Operative Vaginal Delivery

Robert D. Auerbach, M.D. FACOG

Senior Vice President & Chief Medical Officer
CooperSurgical, Inc.
Associate Clinical Professor
Yale University School of Medicine

Normal Birth Mechanism

Introduction
US incidence of Operative Vaginal Delivery (OVD) 10-15%*
Percentage of forceps declining compared with vacuum extraction
Geographic differences
Lowest in the Northeast
Highest in the South
* Bofill JA. Operative Vaginal Delivery: A survey of fellows of
ACOG. OG 1996;88:1007

Indications for OVD

No indication is absolute
Prolonged 2nd stage
Nulliparous: lack of continuous progress
>3hrs with regional anesthesia
>2hrs w/o regional anesthesia

Multiparous: lack of continuous progress

>2hrs with regional anesthesia

>1hr w/o regional anesthesia

Fetal compromise
Maternal benefit to shortened 2nd stage

Station

At the 0 station, the fetal head is at the bony

ischial spines and fills the maternal sacrum.
Positions above the ischial spines are
referred to as -1 through -5
As the head descends past the ischial spines,
the stations are referred to as +1 through +5
(head visible at the introitus).

Four Pelvic Types

Important Landmarks

Fetal attitude and lateral flexion of the fetal head

A: SynclitismThe plane of the biparietal diameter is parallel to the plane

of the inlet
B: AsynclitismLateral flexion of the fetal head leads to anterior parietal
or posterior parietal presentation.

Prerequisites for OVD

Informed consent
Vertex
Engaged
34 weeks (vacuum delivery)
Fully dilated
Membranes ruptured

Adequate maternal pelvis

Adequate anesthesia
Maternal empty bladder
Backup plan

Ongoing fetal and maternal assessment

Contraindication - OVD
Non-cephalic, face or brow presentation
Unengaged vertex

Incompletely dilated cervix

Clinical evidence of CPD
< 34 weeks gestation (vacuum)
Need for device rotation (vacuum)
Deflexed attitude of fetal head
Fetal conditions (e.g. thrombocytopenia)

Classification of OVD
Outlet

Scalp visible @ introitus w/o separating labia

Fetal skull @ pelvic floor
Saggital suture in AP plane (or ROA/LOA)
Fetal head at or on perineum
Rotation < 45 degrees

Low
Leading point of fetal skull > or = +2 station
Rotation < 45 degrees
Rotation > 45 degrees

Mid
Station above +2 station but the head is engaged

High
Not included in classification

Vacuum versus Forceps

Selection of the appropriate instrument and decisions about the maternal
and fetal consequences should be based on clinical findings at the time of
delivery.*
A meta-analysis comparing vacuum extraction to forcep delivery showed
that vacuum extraction was associated with significantly less maternal
trauma and less need for general and regional anesthesia**
*ACOG Practice Bulletin #17 (June 2000)
**Johnson RB. The Cochrane Library Issue 4, 1999

VOL 103, No. 3, March 2004

by the American College of Obstetricans and
Gynecologists
Published by Lippincott Williams & Wilkins.

Effect of Delivery on Neonatal Injury

Towner D et al. Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury. NEJM 1999;341:1709

Delivery

Death

ICH

Other

NSVD

1/5,000

1/1,900

1/216

C/S in Labor

1/1,250

1/952

1/71

C/S p Vac or Forceps

N/R

1/333

1/38

C/S w/o Labor

1/1,250

1/2,040

1/105

Vacuum

1/3,333

1/860

1/122

Forceps

1/2,000

1/664

1/76

Vacuum & Forceps

1/1,666

1/280

1/58

ICH Intracranial Hemorrhage

Classification of Forceps

Williams Obstetrics - 22nd Ed. (2005)

Williams Obstetrics - 22nd Ed. (2005)

Williams Obstetrics - 22nd Ed. (2005)

Williams Obstetrics - 22nd Ed. (2005)

Williams Obstetrics - 22nd Ed. (2005)

Vacuum Delivery
The advantage of the vacuum extractor over forceps include the
avoidance of insertion of space-occupying steel blades within the vagina.

