Vakum Forceps

7/29/2019 Vakum Forceps

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Assisted Vaginal Birth


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Objectives Indications

Prerequisites

Classification

Methods of application and traction

Comparison of techniques

Documentation


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Vacuum Extraction


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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


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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


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Contraindications - Absolute

nonvertex, face or brow presentation

unengaged vertex

incompletely dilated cervix

clinical evidence of CPD


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Contraindications - Relative

prematurity or EFW < 2500 g

mid-pelvic station

unfavourable attitude

Previous fetal scalp sampling is not a contraindication


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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


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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


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Vacuum Cup Application

Application over sagittal suturetouching posterior fontanelle


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Axis of Parturition


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Vacuum Application/Traction

CorrectIncorrect


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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


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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


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VACUUM MNEMONIC


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Forceps Delivery


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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


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Indications

Fetalsuspected fetal compromise requiring immediate

delivery

Maternalprolonged second stage

maternal conditions which contraindicate pushing

conditions requiring a shortened second stage

maternal exhaustion

deflexed attitudes of the fetal head and malposition


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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


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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 Medicin


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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 Medicin


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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


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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 theischial spines (station 0)


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Check the Application


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Checking the Application - Position For Safety

Posterior fontanelle midway between the blades and one finger breadthabove the plane of the shanks with the lambdoid sutures a fingerbreadthabove 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 fetalhead

Sagittal suture perpendicular to the plane of the shanks


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From: Human Labour & Birth, Harry Oxorn


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Axis of Parturition



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Traction1) Direction

2) Amount


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Head Compression


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Rotation

Correct

Incorrect (Ouch!)



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FORCEPS MNEMONIC


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Comparison of Forceps

and Vacuum Delivery


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Comparison of vacuum to forceps 8 randomized, prospective trials

Outcomes

delivery by intended method

cesarean delivery

maternal analgesia requirements

maternal and neonatal morbidity


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Forceps versus Vacuum: Maternal


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Forceps versus Vacuum: Neonatal


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Advantages of Vacuum Extraction

No increase in significant neonatal morbidity

Less need for maternal regional/general anesthetic

Less maternal vaginal/perineal trauma


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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


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Documentation of Operative Delivery

the procedure must be clearly recorded in every case

this documentation should provide an explanation of the operativeintervention which has taken place

including a description of the operative technique employed and itsindication

Need for Intervention must be:convincing, compelling,consented to, charted


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VACUUM EXTRACTION

AUDIT TOOL

Patient Demographics

IndicationsPrerequisites

Procedure

Outcome

Vakum Forceps

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