Chapter 254 Vacuum-Assisted Delivery
DESCRIPTION
Vacuum-assisted delivery is a method of assisting or expediting vaginal vertex delivery through the application of a vacuum assist device. (Discussion here is limited to vacuum-assisted deliveries with the fetus presenting within 45 degrees of directly occiput anterior.)
INDICATIONS
Fetal: nonreassuring fetal status, acute fetal distress. Maternal: fatigue, prolonged second stage of labor (nulliparous women: lack of continuing progress for 3 hours with regional anesthesia or 2 hours without regional anesthesia; multiparous women: lack of continuing progress for 2 hours with regional anesthesia or 1 hour without regional anesthesia), certain types of pulmonary, cardiac, or neurologic disease.
CONTRAINDICATIONS
Incompletely dilated cervix, significant fetal malpresentation, unengaged fetal head, intact fetal membranes, inability to assess fetal position or obtain maternal cooperation, distorted or contracted maternal pelvic anatomy, gestational age less than 34 weeks, fetal demineralization or clotting disorder, prior scalp sampling, or multiple attempts at fetal scalp electrode placement (relative).
TECHNIQUE
Adequate maternal anesthesia or analgesia should be ensured in all but the most extreme circumstances. Whenever possible, the maternal bladder should be emptied (by catheter). The exact position of the fetal head must be ascertained by palpation of the sagittal suture and fontanels. All other preparations for vaginal delivery should be in place before the vacuum device is applied.
Optimal placement of the vacuum cup is over the flexion point of the fetal head. Normally, the flexion point is in the midline, over the sagittal suture, approximately 6 cm from the anterior fontanel and 3 cm from the posterior fontanel. When the center of the vacuum cup is placed over this point, the edges of the cup should be roughly 3 cm from the anterior fontanel and just above the edge of the posterior fontanel.
To place the vacuum cup, the labia are separated and the bell-shaped cup is compressed and inserted it into the vagina while the device is angled toward the posterior vagina. (If an M-shaped or rigid cup is used, the device is flexed at the base of the shaft and inserted sideways into the vagina while being angled backward.)
The cup is placed in contact with the fetal head, with the center of the cup placed over the flexion point. The entire circumference of the cup must then be inspected (visually or by touch) to ensure that no maternal tissues intercede between the cup and the fetal head. The cup should be clear of both fontanels.
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