Failed Vacuum Research Articles

Risk of Preterm Birth among Secundiparas with a Previous Cesarean due to a Failed Vacuum Delivery

Background: Studies have found an association between second-stage cesarean sections (SSCSs) and subsequent preterm birth (PTB). We aimed to evaluate if secundiparas with previous second-stage cesarean sections due to a failed vacuum delivery (SSCS-F-VD) are associated with PTB in the subsequent delivery compared with secundiparas with previous spontaneous vaginal birth (SVB) at term. A secondary aim was to compare this association with secundiparas with a previous SSCS at term. Methods: A historical, prospective, longitudinal cohort study was conducted in a large tertiary university hospital between 2006 and 2019. Matched mothers who experienced first and second births at the indexed hospital, excluding those with a previous miscarriage or multiple pregnancy in either the first or second birth were grouped based on the mode of delivery and gestational week of the first birth. Results: Parturients with term SVB and term SSCSs were less likely to experience PTB in the following delivery compared with those who underwent an SSCS-F-VD, with 496/14,551 (3.4%) versus 6/160 (3.8%) versus 5/61 (8.2%), respectively, at p < 0.001. A logistic regression model revealed that secundiparas with previous SSCS-F-VD had an association with PTB in the following delivery compared with term SVB, with an OR of 2.756 (1.097; 6.922, p = 0.031). Conclusion: Previous SSCS-F-VD is associated with PTB in the following delivery, offering valuable insights for pregnancy management and patient counseling.

Unintended uterine extension at the time of cesarean delivery – risk factors and associated adverse maternal and neonatal outcomes

Objective To identify risk factors, maternal and neonatal adverse outcomes related to unintended lower segment uterine extension during cesarean delivery (CD). Methods A retrospective cohort analysis in a single, university-affiliated medical center between 1 January 2018 and 31 December 2019. All singleton pregnancies delivered by CD were included. Univariate and multivariate analyses were performed to identify maternal and obstetrical predictors for uterine extension during CD. For secondary outcomes, we assessed the correlation between uterine extension and any adverse maternal or neonatal outcome. Risk factors were analyzed using ROC statistics to measure their prediction performance for a uterine extension. Results Overall, 1746 (19.3%) CDs were performed during the study period. Of them, 121 (6.9%) CDs were complicated by unintended uterine extension. There was no difference in maternal demographics and clinical data stratified by uterine extension at CD. Uterine extensions were significantly more common following induction of labor, intrapartum fever, premature rupture of membranes, a trial of labor after cesarean, advanced gestational age, emergent CD, and in particular CD during the second stage of labor (37.2% vs. 6.5%) and after failed vacuum extraction (6.6% vs. 1.1%), p < .05 for all. The incidence of postpartum hemorrhage and re-laparotomy did not differ between the groups. Most of the extensions were caudal-directed (40.4%), and were closed by a two-layer closure (92%). Mean extension size was 4.5 ± 1.7 cm. Using multivariable analysis, the only factor that remained significant was CD at the second stage of labor (adjusted odds ratio (aOR) 54.2, 95% CI 4.5–648.9, p = .002), with an area under the ROC curve 0.653 (95% CI 0.595–0.712, p < .001). Emergent CD, body mass index, birth weight, failed vacuum attempt, and trial of labor after cesarean were not significant. For secondary outcomes, an unintended uterine extension was associated with longer operation time, higher estimated blood loss, greater pre- to post-CD hemoglobin difference, increased blood products transfusion, puerperal fever, and longer hospital stay. No clinically significant neonatal adverse outcomes were observed. Conclusions In our cohort, second-stage CD was the strongest predictor for an unintended uterine extension. Following uterine extension, women had increased infectious and blood-loss morbidity.

