Vacuum Assisted Vaginal Delivery

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Vacuum Assisted Vaginal Delivery

• Siri L. Kjos, MD

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Operative Vaginal Delivery Rates
Rate ()
Year
Hankins GDV Am J Obstet Gynecol 1996175275-82
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Forceps Delivery

• The art and science of forceps delivery is
  becoming a thing of the past1
• The status of forceps in modern obstetrics is
  constantly under discussion and scrutiny within
  the specialty2

1. Douglas RB, Stromme WB. Operative Obstetrics,
5th ed. 1988 2. Dennen EH. Dennens Forceps
Deliveries, 3rd ed. 1989
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Decline in Forceps Use

• Medical-legal implications and fear of litigation
• Reliance on cesarean section as a remedy for
  abnormal labor and suspected fetal jeopardy
• Vacuum perceived by many to be easier to use and
  less risky to fetus and mother
• Fewer programs are actively training residents in
  the use of forceps

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Operative Vaginal Delivery Cycle
? use
? teaching
? fear of litigation
? bad outcomes
? technical skills
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Operative Vaginal Delivery Rates
Natl Vital Stat Rep199947(18)13
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Indications

• Prolonged 2nd stage
• Nullipara no further progress for 3 hours with
  regional anesthesia, or 2 hours without regional
  anesthesia
• Multipara no further progress for 2 hours with
  regional anesthesia or 1 hour without regional
  anesthesia
• Suspicion of immediate or potential fetal
  compromise
• Shortening of the 2nd stage for maternal benefit

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Prerequisites for Vacuum Assisted Vaginal Delivery

• Complete cervical dilatation
• Ruptured membranes
• Vertex presentation
• Head engaged with position known
• Empty bladder
• No fetopelvic disproportion
• Adequate analgesia
• Cesarean section capability
• Experienced operator

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ACOG OVD Classification (1988)

• Outlet
• scalp visible at introitus without separating
  labia
• fetal skull has reached pelvic floor
• sagittal suture in AP diameter or right or left
  OA or OP
• fetal head at or on perineum
• rotation lt 45o
• Low
• leading point of fetal skull at station gt 2 cm
• rotation lt 45o
• rotation gt 45o
• Mid - station above 2 cm but head engaged

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Vacuum - General Principles

• Allows external traction force applied to the
  scalp to be transmitted to the fetal head
• Traction on the vacuum apparatus allows increased
  forces of delivery, and facilitates passage of
  fetus through pelvis
• Both traction on scalp and compression of fetal
  head occur

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Metal Cups
Plastic Cups
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Components of the Kiwi Omni-Cup
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Components of the Kiwi Omni-Cup
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Location of the Median Flexion Point Where to
place the Cup
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Occiput Posterior Placement and Lateral
Displacement
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Contraindications

• Face presentation
• Breech presentation
• True cephalopelvic disproportion
• Undilated cervix
• Congenital anomalies of cranium
• Unengaged fetal head
• Gestational age lt 34 weeks

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Application

• Assemble vacuum extractor system and ensure no
  leaks are present
• Adequate anesthesia - local perineal infiltration
  versus pudendal block
• Insertion of cup into vagina by directing
  pressure toward posterior vagina
• Place cup on scalp toward occiput over the median
  flexion point

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Three Checks

• 1. No maternal tissue included under cup
• margin
• 2. Cup covers fetal occiput in the midline
• 3. Marker or vacuum port of suction cup
• points towards occiput

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Technique

• Initial suction 10 cm Hg (yellow area).
  Reexamine cup edges
• ? pressure to 38-58 cm Hg (green area) at
  beginning of uterine contraction
• Apply traction along pelvic axis as mother pushes
• Release pressure to lower level in between
  contractions (not necessary with Kiwi)
• As vertex delivers, cup should assume 90o
  orientation to horizontal as head extends

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Advantages of Vacuum over Forceps

• Easier to apply
• Less force applied to fetal head
• Less anesthesia needed
• No increase in diameter of fetal head
• Reduces maternal injury
• Reduces fetal scalp injury

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Disadvantages of Vacuum over Forceps

• Cup may detach during procedure
• Used only for term, or near-term vertex
  presentations
• Possibly longer delivery as traction is applied
  only during contractions
• Possibly associated with more fetal head trauma

