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

2. History Simpson 1794 Malmstrom 1954 Bird 1960’s O’Neill 1980’s
Vacco 1990’s

3. Indications Maternal Fetal Exhaustion Hypertension
CPD (with symphysiotomy)
Fetal
Second stage delay
Bradycardia

4. Requirements 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

5. Controversial Gestation 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 dilatation
High second twin

7. 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 g
Maternal BMI >30

8. Risks Fetal Maternal Scalp bruising Jaundice Scalp laceration
Cephalhaematoma
Retinal haemorrhage
Subgaleal haemorrhage
Intracranial haemorrhage
Maternal
Damage to vagina, bladder or bowel

9. Meta Analysis of RCT Ventouse Vs Forceps
Ventouse is associated with a greater rate of failure (about15%)
BUT
Overall Caesarean rate with Ventouse was significantly lower

10. Meta Analysis of RCT Ventouse Vs Forceps
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

11. Meta Analysis of RCT Ventouse Vs Forceps
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

12. Meta Analysis of RCT Ventouse Vs Forceps
Forceps may be associated with:
Facial trauma
Facial or other Cranial Nerve palsies
AND
Spinal cord injury with rotation
But this is rare

13. Meta Analysis of RCT Ventouse Vs Forceps
Ventouse is associated with:
More neonatal jaundice
But
The need for phototherapy is the same as for forceps

14. 12 Year Follow Up of Patients delivered SVD, Forceps & 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)

15. Tips 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

16. After 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

17. A RCT of Kiwi Omnicup vs Conventional Ventouse 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

18. Avoiding 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

19. Any Questions or Comments?
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