Trial of labor after failed vacuum assisted delivery – maternal and neonatal outcomes

Trial of labor after failed vacuum assisted delivery – maternal and neonatal outcomes

Secundiparas following a failed vacuum delivery - factors associated with a successful vaginal delivery

Secundiparas following a failed vacuum delivery - factors associated with a successful vaginal delivery

Secundiparas following a failed vacuum delivery—factors associated with a successful vaginal delivery: a historical prospective cohort

BackgroundFew studies have focused on the delivery subsequent to a failed vacuum delivery (failed-VD) in secundiparas. The objective of the current study was to examine the factors associated with a vaginal delivery following a failed-VD.MethodsAn historical prospective cohort. Obstetric characteristics of secundiparas who underwent a planned caesarean delivery (CD) were compared to those who elected a trial of labour (TOLAC) at single medical-centre, throughout 2006–2019. The latter were further analysed to study for factures associated with successful vaginal birth (VBAC).ResultsAmong the 115 secundiparas included, 89 (77%) underwent TOLAC. Compared to women who underwent an elective CD, those who underwent TOLAC were younger by a mean of 4 years, were more likely to have conceived spontaneously, and had a more advanced gestation by a mean of 10 days. VBAC was achieved in 62 women (70%). New-borns of women with VBAC had in average a lower birth weight compared to those with failed TOLAC, (-)195 g ± 396 g versus ( +)197 g ± 454 g respectively, P < 0.01. Having a higher neonatal birthweight at P2 by increments of 500 g, 400 g or 300 g was associated with a failed TOLAC; OR of 9.7 (95%CI; 2.3, 40.0), 11.5 (95%CI; 2.8, 46.7) and 4.5 (95%CI; 1.4, 13.9), respectively.ConclusionsAmong secundiparas with a previous CD due to a failed-VD, the absolute difference of neonatal BW was found to be significantly associated with achieving VBAC.

VACCUM IS THE PREFERRED INSTRUMENT AMONG OBSTERICIANS IN RECENT TIMES

Obstetricians must be able to perform operative vaginal birth (OVB). It is the most common obstetric emergency intervention, and it necessitates a high level of expertise. To nd out which tool obstetricians prefer when doing surgical vaginal births, as well as the prevalence and hazards of vacuum or forceps assisted vaginal deliveries (AVD). The ACS Medical and Hospital in Chennai conducted this cross-sectional investigation. The survey comprised 500 obstetricians in all. All obstetricians in Chennai were issued an online survey. The best approach for a given situation, tool preference [vacuum or forceps], and perspectives on the difculties associated with both vacuum and forceps use during vaginal delivery were all investigated. We calculated averages and percentages for the overall group and different subgroups based on the responses. The statistical analysis comprised a risk assessment of the result with exposure as an appropriate p-value. The questionnaire had a response rate of 92 percent (460/500). According to the data, obstetricians preferred vacuum because it was easier to use. The two groups had identical baseline characteristics. The most prevalent complication was a failed vacuum owing to cup slippage (65%), followed by caput succedaneum (22%), both of which were statistically signicant. The most important nding was that maternal injuries in the vacuum group were only 3%, which was signicantly lower than maternal injuries in the forceps group (70%) with a p-value of 0.001. The majority of obstetricians seemed to prefer using a vacuum during delivery. The use of a vacuum extractor instead of forceps for assisted delivery appeared to lower maternal morbidity, whereas neonatal injuries were more prevalent in vacuum-delivered babies. The equipment chosen should be tailored to the patient's needs as well as the obstetrician's knowledge and skill.

Gynatresia with cryptomenorrhea following cesarean section after failed vacuum extraction: Case report in a 26-year-old woman

Acquired Gynaetresia is underreported in developing countries and is usually due to harmful cultural practices. It may result from obstructed labor or labor trauma. This is a rare case report of a 26-year-old P1 + 0 who presented with no penetration during coitus and history of amenorrhea about 1 year and 7 months after cesarean delivery. Failed attempts at vacuum extraction were made before surgery. She was investigated and a diagnosis of Gynaetresia with cryptomenorrhea was confirmed. She had vaginoplasty and menstrual and sexual functions were established. Postpartum genital examination should be ensured, no matter the mode of delivery to ensure Gynaetresia is diagnosed early and managed promptly.

