Vacuum Delivery

Last updated 20.09.12

 

Consent

Consent

Equipment

Equip

Procedure

Proc

Management

PostOP

 

Definition

-  Intrumental vaginal birth of cephalic infant from labour via vacuum extraction

 

Features

-  Instrumental delivery dependant on maternal effort & contractions

-  Aim for NVB next delivery

-  80% success rate unless 3rd or 4th degree perineal tear

-  Flexion point

-  3cm ant to post fontanelle

-  Kiwi cup = 6cm therefore center of cup placed at edge of post fontanelle

-  When aligned w axis of pelvis optimal diameter for delivery

-  Station for delivery

-  Outlet: scalp visible wo parting labia, head at/on perineum, suture AP or ROA or LOA (not >45o)

-  Low: At or below +2cm & not on pelvic floor

-  Mid: fetal head not >2cm (1/5) palpable abdominally, not above spines, head engaged

 

 

Consent Top

  Consent

 

Indications

-  Requirement for instrumental delivery

-  Requirements

-  Ruptured membranes

-  Full cervical dilation

-  Fetal station at spines or greater

-  Empty bladder

-  Trial of Vacuum (in OT)

-  Midcavity or >1/5 abdominally

-  OP position

-  Increased BMI >37

-  EFW >4kg or clinically big baby

-  Severe fetal distress

 

Contraindications/Precautions

-  CPD

-  Relative: fetal bleeding diathesis, HIV, HCV

-  Fetal station higher than spines

-  Prior to full dilation

-  Unless prolapsed cord in multip at 9cm or second twin

-  Fetal osteogenesis imperfecta

-  Face, breech or brow presentation

-  Prematurity <36/40

-  GA: mother unable to push with contractions

-  Severly compromised baby --> LUSCS

-  Vacuum is safe after FBS or FSE

 

Complications

-  Failure

-  Forceps

-  LUSCS

-  Maternal

-  Episiotomy

-  Perineal trauma

-  PPH

-  VTE: DVT

-  Shoulder dystocia

-  Neonatal

-  As a result of traction force not negative pressure (suction)

-  Chignon (all babies)

-  Cephalohaematoma 1-25%

-  Intracranial haemorrhage

-  Retinal haemorrhage

-  Subgaleal hamorrhage 1-4%

-  Skull fracture

-  Laceration

-  Abrasions 10%

-  Jaundice (not requiring phototherapy)

 

 

Equipment Top

Equipment

 

Equipment

-  Obstetric cream

-  Sterile gloves

-  Vacuum cup (Kiwi)

-  LA: Lidocaine 1%

-  Drawing up & 23G needles

-  20ml syrine

-  Epsitiomy scissors

-  Packs

 

 

Procedure Top

Procedure

 

ABCDEFGHIJ

-  A

-  Address pt: explanation & consent

-  Assistance: procedure, neonatal resus, document

-  Analgesia

-  Bladder empty

-  Cervix fully dilated

-  Determine position

-  Equipment ready & head engaged

-  F: cup applied to flexion point

-  Gentle traction

-  Halt: know when to

-  I: consider episiotomy incision

-  J: when jaw reachable remove cup

 

Procedure

-  If predict failure or high risk perform in OT (as above)

-  Explanation & consent

-  Continuous CTG (or doppler)

-  Additional staff required

-  Senior staff

-  Neonatal resus

-  Documentation

-  Abdominal exam ensure

-  Vertex presentation

-  1/5+ station

-  CPD?

-  Uterus contracting adequately

-  Consider Syntocinon in primiparous

-  VE ensure

-  Full dilation

-  Membranes ruptured

-  Vertex at or below ischial spines

-  Position: sagital suture AP or ROA or LOA (not greater than 45o)

-  Moulding?

