Vakum Forceps (Edit)

7/29/2019 Vakum Forceps (Edit)

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Prof. dr. Mgs. H. Usman Said, SpOG (K)

Subbagian Fertilitas Endokrinologi & ReproduksiDepartemen Obstetri & Ginekologi

FK. Unsri / RSUP Dr. Muhammad HoesinPalembang2010


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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 requiringimmediate 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 beforereapplying

After 30 minutes of application with no progressreassess


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Vacuum Pop-Off - Causesfaulty 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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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 DeliveryOutlet Forceps

scalp visible at the introitus without separating thelabia

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 midforceps 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 andone finger breadth above the plane of the shanks withthe lambdoid sutures a fingerbreadth above each blad

Fenestrations of the blades should be barely felt andno more than a finger tip should be able to be insertedbetween the blade and the fetal head

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/generalanesthetic

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 operative intervention whichhas taken place

including a description of the operative techniqueemployed and its indication

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


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VACUUM EXTRACTION

AUDIT TOOL

Patient Demographics

IndicationsPrerequisites

Procedure

Outcome

Documents

Vakum Forceps (Edit)