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   "(Bird\net.al demonstrated  provided the cup is applied\ncorrectly over the flexion point and traction\ndirected along the pelvic axis, autorotation of\nfetal head would occur in >90% of the fetal\nOP and OT positions17.\n•\nAnterior placement of the cup (in relation to\nflexion point) will aggravate de-flexion, and\noff-center placement of the cup will cause\nasynclitism. Both the situations will increase\nfailure rate due to larger diameter of engage-\nment and increase the chance of fetal injury.\n•\nAfter checking the correct application and\nensuring that no maternal tissue is included in\n\n--- Page 8 ---\n342\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nthe cup, pressure is raised to 0.8kg/cm2 almost\nstraightaway. There is no advantage in\nstepwise increase in pressure.\n•\nTraction on the apparatus should coincide\nwith uterine contractions and maternal\nvoluntary effort. To avoid the cup detach-\nment, ‘finger thumb’ position of the other\nhand is used.\n•\nThe use of sequential instruments is associated\nwith an increased risk of trauma to the infant.\nHowever, the operator should assess the risk\nof performing a second stage caesarean\nsection with a deeply impacted fetal head\nversus a forceps delivery following a failed\nvacuum.\n•\nBeware of shoulder dystocia, after the ven-\ntouse delivery. The association is co-incidental\nrather than causal.\n10.5   Place of episiotomy for ventouse delivery\nEpisiotomy should be discussed with the woman prior\nto any instrumental delivery and formal consent\nobtained and documented. Episiotomy is not routinely\nrequired for ventouse delivery. Clinical judgement is\nadvised.\nEpisiotomy may be necessary in case of:\n•\nRigid perineum.\n•\nBig baby.\n•\nFetal distress to hasten the delivery.\nIf the perineum seems to be splitting an episiotomy is\noften performed to limit the damage18. Episiotomy\nshould be done under anesthesia. (Local block if\nregional anesthesia is not insitu). Episiotomy is always\ngiven medio-lateral (median, increases chance of 3rd /\n4th degree tear. Premature episiotomy should be avoided\nand should be given at the time of crowning. (In case\nthe instrument fails to deliver the baby and C/S is\nrequired).\n11.  Forceps delivery\n11.1   Indications\n•\nDelay in the 2nd stage of labour.\n•\nFetal distress in the second stage.\n•\nAfter coming head of breech delivery.\n•\nMaternal conditions requiring short second\nstage.\n•\nDelivery of the head at cesarean section.\n11.2  Choice of forceps over ventouse\n•\nAfter coming head in breech vaginal delivery.\n•\nFace presentation (Mento-anterior).\n•\nPre-term infants <36 weeks.\n•\nWomen under anesthesia and unable to\ngenerate substantial expulsion.\n•\nA heavily bleeding scalp sample site.\n•\nSignificant caput in OA positions, when\nventouse cup is likely to come off.\n11.3  Pre-requisites for forceps delivery\n•\nAppropriately experienced operator.\n•\nRupture of membranes.\n•\nFully dilated cervix.\n•\nClear knowledge of the position of the fetal\nhead (use of USS will be helpful if uncertain\nfindings).\n•\nClinically adequate pelvis.\n•\nFetal head engaged at station +1 or lower\n(1/5 or less palpable abdominally).\n•\nAdequate analgesia (regional/pudendal block).\n•\nEmpty bladder.\n•\nAn adequately informed and consented\n(verbal) patient.\n•\nAvailability of pediatric support.\n(The careful abdominal/pelvic examination for the fetal\nhead station, position and fetal size is carried out as in\nventouse protocol.)\n•\nIf episiotomy is given it should be\nmeticulously sutured. Vaginal and rectal\nexamination is mandatory after instrumental\ndelivery.\n•\nThe woman and her partner if available are\ndebriefed regarding the procedure.\n•\nAccurate, legible documentation of the\nprocedure should made. Postoperative care\nplan including prescription of antibiotics,\nanalgesia and thromboprophylaxis should be\ncarried out when needed.",
