VACUUM EXTRACTION

Prof. dr. Mgs. H. Usman Said, SpOG (K)

Subbagian Fertilitas Endokrinologi & Reproduksi Departemen Obstetri & Ginekologi FK. Unsri / RSUP Dr. Muhammad Hoesin Palembang 2010
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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
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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
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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
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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
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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
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Vacuum Cup Application

Application over sagittal suture touching posterior fontanelle

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Axis of Parturition

Vacuum Application/Traction
Incorrect Correct

Vacuum Failure - Rules of Threes

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

faulty equipment/poor seal causing vacuum leak excessive traction force unrecognized CPD mid-pelvic application OP presentations deflexed attitude improper angle of traction causing shearing

impingement of maternal soft tissue at introitus

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VACUUM MNEMONIC

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Forceps Delivery

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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
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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
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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

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Classification of Forceps Delivery Outlet Forceps

scalp visible at the introitus without separating the labia fetal skull has reached the pelvic floor the sagittal suture is in: AP diameter or right/left occiput anterior or posterior position fetal head is at or on the perineum
ACOG: "Committee in Obstetrics, Maternal and Fetal Medicine" 17

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" 18

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

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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)
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Check the Application

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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
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From: Human Labour & Birth, Harry Oxorn 23

Axis of Parturition

From: Human Labour & Birth, Harry Oxorn

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Traction
1) Direction 2) Amount

From: Human Labour & Birth, Harry Oxorn

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Head Compression

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Rotation

Incorrect (Ouch!)

Correct
From: Human Labour & Birth, Harry Oxorn

Rotation should be completed by moving the handle in a wide circle so the toe remains 27 fixed for rotation, otherwise one is carving vaginal sidewalls.

FORCEPS MNEMONIC

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Comparison of Forceps and Vacuum Delivery

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Comparison of vacuum to forceps

8 randomized, prospective trials Outcomes delivery by intended method cesarean delivery maternal analgesia requirements maternal and neonatal morbidity
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Forceps versus Vacuum: Maternal

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Forceps versus Vacuum: Neonatal

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Advantages of Vacuum Extraction

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

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Disadvantages of Vacuum Extraction

Cephalohematoma subaponeurotic (subgaleal) hemorrhage Neonatal retinal hemorrhages uncertain clinical significance

More likely to fail to deliver, requiring alternative Patients must be made aware of these risks
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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

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VACUUM EXTRACTION AUDIT TOOL

Patient Demographics Indications Prerequisites Procedure Outcome

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