Assisted Vaginal Birth

International

Assisted Vaginal Birth

 Assisted Vaginal Birth
International

Objectives
• Indications
• Prerequisites
• Classification
• Methods of application and traction
• Comparison of techniques
• Documentation
 Assisted Vaginal Birth
International
 Assisted Vaginal Birth
International

Vacuum Extraction
 Assisted Vaginal Birth
International

Vacuum
• the vacuum extractor is an obstetrical forceps
• outlet, low and mid applications as for forceps
• rotation procedures are not to be performed

“If a person deficient in dexterity could succeed in applying the (vacuum) tractor
...it is quite probable that he would produce as much injury as benefit...”

Hayes, 1831
 Assisted Vaginal Birth
International

Vacuum Devices
 Assisted Vaginal Birth
International

Indications
• Fetal - suspected fetal compromise requiring immediate
delivery
• Maternal
- prolonged second stage
- maternal conditions which contraindicate pushing
- conditions requiring a shortened second stage
- maternal exhaustion
 Assisted Vaginal Birth
International

Contraindications - Absolute

• nonvertex, face or brow presentation

• unengaged vertex
• incompletely dilated cervix
• clinical evidence of CPD
 Assisted Vaginal Birth
International

Contraindications - Relative

• prematurity or EFW < 2500 g

• mid-pelvic station
• unfavourable attitude

Previous fetal scalp sampling is not a contraindication

 Assisted Vaginal Birth
International

Prerequisites
• vertex presentation, term fetus, EFW >2500 g
• vertex engaged
• cervix fully dilated and membranes ruptured
• adequate maternal pelvis by clinical assessment
• appropriate analgesia
• maternal bladder empty
• experienced operator
• backup plan if procedure not successful
 Assisted Vaginal Birth
International

Avoidance of complications
• Confirm indications and conditions for use
• Proper anatomical placement
• Avoid entrapment of maternal soft tissue
• Correct angle of traction
• Avoid excessive force/torque
• Coordinate traction to maternal effort
• Control descent/expulsion
• Apply the rule of threes; stop procedure
 Assisted Vaginal Birth
International

Vacuum Cup Application

Application over sagittal suture

touching posterior fontanelle
 Assisted Vaginal Birth
International

Axis of Parturition
 Assisted Vaginal Birth
International

Vacuum Application/Traction
Incorrect Correct
 Assisted Vaginal Birth
International
 Assisted Vaginal Birth
International

Vacuum Failure - Rules of Threes

• 3 pulls, over 3 contractions, no progress

• 3 Pop-offs: after one pop off, reassess carefully
before reapplying
• After 30 minutes of application with no progress
reassess
 Assisted Vaginal Birth
International

Vacuum Pop-Off - Causes

• faulty equipment/poor seal causing vacuum leak
• excessive traction force
- unrecognized CPD
- mid-pelvic application
- OP presentations
- deflexed attitude
• improper angle of traction causing shearing
• impingement of maternal soft tissue at introitus
 VACUUM MNEMONIC
Assisted Vaginal Birth
International
 Assisted Vaginal Birth
International

Forceps Delivery
 Assisted Vaginal Birth
International

Function of Forceps
• obstetrical forceps are for the following functions:
- traction of the fetal head
- rotation of the fetal head
- flexion of the fetal head
- extension of the fetal head
• these functions cause fetal head compression
• proper use minimizes this compressive force
 Assisted Vaginal Birth
International

Indications
• Fetal
- suspected fetal compromise requiring immediate
delivery
• Maternal
- prolonged second stage
- maternal conditions which contraindicate pushing
- conditions requiring a shortened second stage
- maternal exhaustion
- deflexed attitudes of the fetal head and malposition
 Assisted Vaginal Birth
International

Prerequisites
• head engaged
• cervix fully dilated and ruptured membranes
• exact position of the head determined
• adequate pelvis
• bladder empty
• appropriate anaesthesia
• experienced operator
• adequate facilities and backup available
Forceps must never be before full dilatation or with an unengaged vertex
 Assisted Vaginal Birth
International

Classification of Forceps Delivery

Outlet Forceps
• scalp visible at the introitus without separating the labia
• fetal skull has reached the pelvic floor
• the sagittal suture is in:
- AP diameter or
- right/left occiput anterior or posterior position
- fetal head is at or on the perineum

ACOG: "Committee in Obstetrics, Maternal and Fetal Medicine"

 Assisted Vaginal Birth
International

Low Forceps
• leading point of the skull is at station + 2 cm or more
• two subdivisions:
- rotation of 45 degrees or less
- rotation more that 45 degrees

ACOG: "Committee in Obstetrics, Maternal and Fetal Medicine"

 Assisted Vaginal Birth
International

Mid Forceps

• head is engaged
• leading position of the skull is above station + 1 cm
• alternative to mid forceps delivery is cesarean
section - access to cesarean is necessary if mid
forceps delivery is attempted
 Assisted Vaginal Birth
International

Station

Engagement
• when the biparietal diameter of the head enters the
plane of the pelvic inlet
• when the leading edge of the skull is at or below the
ischial spines (station 0)
 Assisted Vaginal Birth
International

Check the Application

 Assisted Vaginal Birth
International

Checking the Application - “Position For

Safety”
• Posterior fontanelle midway between the blades and one
finger breadth above the plane of the shanks with the
lambdoid sutures a fingerbreadth above each blade
• Fenestrations of the blades should be barely felt and no
more than a finger tip should be able to be inserted
between the blade and the fetal head
• Sagittal suture perpendicular to the plane of the shanks
 Assisted Vaginal Birth
International

From: Human Labour & Birth, Harry Oxorn

 Assisted Vaginal Birth
International

Axis of Parturition

From: Human Labour & Birth, Harry Oxorn

 Assisted Vaginal Birth
International

Traction
1) Direction
2) Amount

From: Human Labour & Birth, Harry Oxorn

 Assisted Vaginal Birth
International

Head Compression
 Assisted Vaginal Birth
FORCEPS MNEMONIC
International
 Assisted Vaginal Birth
International

Comparison of Forceps
and Vacuum Delivery
 Assisted Vaginal Birth
International

Comparison of vacuum to forceps

• 8 randomized, prospective trials
• Outcomes
- delivery by intended method
- cesarean delivery
- maternal analgesia requirements
- maternal and neonatal morbidity
 Assisted Vaginal Birth
International

Forceps versus Vacuum: Maternal

 Assisted Vaginal Birth
International

Forceps versus Vacuum: Neonatal

 Assisted Vaginal Birth
International

Advantages of Vacuum Extraction

• No increase in significant neonatal morbidity
• Less need for maternal regional/general anesthetic
• Less maternal vaginal/perineal trauma
 Assisted Vaginal Birth
International

Disadvantages of Vacuum Extraction

• Cephalohematoma
- subaponeurotic (subgaleal) hemorrhage
• Neonatal retinal hemorrhages
- uncertain clinical significance
• More likely to fail to deliver, requiring alternative
• Patients must be made aware of these risks
 Assisted Vaginal Birth
International
 Assisted Vaginal Birth
International

Documentation of Operative Delivery

• the procedure must be clearly recorded in every case
• this documentation should provide an explanation of
the operative intervention which has taken place
• including a description of the operative technique
employed and its indication
 Assisted Vaginal Birth
International