Contraindications to vaginal birth (e.g., placenta previa, transverse lie).

Intrapartum TOLAC Nursing Considerations

• Continuous Electronic Fetal Monitoring (EFM) is recommended during TOLAC.
• Epidural Analgesia: An acceptable option during TOLAC. It does not obscure the most common sign of rupture, which is an FHR abnormality; continue continuous surveillance and evaluate new maternal or fetal findings promptly.
• Cervical Ripening Caution: Misoprostol should not be used for term ripening or induction after prior cesarean. Mechanical methods may be options; dinoprostone requires individualized guideline- and policy-based assessment rather than being treated as identical to misoprostol.