Assisted Vaginal Delivery

October 2018
Learning outcomes

• To describe the indications and prerequisites for assisted

vaginal delivery

• To practise the use of vacuum (ventouse) extraction

• To outline the contraindications and when to abandon

procedure

• To discuss forceps delivery

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Terminology

Instrumental vaginal delivery

=
Assisted vaginal delivery

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Rationale for AVD

• Complications from prolonged & obstructed labour:

4-13% maternal deaths in developing world

• CS at second stage: higher risk of surgical injuries to

uterus, ureters and urinary bladder

• Second stage CS: higher risk of puerperal sepsis

• Alternatives to AVD include CS, symphysiotomy and

destructive procedures for non-viable fetuses

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Rationale: Basic EmOC

1. Parenteral antibiotics
2. Parenteral oxytocics
3. Parenteral antihypertensives
4. Manual removal of placenta
5. Manual vacuum aspiration
6. Assisted vaginal delivery
7. Newborn resuscitation with bag and mask

WHO 2007, WHO 2009

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 Proportion of births by AVD

• Developed countries: 5-20% of deliveries (Majoko 2008)

• United Kingdom: 12.9% (RCOG, 2011)
• USA: 4.5% (Martin 2009)

• Developing countries: less than 1% (Bailey 2005)

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Options for AVD

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Vacuum extraction

• Indications
• Conditions necessary
• Pre procedure preparation
• Procedure
• Post procedure actions

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AVD: Indications

• Shorten duration of second stage if prolonged

• Expedite second stage of labour of clinically unstable

pregnant women

• Assist delivery in occipito-posterior

• Fetal distress

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Conditions necessary

• > 36 weeks pregnancy (use with caution between 34 & 36

weeks gestation)

• Live baby in cephalic presentation (fresh stillbirth)

• Cervix fully dilated

• Fetal head at station 0 or not more than 1/5 palpable
above symphysis pubis

• Cooperative mother with good contractions

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Pre-procedure: preparation
• Explain the procedure and gain consent

• Ensure respectful care

• Wash hands with soap & water or use antiseptic hand rub (dry with
sterile cloth)

• Gloves

• Clean vulva

• Drape

• Make sure urinary bladder is empty

• Pudendal block usually not necessary but perform perineal infiltration

if episiotomy is anticipated
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Pre-procedure: assembly

Choose apparatus
• Kiwi : Hard / Soft
• Malmstrom (Bird): Large / Medium / Small

Check apparatus
• Functioning?
• Familiar?

Check suction on gloved hand

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Types of equipment

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 Procedure: application

• Assess position of fetal

head by feeling sagittal
suture line and
fontanelles
• Identify posterior
fontanelle

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 Procedure: application

• Explain to mother
• Apply largest possible cup
• Place centre of cup 2-3
cm anterior to the
posterior fontanelle
• Insert gently and apply to
flexion point
• Check application
• Ensure no soft tissue in
rim of cup

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Procedure: application

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Procedure: application

• Create a vacuum of 0.2kg/cm2 (Yellow)

• Check application of cup
• Increase vacuum to 0.8kg/cm2 (Green)
• Check application of cup
• Ask woman to tell you when next contraction starts

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Procedure: traction

• With each contraction ask

the mother to push

• Place finger on scalp next

to cup to assess descent
and potential slippage

• Start traction in line of

pelvic axis and
perpendicular to cup

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 Procedure: traction
• Between contractions,
check fetal heart rate and
application of cup

• Do not pull if no contraction

• Decide if episiotomy
indicated

• Continue pulls for

maximum of three
contractions if no progress

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 Procedure: action

• When head is delivered release the vacuum and remove cup

• Deliver baby in normal way

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Post procedure actions

• Active management of third stage

• Repair any perineal trauma (tear or episiotomy)

• Write up notes for the procedure

• Observe baby for complications (12-24hrs)

• Neonatal review where available

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Failed vacuum extraction

Classify as ‘failed’ if:

• Fetal head does not advance with each pull
• No descent to pelvic floor after maximum of three
contractions/pulls
• Cup slips off the head twice at proper direction of
pull
with maximum negative pressure

Consider an alternative procedure:

• Caesarean section or symphysiotomy

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Complications
Maternal
• Lower genital tract injuries

Fetal
• Localised scalp oedema (caput
& chignon)
• Scalp abrasions and lacerations
• Cephalhaematoma
• Neonatal jaundice
• Intracranial bleeding (rare) Neonatal cephalhaematoma

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When expert neonatal review not available

•Careful observation - increasing swelling

•Haematocrit (Packed Cell Volume)
•Check Serum Bilirubin

Cephalhaematoma usually resolves

spontaneously within 2-4 weeks !

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Use of obstetric forceps

Consider forceps:
• For after-coming head at breech delivery

• At C/S, for high head

• For speed with prolapsed cord

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?
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 Recap

• Indications and prerequisites for assisted vaginal delivery

• Contraindications
• Indications for forceps delivery

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