Ventouse delivery for Bsc Nursing student

Ventose delivery

1. VENTOUSE DELIVERY

2. Ventouse is an instrumental device designed to assist delivery by creating a vacuum between it and the fetal scalp.

3. Instrument

4. Advantages of ventouse It can be used in unrotated and malrotated occipito - posterior position of the head It can be applied even through incompletely dilated cervix (first stage of labor ) It is not space occupying device like forceps blades It allows the fetal head to follow its own mechanism of descent and rotation Lesser traction force is needed (10 kg ) It can be used safely even when the head remains at a high level and exact position is unsure

5. It is comfortable and injuries to the mother are less Fetal complications are less Requires less technical skill (suitable for trained midwives ) It causes minimum trauma to the mother and the child. The chignon formed disappears with in 24 to 48 hours . Less intracranial tension

6. Types 1.Low ventouse delivery for vertex with failure to progress on perineal floor (only extraction ) 2. Outlet Ventouse delivery for arrested occipitoposterior positions of vertex (rotation and extraction)

7. Indications As an alternative to forceps operation As an alternative to rotational forceps as in occipito transverse or posterior position Delay in descent of the head in case of the second baby twins Delay in the first stage of labour (uterine inertia ) Maternal exhaustion Cut short the second stage of labor Fetal distress Deep transverse arrest

8. Contraindications 1. Any presentation other than vertex ( face,brow , breech ) 2. Preterm fetus (<34 weeks) chance of scalp avulsion or sub-aponeurotic haemorrhage . 3. Suspected fetal coagulation disorder 4. Suspected fetal macrosomia(4 kg or >4kg ) 5. Acute fetal distress as Ventouse entails slower delivery . 6. Following recent scalp blood sampling 7. Cephalopelvic disproportion (CPD ) 8. Intrauterine death

9. Conditions to be fulfilled There should not be slightest bony resistance below the head The head of a singleton baby should be engaged Cervix should be at least 6 cm dilated (preferably only cervical rim may be left behind ) Informed consent Ruptured membrane Analgesia Empty the bladder Gestation >34 wks

10. Principles of ventouse delivery A Suction cup is attached to fetal scalp of vertex where in vacuum is created between scalp and suction cup. Thus artificial caput (chignon) is raised. Head is pulled out by a traction tube attached to the suction cup.

11. CAPUT

12. Tips for safe vacuum delivery The vacuum system is checked for leaks prior to ventouse application Careful vaginal examination to ensure safe instrumental delivery. Before traction is applied, ensure that maternal tissue is not caught with in the cup.

13. Before application of the cup identify the sagittal suture, posterior fontanelle and anterior fontanelle . When the cup is applied it should be bisected by the sagittal suture and there should be at least 3 cm between the edge of the cup and the anterior fontanelle (flexing median application)

14. Procedure Preliminaries: Local infiltration with lignocaine is usually necessary. This can be applied even with out anaesthesia specially in parous women. The instrument should be assembled and the vacuum is tested prior to its application.

15. Step1: Application of the cup-The largest possible cup according to the dilatation of the cervix is to be selected. The cup is introduced after retraction of the perineum with two fingers of the other hand.

16. The cup is placed against the fetal head nearer to the occiput with the knob of the cup pointing towards the occiput. This will facilitate flexion of the head and the knob indicates the degree of the rotation.

17. A vacuum of 0.2 kg /cm2 is induced by the pump slowly, taking atleast 2 minutes . A check is made using the fingers round the cup to ensure that no cervical or vaginal tissue is trapped inside the cup. The pressure is gradually raised at the rate of 0.1 kg /cm2 per minute until the effective vacuum of 0.8 kg/cm2 is achieved in about10 minutes time.

18. The scalp is sucked in to the cup and an artificial caput succedaneum (chignon) is produced. This chignon usually disappears with in few hours.

19. Step-II: Traction must be right angle to the cup. Traction applied parallel to the axis of the birth canal . Traction should be intermittent synchronous with the uterine contractions. Traction also stimulates the uterine contraction in a hypotonic uterus.

20. Traction should be made using one hand along the axis of the birth canal .The fingers of the other hand are to be placed against the cup to note the correct angle of traction, rotation and advancement of the head . If there is no advancement during four successive tractions, it is to be abonded . On no account traction should exceed 30 minutes.

21. As soon as the head is delivered, the vacuum is reduced by opening the screw-release valve and the cup is then detached. The delivery is then completed in normal way.

22. Detachment of the suction cup from the fetal head during traction is termed a “pop –off”. If progress down the birth canal is not obtained with appropriate traction or if two “pop-offs” occur, cephalopelvic disproportion should be suspected and the procedure should be discontinued in favor of cesarean delivery.