454 Pregnancy outcome after cesarean section following a failed vacuum attempt

To compare pregnancy outcome of women who underwent cesarean section (CS) in second stage of labor, with or without a following failed vacuum extraction attempt (VE). A retrospective cohort study of women who underwent cesarean section during the second stage of labor in a single tertiary university affiliated medical center (2012-2019). Pregnancy outcome was compared for women who underwent cesarean section following a failed vacuum extraction to women who had cesarean section during the second stage of labor with no vacuum extraction attempt. Neonatal outcomes included umbilical artery pH less than 7.1, Apgar at 5 minutes < 7, hypoxemic ischemic encephalopathy and NICU admission. Maternal outcomes included duration of hospitalization, need for blood transfusion and need for re-surgery in 45 days. Overall, 88,375 women delivered during the study period. Of them, 120 women had a cesarean section following failed vacuum (study group). Another 551 women underwent cesarean section in the second stage of labor without VE attempt (control group). The groups were similar with regard to obstetrical and demographic characteristics. The rates of umbilical artery pH<7.1 (17.50% vs 6.53%, p<0.001), NICU admission (13.33% vs 2.90%, p<0.001), hypoxemic ischemic encephalopathy (5.83% vs 0.18%, p<0.001) and epicranial sub-aponeurotic hemorrhage (16.67% vs 2.18%, p<0.001) were significantly higher in the study group. No significant differences were found in maternal outcomes. In a sub-analysis including only labor with reassuring fetal heart tracing, failed vacuum attempt was associated with higher rate of NICU admission and epicranial hemorrhage (16.67% vs 3.13%, p=0.009, 27.78% vs. 3.41, p=0.001, respectively). Failed vacuum attempt is associated with a significant increased neonatal morbidity, but not increased maternal morbidityView Large Image Figure ViewerDownload Hi-res image Download (PPT)

368 Predictors and adverse outcome of uterine extension at the time of cesarean delivery

To identify risk factors and perinatal adverse outcomes related to unintended lower segment uterine extension during cesarean delivery (CD). A retrospective cohort analysis in a single, university affiliated medical center between January 1st 2018 to December 31st 2019. All singleton pregnancies delivered by CD were included. Univariate and multivariate analysis were performed to identify maternal and obstetrical predictors for uterine extension during CD. For secondary outcomes, we assessed correlation between uterine extension and any adverse maternal or neonatal outcome. ROC statistics was utilized to measure predictors prediction performance for uterine extension. Overall, 1,746 (19.3%) CDs were performed during study period. Of them, 121 (6.9%) CDs were complicated by unintended uterine extension. Uterine extensions were more common following induction of labor, intrapartum fever, premature rupture of membranes, trial of labor after cesarean, advanced gestational age, urgent CD and in particular during second stage of labor (37.2% vs. 6.5%) and after failed vacuum extraction (6.6% vs. 1.1%), p<0.05 for all. Using a multivariable analysis, the only factor that remained significant was CD at second stage of labor (aOR 54.2, 95% CI 4.5-648.9, p=0.002), with area under the ROC curve 0.653 (95% CI 0.595-0.712, p<0.001). For secondary outcomes, unintended uterine extension was associated with longer operation time, higher estimated blood loss, greater pre- to post CD hemoglobin difference, increased blood products transfusion, puerperal fever and longer hospital stay. No clinically significant neonatal adverse outcomes were observed. In out cohort, second stage CD was the strongest predictor for unintended uterine extension. Following uterine extension, women had increased infectious and blood loss morbidity.

The association between low birth weight and outcomes of vacuum assisted vaginal delivery

ObjectiveIt is often hypothesized that poor neonatal outcomes are more frequently observed in low birth weight (LBW) neonates following vacuum assisted vaginal delivery (VAVD). We sought to assess the association between low birth weight (< 2500 g) and neonatal outcomes, following vacuum extraction. Study designThis was a retrospective cohort study, including 1085 deliveries in a tertiary medical center between 2003 and 2015. Maternal and neonatal outcomes, including birth trauma related complications, were compared between women with singleton pregnancies beyond 34 weeks' gestation and fetal weight < 2500 g who were delivered by vacuum extraction (n=345) and a control group (n=740) with fetal weight ≥ 2500 g, matched in maternal age, parity and gestational week. ResultsDuring the study period, 370 women met the inclusion criteria for the study group, with 25 cases eventually excluded due to missing neonatal birth trauma related data. 740 patients were included in the matched control group. Induction of labor and non-reassuring fetal heart rate as an indication for VAVD were more prevalent in the LBW group. The composite birth trauma related adverse outcome was higher in the control group (9.1 % vs. 4.4 %, p = 0.008), mainly due to increased rate of cephalohematoma in this group (6.8 % vs. 2.9 %, p = 0.01). All other adverse neonatal outcomes rates did not differ between the groups. Women in the control group were more prone to post-partum hemorrhage (p < 0.001), had more episiotomies (p = 0.004) and a higher failed VAVD rate (11.4 % vs. 2.6 %, p < 0.001), leading to emergency cesarean delivery. A sub-group analysis of failed VAVD did not reveal a difference in neonatal complications between the LBW and the control group. ConclusionNeonatal birth trauma and adverse outcomes following vacuum extraction are no more common in neonates weighing less than 2500 g than those with higher birth weights, even in failed vacuum cases.