   "Vaginal and rectal\nexamination is mandatory after instrumental\ndelivery.\n•\nThe woman and her partner if available are\ndebriefed regarding the procedure.\n•\nAccurate, legible documentation of the\nprocedure should made. Postoperative care\nplan including prescription of antibiotics,\nanalgesia and thromboprophylaxis should be\ncarried out when needed.\n\n--- Page 9 ---\n343\nVol. 43, No. 4, December 2021\nSLCOG Guideline\n11.4 Management of a failed attempted\nforceps delivery\n•\nIf the forceps cannot be applied easily, or if\nthe blades does not lock, or if there is  lack of\ndecent with moderate traction and maternal\npushing, it is prudent to abandon the forceps\ndelivery and resort to an emergency caesarean\nsection.\n•\nWhen attempting rotational forceps, the\nrotation should be achieved with ease and if\nnot should discontinue the procedure.\n•\nThe procedure should be abandoned and\nresorted to an emergency caesarean section\nif the birth is not imminent even after 3 pulls\nof a correctly applied instrument and a correct\ndirection in traction.\n•\nIf resorted to an emergency caesarean section\ndue to failed forceps, the obstetrician should\nbe aware that there is an increased risk of\nhead impaction and be ready to dis-impact\nthe head with known maneuvers.\n•\nThe neonatology team should be informed\nclearly about the failed forceps as there is\nincreased risk of neonatal morbidity following\ncaesarean section for failed forceps.\n12. Prophylactic antibiotics\n•\nFollowing instrumental vaginal birth, it is\nrecommended to give a single prophylactic\ndose of intravenous antibiotics to prevent\nmaternal infection.\n•\nAmoxicillin and clavulanic acid single dose can\nbe used for this purpose after confirming\nallergy status.\n13.  Postnatal care following instrumental\ndelivery\n•\nPostnatal care following instrumental vaginal\ndelivery requires the need to assess the\nrequirement of thromboprophylaxis to prevent\nthromboembolism, adequate pain relief,\nvoiding function, pelvic floor rehabilitation and\ndebriefing about the events in current birth\nand about future births.\n•\nFor pain relief NSAIDs and paracetamol\nadministered is adequate.\n•\nRoutine bladder emptying should be\nencouraged after instrumental vaginal birth to\nprevent urinary retention. It is prudent to\ndocument the timing and the volume of the\nfirst void urine following an instrumental\ndelivery.\n14. Postnatal psychological morbidity\n•\nDifficult childbirth can leave a traumatic\nexperience in women and ultimately result in\nfear of future childbirth. It will also impact\nquality of life with her partner and family,\nultimately leading to psychological morbidity.\n•\nShared decision making with the woman,\ngood communication, and continuous support\nduring and immediately after the childbirth\nhave the potential to reduce the psychological\nmorbidity following instrumental childbirth.\n•\nIt is best practice to discuss the indications\nfor the instrumental delivery, how the\ncomplications were managed and to advise\nregarding future births. This should ideally be\ndone by the obstetrician who attended the\nprocedure.\n•\nIt should be informed that there is a high\npossibility of a successful spontaneous vaginal\nbirth in the future pregnancies.\n15.  Clinical governance\n15.1  Proper documentation\na. Documentation should include detailed\ninformation on the assessment, decision making\nand conduct of the procedure, a plan for\npostnatal care and counselling for future\npregnancies.\nb. Use of a standard proforma for this purpose is\nrecommended and is best to be audited at\nregular intervals.\nc. Training the staff with using mannequins and\naccreditation of the trainees.\n15.2  Obtaining cord blood\nd. If facilities are available, cord blood be obtained\nin  instrumental delivery, and this should include\narterial as well as venous blood sampling. The",
   "If facilities are available, cord blood be obtained\nin  instrumental delivery, and this should include\narterial as well as venous blood sampling. The\n\n--- Page 10 ---\n344\nSri Lanka Journal of Obstetrics and Gynaecology\nSLCOG Guideline\nPH and base deficit can be documented in the\npatient operative notes.\ne. Institutes may strive to provide obstetric care\nunits with required facilities to perform cord\nblood gases.\n15.3  Risk management\nAdverse outcomes, including failed instrumental\ndeliveries, major obstetric haemorrhage, fetal injuries,\nand morbidity, OASI, shoulder dystocia and associated\ncomplications should trigger risk management meeting\nwith unit consultant. Adequate steps can be taken to\nreduce these events in the future and to properly\nmanage such complications. Frequent audits should\nbe undertaken on these complication rates and trends.