Slide 1: VACUUM-OR FORCEPS ASSISTED DELIVERIES?
A DANGER? Dr. Mohammed Abdalla
Domiat general hospital Slide 2: In 1998, the US Food and Drug Administration (FDA) issued a warning about the potential dangers of delivery with the vacuum extractor. This followed several reports of infant fatality secondary to intracranial haemorrhage. VACUUM-ASSISTED DELIVERIES A DANGER? based upon data from 1989-1995, Slide 3: FDA has received reports of 12 deaths and nine serious injuries among newborns on whom vacuum assisted delivery devices were used VACUUM-ASSISTED DELIVERIES A DANGER? Slide 4: the FDA urged caution in use of the popular devices VACUUM-ASSISTED DELIVERIES A DANGER? Slide 5: Afterward, ACOG became concerned that the FDA’s warning might itself endanger women and babies if it encouraged physicians to choose forceps or Caesarean over a properly performed vacuum-assisted delivery. Slide 6: ACOG issued an advisory to its members reiterating the contraindications for use of the devices but encouraging their continued use by trained physicians. Can operative vaginal delivery be avoided? : Can operative vaginal delivery be avoided? Can operative vaginal delivery be avoided? : Can operative vaginal delivery be avoided? All women should be encouraged to have continuous support during labour.
Use of a partogram,
use of upright or lateral positions and avoiding epidural analgesia, will reduce the need for operative vaginal delivery.
Oxytocin in primiparous women with epidurals will decrease the need for operative vaginal delivery.
Delayed pushing in primiparous women with an epidural will reduce the risk of rotational and mid-cavity deliveries. Classification for operative vaginal delivery (adapted from ACOG 2000) : Classification for operative vaginal delivery (adapted from ACOG 2000) Outlet
Fetal scalp visible without separating the labia
Fetal skull has reached the pelvic floor
Sagittal suture is in the antero-posterior diameter or right or left occiput anterior or posterior position(rotation does not exceed 45 degrees)
Fetal head is at or on the perineum
Leading point of the skull (not caput) is at station plus 2 cm or more and not on the pelvic floor
Fetal head is 1/5 palpable per abdomen
Leading point of the skull is above station plus 2 cm but not above the ischial spines Indications for operative vaginal delivery : Indications for operative vaginal delivery Fetal
Presumed fetal compromise
Medical indications to avoid Valsalva (e.g. cardiac disease Class III or IV,a hypertensive crises, cerebral vascular disease, particularly uncorrected cerebral vascular malformations, myasthenia gravis, spinal cord injury)
Nulliparous women: lack of continuing progress for three hours (total of active and passive second stage labour) with regional anaesthesia, or two hours without regional anaesthesia
Multiparous women: lack of continuing progress for two hours (total of active and passive second stage labour) with regional anaesthesia, or one hour without regional anaesthesia
Maternal fatigue/exhaustion Prerequisites for operative vaginal delivery (adapted from SOGC, 2004) : Prerequisites for operative vaginal delivery (adapted from SOGC, 2004) Head is ≤ 1/5 palpable per abdomen
Cervix is fully dilated and the membranes ruptured
Exact position of the head can be determined so proper placement of the instrument can be achieved
Pelvis is deemed adequate
Informed consent must be obtained and clear explanation given
Appropriate analgesia is in place, for mid-cavity rotational deliveries this will usually be a regional block
A pudendal block may be appropriate, particularly in the context of urgent delivery
Maternal bladder has been emptied recently
Indwelling catheter should be removed or balloon deflated
Operator must have the knowledge, experience and skills necessary to use the instruments
Adequate facilities and back-up personnel are available
Back-up plan in place in case of failure to deliver
Anticipation of complications that may arise (e.g. shoulder dystocia, postpartum haemorrhage)
Personnel present who are trained in neonatal resuscitation Slide 12: Use of the vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity.
The reduction in cephalhaematoma and retinal haemorrhages seen with forceps may be a compensatory benefit.
Cochrane Library, Issue 2, 2002. Slide 13: Metal cups appear to be more suitable for 'occipito-posterior', transverse and difficult 'occipito-anterior' position deliveries.
The soft cups seem to be appropriate for straightforward deliveries. Cochrane Library, Issue 2, 2002 Slide 14: The options available for rotational delivery include:
manual rotation followed by direct traction forceps or
rotational vacuum extraction .
Rotational deliveries should be performed by
experienced operators, the choice depending upon the expertise of the individual operator. Slide 15: In Labour Interventions controversies Dr Mohammed Abdalla