Pregnancy outcome after cesarean section following a failed vacuum attempt

Objective To compare the pregnancy outcome of women who underwent cesarean section in the second stage of labor, with or without a vacuum extraction attempt Methods A retrospective cohort study of women who underwent a cesarean section during the second stage of labor in a single tertiary university-affiliated medical center (2012–2019). Pregnancy outcome was compared for women who underwent cesarean section following a failed vacuum extraction to women who had cesarean section during the second stage of labor with no vacuum extraction attempt. Neonatal outcomes included umbilical artery pH less than 7.1, Apgar at 5 min < 7, hypoxemic ischemic encephalopathy and NICU admission. Maternal outcomes included duration of hospitalization, need for blood transfusion and need for re-surgery in 45 days. Results Overall, 88,375 women delivered during the study period. Of them, 120 women had a cesarean section following a failed vacuum (study group). Another 551 women underwent a cesarean section in the second stage of labor without a VE attempt (control group). The groups were similar with regard to obstetrical and demographic characteristics. The rates of umbilical artery pH < 7.1 (17.50% vs 6.53%, p < .001), NICU admission (13.33% vs 2.90%, p < .001), hypoxemic ischemic encephalopathy (5.83% vs 0.18%, p < .001) and epicranial sub-aponeurotic hemorrhage (16.67% vs 2.18%, p < .001) were significantly higher in the study group. No significant differences were found in maternal outcomes. In a sub-analysis including only labor with reassuring fetal heart tracing, failed vacuum attempt was associated with higher rate of NICU admission and epicranial hemorrhage (16.67% vs 3.13%, p = .009, 27.78% vs. 3.41, p = .001, respectively). Conclusion Failed vacuum attempt is associated with a significant increased neonatal morbidity, but not increased maternal morbidity

Bladder Rupture Following Both Successful and Failed Trial of Labor After Cesarean [02L

INTRODUCTION: The incidence of bladder injury during cesarean section is estimated to be 0.08 to 0.94%. In patients with previous cesarean delivery, rate of bladder injury after successful VBAC is 0.2% while unsuccessful TOLAC confers 1.1% risk. The average length of bladder injury is 4.2 cm. METHODS: Case presentation. RESULTS: The first patient is a 26 year-old gravida 3 para 2 presenting at 39w3d in spontaneous labor with history of 31 week emergent cesarean for breech presentation at complete dilation. Labor augmented with oxytocin and patient progressed to complete. Successful vacuum-assisted delivery performed for fetal bradycardia. Approximately 90 minutes after delivery, patient was noted to have copious amounts of fluid from the vagina upon retrograde bladder fill. Exploratory laparotomy demonstrated posterior bladder rupture from dome to neck and anterior cervicovaginal rupture causing cervical avulsion. The second patient is a 34 year-old gravida 2 para 1 presenting at 38w6d in spontaneous labor with history of cesarean for failed vacuum delivery. Patient progressed to complete by own mechanism but opted for cesarean after 1 hour of pushing. After an atraumatic delivery of infant, entirety of Foley catheter was noted within surgical field. Large cystotomy present from posterior aspect of dome distally through trigone and bladder neck concurrent with uterine rupture demonstrating vaginal extension. CONCLUSION: Successful VBAC does not preclude urologic injury. TOLAC counseling should be individualized based upon prior operative reports, with high indices of suspicion when hysterotomy may have been performed lower than anticipated. With early recognition of injury, favorable prognosis can be achieved.

