This document provides an overview of vacuum-assisted delivery, including: 1) The introduction, instruments, advantages, indications, techniques, rules, procedures, disadvantages, contraindications, and complications of vacuum-assisted delivery. 2) Details on the components of vacuum devices, classification of assisted delivery, advantages of vacuum over forceps, and the 10 step procedure for vacuum delivery from asking for help to releasing the vacuum once the baby's jaw can be reached. 3) Potential maternal and fetal complications that can arise from technical errors or other issues with the procedure. Management, documentation and references are also covered.

1. MRS. SONY SARA P.J
ASSO. PROFESSOR
MSC (N),OBSTETRICS AND GYNECOLOGICAL NURSING
GANGA COLLEGE OF NURSING
COIMBATORE

2. VACCUM ASSISTED DELIVERY

3. CONTENT OVERVIEW
Introduction
Instruments
Advantages
Indications
Non conventional uses in Obstetrics
Technique
Rules for use of vaccum
Procedure
Disadvantages
Contraindications
Complications
Management
Documentation

4. INTRODUCTION
Vacuum (Ventouse) is an operation for the delivery of
the fetal head from the mother by use of a vacuum
extractor applied to the fetal scalp on presence of
maternal effort (Hughes)

5. INSTRUMENTS
Components:
•A suction cup with four sizes (30mm, 40mm, 50mm, 60mm)
– Metal cup
– Soft cup
– Silastic cup
– Rigid plastic cup
•Vacuum pump,
•Traction tubing

6. VACUUM DEVICES

7. ADVANTAGES
• Simple to use
• Less force applied to fetal head
• Done in LA/Block
• No increase in diameter of presenting head
• Less maternal soft tissue injury
• Less fetal injury

8. INDICATION
MATERNAL INDICATION
1. Maternal distress, exhaustion after a long, painful labor,
due to inefficient uterine contractions.
2. Prolonged second stage of labor
3. Maternal medical disorders such as heart disease,
hypertensive disorders and moderate to severe anemia.
4. Previous cesarean section or genital prolapse repair.
5. Intrapartum infection, certain neurological conditions.

9. INDICATION
Fetal indication
1. Prolapse of umbilical cord
2. Premature separation of placenta
3. Non reassuring fetal heart rate pattern
4. Fetal distress
5. Non rotated heads or occipitotransverse positions
6. Occipitoposterior position

10. NON CONVENTIONAL USES IN OBSTETRICS
1. To deliver 2nd of twin if head is presenting part
2. To deliver head at LSCS in following conditions :
– Large head
– Thin lower uterine segment in women with narrow pelvis
predisposes to laceration when manual extraction of fetal
head is performed so ventouse helps to prevent
manipulations which may endanger integrity of lower
uterine segment.

11. 3. To deliver frank breech : cup is applied on anterior
buttock
4. To arrest brisk hemorrhage in minor degree placenta
praevia with vertex presentation
NON CONVENTIONAL USES IN OBSTETRICS

12. • Outlet forceps or vacuum:
– where the fetal skull is on the pelvic floor
• Low forceps or vacuum:
– where the fetal skull is at or below +2 station
• Mid forceps or vacuum:
– where the fetal head is engaged but above +2
station
ASSISTED DELIVERY MAY BE CLASSIFIED AS

13. ADVANTAGE OF VACUUM OVER FORCEPS
• Can be applied at relatively higher station at head
• Can be applied to non rotated head
• Permits autorotation at head along with traction
• Compression force is less (1/20th as compared to
forceps)
• Does not require additional space between tight
fitting head and pelvis.
• Maternal trauma less

14. ADVANTAGE OF FORCEPS OVER VACCUM
• After coming head of breech
• Dead fetus
• Face presentation

15. TECHNIQUE
•The woman's bladder should be empty (via voiding or
catheterization).
•The patient is placed in the lithotomy position.
•Vaginal examination to check pelvic capacity, cervical
dilatation, presentation, position, station and degree of
flexion of head and that the membranes are ruptured
•Determination of flexion point

16. TECHNIQUE contd...
• Proper cup placement over flexion point
• Exclude maternal soft tissue entrapment by palpation
• Vacuum creation by increasing the suction in
increments of 0.2 kg/cm2 every 2 mins until 0.8 kg/cm2
• A check is made using the fingers round the cup to
ensure that no cervical or vaginal tissue is trapped
inside the cup

17. • The pressure is gradually raised at the rate of
0.1kg/cm2 per minute until the effective vacuum of
0.8kg/cm2 is achieved in about 10 minutes time
• The scalp is sucked into the cup and an artificial caput
succedaneum is produced, which dissapears withinn
few hours.
• Instrument handle is grasped, and initiation of
traction
TECHNIQUE contd...

18. TECHNIQUE contd...
• Traction is initiated by using a two-handed technique, i.e
the fingers of one hand are placed against the suction
cup, while the other hand grasps the handle of the
instrument
• Traction must be at right angle to the cup
• Traction directed initially downward then progressively
extended upward as head emerge
• Traction should be synchronous with the uterine
contractions; released in between the contractions.

19. • Once head is extracted, vacuum pressure is relieved;
cup is removed; vaginal delivery followed
• The total time from the application until delivery
should not exceed 20 minutes
• If >20 minutes, the risk of fetal scalp trauma and
intracranial damage increases
• Many pulls to achieve progress should not be done
• The operator should be wiling to abandon the
procedure if it does not proceed easily or if the cup
dislodges >3 times
TECHNIQUE contd...

