Assisted Vaginal Birth

International

Assisted Vaginal Birth

Assisted Vaginal Birth

International

Objectives
Indications
Prerequisites
Classification
Methods of application and traction
Comparison of techniques
Documentation

Assisted Vaginal Birth

International

Vacuum Extraction

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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

Assisted Vaginal Birth

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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

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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

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Vacuum Application/Traction
Incorrect

Correct

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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

Assisted Vaginal Birth

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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"

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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"

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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

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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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Rotatio
n
Incorrect (Ouch!)

Correct

From: Human Labour & Birth, Harry Oxorn

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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

Assisted Vaginal Birth

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VACUUM EXTRACTION
AUDIT TOOL
Patient Demographics
Indications
Prerequisites
Procedure
Outcome