5.4 Vacuum Delivery - 2017

PRESENTATION 5.
Vacuum Extractor Assisted Delivery
Federal Democratic Republic of Ethiopia

Ministry of Health
BEmONC – LRP
ETHIOPIA Best Practices in Maternal and Newborn Care
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
BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

2
Best Practices in Maternal and Newborn
Vacuum extractor

3
Parts of vacuum extractor:
vacuum source
 Vacuum pump (Electrical or Manual).
 Pressure gauges provided with vacuum are accurate;
equipment designed specifically for vacuum are the
most reliable
 Suction cup (metallic or plastic) with different size
 Traction devices (handle and connections).
 Presence or absence of fluid trap does not affect
effectiveness of vacuum

4
Parts of vaccum extractor:
CUP
 Differ in materials they are made of:-
 Metalic
 Plastic
 Differ in shape and size

5
Bird (Modified Malmstrom) Cup
 Both an OP and OA cup esigned,

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

the side of the cup

6
7
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
 deflexed head
scalp injuries
 Can be autoclaved
 Already available in many
locations where newer cups
cannot be purchased
 Still used and available
8
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
9
Advantages of Soft Cups
 Easier assembly & application

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

10
 Which cup is available in your practice
site?
 How do you choose which cup to use?

11
Application
Clinical and Technical Principles

12
Courtesy of Aldo Vacca, M.D.
13
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

14
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

15
Contraindications
 Incompetent or inexperienced provider
 CPD
 Moderate or severe caput
 Gestational age of ≤34 weeks
 Malpresentation (breech, footling, face, brow,
shoulder)/ Non vertex presentation
 Unengaged vertex
 Lack of adequate anesthesia, if needed
 Inadequate strength & frequency of contractions
 Inability to achieve proper suction
 Prior failed forceps
16
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.
 To shorten second stage in:-
• Severe anemia
• Cardiac and cerebrovascular diseases
• Eclampsia
• Glaucoma
 Maternal exhaustion is an indication when the mother is
unable to complete second stage spontaneously because of
inadequate expulsive efforts or ineffective bearing down

18
Delivery using ventouse: contd…
 Prerequisites
 Vertex presentation with fetal position identified
 Fully dilated cervix
 Engaged head:
 Ruptured membranes
 Adequate pelvis
 Live fetus
 Term fetus
 Functioning equipment
 Provider should be skilled in performing vacuum deliver

19
Preparation
 Explain the procedure and get written consent

 Empty bladder
 Local anesthesia infiltration for episiotomy
 Assembled and tested vacuum extractor

20
Delivery using ventouse:
Pulling Downward

21
Pulling Horizontal

22
Pulling Straight Up

23
Crowning

24
FAILURE
 Vacuum extraction failed if:
 The head does not advance with each pull;
 The fetus is not delivered within 30 minutes of vacuum
application
 The fetus is undelivered after three pulls
 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.

25
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
26
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

27
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
 Maternal complications
 Tear / laceration of the vulva, perineum , vagina, and
cervix

28
Cephalohematoma Cup mark
Scalp abrasion
Courtesy of Ross McQuivey, MD Dark chignon
29
Management of complications
 Localized scalp oedema (caput succedaneum or

chignon) and simple scalp abrasions usually don’t
require any treatment and will subside without any
treatment.
 For all other neonatal complications refer the neonate

for further management.
 For genital tract tear / laceration, repair or refer
accordingly

30
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

31
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:
 The head does not advance with each pull;
 The fetus is undelivered after three pulls or 30 minutes;
 The cup slips off the head twice
32

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PRESENTATION 5.

Vacuum Extractor Assisted Delivery

Federal Democratic Republic of Ethiopia

 At the end of the session, participants will be able to:

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

 Both an OP and OA cup esigned,

OP Cup has vacuum port placed at

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

 Shapes such as bell, funnel and mushroom

 Easier assembly & application

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

 How do you choose which cup to use?

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

 Vacuum failure rates range from 2-27%

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

 Explain the procedure and get written consent

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

 Retinal hemorrhage less when:

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

 Localized scalp oedema (caput succedaneum or

 For all other neonatal complications refer the neonate

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

BEmONC – LRP: Ethiopia Vacuum Extractor Assisted Delivery

 Have a clear indications for the use of the vacuum

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