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Maternal Complications Vacuum vs. Forceps
Broekhuizen FF Obstet Gynecol 198769338-42
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Perinatal Complications Vacuum vs. Forceps
Broekhuizen FF Obstet Gynecol 198769338-42
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Maternal Complications Vacuum vs. Forceps
Bofill JA Am J Obstet Gynecol 19961751325-30
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Neonatal Complications Vacuum vs. Forceps
Bofill JA Am J Obstet Gynecol 19961751325-30
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Effect of Delivery on Neonatal Injury
Delivery Method Death Intracranial
Other Hemorrhage Spontaneous vaginal
1/5000 1/1900 1/216 C/S during labor
1/1250 1/952 1/71 C/S after OVD
N/R 1/333 1/38 C/S without labor
1/1250 1/2040 1/105 Vacuum alone
1/3333 1/860 1/122 Forceps alone
1/2000 1/664 1/76 Vacuum and forceps
1/1666 1/280 1/58
Facial nerve/brachial plexus injury,
convulsions, CNS depression, mechanical
ventilation
Towner, D N Engl J Med 19993411709-1714
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Shoulder Dystocia and Time to Delivery with
Operative Vaginal Delivery
8/24
Percentage
8/123
5/490
Birth weight
Bofill JA J. Matern.-Fetal Med.19976220-4
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Neonatal Complications

• Superficial scalp markings - benign
• Cephalohematoma (6)
• bleeding beneath periosteum
• Subgaleal hematoma (50/10,000)
• bleeding in loose subaponeurotic tissues of
  scalp
• Intracranial hemorrhage (0.35)
• Retinal hemorrhage (28 - 56)

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Vacuum Subgaleal Hematomas
No. Spontaneous 35
28.4 Forceps 17 13.8 Vacuum
extraction 60 48.8 Cesarean section 11
8.9 TOTAL 123 100
Plauche WC JAMA 19802441597-8
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FDA Public Health AdvisoryVAVD May 21, 1998

• Purpose
• to advise that vacuum assisted delivery devices
  may cause serious or fatal complications
• Background
• 12 deaths, 9 serious injuries reported during
  prior 4 years in newborns delivered by VAVD
  (average of 5 events/year)
• ? 5xs rate c.f that reported in preceding 11
  years

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Recommendations

• Use only when specific obstetric indication is
  present
• Persons should be experienced and aware of
  indications, contraindications, precautions
• Read and understand devices instructions
• Alert those who will be responsible for care of
  neonate that a vacuum has been used
• Educate neonatal care staff about complications
  of vacuum
• Report adverse reactions to FDA

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Safety Guidelines

• Pull only with maternal pushing
• Never apply torsion to rotation
• Time procedure from moment of application of cup
  until delivery of infant
• Duration of time from
• cup application to delivery lt 20 minutes
• total traction (at max pressure) lt 10 minutes
• Abandon after 2 (max 3) pop offs
• Abandon if no fetal descent

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Documentation

• Indication for procedure, patient consent
• Fetal station head position at time of vacuum
  application(s)
• Type of vacuum device
• Total vacuum application time
• Number of applications and pop-offs
• Failure/subsequent mode of delivery
• Delivery data as usual

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Factors Influencing Effective Vacuum Extraction

• Cup design, shape, size, application site
• Consistency strength of vacuum
• Maternal cervical dilatation
• Strength of maternal expulsive efforts
  coordination with traction
• Fetal size extent of CPD
• Station deflection of fetal head
• Angle technique of traction

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ACOG Committee Opinion Number 208, September 1998

• Represents an extraordinarily low risk of adverse
  event
• Concern over possible increase in cesarean
  section rate if there is decrease in
  vacuum-assisted vaginal deliveries
• Strongly recommends continued use of
  vacuum-assisted delivery devices in appropriate
  clinical settings

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Conclusions

• Vacuum delivery has been proven to be useful in
  assisting with vaginal delivery
• The potential for both fetal and maternal injury
  does exist
• The operator must be familiar with the
  indications, contraindications, application, and
  use of the vacuum device
• Safe effective guidelines should exist to
  facilitate a safe and effective delivery

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How to determine Distance from Fourchette to
Median Flexion Point
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OmniCup
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OmniCup
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OmniCup
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ProCup
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ProCup
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Time to Delivery with Operative Vaginal Delivery
6/76
12/304
Percentage
1/195
Time required to complete delivery
Bofill JA J.Matern.-Fetal Med 19976220-4
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Vacuum Cycle
? use
? teaching
? fear of litigation
? bad outcomes
? technical skills
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• Types of Complications
• Subgaleal hematoma - accumulation of blood in
  potential space between galea aponeurotica and
  periosteum of skull
• possibility of life-threatening hemorrhage
• Intracranial hemorrhage
• can include subdural, subarachnoid,
  intraventricular, and/or intraparenchymal
  hemorrhage