WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital

CLINICAL GUIDELINES
SECTION B: OBSTETRICS AND MIDWIFERY

5 INTRAPARTUM CARE
5.11 ASSISTED VAGINAL DELIVERY

Date Issued: July 2003

Date Revised: January 2011
Review Date: January 2014
Authorised by: OGCCU
Review Team: OGCCU

5.11.2 Vacuum Extraction Birth

Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia

5.11.2 VACUUM EXTRACTION BIRTH

This guideline must be read in conjunction with Clinical Guideline, Section B 5.11 Instrumental
Vaginal Delivery.
KEY POINTS
1.

2.
3.

4.
5.
6.

7.

8.

Medical officers performing assisted deliveries should be deemed competent in accredited

skills required to conduct vacuum extraction assisted births. An obstetric trainee must be
supervised by an accredited medical doctor if conducting an assisted delivery.
The use of the vacuum extraction for assisted vaginal delivery is recommended as the first
line method in situations where there are no clear indications for a specific instrument.1
Limited evidence indicates that the use of a rapid negative pressure application of vacuum
suction rather than increasing pressure in a stepwise increment reduces the duration of the
procedure, and there are no difference in outcomes to the mother or neonate.2
The use of the metal vacuum cup is superior at achieving greater traction and a higher rate of
successful deliveries than a soft cup e.g. for occipito-lateral or occipito-posterior positions.1
The use of the metal cup is associated with more cases of scalp injury and
cephalhaematoma1, 3, and retinal haemorrhage3 than the soft cup.
The preferred option in situations where women are infected or at high risk of infection (e.g.
viral infections such as HIV or hepatitis) is to use forceps or a soft cup rather than a metal cup
for assisted vaginal deliveries.1
To decrease risk of cephalhaematoma and intracranial bleeding the utilisation of the vacuum
extractor is not recommended it situations with face, brow or breech presentations, or if the
fetus is less than 34 weeks gestation.2
To decrease risk of adverse events correct application of the cup to avoid disengagement,
limiting time application to 20 minutes, and limiting the number vacuum pulls to three
contractions is recommended.3 There must be descent of the presenting part with each pull.

CONTRA-INDICATIONS

2008

See Clinical Guideline, Section B 5.11 Instrumental Vaginal Delivery.

See under Key Points number 7 in this guideline.

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 1 of 6

PREPARATION PRIOR TO THE PROCEDURE

1.

Check all equipment is available for use:

Sterile bowl pack

Instrument pack including X4 Howard Kelly forceps, X1 episiotomy scissors, X1 cord
cutting scissors
Sterile trolley cover
Sterile gloves
Plastic apron, protective glasses/face shield and mask
Sterile cotton wool balls
Sterile large combine pad
Urinary catheter
Lubricant
Lithotomy poles

2.

Ensure equipment is available as required to perform an episiotomy

3.
4.
5.
6.
7.
8.

1X 20 mL syringe
1X 19 gauge needle
1X 22 gauge needle
10 mL 1%Lignocaine

Ensure equipment is available for analgesia

Pudendal needle
Lignocaine 1%
Vacuum extraction machine ensure it is tested and working prior to commencement.
Provide a selection of vacuum cup types and sizes
Check the Neonatal resuscitation cot is warmed checked, and equipment is operational.

PROCEDURE
1

ADDITIONAL INFORMATION

Informed consent
Ensure the woman has given informed
consent.

Analgesia
Assess and provide appropriate analgesia.

Notify appropriate personel

Inform the midwifery shift co-ordinator

Advise the paediatrician to attend the

birth.

Date Issued: July 2003

Date Revised: January 2011
Review Date: January 2014
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2008

Pudendal block, regional block, or perineal

infiltration is appropriate for low and outlet
deliveries.5 However it is not essential for
vacuum extraction.

See Clinical Guidelines, Section B 5.9.4.3

Labour & Birth Suite Quick Reference Guide
Paediatric Medical Staff attendance for At
Risk births.

