Assisted Vaginal Birth

Objectives

Indications
Prerequisites Classification Methods of application and traction Comparison of techniques Documentation

Vacuum Extraction

Vacuum

the vacuum extractor is an obstetrical forceps

outlet, low and mid applications as for forceps rotation procedures are not to be performed

If a person deficient in dexterity could succeed in applying the (vacuum) tractor ...it is quite probable that he would produce as much injury as benefit...
Hayes, 1831

Indications
Fetal

- suspected fetal compromise requiring immediate delivery

Maternal

prolonged second stage maternal conditions which contraindicate pushing conditions requiring a shortened second stage exhaustion

maternal

Contraindications - Absolute

nonvertex, face or brow presentation unengaged vertex

incompletely dilated cervix

clinical evidence of CPD

Contraindications - Relative

prematurity or EFW < 2500 g mid-pelvic station unfavourable attitude

Previous fetal scalp sampling is not a contraindication

Prerequisites

vertex presentation, term fetus, EFW >2500 g

vertex engaged
cervix fully dilated and membranes ruptured adequate maternal pelvis by clinical assessment

appropriate analgesia
maternal bladder empty experienced operator backup plan if procedure not successful

Avoidance of complications

Confirm indications and conditions for use

Proper anatomical placement

Avoid entrapment of maternal soft tissue Correct angle of traction

Avoid excessive force/torque

Coordinate traction to maternal effort Control descent/expulsion Apply the rule of threes; stop procedure

Vacuum Cup Application

Application over sagittal suture touching posterior fontanelle

Axis of Parturition

Vacuum Application/Traction
Incorrect Correct

Vacuum Failure - Rules of Threes

3 pulls, over 3 contractions, no progress Pop-offs: after one pop off, reassess carefully before reapplying After 30 minutes of application with no progress reassess

Vacuum Pop-Off - Causes

faulty

equipment/poor seal causing vacuum leak traction force

excessive

unrecognized CPD mid-pelvic application OP presentations deflexed attitude

improper

angle of traction causing shearing of maternal soft tissue at introitus

impingement

VACUUM MNEMONIC

Forceps Delivery

Function of Forceps

obstetrical forceps are for the following functions:

traction of the fetal head rotation of the fetal head flexion of the fetal head extension of the fetal head

these functions cause fetal head compression proper use minimizes this compressive force

Indications
Fetal

suspected

fetal compromise requiring immediate

delivery
Maternal

prolonged

second stage maternal conditions which contraindicate pushing conditions requiring a shortened second stage maternal exhaustion deflexed attitudes of the fetal head and malposition

Prerequisites

head engaged cervix fully dilated and ruptured membranes exact position of the head determined adequate pelvis bladder empty appropriate anaesthesia experienced operator adequate facilities and backup available

Forceps must never be before full dilatation or with an unengaged vertex

Classification of Forceps Delivery Outlet Forceps

scalp fetal the

visible at the introitus without separating the labia

skull has reached the pelvic floor

AP diameter or right/left occiput anterior or posterior position fetal head is at or on the perineum

sagittal suture is in:

ACOG: "Committee in Obstetrics, Maternal and Fetal Medicine"

Low Forceps

leading point of the skull is at station + 2 cm or more two subdivisions:

rotation of 45 degrees or less rotation more that 45 degrees

ACOG: "Committee in Obstetrics, Maternal and Fetal Medicine"

Mid Forceps

head is engaged leading position of the skull is above station + 1 cm alternative to mid forceps delivery is cesarean section - access to cesarean is necessary if mid forceps delivery is attempted

Station

Engagement
when the biparietal diameter of the head enters the plane of the pelvic inlet when the leading edge of the skull is at or below the ischial spines (station 0)

Check the Application

Checking the Application - Position For Safety

Posterior fontanelle midway between the blades and one finger breadth above the plane of the shanks with the lambdoid sutures a fingerbreadth above each blade Fenestrations of the blades should be barely felt and no more than a finger tip should be able to be inserted between the blade and the fetal head Sagittal suture perpendicular to the plane of the shanks

From: Human Labour & Birth, Harry Oxorn

Axis of Parturition

From: Human Labour & Birth, Harry Oxorn

Traction
1) Direction 2) Amount

From: Human Labour & Birth, Harry Oxorn

Head Compression

Rotation

Incorrect (Ouch!)

Correct

From: Human Labour & Birth, Harry Oxorn

FORCEPS MNEMONIC

Comparison of Forceps and Vacuum Delivery

Comparison of vacuum to forceps

8 randomized, prospective trials

Outcomes

delivery by intended method cesarean delivery maternal analgesia requirements maternal and neonatal morbidity

Forceps versus Vacuum: Maternal

Forceps versus Vacuum: Neonatal

Advantages of Vacuum Extraction

No increase in significant neonatal morbidity Less need for maternal regional/general anesthetic

Less maternal vaginal/perineal trauma

Disadvantages of Vacuum Extraction

Cephalohematoma

subaponeurotic (subgaleal) hemorrhage uncertain clinical significance

Neonatal retinal hemorrhages

More likely to fail to deliver, requiring alternative

Patients must be made aware of these risks

Documentation of Operative Delivery

the procedure must be clearly recorded in every case this documentation should provide an explanation of the operative intervention which has taken place including a description of the operative technique employed and its indication

Need for Intervention must be: convincing, compelling, consented to, charted

VACUUM EXTRACTION AUDIT TOOL

Patient Demographics Indications Prerequisites Procedure Outcome