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Vacuum-assisted Vaginal Delivery

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Presentation on theme: "Vacuum-assisted Vaginal Delivery"— Presentation transcript:

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

6

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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