Vacuum-assisted Vaginal Delivery Max Brinsmead MB BS PhD May 2015

Vacuum-assisted Vaginal Vacuum-assisted Vaginal DeliveryDelivery

Max Brinsmead MB BS PhD

May 2015

HistoryHistory

Simpson 1794Malmstrom 1954Bird 1960’sO’Neill 1980’sVacco 1990’s

IndicationsIndications

Maternal– Exhaustion– Hypertension– CPD (with symphysiotomy)

Fetal– Second stage delay– Bradycardia

RequirementsRequirements

A trained operator Tested equipment Gestation >36w Cephalic presentation Dilatation 10 cm (unless skilled) Descent beyond spines (unless skilled) You must identify the occiput Contracting uterus Co operative mother Anaesthesia Empty bladder Episiotomy

ControversialControversialGestation 34 – 35 completed weeks

It is generally agreed that Ventouse should not be used at <34 weeks

Forceps are acceptable

Fetal bleeding disorder For example thrombocytopenia

Maternal blood borne viral infections For example HIV Acceptable if fetal trauma is avoided

Incomplete cervical dilatationHigh second twin

Who should go to theatre for a trial?Who should go to theatre for a trial?

Any head is palpable above the brim or the head is station < 2 cm from spines

Unless there is clearly no CPD and the indication is suspected fetal compromise

Weigh up risk associated with delay vs risk associated with failure

Fetal head rotation is >45 degrees from occipito anterior

Estimated fetal weight >4000 gMaternal BMI >30

RisksRisks

Fetal– Scalp bruising– Jaundice– Scalp laceration– Cephalhaematoma– Retinal haemorrhage– Subgaleal haemorrhage– Intracranial haemorrhage

Maternal– Damage to vagina, bladder or bowel

Meta Analysis of RCT Ventouse Meta Analysis of RCT Ventouse Vs ForcepsVs Forceps

Ventouse is associated with a greater rate of failure (about15%)

BUT

Overall Caesarean rate with Ventouse was significantly lower


Ventouse is associated with:– Less maternal trauma (RR 0.41, CI 0.33 – 0.50)– More vaginal deliveries (RR 1.69 CI 1.31 – 2.19)– Less sphincteric dysfunction– Less need for major analgesia– Less perineal pain at 24 hours

But– More cephalhaematomas (RR 2.38, CI 1.68 – 3.37)– More retinal haemorrhages (RR 1.99, CI 1.35 – 2.96)– More maternal concern about baby– And forceps may be quicker


Ventouse may be associated with– Lower 5 minute Apgar score

If used over a long period of time

– More scalp trauma If the cup detaches

AND Subgaleal & Intracranial haemorrhages

But these are rare


Forceps may be associated with:– Facial trauma– Facial or other Cranial Nerve palsies

AND Spinal cord injury with rotation

But this is rare


Ventouse is associated with:– More neonatal jaundice

But– The need for phototherapy is the same as for

forceps

12 Year Follow Up of Patients delivered SVD, 12 Year Follow Up of Patients delivered SVD, Forceps & Ventouse or CSForceps & Ventouse or CS

Forceps was associated with:– Increased risk of fecal incontinence – 17% cf 11% for Ventouse– (and 11% for SVD or CS)

But– Slightly lower risk of urinary incontinence– 54% cf 56% after Ventouse– (and 55% for SVD, 40% for exclusive CS)

Tips for Safe & Successful UseTips for Safe & Successful Use Wait for chignon formation

Not required for soft cups A study of rapid vs slow suction found no difference in success

PULL ONLY WITH CONTRACTIONS Use a finger from the 2nd hand to prevent edge lifting of

the cup Pull at right angles to the cup

And this will follow the curve of Carus

The skill is akin to cord traction Knowing how firmly to pull short of detachment

Progress with every pull OR STOP Deliver within 20 minutes OR STOP Judicious use of episiotomy Sequential use of forceps only for “lift out” Collect paired cord blood for pH and gases Document carefully

After Care of the WomanAfter Care of the Woman Rectal NSAID and regular oral thereafter plus Paracetamol

Consider the need for: Thromboprophylaxis Antibiotics (not routine) Faecal softening agents

Document the time and volume of the first void Check residual volume if any doubt about complete emptying

Physiotherapy for the pelvic floor Preferably conducted by physiotherapist with expertise

Debriefing by the accoucheur The evidence for special interventions to avoid depression

does not support the practice

A RCT of Kiwi Omnicup vs Conventional A RCT of Kiwi Omnicup vs Conventional Ventouse BJOG 2006Ventouse BJOG 2006

206 women at Queen Charlotte and Chelsea hospitals London randomised

44% detachment rate with Kiwi cup vs 18% with conventional ventouse

Overall failure therefore was more common (RR 1.58, CI 1.10 – 2.24

Rate of maternal injury the same

No serious neonatal trauma

Avoiding the need for assisted deliveryAvoiding the need for assisted delivery Provide continuous one-to-one support for women in

labour

Encourage the upright position

Avoid epidural anaesthesia if possible

Delayed pushing if an epidural is used

Judicious use of oxytocin in the second stage

Scalp sampling for lactate for non reassuring cardiotocography

Any Questions or Comments?Any Questions or Comments?

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Vacuum-assisted Vaginal Delivery Max Brinsmead MB BS PhD May 2015