Low volume forceps practice and anal sphincter injury rate.

While the increased rates of high degree perineal tears were previously associated with the use of forceps, in the current era of low volume of forceps practice, factors associated with the occurrence of this potential complication remain understudied. We aim to evaluate factors associated with obstetric anal sphincter injury (OASIS) in obstetric units with a low volume forceps practice. A retrospective cohort study was conducted at two tertiary medical centers. All singleton pregnancies delivered by forceps extraction between 2011 and 2019 were analyzed. Women who experienced anal sphincter injury were compared to those who did not. The study cohort included 764 forceps deliveries. There were 19 (2.5%) cases of OASIS. Women with anal sphincter injury had higher rates of gestational diabetes mellitus (21% vs. 5.6%, OR [95% CI] 4.46 (1.41-14.04), p = 0.02). Birth weights and the rate of macrosomia did not differ between groups. Induction of labor was more common among the OASIS group (68% vs. 41.7%, OR [95% CI] 3.0 (1.1-8.0), p = 0.02). Sequential use of forceps (after failed vacuum attempt) was associated with OASIS (8 (42%) vs. 76 (10.2%), OR [95% CI] 6.4 (2.5-16.4), p < 0.001). In a multivariate logistic regression, sequential forceps was the only factor independently associated with OASIS (OR [95% CI] 4.7 (1.3-18.2), p = 0.02). Rate of OASIS was relatively low in the current cohort. Sequential use of forceps was found to be the most important determinant in OASIS occurrence.

Quelle voie d’accouchement choisir après échec d’extraction par ventouse

ObjectivesCompare maternal and neonatal morbidity in patients delivered by a second instrument versus cesarean section after failed vacuum. MethodsWe performed a retrospective study between January 2006 and December 2014. Case notes of 172 failed vacuum deliveries were studied. The studied parameters were blood loss, perineal tears, pH, Apgar score, neonatal reanimation and length of stay in neonatology. ResultsThe frequency of vacuum failure was 8.7%. The use of the second instrument (77.9%) was associated with a higher prevalence of third degree perineal tears (13.4% vs. 0%; P=0.017) and more episiotomy (72.2% vs. 0%; P<0.0001). There was no significant difference regarding post partum hemorrhage between cesarean section and second instrument delivery. There was no significant difference regarding neonatal morbidity between cesarean section and second instrument delivery after failed vacuum. When an attempted second instrument delivery failed, the risk of adverse neonatal outcome was increased: newborns had a significantly longer stay in a neonatal unit (2.4 versus 0.6 days; P=0.026), lower pH (P=0.017), lower Apgar scores (7.4 versus 8.8; P=0.0373), needed intubation (P=0.0471) and had seizures (P=0.04) more often. ConclusionCompared to cesarean section, the use of the second instrument increased maternal morbidity but doesn’t seem to increase neonatal morbidity. If the second instrument fails, neonatal morbidity is significantly increased.

A simple sonographic finding is associated with a successful vacuum application: the fetal occiput or forehead sign

Intrapartum ultrasound scanning has been proposed as an ancillary tool in the decision-making process of instrumental vaginal delivery. The purpose of this study was to evaluate the correlation between the sonographic visualization with a transperineal scan of the fetal occiput or forehead distal to the pubic symphysis with anterior or posterior presentation, respectively (fetal occiput or forehead sign), and the outcome of a vacuum delivery. We conducted a retrospective cohort study of patients who underwent a vacuum application in our hospital from 2011-2017, excluding outlet applications. In each case, a preliminary transperineal scan was performed to confirm fetal presentation and position and to demonstrate the presence or absence of the fetal occiput or forehead sign. The head direction, angle of progression, and the head perineum distance were also noted. The primary outcome measure was the success of the vacuum. The secondary outcome measures included fetal complications and perineal lacerations. A total of 196 consecutive patients were enrolled in the study. The occiput or forehead sign was present in 150 and was associated with a successful vaginal extraction in all cases. Of the 46 cases without the sign, 5 babies (10.8%) were delivered by cesarean section after a failed vacuum (P=.0006). The occiput or forehead sign was also associated with fewer grade 3-4 perineal lacerations (10.7% vs 35.7%; P=.0005) and cephalohematomas, although the difference was not statistically significant (1.4% vs 4.3%). There was a good correlation between the occiput or forehead sign and the other sonographic methods that previously had been proposed to predict a successful vacuum extraction, such as head direction, angle of progression, and head perineum distance. In our hands, the fetal occiput or forehead sign was associated strongly with successful vacuum application and with a very low rate of maternal and fetal complications.