5.11.2 Vacuum Extraction Birth

Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 2 of 6

PROCEDURE
4

Abdominal Palpation
Perform an abdominal palpation, followed by
a bimanual vaginal examination.

ADDITIONAL INFORMATION

The head should be engaged6 and assisted

delivery should not be performed if the head
is > 1/5 palpable abdominally.7

Maternal positioning
Place the woman in the dorsal lithotomy
position

Bladder Care

Ensure the bladder is empty

See Clinical Guidelines, Section B

6.2.2.1 Bladder Care for information
regarding bladder management post
instrumental vaginal deliveries.

Fetal Heart Rate Monitoring

Monitor the fetal heart rate during the
procedure.

A full bladder may inhibit the progress of

labour.7

See Clinical Guidelines, Section B 5.6

Intrapartum Fetal Heart Monitoring.

Vaginal examination
Perform a vaginal examination to determine:

dilatation

position

station

moulding

presence of caput

Application of the vacuum cup

9.1

Apply the centre of the cup at or behind the

flexion point located over the sagittal suture
3cm in front of the posterior fontanelle.7

Allowance should be made for extensive

caput and/or moulding of the fetal head.8 If
substantial caput is present soft parts of the
fetal head may be felt below the ischial
spines, but the leading bony part of the head
may be above the ischial spines.9

Application of the cup over the flexion point

maximises traction and minimises cup
detachment.3, 7 Placing the cup in front of the
flexion point can result unwanted extension
of the head.
Placing the cup over the flexion point
presents the smallest diameter of the head to
the maternal pelvis resulting in less force
required to assist delivery.10

9.2

Check the position and application of the

cup.

Date Issued: July 2003

Date Revised: January 2011
Review Date: January 2014
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2008

Ensure no vaginal or cervical tissue is caught

by the cup.3, 11 Risk for subgaleal
haemorrhage increases if the cup is
positioned incorrectly on the edge of a
sagittal suture.3

5.11.2 Vacuum Extraction Birth

Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 3 of 6

PROCEDURE

ADDITIONAL INFORMATION

10

Applying traction

10.1

Note the time the cup is applied and traction

is initiated.

Discontinue traction between contractions or

if an audible hiss is heard indicating a loss of
vacuum. Rotating or side-to-side movements
should be avoided as this increases the risk
for cup detachment and vaginal wall injury.10

10.2

Turn on the suction pressure as requested by

the medical practitioner up to the limit of 80
kilopascals (kPa).

Limited evidence indicates that the use of

rapid negative pressure application method
rather than increasing pressure in a stepwise
method reduces the duration of the
procedure. There is no difference shown to
maternal or neonatal outcomes when utilising
the rapid method.2

Note: some practitioners may request the

pressure be initially turned up to 20 kPa; the
position of the cup is checked, then the
assistant may be requested to turn up the
pressure to 80 kPa.

An adequate chignon is formed within 2

minutes of creating the vacuum, and traction
may be commenced after 1 minute without
effecting the efficiency or safety.12
10.3

10.4

During a contraction apply gentle steady

traction, at right angles to the cup, with the
axis of traction following the pelvic curve
during a contraction.7

Maternal expulsive effort during the

contraction aids traction and descent.11

Note the time of each traction pull.

Prolonged traction may lead to intracranial

injury.7

Abandon the procedure if there is:

difficulty in application of the instrument

no evidence of progressive descent with

each pull7

no evidence of imminent birth following

three pulls of a correctly placed
instrument by an experienced operator.3,

cup detachment three times7

more than 157 to 203 minutes has

elapsed since the time of application.7

10.5

Evaluate the need for episiotomy.