23. Complications: Fetal: 1.Superficial scalp abrasion 2. Sloughing of the scalp 3.Cephalhaematoma-due to rupture of emissary veins beneath the periosteum (usually it resolves by one or two weeks) 4. Sub – aponeurotic ( subgaleal ) haemorrhage (not limited by suture lines as it is not subperiosteal )

24. 5. Intracranial haemorrhage (rare ) 6. Retinal haemorrhage (no long term effect ) 7. Scalpinjury,lacerations,alopecia

25. Maternal : The injuries are uncommon but may be due to inclusion of the soft tissues such as the cervix or vaginal wall inside the cup.

26. Disadvantage : The equipment is more complex and requires more maintenance 2. The equipment is less portable than forceps 3. The time taken for delivery is a minimum of 10 to 15 minutes 4 . The incidence of neonatal jaundice and fetal hematoma is higher with vacuum than with forceps.

27. Nursing care: During an assisted delivery the nurse obtains needed equipment and supplies, monitors maternal and fetal status before, during, and after the procedure, provides support for the mother,and document the type of procedure as well as maternal and fetal response. The nurse is aware that the use of a technique to assist vaginal delivery may not work and anticipates the possibility of cesaerean delivery.

28. For vacuum assisted delivery inspect the infant carefully for signs of trauma . Reassure the parents that exaggerated caput (chignon) from vacuum deliveries will subside in a few days . Maternal soft tissue trauma may also result from an operative delivery.

29. Inspect the perineum for bruising and edema. Monitor closely for excessive bleeding or development of hematoma.

30. Nursing care plan 1 . Nursing Diagnosis Anxiety related to outcome of labour . Goal : The woman’s anxiety is reduced. Expected outcome : Available social supports are used. Effective coping strategies are used. Decreased levels of anxiety are reported.

31. Interventions : Care should be taken to attend the women emotional needs Use a calm and confident manner Offer explanation for all procedures Encourage the presence of supportive family members

32. 2.Nursing Diagnosis Risk for injury:Postpartum hemorrhage related to undetected lacerations or hematoma formation . Goal: Maternal injury from postpartum hemorrhage is avoided Expected outcome: Fundus firm and in the midline Lochia flow is rubra and small to moderate in amount There is no bright red bleeding from any source

33. Interventions : If the uterus feels boggy or soft to palpation massage it until it tones up beneath fingers Monitor IV fluids and administer oxytocics such as pitocin to prevent uterine atoney Teach women to perform periodic self fundal massage

34. Bright red bleeding that occurs in a steady stream in the presence of a firm fundus is most likely caused by a vaginal or cervical laceration Report bleeding from or separation of the edges of the episiotomy Monitor for and report any very painful,soft and possibly pulsing ,masses palpable in the perineal area. these are signs of hematoma.

35. 3.Nursing Diagnosis Acute pain related to episiotomy discomfort. Goal : The womens pain is manageable Expected outcome: The women report pain before it becomes severe The woman verbalizes a tolerable pain level and decrease in pain level after interventions

36. Interventions : make certain episiotomy is well approximated Apply ice back to the perineum for 20 minutes will help to reduce swelling and painful sensations(first 24 hours ) Warmsitz bath can be especially comforting to a sore perineum Administration of analgesics

37. 4. Nursing Diagnosis Risk for infection related to multiple portals of entry for pathogens, including the former site of the placenta, episiotomy, bladder and breasts . Goal : The women shows no signs of infection Expected outcome : Vital signs remain within expected limits. Fever is absent and the white blood cell count remains with in the normal limit

38. Interventions : Use aseptic technique Teach the women to wash her hands before and after eating, using the rest room and performing perineal care. Monitor temperature and white blood cell count Instruct the women to report any vaginal discharge with foul odor

39. 5. Nursing Diagnosis :Disturbed sleep pattern related to excess fatigue, overstimulation or adjusting to newborn frequent feeding needs . Goal: Experiences adequate amounts of restful sleep Expected outcome: Verbalizes feeling rested with adequate energy to care for self and infant

40. Interventions : Monitor the women sleep wake cycle Encourage her to continue pre sleep routines she normally uses at home Promote relaxing low stress environment before sleep Dim the light and monitor the noise

41. 6. Nursing Diagnosis Risk for injury(fetal) birth trauma related to ventouse delivery . Goal: The fetus will avoid birth trauma Expected outcome: No birth injury results from ventouse delivery

42. Interventions : Rule out presentation , gestational age , cephalopelvic disproportion, coagulation disorder , macrosomia,fetal distress before the application of ventouse . Careful vaginal examination before application of the ventouse . Proper selection and application of the cup.

43. Proper application of the traction. Inspect the newborn carefully for signs of trauma ( cephalhematoma , retinal hemorrhage , bruising, edema, exaggerated caput(chignon ). Reassure the parents that caput from vacuum assisted deliveries will subside in a few days.