Xvakum Forceps (Edit)

7/29/2019 Xvakum Forceps (Edit)

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

Subbagian Fertilitas Endokrinologi & Reproduksi

Departemen Obstetri & Ginekologi

FK. Unsri / RSUP Dr. Muhammad Hoesin

Palembang

2010

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 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

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 progressreassess


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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 followingfunctions:

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

Fetal suspected fetal compromise requiring immediate

delivery

Maternal

prolonged 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 breadth above the plane of the

shanks with the lambdoid sutures a fingerbreadth

above each blade

Fenestrations of the blades should be barely feltand no more than a finger tip should be able to b

inserted between the blade and the fetal head

Sagittal suture perpendicular to the plane of theshanks


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23From: Human Labour & Birth, Harry Oxorn


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Axis of Parturition

From: Human Labour & Birth, Harry Oxorn


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25From: 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

Rotation should be completed by moving the handle in a wide circle so the toe remains

fixed for rotation, otherwise one is carving vaginal sidewalls.


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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 operative intervention

which has taken place

including a description of the operative

technique employed and its indication

Need for Intervention must be:

convincing, compelling,consented to, charted


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VACUUM EXTRACTION

AUDIT TOOL

Patient DemographicsIndications

Prerequisites

ProcedureOutcome

Documents

Xvakum Forceps (Edit)