\nReferences\n1.\nNHS Maternity Statistics, England 2016-17\n[https://digital.nhs.uk/data-information/\npublications/statistical/nhs-maternity-statistics/\n2016-17].\n2.\nDemissie K, Rhoads GG, Smulian JC, Balasubra-\nmanian BA, Gandhi K, Joseph KS, et al. Operative\nvaginal delivery and neonatal and infant adverse\noutcomes: population based retrospective analysis.\nBMJ 2004; 329: 24-9.\n3.\nTowner D, Castro MA, Eby-Wilkens E, Gilbert\nWM. Effect of mode of delivery in nulliparaous\nwomen on neonatal intracranial injury. N Engl J\nMed 1999; 341: 1709-14.\n4.\nNHS Maternity Statistics, England 2016-17 [https:/\n/digital.nhs.uk/ data-and information /publications/\nstatistical/nhs-maternity-statistics/ 2016-17]. last\naccessed 04 February 2021.\n5.\nPhilpott RH. The recognition of cephalopelvic\ndisproportion. Clinics in Obstet Gynaecol 1982;\n9:  609-24.\n6.\nMurphy DJ, et al. Cohort study of operative\ndelivery in the second stage of labour and standard\nof obstetric care. BJOG 2003; 110: 610-15.\n7.\nKean LH, Baker PN, Edelstone DI. Best Practice\nin Labor Ward management, Scotland: Elsevier\nScience Limited, 2002.\n8.\nO’Connel MO, Hussain J, Maeclennan FA, Lindow\nSW. Factors associated with prolonged second\nstage of labour – a case-controlled study of 364\nnulliparous labours. J Obstet Gynaecol 2003; 23:\n255-7.\n9.\nPaterson CM, Saunders NG, Wadsworth J. The\ncharacteristics of the second stage of labour in\n25,069 singleton deliveries in the North West\nThames Health Region 1988. BJOG 1992; 99:\n377-80.\n10. Arulkumaran S, Ingemarsson I, Ratnam SS. Oxy-\ntocin augmentation in dysfunctional labour after\nprevious caesarean section. BJOG 1989; 96:\n939-41.\n11. Chelmow D, Laros RK. Maternal and Neonatal\nOutcomes After Oxytocin Augmentation in Patients\nUndergoing a Trial of Labour After Prior Cesarean\nDelivery. Obstet Gynecol 1992; 80: 966-71.\n12. Weerasekera DS, Premartane S. A randomised\nprospective trial of the obstetric forceps versus\nvacuum extraction using defined criteria. J Obstet\nGynaecol 2002; 22: 344-5.\n13. Miksovsky P, et al. CME Review Article: Obstetric\nvacuum extraction: state of the art in the new\nmillennium. Obstet Gynecol Survey 2001; 56: 736-\n51.\n14. Lowe B. Fear of failure: a place for trial of\ninstrumental delivery. BJOG 1987; 94: 60-6.\n15. Johanson R, Cox C, Grady K, Howell C. Managing\nobstetric emergencies and trauma, The  MOET\nCourse Manual. RCOG Press 2003.\n16. Johanson RB, et al. North Staffordshire/Wigan\nassisted delivery trial. BJOG 1989; 96: 537-44.\n17. Bird GC. The importance of flexion in vacuum\nextraction delivery. BJOG 1976; 83: 194-200.\n18. De Jonge ETM, Lindeque BG. A properly\nconducted trial of a ventouse can prevent\nunexpected failure of instrumental delivery. SAMJ\n1991; 70: 545-6.",
-  "A properly\nconducted trial of a ventouse can prevent\nunexpected failure of instrumental delivery. SAMJ\n1991; 70: 545-6.\n\n--- Page 11 ---\n \n \n \n \nAnnexure 1 \n \n345 \nVol 43, No. 4, December 2021 \nSLCOG Guideline\n\n--- Page 12 ---\n \n \n \n \n \nAnnexure 1 (Continued) \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n             \n \n               \n \n \n \n \n346 \nSri Lanka Journal of Obstetrics and Gynaecology \n SLCOG Guideline\n\n--- Page 13 ---\n \n \n \n \nAnnexure 2 \n \n \n \n \n347 \nVol 43, No. 4, December 2021 \nSLCOG Guideline  \nPOSTPARTUM BLADDER CARE FOLLOWING \nINSTRUMENTAL DELIVERY"
+  "A properly\nconducted trial of a ventouse can prevent\nunexpected failure of instrumental delivery. SAMJ\n1991; 70: 545-6.\n\n--- Page 11 ---\n \n \n \n \nAnnexure 1 \n \n345 \nVol 43, No. 4, December 2021 \nSLCOG Guideline\n\n--- Page 12 ---\n \n \n \n \n \nAnnexure 1 (Continued) \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n             \n \n               \n \n \n \n \n346 \nSri Lanka Journal of Obstetrics and Gynaecology \n SLCOG Guideline\n\n--- Page 13 ---\n \n \n \n \nAnnexure 2 \n \n \n \n \n347 \nVol 43, No. 4, December 2021 \nSLCOG Guideline  \nPOSTPARTUM BLADDER CARE FOLLOWING \nINSTRUMENTAL DELIVERY",
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