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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
From: Human Labour & Birth, Harry Oxorn
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From: Human Labour & Birth, Harry Oxorn
Traction1) Direction
2) Amount
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Head Compression
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Rotation
Correct
Incorrect (Ouch!)
From: Human Labour & Birth, Harry Oxorn
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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