Previously described instruments were mostly unsuccessful until

Malmstrom (1954) applied traction on a metal cap designed so that the
suction creates an artificial caput, or chignon, within the cup that holds
firmly and allows adequate traction.
In the United States, the metal cup generally has been replaced by newer
soft cup vacuum extractors

Vacuum Cups

Bell vs. Mushroom

Most soft cups are bell shaped while most rigid cups are mushroom (M-cup).
Bell cups generate less traction force than M-cups.*
M-cup is low profile and may facilitate application with asynclitism or non-OA
presentations.

Soft vs. Rigid

Soft cups were more likely to fail to achieve vaginal delivery (OR 1.65; 95% CI 1.192.29)**
Soft cups were associated with less scalp injury (OR 0.45; 95% CI 0.15-0.60)**

* Muise, KL, Duchon, MA, Brown, RH. The effect of artificial caput on
performance of vacuum extractors. Obstet Gynecol 1993; 81:170.
** Johanson, R, Menon, V. Soft versus rigid vacuum extractor cups for
assisted vaginal delivery. Cochrane Database Syst Rev 2000

Rigid Cup Design

Vol 100, No. 6, December 2002

2002 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.

Risk of a Rigid Cup

Vacuum Cups
The use of soft, bell-shaped vacuum extractor is recommended for
uncomplicated, occiput anterior deliveries.
The rigid M-style cup is recommended for deliveries likely to require greater
traction forces.
Non OA
Asynclitism
Use at cesarean section

Types of Vacuum

Insertion

Vacuum Placement
Proper cup placement is the most important determinant of success in
vacuum extraction.
The center of the cup should be over the sagittal suture and about 3 cm in
front of the posterior fontanelle toward the face median flexion point.

Vacuum Procedure
The entire 360 circumference of the cup must then be digitally inspected to
insure that no vaginal or vulvar tissues are trapped between the cup and the
fetal surface.
After correct placement of the cup is confirmed, vacuum pressure should be
raised to 100 to 150 mmHg to maintain the cup's position.
Vacuum suction pressures of 500 to 600 mmHg have been recommended
during traction.

Vacuum Procedure
A slow, stepwise increase in vacuum pressure was initially practiced, but is
no longer recommended.
gradual versus rapid application of vacuum pressure demonstrated the rapid
technique reduced the duration of the vacuum extraction procedure without
compromising efficiency and safety
Lim, FT, Holm, JP, Schuitemaker, NW, et al. Stepwise compared with rapid
application of vacuum in ventouse extraction procedures. Br J Obstet Gynaecol 1997;
104:33.
Svenningsen, L. Birth progression and traction forces developed under vacuum
extraction after slow or rapid application of suction. Eur J Obstet Gynecol Reprod
Biol 1987; 26:105.

Vacuum Procedure
Suction pressure is measured in various units: 0.8 kg/cm2 of atmospheric
pressure = 600 mmHg = 23.6 inches of Hg = 11.6 lb/in(2).

Vacuum suction pressures of 500 to 600 mmHg have been recommended

during traction, although pressures in excess of 450 mmHg are rarely
necessary

Ross, MG, Fresquez, M, El-Haddad, MA. Impact of FDA advisory on reported

vacuum-assisted delivery and morbidity. J Matern Fetal Med 2000; 9:321.10.
Billings, RG. The physics of vacuum extraction. OBG Manag 2004; Suppl S7-8.

2005 UpToDate www.uptodate.com

The absolute "safe" traction force for vacuum extraction is unknown.

However, since traction force needs to be individually calculated and will vary
with cup size, suction pressure, and altitude, it is reasonable and practical to
rely solely on the suction pressure, which is displayed on all the commercially
available devices.
UpToDate performs a continuous review of over 330 journals and other resources.
Updates are added as important new information is published. The literature
review for version 13.2 is current through April 2005; this topic was last changed on
March 28, 2005. The next version of UpToDate (13.3) will be released in October
2005.

Vacuum Delivery
Practitioners assist by adding to the momentum of the maternal expulsive
efforts rather than pulling the baby out independently.

