Vacuum assisted vaginal delivery with repair of first-degree vaginal tear

PREOPERATIVE DIAGNOSIS:                This a 34- to 35-week intrauterine gestation, preterm labor, arrest of fetal descent/maternal exhaustion.

POSTOPERATIVE DIAGNOSIS:             This 34- to 35-week intrauterine gestation, preterm labor, arrest of fetal descent/maternal exhaustion.

OPERATION PERFORMED:                    Vacuum assisted vaginal delivery with repair of first-degree vaginal tear.

ANESTHESIA:                                             Epidural.

FINDINGS:                                                    Live male infant with Apgar of 7 and 9, weight 4 pounds, 15 ounces.  Cord gases sent.  Venous pH 7.351 with a base excess of –5.1.  Arterial pH 7.159 with a base excess of –7.5.

INDICATIONS:                                             The patient is a 31-year-old primigravida, who presented at 34 weeks and 3 days with spontaneous rupture of membranes and labor.  The patient was admitted for observation of labor.  The patient progressed initially from 3 to 7 and then to full dilatation.  The patient began with maternal pushing efforts and successfully descended the fetal vertex down to the +4 station.  The patient was pushing for approximately one and half hours with arrest of fetal descent at the +4 station and with the position of the head in the direct OA position with the head visible without parting the labia and a outlet vacuum delivery was advised.  The patient and her husband were counseled regarding risks, benefits and alternatives.  They appear to understand and they agreed to proceed.

PROCEDURE IN DETAIL:                        Under adequate epidural anesthesia, the patient was prepped and draped in the dorsal lithotomy position in the standard fashion.  Fetal station was confirmed at +4 with the head visible in the direct OA position and the head visible without parting the labia.  The Mityvac mushroom-shaped vacuum was placed about the fetal head.  Adequate confirmation was identified in association with a single maternal pushing effort and uncomplicated delivery of the head was accomplished.  The nuchal area was checked and a nuchal cord x2 was identified.  These were reduced easily on the perineum.  The infant was bulb suctioned on the perineum.  The head spontaneously rested and the shoulders were brought to direct the anterior posterior diameter of the pelvis.  After confirmation of descent, the anterior _____ this and into the vaginal canal.  Gentle downward retraction was placed in association, with maternal pushing effort an uncomplicated delivery of the anterior shoulder was accomplished followed by spontaneous delivery of the posterior shoulder and remaining body and small parts.  The cord was then doubly clamped and cut.  The infant passed off to neonatal pediatrician for further care.  When a 5-minute Apgar scores were 7 and 9, segment of cord was sent.  From venous and arterial cord gases, venous pH was 7.351 with a base excess of –5.1, arterial pH was 7.159 with a base excess of –7.5.  The placenta was then delivered manually and all placental parts were accounted for.  An examination of the uterus was then performed manually and an empty cavity was confirmed.  The cervix and vagina were then examined for hemostasis, which was assured.  A small first-degree tear of the vagina and superficial perineum was identified.  The vagina was repaired using a running lock suture of 2-0 chromic.  The perineum was reapproximated using 2-0 chromic in an interrupted fashion and the perineal skin was reapproximated with interrupted mattress sutures of 3-0 chromic.  Adequate reapproximation and adequate hemostasis was obtained.  The vagina was scored at the end of procedure, found it to be free of foreign bodies.  Needle and sponge counts were correct.  The patient was then left to recover in LDRP spectrum.