Vacuum extractors for operative assisted vaginal deliveries require the application of a soft cup to be applied to the baby's head sufficient to apply traction to accomplish delivery of the fetal head. Because the vacuum seal is rarely perfect, periodic application of negative pressure (suction) must be used. Over the last few decades, the long term safety to the fetus of forceps operative vaginal deliveries has come into question with the resulting increase in use of vacuum extractors to accomplish an operative vaginal delivery. Information supporting a higher incidence of long-term adverse consequences to the newborn has contributed to the continued controversy whether to persist in the use of vacuum extractors for operative vaginal deliveries.
At present, vacuum assisted operative vaginal deliveries account for less than 10% of vaginal deliveries. A variety of vacuum instruments have particular designs for a particular purpose. All vacuum extractors include a rigid or flexible vacuum cup that applies to the fetal head, a combined vacuum pump and a handle or chain for traction. Soft vacuum cups have a higher rate of failure due to the high frequency of spontaneous detachment of the cup from the fetal head. This may result in the need for multiple applications.
Vacuum extraction deliveries are classified in accordance with the level of descent of the leading bony point of the fetal head in the mother's pelvis. At times, vacuum extractors are used to assist during a cesarean section delivery. Types of vacuum extraction deliveries include:
High vacuum operation
Mid vacuum operation
Low vacuum operation
Outlet vacuum operation
Vacuum assisted cesarean section
Indications for operative vaginal delivery are similar for vacuum extractors and forceps. Taking into account that no indication is an absolute indication, they include:
Prolonged second stage without cephalopelvic disproportion
Immediate or potential fetal compromise during the second stage of labor
Interruption of second stage of labor because of acute bleeding, cardiac disease, pulmonary disease or maternal exhaustion (see below)
Operative vaginal delivery with vacuum extractor should not be undertaken without a valid indication. Attempts to shorten labor for maternal and/or physician's convenience does not support the use of vacuum extractor at any time. Maternal exhaustion, although a valid indication at times, requires the medical provider to assess the underlying reason for the maternal exhaustion. Prolonged labors are quite often an indication of the presence of cephalopelvic disproportion or fetal malposition. Cephalopelvic disproportion exists when the the dimensions of the fetal head are larger than the dimensions of the maternal pelvis. Delivery of such an infant can only be accomplished at the expense of excessive traction on the fetal head with consequent injury to the baby. Contraindications to the use of vacuum extractor include:
Inadequate trail of labor
Unknown fetal position and station
Suspicion of cephalopelvic disproportion
Fetal coagulation disorder
Prior failed forceps
Inability to achieve proper application
Prerequisites for the use of vacuum extractors include:
Amniotic membranes must be ruptured
Type of pelvis must be known
Cervix must be fully dilated
Position of the fetal head must be known
Fetal head must be engaged in the pelvis
No cephalopelvic disproportion is present
Adequate anesthesia given
Physician must be fully trained in the use of forceps
Operative vaginal delivery increases the risk of neonatal intracranial bleeds when compared with normal spontaneous vaginal delivery or cesarean section. Complications associated with vacuum extractor operative vaginal deliveries can be divided into maternal complications and fetal complications. Maternal complications with vacuum extractors are fewer and less severe than with forceps deliveries. Maternal complications include:
Lacerations of the vagina
Lacerations of the cervix
increase in blood loss
Injury to the urinary bladder
Anal sphincter injuries
Fetal complications associated with the use of vacuum extractors is low but can be severe. Subgaleal or subaponeurotic hemorrhage from rupture of the emissary vein has a mortality rate of 1 in 4 affected infants. Approximately half of the subgaleal hemorrhages are due to vacuum extractors and the rest are due to forceps deliveries. fetal complications include:
Transient facial bruising or lacerations
Subgaleal or subaponeurotic hemorrhage
The combined use of operative vaginal delivery instruments such as forceps followed by vacuum extractor delivery (or vice-versa) or the multiple attempts such as more than 3 traction episodes to accomplish delivery are clearly contraindicated. Regardless of the ultimate success in accomplishing a vaginal delivery under these circumstances, the risk of neonatal intracranial hemorrhage is markedly increased.
If your child was delivered by vacuum extraction and is now suffering from a birth related injury, or you are suffering from a maternal complication, Dr. Borten and the Boston area medical malpractice attorneys at Gorovitz & Borten can help you assert your rights and get the compensation you deserve.
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