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Vaccum delivery
- 1. Vacuum delivery Indunil Piyadigama 54thAnnual Scientific Congress Sri Lanka College of Obstetricians and Gynaecologists Labour Care and Ward Management – Pre-congress Workshop 25th November 2021
- 2. • The initialapplications of vacuum in deliveries began in the 18th century • Developed in 1705 by Dr. James Yonge • Was not popular until the 1950s • Was popularised due to series of studies published by a Swedish obstetrician called Dr. Tage Malmström • Older clinicians preferred forceps – Due to medical conservatism and original training, higher success rates, and a presumption of improved speed and control of the birth process • Trends in usage is changing - seemingly easy to use, requires less anaesthesia/analgesia, has lower maternal morbidity, and is commonly believed to be safe
- 3. Common features of a vacuum extractor Avacuum cup of varying shape, composition, diameter, and depth A fixed internal vacuum grid or guard within the vacuum cup A combined vacuum pump / handle or a vacuum port for a vacuum hose attachment A handle for traction
- 4. Different vacuum extractioninstruments Type of the cup - Stainless steel, Polyethylene or silastic plastic Location of the handle How the vacuum is generated
- 5. Metal cup • Amushroom-shaped metal cup varying from 40 to 60 mm in diameter • A centrally attached chain connects the cup to a detachable handle that is used to apply traction • A mechanical or electrical suction device is attached to the metal cup via a peripherally located vacuum port • The advantages • Higher success rate • Easier cup placement in the occipitoposterior (OP) position • Disadvantages • Difficult application • Uncomfortable • Associated with an increased risk of fetal scalp injuries
- 6. Soft or flexible vacuumcups • A bell shaped cup • Centrally connected vacuum pump • This same vacuum port is used for suction • Advantages • Less fetal cosmetic injury (principally scalp injury) than rigid cups • This partially reflects the inability of soft cups to generate the same degree of scalp traction as is possible when rigid cups are applied • Disadvantages • Have a higher incidence of failure than either rigid vacuum cups (plastic or metal)
- 7. Advances in vacuum devises •Traditionally, the soft cups are bell or funnel shaped. • A newer variety, the mushroom-shaped vacuum cup, or M-cup, combines the advantages of soft and metal cups • In some plastic extractor designs, the relatively rigid tube connecting the handle to the cup precludes accurate placement of the instrument when the fetal head is markedly deflexed or occiput posterior • The pump was in cooperated into the devise
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- 9. Indications for vacuum delivery No indicationis absolute • Distress Fetal • Shorten or reduce the effects of 2nd stage of labour • Ex – Class III, IV heart disease, hypertensive crisis, myasthenia, proliferative retinopathy • Previous CS • Maternal exhaustion Maternal • Primi - > 3hrs, >4hrs with regional anaesthesia • Multi - > 2hr, >3hrs with regional anaesthesia Inadequate progress
- 10. Relative contraindications for vacuum delivery Vacuum shouldnot be used before 34+0 Fetal bleeding disorders Predisposition to fracture Maternal blood borne viral infections Before full dilatation
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- 12. Examination • Head 1/5thor less palpable Abdominal • Vertex • FD, Membranes ruptures • Position of the head • Caput/ moulding – 0, +1, +2 (can separate), +3 (cannot separate) • Adequacy of pelvis Vaginal
- 13. Preparation • Explanation ofthe procedure • Informed consent • Verbal • In theatre written • Empty the bladder • Lithotomy position • Edge of the table • Continuous CTG monitoring • Additional help
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- 15. Setting • Higher riskof failure should be considered a trial – Theatre should be ready for CS within 30 minutes • Ex – • BMI >30 • EFW > 4kg • OP position • Mid cavity delivery/ head is palpable 1/5th • Delivering in theatre doubles the decision to delivery interval (from 20 minutes to 59 minutes) • For fetal distress in LR delivery can be done in 15minutes and in theatre in 30 minutes • Therefore, risk benefit should be assessed before transferring
- 16. Other problems tobe expected • Shoulder dystocia • PPH • Neonatal resuscitation
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- 20. • Episiotomy -is not recommended as a routine measure during a VE operation unless the soft tissue impedes the descent of the presenting part • Ideally, descent of the presenting part should begin with the initial traction effort • If the operator is uncertain that descent has occurred, a maximum of 2 additional tractions may be attempted
- 21. • The maximumduration of a vacuum extraction is unknown • A maximum of 2-3 pop offs, three sets of pulls and/or a total application time of 15-20 minutes have all been recommended
- 22. When to abandon When noprogressive descent with moderate traction during each contraction Where delivery is not imminent following 3 contractions of a correctly applied instrument by an experience operator
- 23. Sequential use ofinstruments • Increased risk of trauma to the infant – ICH, seizures, facial nerve injury, low APGAR • Increase risk of lacerations and PPH • Changing the delivery instruments can constitute good management. These include those in which technical problems, such as a malfunctioning hand pump, a misapplied vacuum cup, or traction in the incorrect vector of force • The least desirable cases are those in which traction without progress or multiple pop-offs occur following a correct application of the vacuum extractor and appropriate traction • Outlet or low cavity forceps following vacuum can be used to reduce the risk of CS
- 24. Following procedure • Cordblood • Simple analgesics • Antibiotics • Documentation – Contemporaneous • Attention to bladder function • Counselling before discharge
- 25. Comparison of vacuumvs forceps - Disadvantages More likely to fail Slower More cephalhematomas (10%) More retinal haemorrhages (50%) More maternal worries about the baby
- 26. Comparison of vacuumvs forceps - Advantages 3 times less perineal trauma than forceps Less risk of PPH Less pain at 24 hours Lesser chance of feacal incontinence within the first 24 hours
- 27. Comparison of vacuumvs forceps - No difference CS Low Apgar Need of phototherapy Long term faecal incontinence Infant outcomes at 5 years
- 28. Neonatal complications • Reportedincidence of fetal death or severe fetal injury from vacuum extraction is low • This range from 0.1-3 cases per 1,000 extraction procedures • Birth trauma is the major complication of operative vaginal delivery • The most serious complication is intracranial haemorrhage • Other complications • Hematoma • Abrasion • Laceration • Nerve palsy • Cephalohematoma • Retinal haemorrhage • Subgaleal haemorrhage • Skull fracture
- 30. • Cephalohematomas • Common •But clinically unimportant • Subgaleal hemorrhages • Relatively rare • But potentially life-threatening
- 31. Subgaleal or subaponeurotichaemorrhage • From rupture of the emissary vein • Condition is potentially life threatening – Mortality 20% • These bleeds happen occasionally after spontaneous delivery • Incidence varies from 0-50 per 1,000 vacuum extractions
- 32. Rotational vacuum vs Keilands Rotational vacuum deliveriesare 4 times more likely to fail Increased neonatal trauma and admissions with rotational vacuum
- 33. Summary • Newer vacumdevices are easy to use • There are no absolute indications for a delivery. Each case must be individually assessed • Cooperation of the patient is important • Systematic approach can reduce complications • Flexion point and the direction of pull are important technical aspects to master • Any procedure can be associated with complications
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