20. RULES FOR USE OF VACUUM
 Traction is bimanual in the pelvic curve with close
attention to cup detachment and 3 finger grip
 All applications are subject to “three checks” prior to
traction
 Traction augments spontaneous or induced uterine
contractions
 Maximum time for cup application is 25 min
 Max. of five traction pulls

21.  Max of two cup detachments
 Advancement of fetal head should begin with first
attempted traction
 Applications to premature infants are to be avoided
 If cup slips -Second correct application at same place (do
not apply > twice)
RULES FOR USE OF VACUUM

22. PROCEDURE
There are 10 steps to be followed for vacuum delivery
 In English, these are easily remembered as A-J
– This comes from the ALSO (Advanced Life
Support in Obstetrics) organisation

23. VACUUM DELIVERY – STEP 1
Ask for help
 Address the woman (explain the procedure and ask
for consent)
 Adequate anaesthesia
 Abdominal palpation

24. 24
VACUUM DELIVERY – STEP 2
Bladder empty
• May need to be catheterised

25. 25
VACUUM DELIVERY – STEP 3
Cervix fully dilated
 Examine the woman
 Cervix should be fully dilated

26. VACUUM DELIVERY – STEP 4
Determine the position of the fetal head
– the anterior fontanelle is larger and forms a cross
– the posterior fontanelle is smaller and forms a Y
– assess for bending the ear
 Remember moulding of the head makes assessment
difficult
 Think about dystocia (is the fetus going to fit
through the pelvis?)

27. VACUUM DELIVERY – STEP 5
Equipment
Equipment and vacuum extractor need to be ready

28. VACUUM DELIVERY – STEP 6
Fontanelle
 Apply the cup over the sagittal suture 3 cm in front of
the posterior fontanelle
 Flexion point: proper application of the cup results in
flexion of the fetal head when traction is applied

29. VACUUM DELIVERY – STEP 7
Gentle traction
• Gentle traction at right angles to the plane of the
cup
 This must only be performed during contractions
 Rotary force, or para median application will cause
the cup to fall off

30. VACUUM DELIVERY – STEP 8
Halt
 Halt (stop) traction after each contraction
 Halt (stop) procedure:
– If the cup falls off three times
– If there is no progress in three consecutive pulls
 Do not take longer than
20 minutes for total application of the cup, or 30
minutes from the commencement of the procedure

31. VACUUM DELIVERY – STEP 9
Incision
 Incision or episiotomy needs to be considered when
the fetal head is being delivered
 This is not always necessary for vacuum delivery
although may be necessary for shoulder dystocia or
difficult delivery

32. VACUUM DELIVERY – STEP 10
Jaw
Release the vacuum when you are able to reach the
baby’s jaw

33. VACUUM DELIVERY ILLUSTRATED

34. DISADVANTAGES OF VACUUM DELIVERY
 It may take longer than forceps
 It needs the woman to co-operate
 There needs to be minimal cephalopelvic disproportion
i.e. the fetus should fit fairly easily through the mother’s
pelvis
 The cup needs to be placed properly
 Traction is necessary to avoid losing vacuum
 There may be a small increase in cephalhaematoma i.e.
bruising under the baby’s scalp

35. CONTRAINDICATION
• Operator inexperience
• Inability to assess fetal position
• Suspicion of cephalopelvic disproportion
• Fetal coagulopathy
• Preterm babies (<34 weeks) due to risk of fetal
intraventricular hemorrhage

36. •Macrosomia (≥4 kg)
•Soft tissues obstruction in the pelvis
•Breechpresentation and face presentation &
Transverse lie
•Incomplete cervical dilatation
CONTRAINDICATION

37. TECHNICAL ERRORS
• Vacuum leakage
• Incomplete or defective equipment
• Oblique traction
• Poor maternal effort

38. MATERNAL COMPLICATIONS
•Soft tissues injuries such as cervical tears, annular
detachment of the cervix, vaginal tears, perineal
lacerations and tears, extension of episiotomy, vaginal
wall and perineal hematomas.
•Traumatic postpartum hemorrhages
•Infection
•Genital prolapse

39. FETAL COMPLICATIONS
• Scalp laceration and bruising
• Subglial hematoma,
Cephalohematoma
• Intracranial hemorrhage,
intraventricular and cerebral
hemorrhages
• Retinal and sub-conjunctival
hemorrhages

40. •Neonatal jaundice
•Clavicular fracture, Shoulder dystocia
•Injury to CVI, CVII nerves, Erb palsy
•Hypoxia, particularly when extraction has taken a
long time and has been difficult
•Fetal death
FETAL COMPLICATIONS

41. MANAGEMENT
•To assess the effect on the mother and the fetus
•To start a Ringer’s solution drip and to arrange for blood
transfusion, if required & To exclude rupture of the uterus
•To assess if procedure is to be abandoned and consider delivery
by cesarean section
•Laparotomy should be done in a case with rupture of uterus.
•To administer parenteral antibiotic

42. DOCUMENTATION
• Indication for the procedure
• Anesthesia
• Personnel patient
• Instruments used : Cup, Tube, Vacuum
• Station
• Position
• Deflexion
• Complication

43. REFERENCES
• D.C.Dutta,”Textbook of Obstetrics including
Perinatology and Contraception". Seventh Edition.
• J.B. Sharma, “Midwifery & Gynaecological Nursing”
Avichal Publishing company:1st edition
• Jacob, Annamma (2009). A Comprehensive Textbook
of Midwifery.Second Edition. New Delhi: Jaypee Broth
ers Medical Publishers.