The fingertips of the dominant hand pull the device's crossbar, while the
nondominant hand monitors the progress of descent and prevents cup
detachment by placing counter pressure with the thumb

Vacuum Delivery
Apply traction along the axis of the pelvic curve.
Initially, the angle of traction is downward (toward the floor); the higher the
beginning station, the steeper the angle of downward traction required.
The axis of traction is then extended upwards to a 45 degree angle to the floor as
the head emerges from the pelvis and crowns.
The handle of the device is allowed to passively turn as the head auto-rotates
through its descent.

Mid Pelvis

Pelvic Floor

Outlet

Vacuum Delivery

Traction is gradually discontinued as the contraction ends or the mother stops

pushing.
Between contractions, suction pressure can be fully maintained or reduced to
<200 mmHg
fetal morbidity is similar for both regimens*

Descent should occur with each application of traction

When the head is delivered, the suction is released, the cup is removed, and the
remainder of the delivery proceeds as usual.
* Bofill, JA, Rust, OA, Schorr, SJ, Brown, RC, Roberts, WE, Morrison,
JC. A randomized trial of two vacuum extraction techniques. Obstet
Gynecol 1997; 89:758.

Axis Animation

Outlet Vacuum

DURATION of Vacuum 2005 UpToDate

www.uptodate.com
The maximum time to safely complete a vacuum assisted delivery and the
number of acceptable "pop-offs" is unknown.

These recommendations are based more upon common sense and

experience than scientific data as observational series have shown no longterm differences in neonatal outcome related to these variables.
A maximum of two to three cup detachments
3 sets of pulls
Total vacuum application time of 15 to 30 minutes

Failed Procedures
Reasons for failure:
CPD
Incorrect technique
Traction w/o maternal pushing efforts
Upward traction prior to crowning

Paramedian or deflexing application

Large caput seccedaneum
Large volume of scalp into cup reduces the total vacuum area
More pronounced with bell compared to mushroom cups
More pronounced with soft compared to rigid cups

Avoiding Problems
Confirm cup placement
Avoid entrapping vaginal soft tissue

Know when to abandon the procedure

Practitioners must be willing and able to abandon the procedure and proceed
to cesarean delivery promptly when the vaginal delivery is not progressing
normally.
An indicated vaginal delivery that could not be completed with vacuum
assistance is unlikely to progress to a spontaneous vaginal delivery with a little
more time and delay may increase the risk of neonatal or maternal morbidity.

Vacuum Use at Cesarean Section

Swellings and Bleeds Associated With Normal and

Operative Vaginal Delivery

Molding

Subgaleal Hematoma

CT of Subgaleal

SUMMARY AND RECOMMENDATIONS - UpToDate

March 28, 2005
There is inadequate evidence upon which to base a recommendation for use
of a particular type of vacuum for all circumstances when a vacuum assisted
delivery is attempted.
A successful vacuum extraction is most likely:
accurate cup application
appropriate traction technique

a favorable flexed fetal cranial position

low station at the time of application

SUMMARY AND RECOMMENDATIONS - UpToDate

March 28, 2005
Only attempt a vacuum assisted delivery when a specific obstetric indication
is present.
No indication is absolute

The use of soft, bell-shaped vacuum extractor is recommended for

uncomplicated, OA deliveries.
Apply the cup at the flexion point.

SUMMARY AND RECOMMENDATIONS - UpToDate

March 28, 2005
Rapid application of vacuum suction pressures of 500 to 600 mmHg have
been recommended during traction.
Apply gentle traction along the axis of the pelvic curve in concert with
maternal pushing.
Limit vacuum assisted procedures to 2 to 3 "pop-offs," and a total time of
15 to 30 minutes.

SUMMARY AND RECOMMENDATIONS - UpToDate

March 28, 2005
Failure of an attempted vacuum assisted delivery increases the likelihood
of neonatal morbidity; the subsequent use of sequential forceps in this
setting should be undertaken with extreme caution.

Prompt cesarean delivery is advised after an unsuccessful vacuum assisted

procedure.

FDA: Vacuum Delivery Devices