Post on 03-Apr-2018
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Prof. dr. Mgs. H. Usman Said, SpOG (K)
Subbagian Fertilitas Endokrinologi & Reproduksi
Departemen Obstetri & Ginekologi
FK. Unsri / RSUP Dr. Muhammad Hoesin
Palembang
2010
VACUUM EXTRACTION
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Vacuum
the vacuum extractor is an obstetrical forceps
outlet, low and mid applications as for forceps
rotation procedures are not to be performed
If a person deficient in dexterity could succeed in applying the (vacuum) tractor
...it is quite probable that he would produce as much injury as benefit...
Hayes, 1831
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Indications
Fetal - suspected fetal compromise requiringimmediate delivery
Maternal
prolonged second stage
maternal conditions which contraindicate
pushing
conditions requiring a shortened second stage
maternal exhaustion
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Contraindications - Absolute
nonvertex, face or brow presentation
unengaged vertex
incompletely dilated cervix
clinical evidence of CPD
Contraindications - Relative
prematurity or EFW < 2500 g
mid-pelvic station
unfavourable attitude
Previous fetal scalp sampling is not a contraindication
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Prerequisites
vertex presentation, term fetus, EFW >2500 g vertex engaged
cervix fully dilated and membranes ruptured
adequate maternal pelvis by clinical assessment
appropriate analgesia
maternal bladder empty
experienced operator
backup plan if procedure not successful
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Avoidance of complications
Confirm indications and conditions for use
Proper anatomical placement
Avoid entrapment of maternal soft tissue
Correct angle of traction Avoid excessive force/torque
Coordinate traction to maternal effort
Control descent/expulsion Apply the rule of threes; stop procedure
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Vacuum Cup Application
Application over sagittal suturetouching posterior fontanelle
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Axis of Parturition
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Vacuum Application/Traction
CorrectIncorrect
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Vacuum Failure - Rules of Threes
3 pulls, over 3 contractions, no progress
3 Pop-offs: after one pop off, reassess carefully
before reapplying
After 30 minutes of application with no progressreassess
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Vacuum Pop-Off - Causes
faulty equipment/poor seal causing vacuum leak
excessive traction force
unrecognized CPD
mid-pelvic application
OP presentations deflexed attitude
improper angle of traction causing shearing
impingement of maternal soft tissue at introitus
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VACUUM MNEMONIC
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Forceps Delivery
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Function of Forceps
obstetrical forceps are for the followingfunctions:
traction of the fetal head
rotation of the fetal head
flexion of the fetal head
extension of the fetal head
these functions cause fetal head compression
proper use minimizes this compressive force
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Indications
Fetal suspected fetal compromise requiring immediate
delivery
Maternal
prolonged second stage
maternal conditions which contraindicate pushing
conditions requiring a shortened second stage
maternal exhaustion deflexed attitudes of the fetal head and malposition
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Prerequisites
head engaged
cervix fully dilated and ruptured
membranes
exact position of the head determined
adequate pelvis bladder empty
appropriate anaesthesia
experienced operator adequate facilities and backup available
Forceps must never be before full dilatation or with an unengaged vertex
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Classification of Forceps Delivery Outlet Forceps
scalp visible at the introitus without separating the
labia
fetal skull has reached the pelvic floor
the sagittal suture is in: AP diameter or
right/left occiput anterior or posterior position
fetal head is at or on the perineum
ACOG: "Committee in Obstetrics, Maternal and Fetal Medicin
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Low Forceps
leading point of the skull is at station + 2 cm or
more
two subdivisions:
rotation of 45 degrees or less
rotation more that 45 degrees
ACOG: "Committee in Obstetrics, Maternal and Fetal Medicin
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Mid Forceps
head is engaged
leading position of the skull is above station + 1 cm alternative to mid forceps delivery is cesarean
section - access to cesarean is necessary if mid
forceps delivery is attempted
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Station
Engagement
when the biparietal diameter of the head enters the
plane of the pelvic inlet
when the leading edge of the skull is at or below theischial spines (station 0)
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Check the Application
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Checking the Application - Position For Safety
Posterior fontanelle midway between the blades
and one finger breadth above the plane of the
shanks with the lambdoid sutures a fingerbreadth
above each blade
Fenestrations of the blades should be barely feltand no more than a finger tip should be able to b
inserted between the blade and the fetal head
Sagittal suture perpendicular to the plane of theshanks
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23From: Human Labour & Birth, Harry Oxorn
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Axis of Parturition
From: Human Labour & Birth, Harry Oxorn
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25From: Human Labour & Birth, Harry Oxorn
Traction1) Direction
2) Amount
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Head Compression
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Rotation
Correct
Incorrect (Ouch!)
From: Human Labour & Birth, Harry Oxorn
Rotation should be completed by moving the handle in a wide circle so the toe remains
fixed for rotation, otherwise one is carving vaginal sidewalls.
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FORCEPS MNEMONIC
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Comparison of Forceps
and Vacuum Delivery
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Comparison of vacuum to forceps
8 randomized, prospective trials
Outcomes
delivery by intended method
cesarean delivery
maternal analgesia requirements
maternal and neonatal morbidity
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Forceps versus Vacuum: Maternal
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Forceps versus Vacuum: Neonatal
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Advantages of Vacuum Extraction
No increase in significant neonatal morbidity
Less need for maternal regional/general
anesthetic Less maternal vaginal/perineal trauma
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Disadvantages of Vacuum Extraction
Cephalohematoma
subaponeurotic (subgaleal) hemorrhage
Neonatal retinal hemorrhages
uncertain clinical significance
More likely to fail to deliver, requiring
alternative
Patients must be made aware of these risks
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Documentation of Operative Delivery
the procedure must be clearly recorded in
every case
this documentation should provide an
explanation of the operative intervention
which has taken place
including a description of the operative
technique employed and its indication
Need for Intervention must be:
convincing, compelling,consented to, charted
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VACUUM EXTRACTION
AUDIT TOOL
Patient DemographicsIndications
Prerequisites
ProcedureOutcome