vacuum-assisted vaginal delivery max brinsmead mb bs phd may 2015
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Vacuum-assisted Vaginal Vacuum-assisted Vaginal DeliveryDelivery
Max Brinsmead MB BS PhD
May 2015
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HistoryHistory
Simpson 1794Malmstrom 1954Bird 1960’sO’Neill 1980’sVacco 1990’s
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IndicationsIndications
Maternal– Exhaustion– Hypertension– CPD (with symphysiotomy)
Fetal– Second stage delay– Bradycardia
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RequirementsRequirements
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
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ControversialControversialGestation 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 dilatationHigh second twin
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Who should go to theatre for a trial?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 gMaternal BMI >30
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RisksRisks
Fetal– Scalp bruising– Jaundice– Scalp laceration– Cephalhaematoma– Retinal haemorrhage– Subgaleal haemorrhage– Intracranial haemorrhage
Maternal– Damage to vagina, bladder or bowel
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Meta Analysis of RCT Ventouse Meta Analysis of RCT Ventouse Vs ForcepsVs Forceps
Ventouse is associated with a greater rate of failure (about15%)
BUT
Overall Caesarean rate with Ventouse was significantly lower
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Meta Analysis of RCT Ventouse Meta Analysis of RCT Ventouse Vs ForcepsVs 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
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Meta Analysis of RCT Ventouse Meta Analysis of RCT Ventouse Vs ForcepsVs 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
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Meta Analysis of RCT Ventouse Meta Analysis of RCT Ventouse Vs ForcepsVs Forceps
Forceps may be associated with:– Facial trauma– Facial or other Cranial Nerve palsies
AND Spinal cord injury with rotation
But this is rare
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Meta Analysis of RCT Ventouse Meta Analysis of RCT Ventouse Vs ForcepsVs Forceps
Ventouse is associated with:– More neonatal jaundice
But– The need for phototherapy is the same as for
forceps
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12 Year Follow Up of Patients delivered SVD, 12 Year Follow Up of Patients delivered SVD, Forceps & Ventouse or CSForceps & 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)
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Tips for Safe & Successful UseTips 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
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After Care of the WomanAfter 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
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A RCT of Kiwi Omnicup vs Conventional A RCT of Kiwi Omnicup vs Conventional Ventouse BJOG 2006Ventouse 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
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Avoiding the need for assisted deliveryAvoiding 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
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