Most surgical conditions that occur in the nonpregnant patient also occur in pregnancy. For a surgical problem that arises during pregnancy, the urgency of surgical treatment must be balanced against the risk that such treatment poses to the mother and the fetus. Current obstetric literature and legal case reports reveal that obstetric forceps and the vacuum extractor are coming back into the mainstream of obstetric practice. Cesarean delivery has been a major tool to assist the obstetrician in improving pregnancy outcome. Urologic injuries occurring during the course of pregnancy or more commonly during surgical or instrumental delivery, can result in serious and potentially life-threatening complications to both the mother and the unborn infant. Most urologic injuries from vaginal or abdominal surgical procedures on pregnant women involve some form of direct mechanical injury or compromise to the bladder or ureters.

This chapter discusses instrument design, technique of application, and the risks and benefits of assisted delivery. The principal controversies concerning instrumental delivery by both forceps and the vacuum extractor are reviewed, and recommendations are made about the use of these instruments. The focus of this presentation remains the desirability and safety of instrumental delivery and a critical analysis of what constitute the best modern practice. Delivery instruments are conveniently classified into eight types: five of forceps, two of vacuum extractors, and one for miscellaneous instruments. The most important contraindications to vaginal delivery operations are operator inexperience and the inability to achieve a proper application. Educating clinicians in the appropriate use of force in instrumental deliveries is a difficult task. Instrument application involves forceps operation, and vacuum extraction. Maternal perineal lacerations are common complications of all operative vaginal deliveries; most are associated with episiotomy.

This chapter presents an overview of both maternal and infant birth injuries, considering their etiology, potential methods of avoidance, and critiques of current obstetric practices. The more significant maternal complications of parturition include birth canal lacerations, episiotomy extensions, other perineal or rectal injuries, and various degrees of intrapartum and postpartum hemorrhage. Certain clinical settings predispose to birth injury, including labor stimulation, dystocia/macrosomia, preterm delivery, the diagnosis of acute fetal jeopardy from any cause, and instrumental or cesarean delivery. Superficial maternal birth canal injuries such as soft-tissue abrasions, ecchymoses, or small lacerations are common enough to be considered normal. Vaginal and cervical lacerations, urinary tract dysfunction, uterine infection, uterine rupture are other specific maternal birth injuries discussed in the chapter. The most common direct fetal injury after maternal blunt trauma is a cranial fracture.

This chapter explains the indications for the Caesarean section organised into four categories. In principle, the considerations are that the decision to delivery time for category 1, where immediate threat to life of women or fetus, should be less than 30 minutes and mother's safety is paramount. The majority of deliveries are achieved through a low transverse abdominal skin incision and a transverse incision through the lower segment of the uterus. The chapter discusses the maternal or fetal compromise, the necessity of early delivery, and elective Caesarean section, explaining their ractical surgical steps, complications, and Caesarean hysterectomy. Instrumental delivery can be achieved through the use of vacuum extractor and forceps. Obstetricians should remain familiar with the technique of assisted vaginal breech delivery, as some patients will present with breech presentation in preterm labour or in advanced labour. Twin pregnancies have a higher incidence of pre-term labour, IUGR and preeclampsia.

This chapter discusses the effect of neuraxial analgesia on caesarean section rates, instrumental delivery rates and the duration of labour. Neuraxial analgesia effectively relieves labour pain and is often chosen by parturients because of the known efficacy of the technique. Although in most cases, randomised controlled trials (RCTs) are the strongest study design in the sense that, when properly performed, they result in the least amount of bias, there are a number of barriers to consider when studying labour analgesia. The duration of first and second stage of labour has been compared in RCTs in patients who received neuraxial analgesia and opioid analgesia controls. Conversely, neuraxial analgesia may cause an increase in the incidence of instrumental vaginal delivery. When deciding which type of analgesia to offer a parturient, the benefits and risks must be assessed. Neuraxial analgesia provides the most complete analgesia when compared to any other mode of treatment.