11

Removing the vacuum cup

11.1

Cease the suction pressure and remove the

cup when the jaw is visible.7

Date Issued: July 2003

Date Revised: January 2011
Review Date: January 2014
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2008

The majority of malpractice litigation results

from failure to abandon the procedure at an
appropriate time. Increased risk of neonatal
trauma and admission to special care units
are associated with excessive pulls and
sequential use of instruments.13
With effective uterine contractions and
maternal expulsive effort observational
studies have shown almost all vacuum
extraction deliveries can be completed within
15 minutes.12
Routine episiotomy does not reduce and may
increase the incidence of maternal trauma.7

5.11.2 Vacuum Extraction Birth

Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 4 of 6

PROCEDURE
11.2

Note the time the cup was removed.

Note the time of birth.

12

Documentation

12.1

Document the forceps delivery on the:

MR275 Operative Vaginal Delivery

MR230.01 Labour and Birth Summary

Complete an AIMS form if an attempt at

assisted vaginal delivery was unsuccessful.
13

Post procedure management

15.1

Assess the vagina for trauma and repair as

required.

15.2

Discuss bladder management with the

woman.
See Clinical Guidelines, Section B 6.2.2.1
Bladder Care

15.3

Initiate measures to reduce swelling and pain

to the perineum if trauma has occurred.

ADDITIONAL INFORMATION

The AIMS form is sent to the Obstetrical

Clinical Review Committee as part of
effective risk management process.

Women who hae spinal or epidural top-ups

for a vacuum delivery should be informed
they will have an indwelling catheter in situ
for 12 hours post procedure.
See Clinical Guidelines, Section B 6.2.2.2
Perineal Care.

REFERENCES
1.
2.

O'Mahony F, Hofmeyr GL, Menon V. Choice of instruments for assisted vaginal delivery. The Cochrane
Database of Systematic reviews. 2010(11).
Suwannachat B, Lumbiganon P, Laopaiboon M. Rapid versus stepwise negative pressure application for
vacuum extraction assisted delivery. Cochrane Database of Systematic Reviews. 2008(3).

3.

Hook CD, Damos JR. Vacuum-Assisted Vaginal Delivery. American Family Physician. 2008;78(8):95360.

4.

Royal College of Obstetricians and Gynaecologists. Operative Vaginal Delivery. Consent Advice No 11.
2010.
The Society of Obstetricians and Gynecologists of Canada. SOGC Clinical Practice Guidelines. Number
148. Guidelines for operative vaginal birth. International Journal of Gynecology and Obstetrics.
2005;88:229-36.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Instrumental
Vaginal Delivery. College Statement C-Obs 16. 2009.

5.

6.
7.
8.
9.

10.

Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & research Clinical
Obstetrics and Gynaecology. 2007;21(4):639-55.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Rotational forceps
C-Obs 13. RANZCOG College statement. 2009.
The Society of Obstetricians and Gynecologists of Canada. SOGC Clinical Practice Guidelines. Number
148. Guidelines for operative vaginal birth. International Journal of Gynecology and Obstetrics.
2004;88:581-98.
McQuivey RW. Vacuum-assisted delivery: a review. The Journal of Maternal-Fetal and Neonatal
Medicine. 2004;16:171-9.

Date Issued: July 2003

Date Revised: January 2011
Review Date: January 2014
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2008

5.11.2 Vacuum Extraction Birth

Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 5 of 6

11.

Thorogood C, Donaldson C. Disturbances in the rhythm of labour. In: Pairman S, Pincombe J,

Thorogood C, Tracy S, editors. Midwifery Preparation for Practice. Sydney: Churchill Livingstone;
2006. p. 679-716.

12.

Vacca A. Vacuum-assisted delivery. Best Practice & Research Clinical Obstetrics and Gynaecology.
2002;16(1):17-30.

13.

Royal College of Obstetricians and Gynaecologists. Operative Vaginal Delivery. Green-Top Guideline
No 26. 2005.

Date Issued: July 2003

Date Revised: January 2011
Review Date: January 2014
Written by:/Authorised by: OGCCU
Review Team: OGCCU
2008

5.11.2 Vacuum Extraction Birth

Section B
Clinical Guidelines
King Edward Memorial Hospital
Perth Western Australia

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual

Page 6 of 6