Ventouse in obgyn

vaccume

1. NUR FARRA NAJWA BINTI ABDUL AZIM 082015100035 VENTOUSE

2. LEARNING OBJECTIVE Ventouse Instrument part Indication Contraindication Procedures Complication Summary Benefits

3. INTRODUCTION An instrumental device designed to assist delivery By creating a vacuum between it and the fetal scalp.  The pulling force is dragging the cranium in vaccum > while in forceps, the pulling force is directly transmitted to the base of the skull

4. INSTRUMENTS Metal cups Were initially used.  Soft cups, silc cup ( Mityvac ) Better adherence to the fetal scalp. Silastic cup Less scalp trauma and there is no chignon formation. Rigid plastic cup (Kiwi Omnicup ) Is safe, effective and is useful for rotational delivery. These cups could be folded and introduced into the vagina without much discomfort.

5. PARTS Ventouse is an instrument, designed to assist delivery by creating vacuum between it and fetal scalp. The instrument, as deviced by Malmstrom , consists of: (1) Suction cup (2) Vacuum generator (3) Traction tubing device.   Silc cups  are found more convenient. 

6. Cont. The cup is connected to a pump through a thick-walled rubber tube by which air is evacuated. Vacuum is created by a hand pump or by electric pump. The parts of the device are: (1) Suction cups with four sizes (30 mm, 40 mm, 50 mm and 60 mm) (2) A vacuum generator and  (3) Traction tubings

7. INDICATIONS   Same as those of forceps 

8. CONTRAINDICATIONS Any presentation other than vertex Preterm fetus (< 34 weeks). Suspected fetal coagulation disorder and Suspected fetal macrosomia (≥ 4 kg). Unengaged fetal head Obvious  CPD Patient’s refusal Fetus having unacute bleeding diathesis (hemophilia)

9. PRELIMINARIES ANESTHESIA —either general or local is used. In some cases, the operation may be performed with intravenous diazepam sedation. LITHOTOMY position. Full SURGICAL ASEPSIS  is to be taken: Surgical team is to wear sterile cap, mask, thorough hand wash and to wear gown and gloves Vulva and vagina are to be swabbed with antiseptic solution Cervix is cleaned with povidone -iodine solution Leggings. To empty the EMPTY  THE  BLADDER  before  she  is placed on the table or catheterization Vaginal examination  is done

10. Cont. Pudendal block or perineal infiltration with 1% lignocaine is sufficient. It may be applied even without anesthesia, especially in parous women.  The instrument should be assembled The vacuum is tested prior to its application

11. PROCEDURE

12. Step I (Application of the cup) The  largest possible  cup is  to be selected. The  cup is  introduced after retraction of the perineum with two fingers of the other hand. The cup is placed against the fetal head  nearer the occiput (flexion point) with the “knob” of the cup pointing towards the occiput .  Flexion or pivot point  is an imaginary site located midsagittally about 6 cm from the center of the anterior fontanel or about 3 cm in front of the posterior  fontanel.

13. Cont. Traction over this flexion point facilitates flexion and presents the smaller diameter to the pelvis  The knob indicates the degree of rotation. Betadine (antiseptic) solution is applied to the rim of the malstrom metal cup. A vacuum of 0.2 kg/cm2 is induced by the pump slowly, taking at least 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 about 10 minutes time. The scalp is sucked into the cup and an artificial caput succedaneum (chignon) is produced. The chignon usually disappears within few hours Start- 0.2 Kg/cm2 Increment rate/min- 0.1 Kg/cm2 Final- 0.8 Kg/cm2 Within- 8 Min Max- 10 Min

14. Step 2 (Traction) Traction must be at right angle to the cup Traction should be synchronous with the uterine contractions Traction is released in between uterine contractions 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 Operative vaginal delivery (forceps/ ventouse ) should be abandoned, where there is no descent of the presenting part with each pull or when delivery is not imminent after three pulls with correctly applied instruments by an experienced operator. On no account, traction should exceed 30 minutes 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 the normal way.

15. COMPLICATIONS (Neonate) (1)  Superficial  scalp  abrasion  (2)  Sloughing  of  the  scalp  and  (3)  Cephalhematoma (4) Subaponeurotic ( subgaleal ) hemorrhage (5) Intracranial hemorrhage (rare) (6) Retinal hemorrhage (no long-term effect) (7) Jaundice.

16. COMPLICATION (maternal) Uncommon May be due to inclusion of the soft tissues such as the cervix  or  vaginal  wall  inside  the  cup.  The sequential use of ventouse and forceps increases the risk of trauma both to the mother and the neonate. Outlet forceps may be used following failure of ventouse .

17. BENEFITS  OF OPERATIVE VAGINAL DELIVERY Most women desire a vaginal delivery. Safe and effective use of instrumental delivery fulfills women’s desire and satisfaction. Many women (79%) desire subsequent vaginal delivery compared with women delivered by cesarean section (39%).

18. SUMMARY Ventouse Instrument part Indication Contraindication Procedures Complication Summary Benefits

19. REFERENCES Mudaliar and Menon’s Clinical Obstetrics, 11 th edition, Sarala Gopalan and Vanita Jain, Ventouse DC Dutta’s Textbook of Obstetrics, 9 th edition, Hiralal Konar , Ventouse Essential Of Obstrectric , Lakshmi Seshadri , Gita Arjun , Ventouse