-  Analgesia

-  Unless urgent delivery then use

-  Consider perineal infiltration with LA

-  +/- regional block, pudendal nerve block

-  May have existing epidural

-  Position

-  Mother: lithotomy +/- lateral tilt

-  Buttocks should be close to edge of bed to allow downward traction

-  Expulsive effort can be reinforced by mother grasping thighs

-  Operator: kneel or seated to apply traction

-  Ensure bladder is empty: remove IDC if insitu or use in-out catheter

-  Locate flexion point

-  Palpate flexion point with index finger

-  Measure distance from flexion point to posterior forchette

-  DIP +/-5cm (6)

-  MCP 10cm (10.5)

 

Flexion Point

 

Felxion

Cup Application

 

 

 

-  Cup application

-  Test suction of device on hand

-  Lulbricate rim of cup with obstetric cream (avoid application to inside of cup)

-  Holding cup with dominant hand from top open introitus with non-dominant hand

-  Insert cup in one movement

-  Manouvre cup to flexion point

-  Flexing median application optimal position

-  Deflexing paramedian most difficult to deliver

-  Need at least 3cm clearance from anterior fontanelle

-  Ensure no maternal tissue under cup

-  Pump vacuum to yellow zone

-  Re-examine to ensure no maternal tissues entrapped

-  Acceptable to wait 1 min for chignon to form prior to strong traction

-  Pump vacuum to green zone

-  Cup traction

-  Use two hands

-  Non-dominant hand to hold cup from top & apply counter pressure

-  Dominant hand to hold vacuum handle

-  Apply traction in axis of pelvis with contractions

-  Watch for progress

-   Descent of presenting part

-   Autorotation

-   Flexion & correction of asynclitism

-  3x3 rule esp if primiparous & epidural in situ

-  Descent phase: cup application to fetal head at pelvic floor

-  x3 pulls acceptable

-  Perineal phase: cup visible until complete delivery of fetal head

-  x3 pulls acceptable

-  Once head delivered remove suction from cup

-  Assess fetal head for obvious trauma

-  Proceed with normal delivery & management of third stage

-  Pre-empt shoulder dystocia & PPH

-  Cease attempted vacuum delivery when

-  20 min of cup application

-  No progression of descent with each pull (x3)

-  Cup detachment x3

-  Pulling too hard

-  Pulling in wrong direction or with rocking motion

-  Incorrect cup application

-  Entrapment of maternal tissue or FSE under cup

-  Faulty equipment

-  Inadequate vacuum pressure

-  x3 pulls without imminent birth with correctly applied cup

-  Failed vacuum

-  Attempt forceps delivery

-  Caesarean (LUSCS)

 

Delivery

 Delivery

Operation Report

-  Procedure

-  Vacuum assisted vaginal delivery

+/- Trial of Vacuum

-  Indication

-  Reason for vacuum

-  Description

-  Consent & explanation

-  Lithotomy

-  Analgesia

-  Contractions: frequency, strength, +/- Syntocinon

-  Paeds in attendance

-  VE & Abdo palp

-  Type of vacuum

-  Number of pulls for delivery of head

-  +/- Detachments

-  Episiotomy &/or perineal trauma

-  APGARs

-  Fetal scalp condition

-  Operative Findings

-  Cord gases

-  Post Op Orders

-  Monitor urine output for 24hrs

-  Analagesia

-  No hats or bonnets for 24hrs & monitor scalp for SGH

 

 

Management Top

Post Delivery Management

 

Post Delivery

-  Venous & arterial cord gases

-  Repair of perineal trauma/episiotomy

-  Monitor urine output for 24hrs (to avoid retention)

-  Analgesia

-  Paracetamol + Diclofenac regular

-  +/- ice pack

-  Consider Enoxaparin for DVT prophylaxis

-  Vitamin K to infant

-  Inspect infant for signs of injury

-  Monitoring for SGH esp <24/24

-  No hats/bonnets to allow ready examination

 

 

 

References

 

RWH CPG: Assisted Vaginal Birth, 10/08/2007

Pic: insights.clinicalinnovations.com/November2001.htm

Pic: patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6%28suppl1%29/Pages/07.aspx

Pic (delivery): Handbook of Vacuum Delivery, Aldo Vacca, 3rd Edition