Vacuum Delivery

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1. V acuum Delivery/ ventouse / vacuum extractor Sunil Kumar Daha

2. “ Instrumental device designed to assist delivery by applying traction to a suction cup attached to the fetal scalp” Any condition threatened to mother or fetus that is likely to be relieved by delivery Fetus of atleast 34 weeks Introduction

3. Maternal indication Maternal distress, exhaustion after a long, painful labor, due to inefficient uterine contractions. Prolonged second stage of labor ( Nulliparous: >3hrs with regional analgesia >2hrs without regional analgesia Parous: >2hrs with regional analgesia >1 hr without regional analgesia) Maternal medical disorders such as heart disease, hypertensive disorders and moderate to severe anemia. Previous cesarean section or genital prolapse repair. Intrapartum infection , certain neurological conditions.

4. Fetal indication Prolapse of umbilical cord Premature separation of placenta Non reassuring fetal heart rate pattern Fetal distress Non rotated heads or occipitotransverse positions Occipitoposterior position

5. Contraindication Operator inexperience Inability to assess fetal position Suspicion of cephalopelvic disproportion Fetal coagulopathy Preterm babies (<34 weeks) due to risk of fetal intraventricular hemorrhage Macrosomia (≥4 kg) Soft tissues obstruction in the pelvis Breach presentation and face presentation

6. Instrumentation Components: a suction cup with four sizes(30mm, 40mm, 50mm, 60mm) Metal cup Soft cup Silastic cup Rigid plastic cup vacuum pump, traction tubing

7. Mityvac pump with tube and soft cup Silastic vacuum cup Application of vacuum cup

8. Technique The woman's bladder should be empty (via voiding or catheterization). The patient is placed in the lithotomy position. Vaginal examination to check pelvic capacity, cervical dilatation, presentation, position, station and degree of flexion of head and that the membranes are ruptured Determination of flexion point

9. Continue…. Proper cup placement over flexion point Exclude maternal soft tissue entrapment by palpation Vacuum creation by increasing the suction in increments of 0.2 kg/cm2 every 2 mins until 0.8 kg/cm2 A check is made using the fingers round the cup to ensure that no cervical or vaginal tissue is trapped inside the cup

10. Continue…. The pressure is gradually raised at the rate of 0.1kg/cm2 per minute until the effective vacuum of 0.8kg/cm2 is achieved in about 10 minutes time The scalp is sucked into the cup and an artificial caput succedaneum is produced, which dissapears withinn few hours. Instrument handle is grasped, and initiation of traction

11. Continue…. Traction is initiated by using a two-handed technique , i.e the fingers of one hand are placed against the suction cup, while the other hand grasps the handle of the instrument Traction must be at right angle to the cup Traction directed initially downward then progressively extended upward as head emerge

12. Continue…. Traction should be synchronous with the uterine contractions; released in between the contractions. Once head is extracted, vacuum pressure is relieved; cup is removed; vaginal delivery followed

13. Continue…. The total time from the application until delivery should not exceed 20 minutes If >20 minutes, the risk of fetal scalp trauma and intracranial damage increases Many pulls to achieve progress should not be done The operator should be wiling to abandon the procedure if it does not proceed easily or if the cup dislodges >3 times

14. Summary A sk for help, A ddress the patient, A nesthesia B ladder empty C ervix fully dilated D etermine fetal position and think shoulder dystocia E xtractor and resuscitation equipment ready F lexion point – apply cup G entle traction in the proper axis H alt traction when the contraction is over, halt the procedure if it is not progressing normally

15. Fetal Complications Scalp laceration and bruising Subglial hematoma, Cephalohematoma Intracranial hemorrhage , intraventricular and cerebral hemorrhages Retinal and sub- conjunctival hemorrhages Neonatal jaundice Clavicular fracture, Shoulder dystocia Injury to CVI, CVII nerves, Erb palsy Hypoxia, particularly when extraction has taken a long time and has been difficult Fetal death

16. Maternal Complications Soft tissues injuries such as cervical tears, annular detachment of the cervix, vaginal tears, perineal lacerations and tears, extension of episiotomy, vaginal wall and perineal hematomas. Traumatic postpartum hemorrhages Infection Genital prolapse

17. Management To assess the effect on the mother and the fetus To start a Ringer’s solution drip and to arrange for blood transfusion, if required To exclude rupture of the uterus To assess if procedure is to be abandoned and consider delivery by cesarean section Laparotomy should be done in a case with rupture of uterus. To administer parenteral antibiotic

18. Cunningham et.al., Williams OBSTETRICS, 24E, McGraw-Hill Education, 2014, DC Dutta’s textbook of Obstetrics References

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