Vacuum Extraction

• Ventouse is an instrumental device designed to

assist delivery by creating a vacuum between
it and the fetal scalp. The pulling force is
dragging the cranium while in forceps, the
pulling force is directly transmitted to the base
of the skull.
 INSTRUMENTS
consists of the following basic components
1. Suction cups(30 mm, 40 mm, 50 mm and 60 mm)
2. a vacuum generator
3. traction tubings
• Metal cups were initially used. Soft cups, silc
cup. cups could be folded and introduced into
the vagina without much discomfort. Silastic
cup causes less scalp trauma and there is no
chignon formation. Rigid plastic cup (Kiwi
Omnicup) is safe, effective and is useful for
rotational delivery. 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
 Indications
• The indications are same as those of forceps
except that it cannot be employed in face or
after coming head of breech
• During caesarean section it may be used to
extract the foetal head through the uterine
incision.
 Types
• The main difference between vacuum
extractors lies in the cup
– Malmstrom cup
– Bird’s cup
– Soft cup
• PROCEDURE
 1 Preliminaries
• 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
and the vacuum is tested prior to its
application
 2 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.
• 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. n
usually disappears within few hours
 3 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
• N.B. vacuum is not an instrument for rotation
of the head but it rotates spontaneously when
meets the pelvic floor. Trial to rotate the head
with the cup will cause it to slip.
 COMPLICATIONS
• Neonate:
– Superficial scalp abrasion
– sloughing of the scalp and
– cephalhematoma—due to rupture of emissary veins
beneath the periosteum. Usually it resolves by one or two
weeks
– subaponeurotic (subgaleal) hemorrhage (not limited by
suture line as it is not subperiosteal)
– intracranial hemorrhage (rare)
– retinal hemorrhage (no long-term effect) and
– jaundice.
• 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.
CAESAREAN SECTION
 Caesarean section
• It is an operative procedure whereby
the fetuses after the end of 28th
weeks are delivered through an
incision on the abdominal and
uterine walls
 Indication
• Cesarean delivery is done when
1. labor is contraindicated
2. vaginal delivery is found unsafe for the fetus
3. vaginal delivery is found unsafe for the mother
• The indications are broadly divided into two
categories:
1. Absolute
2. Relative
 indication
Absolute indication
Vaginal delivery is not possible.
Cesarean is needed even with a
dead fetus
• Central placenta previa
• Contracted pelvis or cephalopelvic
disproportion (absolute)
• Pelvic mass causing obstruction
• Advanced carcinoma cervix
• Vaginal obstruction
• Non progress of labor
• Malposition and malpresentation
Relative indication
with a dead fetus Indications are
few: Vaginal delivery may be
possible but risks to the mother
and/or baby are high
• Cephalopelvic disproportion
(relative)
• Previous cesarean delivery
•  Non-reassuring FHR (fetal
distress)
•  Dystocia (3P’s)
• APH
• Malpresentation: Breech,
shoulder (transverse lie), brow
• Failed surgical induction of
labor, failure to progress in
labor
• Hypertensive disorders
 contraindication
1. Dead fetus except in extreme degree of pelvic contraction,
neglected shoulder or sever accidental hemorrhage
2. Disseminated intra vascular coagulation to minimize blood
loss
3. Extensive scar or pyogenic infection in the abdominal wall
e.g. In burns
 Types of Caesarean section
1. According to time of operation
I. Elective
II. Emergency (category 1,2 and 3)
2. According to site of uterine incision
1. Upper segment Caesarean section (always vertical)
2. Lower uterine segment caesarean section (commoner type)
3. According to number of operation
1. Primary caesarean section
2. Repeated caesarean section
4. According to opening the peritoneal cavity
1. Transperitoneal
2. Extraperitoneal
Comparison between lower and upper
segment C-S