Effect of team training and monitoring on the rate of failed mid and low cavity vacuum extraction: a hospital based intervention study

BackgroundClinical team training has been advocated as a means to improve delivery care, and failed extractions is a suggested variable for clinical audit in instrumental vaginal delivery.Other activities may also have intended or unintended effects on care processes or outcomes.MethodsWe retrospectively observed 1074 mid and low vacuum extraction deliveries during three time periods (prevalence periods): Baseline (period 0), implemented team training (period 1 and 2) and monitoring of traction force during vacuum extraction (period 2). Our primary outcome was failed extraction followed by emergency cesarean section or obstetric forceps delivery.ResultsThe prevalence proportion (relative risk) of failed extraction decreased significantly after implementation of team training, from 19% (period 0) to 8 % (period 1), corresponding to a relative risk of 0.48 [0.26–0.87]. The secondary procedural outcome complicated delivery (duration > 15 min or number of pulls > 6, or cup detachment > 1) was decreased in period 2 compared to period 1, RR 0.42 [0.23–0.76]. Secondary clinical (neonatal) outcome were not affected.ConclusionClinically based educational efforts and increased monitoring improved procedural outcome without improving neonatal outcome. The study design has inherent limitations in making causal inference.

Randomised Italian Sonography for occiput POSition Trial Ante vacuum (R.I.S.POS.T.A.).

To assess whether sonographic diagnosis of fetal head position before instrumental vaginal delivery can reduce the risk of failed vacuum extraction and improve delivery outcome. Randomised Italian Sonography for occiput POSition Trial Ante vacuum (R.I.S.POS.T.A.) is a randomized controlled trial of term (37 + 0 to 41 + 6 weeks' gestation) singleton pregnancies with cephalic presentation requiring instrumental delivery by vacuum extraction, which was conducted between April 2014 and June 2017 and involved 13 Italian maternity hospitals. Patients were randomized to assessment of fetal head position before attempted instrumental delivery by either vaginal examination (VE) alone or VE plus transabdominal sonography (TAS). Primary outcome was incidence of emergency Cesarean section due to failed vacuum extraction. A sample size of 653 women per group was planned to compare the primary outcome between the two groups. The sample size estimation was based on the hypothesis that the risk of failed vacuum delivery in the VE group would be 5% and that ultrasound assessment of fetal position prior to vacuum extraction would decrease this risk to 2%. On interim analysis, the trial was stopped for futility. During this period, 222 women were randomized and 221 were included in the final data analysis, of whom 132 (59.7%) were randomized to evaluation of fetal head position by VE only and 89 (40.3%) to assessment by VE plus TAS prior to vacuum extraction. No significant differences were observed between the two groups with respect to incidence of emergency Cesarean section due to failed instrumental delivery and other maternal and fetal outcomes. Women randomized to assessment by VE plus TAS showed higher incidence of non-occiput anterior position of the fetal head at randomization and lower incidence of incorrect diagnosis of occiput position compared with women undergoing assessment by VE alone. A higher rate of episiotomy was noted in the women undergoing both VE and TAS compared with those in the VE-only group. Our prematurely discontinued randomized controlled trial did not demonstrate any benefit in terms of reduced risk of failed instrumental delivery or maternal and fetal morbidity in women undergoing sonographic assessment of fetal head position prior to vacuum extraction. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Legal Briefs: 3 Vacuum-Assisted Deliveries, 3 Bad Outcomes

