Vacuum Extractor Assisted

Delivery
 Session Objectives
• At the end of the session, participants will be
able to:
– State indications and contraindications for the use
of the vacuum extractor
– State complications associated with vacuum
extractor use for mother and baby
– Demonstrate the steps for using the vacuum
extractor using fetal and pelvis models and a skills
checklist, including identification of the flexion
point
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Vacuum extractor

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 Parts of vaccum extractor:
vaccum source

• Electrical, hand pump or pedal pump.

• Pressure gauges provided with vacuum are
accurate; equipment designed specifically for
vacuum are the most reliable
• Presence or absence of fluid trap does not
affect effectiveness of vacuum

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 Parts of vaccum extractor:
CUP

• Differ in materials they are made of:-

– Metalic
– Plastic
• Differ in shape and size

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 Bird (Modified Malmstrom) Cup

• Both an OP and OA cup esigned,

• OA cup has vacuum
– inflexible metal
port placed
– port separated from
traction device
accentrically,
Bird OA Cup
on the
top of cup

Bird OP Cup

OP Cup has vacuum port placed at

the side of the cup

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 Metal Cups
ADVANTAGES DISADVANTAGES
• Posterior metal cups are
• More difficult to apply
effective for:
– Posterior position • More uncomfortable
– large baby • Higher incidence of fetal
– significant caput scalp injuries
– deflexed head
• Can be autoclaved
• Already available in many
locations where newer
cups cannot be purchased
• Still used and available

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 Plastic Cup Characteristics

• Shapes such as bell, funnel and mushroom

• Consistencies: pliable to semi-rigid

• Disposable and reusable

• Mushroom cups have higher success rate

• Materials: synthetic plastics (e.g. silicone,

polyethylene, polyurethane, silastic) or rubber
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 Advantages of Soft Cups

• Easier assembly & application

• Faster from application to effective traction
• Less pronounced chignon
• Fewer superficial scalp injuries
• Less retinal hemorrhage

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• Which cup is available in your practice
site?

• How do you choose which cup to use?

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 Application
Clinical and Technical Principles

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Courtesy of Aldo Vacca, M.D.
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 Prerequisite Knowledge, Skills, and
Clinical Practice Considerations

• Knowledge of:
– anatomy of female pelvis
– anatomy of fetal skull
– mechanism of labor
– clinical practice issues
• Skill in:
– assessment of maternal and fetal well being
– abdominal and pelvic exam

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 Effectiveness
• Vacuum failure rates range from 2-27%
• Metal cups have slightly higher success rates than
plastic cups, but also higher rates of adverse
outcomes
• Greater failure rate of vacuum versus forceps when
the position was posterior and silastic cup was
used.
• Highest VE success rate with a non-metal cup was
with the M-cup, which has a delivery rate as high as
forceps
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 Contraindications
• Incompetent or inexperienced provider
• CPD
• Moderate or severe caput
• Prematurity (less than 37 weeks)
• Malpresentation (breech, footling, face, brow,
shoulder)
• Unengaged vertex
• Lack of adequate anesthesia, if needed
• Inadequate strength & frequency of contractions
• Inability to achieve proper suction
• Prior failed forceps
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 Exercise 5.5 – SDA – Vacuum Extraction

• Two and two: 10 minutes

• Find vacuum delivery action card and procedures in SDA,

discuss and share to the large group on,
– Indications: When to use VE?
– Prerequisites: What to assess?
– Procedures and referral : A-J

Facilitator then summarizes

All watch the SDA film on Vacuum delivery
 Indications
• Prolonged second stage of labor
• Fetal distress and cord prolapse in second stage of
labor.
• Severe anemia in second stage
• Maternal cardiac problems
• Eclampsia in second stage
• Maternal exhaustion is an indication when the mother
is unable to complete second stage spontaneously
because of inadequate expulsive efforts or ineffective
bearing down
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 Delivery using ventouse: contd…
• Prerequisites
– Vertex presentation with fetal position identified
– Fully dilated cervix
– Engaged head:
– Ruptured membranes
– Live fetus
– Term fetus
• Preparation
– Empty bladder
– Local anesthesia infiltration for episiotomy
– Assembled and tested vacuum extractor
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Delivery using ventouse:
Pulling Downward

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Delivery using ventouse:
Pulling Horizontal

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Delivery using ventouse:
Pulling Straight Up

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Delivery using ventouse:
Crowning

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 Delivery using ventouse:
FAILURE

• Vacuum extraction failed if:

– The head does not advance with each pull;
– The fetus is undelivered after three pulls with no
descent, or after 30 minutes;
– The cup slips off the head twice at the proper direction
of pull with a maximum negative pressure.
• Every application should be considered a trial of
vacuum extraction.
• If vacuum extraction fails, refer her urgently
providing basic support.
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Complications
Caput
• Caput occurs at vacuum cup
application site; also called chignon
• Interstitial hemorrhages and fluid
accumulate to form caput; longer
2nd stage & longer procedure leads
to more accumulation
• Makes tissue more vulnerable to
abrasion, laceration, hematoma
• Resolves spontaneously in a few
days
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 COMPLICATIONS: contd…
• Scalp Injuries
• Subaponeuorotic or Subgaleal Hemorrhage:
Collection of blood under scalp aponeurosis
– Can accommodate half or more of the blood
volume of the neonate
– May cause coagulopathy, difficult to control
– Occurs in approximately 1 in 1000 VE deliveries

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 COMPLICATIONS: contd…
• Intracranial hemorrhage
– Occurs in 1 of 860 VE deliveries, 1 of 1900 SVDs
– Rate markedly decreased with soft plastic cups

• Retinal hemorrhage less when:

– May result from changes in intracranial venous
pressure

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 Cephalohematoma Cup mark

Scalp abrasion
Courtesy of Ross McQuivey, MD Dark chignon
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 Disengagement
• Associated with increased fetal head trauma
• Caused by:
– Maternal tissue or scalp electrode caught under edge of
cup
– Incorrect technique (pulling too hard, in wrong direction,
or without a contraction)
– Large caput succedeneum
– Deflexing or paramedian application
– Bending or twisting the cup, handle, or shaft
– Rotating the cup
– Inadequate pressure or faulty equipment
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 Summary
• Have a clear indications for the use of the
vacuum extractor
• Check for prerequisites before applying
vacuum
• Either the metal or plastic cup can be used
• The center of the cup should be over the
flexion point
• Pulling should be along the pelvic curve: First
down ward, then horizontal and finally
upward
• Signs suggesting failed vacuum extraction are:30
THANK YOU!