• Vacuum Delivery/ ventouse/vacuum extractor

Sunil Kumar Daha

“Instrumental device designed to assist delivery by applying traction to a suction cup attached to the fetal scalp”• Any condition threatened to mother or fetus that is

likely to be relieved by delivery

• Fetus of atleast 34 weeks

Introduction

Maternal indication1. Maternal distress, exhaustion after a long, painful labor, due

to inefficient uterine contractions.2. Prolonged second stage of labor ( Nulliparous: >3hrs with regional analgesia >2hrs without regional analgesia Parous: >2hrs with regional analgesia >1 hr without regional analgesia)

3. Maternal medical disorders such as heart disease, hypertensive disorders and moderate to severe anemia.

4. Previous cesarean section or genital prolapse repair.5. Intrapartum infection, certain neurological conditions.

Fetal indication1. Prolapse of umbilical cord2. Premature separation of placenta3. Non reassuring fetal heart rate pattern4. Fetal distress5. Non rotated heads or occipitotransverse positions6. Occipitoposterior position

Contraindication

• Operator inexperience• Inability to assess fetal position• Suspicion of cephalopelvic disproportion• Fetal coagulopathy• Preterm babies (<34 weeks) due to risk of fetal

intraventricular hemorrhage• Macrosomia (≥4 kg)• Soft tissues obstruction in the pelvis• Breach presentation and face presentation

Instrumentation Components:• a suction cup with four sizes(30mm, 40mm,

50mm, 60mm)– Metal cup– Soft cup– Silastic cup– Rigid plastic cup

• vacuum pump, • traction tubing

Mityvac pump with tube and soft cup

Silastic vacuum cup

Application of vacuum cup

Technique• The woman's bladder should be empty (via

voiding or catheterization). • The patient is placed in the lithotomy position.• Vaginal examination to check pelvic capacity,

cervical dilatation, presentation, position, station and degree of flexion of head and that the membranes are ruptured

• Determination of flexion point

Continue….• Proper cup placement over flexion point• Exclude maternal soft tissue entrapment by

palpation• Vacuum creation by increasing the suction in

increments of 0.2 kg/cm2 every 2 mins until 0.8 kg/cm2

• A check is made using the fingers round the cup to ensure that no cervical or vaginal tissue is trapped inside the cup

Continue….

• The pressure is gradually raised at the rate of 0.1kg/cm2 per minute until the effective vacuum of 0.8kg/cm2 is achieved in about 10 minutes time

• The scalp is sucked into the cup and an artificial caput succedaneum is produced, which dissapears withinn few hours.

• Instrument handle is grasped, and initiation of traction

Continue….• Traction is initiated by using a two-handed

technique, i.e the fingers of one hand are placed against the suction cup, while the other hand grasps the handle of the instrument

• Traction must be at right angle to the cup

• Traction directed initially downward then progressively extended upward as head emerge

Continue….

• Traction should be synchronous with the uterine contractions; released in between the contractions.

• Once head is extracted, vacuum pressure is relieved; cup is removed; vaginal delivery followed

Continue….• The total time from the application until delivery

should not exceed 20 minutes• If >20 minutes, the risk of fetal scalp trauma and

intracranial damage increases• Many pulls to achieve progress should not be

done• The operator should be wiling to abandon the

procedure if it does not proceed easily or if the cup dislodges >3 times

Summary

• Ask for help, Address the patient, Anesthesia• Bladder empty• Cervix fully dilated• Determine fetal position and think shoulder dystocia• Extractor and resuscitation equipment ready• Flexion point – apply cup• Gentle traction in the proper axis• Halt traction when the contraction is over, halt the

procedure if it is not progressing normally

Fetal Complications

• Scalp laceration and bruising• Subglial hematoma, Cephalohematoma• Intracranial hemorrhage, intraventricular and cerebral

hemorrhages • Retinal and sub-conjunctival hemorrhages• Neonatal jaundice• Clavicular fracture, Shoulder dystocia• Injury to CVI, CVII nerves, Erb palsy• Hypoxia, particularly when extraction has taken a long time

and has been difficult• Fetal death

Maternal Complications• Soft tissues injuries such as cervical tears,

annular detachment of the cervix, vaginal tears, perineal lacerations and tears, extension of episiotomy, vaginal wall and perineal hematomas.

• Traumatic postpartum hemorrhages• Infection• Genital prolapse

Management• To assess the effect on the mother and the fetus• To start a Ringer’s solution drip and to arrange for

blood transfusion, if required• To exclude rupture of the uterus• To assess if procedure is to be abandoned and

consider delivery by cesarean section• Laparotomy should be done in a case with

rupture of uterus.• To administer parenteral antibiotic

• Cunningham et.al., Williams OBSTETRICS, 24E, McGraw-Hill Education, 2014,

• DC Dutta’s textbook of Obstetrics

References

Thank you