A 39 2/7–week gestational age female infant with a birthweight of 2,995 g was born to a 31-year-old gravida 3 para 2 woman with an unremarkable pregnancy. Membranes ruptured spontaneously 19 hours before delivery with clear fluid. Because labor was not progressing, oxytocin was used to “expedite” the process. The fetus was initially occiput transverse, then occiput posterior. The obstetrician applied vacuum on the fetal scalp twice, but no descent was recorded. It was unclear what station the fetus was in when the vacuum was applied because of lack of documentation. The obstetrician retained by the plaintiff was critical of the treating obstetrician for not documenting the station of the fetus and repeating the vacuum because no descent was found after the first pull. He stated that without descent, reapplication of the vacuum is below standard. The obstetrician requested Simpson forceps after the failed vacuum. The treating nurse, in her deposition, admitted that it was against hospital policy to use forceps after a failed vacuum and stated that she questioned the obstetrician but that he ignored her. The plaintiff obstetrical nurse said that the nurse should have refused to bring the forceps and should have called her supervisor . The fetal heart rate monitoring tracings were largely unreadable, even when an internal monitor was placed 2 hours before delivery. The plaintiff obstetrician was critical of this and said that the obstetrical team needed to ensure adequate monitoring . The forceps were applied and considered “partially effective,” as documented by the treating obstetrician, but the vacuum was reapplied. The plaintiff obstetrician was highly critical of using forceps after a failed vacuum attempt as well as the reapplication of the vacuum. The treating nurse said that she was uncomfortable with this process and tried to communicate this to the obstetrician. The treating …

Fetal rotation during vacuum extractions for prolonged labor: a prospective cohort study.

The aim of the study was to investigate fetal head rotation during vacuum extraction. We conducted a prospective cohort study from November 2013 to July 2016 in seven European hospitals. Fetal head position was determined with transabdominal or transperineal ultrasound and categorized as occiput anterior (OA), occiput transverse (OT) or occiput posterior (OP) position. Main outcome was the proportion of fetuses rotating during vacuum extraction. Secondary outcomes were conversion of delivery method, duration of vacuum extraction, umbilical artery pH <7.10 and agreement between clinical and ultrasound assessments. The study population comprised 165 women. During vacuum extraction 117/119 (98%) remained in OA and two fetuses rotated to OP position. Rotation from OT to OA position occurred in 14/19 (74%) and to OP position in 5/19 (26%). Rotation from OP to OA position occurred in 15/25 (60%), and 10/25 (40%) fetuses remained in OP position. Delivery information was missing in two cases. The conversion rate from vacuum extraction to cesarean section or forceps was 10% in the OA group vs. 23% in the non-OA group; p<0.05. The estimated duration of vacuum extraction was significantly shorter in OA fetuses, 7min vs. 10min (log rank test p<0.01). There was no significant difference in umbilical artery pH <7.10 between OA and non-OA position. Cohens Kappa of agreement between clinical and ultrasound assessments was 0.42 (95% CI 0.26-0.57). Most fetuses in OP or OT positions rotated to OA position during vacuum extraction, but the proportion of failed vacuum extractions remained high.

Vacuum extraction failure is associated with a large head circumference

Objective: To determine whether large head circumference increases the risk of vacuum extraction failure.Study design: This EMR-based study included all attempted vacuum extractions performed in a tertiary center between January 2010 and June 2015. All term singleton live births were eligible. Cases were divided into four groups: head circumference ≥90th percentile both with birth weight ≥90th percentile and <90th percentile and fetal head circumference <90th percentile with birth weight ≥90th and <90th percentile. Risk of failed vacuum extraction was compared among these groups. Other neonatal and maternal parameters were also evaluated as potential risk factors. Multinomial multivariable regression provided adjusted odds ratio for vacuum extraction failure while controlling for potential confounders.Results: During the study period, 48,007 deliveries met inclusion criteria, of which 3835 had an attempt at vacuum extraction. We identified 215 (5.6%) cases of vacuum extraction failure. The adjusted odds ratios (aOR) for vacuum extraction failure in cases of large fetal head circumference was 2.31 (95%CI, 1.7–3.15, p < .001). Primiparity, prolonged second stage and occipito-posterior presentation were also found to be significant risk factors for failed vacuum extraction.Comments: In this study, we found that large head circumference was associated with vacuum extraction failure rather than high birth weight.