Vacuum-assisted Delivery Research Articles

666: Angle of progression of the fetal head measured by transperineal ultrasound as a predictive factor of instrumental extraction success

Several small studies have suggested that the angle of progression of the fetal head might predict the diagnosis of fetal head engagement in occipito-anterior position. We sought to evaluate the angle of progression measured by transperineal ultrasound (TPU) as a predictive factor of VE success in a large series whatever the fetal head position.

Mode of Delivery in Nulliparous Women and Neonatal Intracranial Injury

To compare neonatal neurologic complication rates of cesarean deliveries, forceps-assisted vaginal deliveries, and vacuum-assisted vaginal deliveries. Data on singleton live births at 34 weeks or greater gestation born to nulliparous women from 1995 to 2003 in New York City were linked to hospital discharge data. Any diagnosis of neonatal subdural hemorrhage, intraventricular hemorrhage, seizures, scalp laceration or cephalohematoma, fracture, facial nerve palsy, brachial plexus injury, or 5-minute Apgar score of less than 7 was considered significant. Multivariable logistic regression was used to estimate associations between delivery mode and these neonatal morbidities. Forceps-assisted vaginal deliveries were associated with significantly fewer seizures and 5-minute Apgar scores less than 7 compared with vacuum-assisted vaginal deliveries and cesarean deliveries. Cesarean deliveries were linked to less subdural hemorrhages compared with forceps-assisted vaginal deliveries or vacuum-assisted vaginal deliveries. When seizure, intraventricular hemorrhage, and subdural hemorrhage were examined collectively to best predict neurologic outcome, forceps-assisted vaginal deliveries had an overall reduced risk compared with both vacuum-assisted vaginal deliveries (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40-0.90) and cesarean deliveries (OR 0.68, 95% CI 0.48-0.97). The number needed to treat to prevent one case of severe neurologic morbidity is 509 for forceps-assisted vaginal deliveries compared with vacuum-assisted vaginal deliveries and 559 for forceps-assisted vaginal deliveries compared with cesarean deliveries. Compared with vacuum-assisted vaginal delivery or cesarean delivery, a forceps-assisted vaginal delivery is associated with a reduced risk of adverse neonatal neurologic outcomes. II.

Assisted delivery of high floating fetal head: a comparison of vacuum-assisted delivery with manual extraction

Background: It is a well-established obstetric practice to use a vacuum device to assist in delivery of the fetal head at cesarean delivery. As a vacuum sauce, the hospital piped-vacuum supply is often used. However, no study has compared the safety and efficacy of vacuum-assisted delivery with the traditional manual extraction. Objective: Compare the safety and efficacy of delivery of the high floating fetal head using a soft cup vacuum extractor with the traditional manual extraction. Methods: This randomized study included 90 cases of caesarean sections with vacuum-assisted delivery using the soft cup vacuum extractor (V group) and 90 cases of caesarean sections with manual extraction of the head (M group). The hospital piped-vacuum supply was used to develop the required vacuum. Operative and postoperative maternal and neonatal data of importance were analyzed using Student t-test for continuous variables and Chi Square test for categorical variables. Results: The U-D interval (the time of entry into the uterus until the full delivery of the fetal head) was significantly prolonged (p Conclusion: The extraction of the fetal head at caesarean section with vacuum extractor was a non-traumatic and rapid method that did not need the prolonged fundal compression and thus avoid unwanted consequences. Keywords: Cesarean section, high floating fetal head, manual deliver of the head, soft cup vacuum extractor

Index of Suspicion in the Nursery

A 3.3-kg male term infant is born via vacuum-assisted vaginal delivery to a 26-year-old G2P1001, now P2002, woman whose serology results were within normal parameters. Membranes ruptured 4 hours before delivery, and Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. A hematocrit obtained shortly after birth is 46% (0.5). At 14 hours after birth, the infant has swelling around the posterior scalp that increases in size over the next 6 hours. The swelling is fluctuant and shifts with movement of the infant's head and body. The infant appears pale, and a complete blood count is obtained. The infant's hematocrit 22 hours after birth is 12% (0.12). Skull radiographs appear normal. The infant is transfused with packed red blood cells. Coagulation studies reveal a prothrombin time of 15.8 sec, International Normalized Ratio of 1.3, and partial thromboplastin time of 60 sec. The infant is transferred to a tertiary care hospital neonatology unit for further management. A previously well 11-day-old infant is brought to the emergency department for evaluation of fever and eye discharge. The maximum temperature measured at home was 39.2°C. The mother mentions that the baby is sleepier and has had reduced oral intake of formula as well as redness in one eye over the past 24 hours. The baby was born at term via spontaneous vaginal delivery and had uncomplicated prenatal and perinatal periods. Physical examination in the emergency department reveals a well-appearing febrile infant whose rectal temperature is 39.5°C, heart rate is 176 beats/min, respiratory rate is 32 beats/min, and oxygen saturation is 100%. He does not appear to be in any distress and is alert and easily consolable. The rest of the physical examination findings are within normal limits, except for right eye …

Accidental Fetal Decapitation

Blunt trauma to the head and neck of a newborn during delivery process is a rare event. We report a peculiar case of decapitation of a live fetus during vacuum-assisted delivery, where excessive traction on the head of the full-term macrosomic fetus with shoulder dystocia resulted in overstretching of the neck up to the point of decapitation. The ethical considerations related to the case are discussed in light of the policy of complete transparency advocated by the medical profession. Despite the existence of regulations regarding full disclosure of errors to the medical institution, the Ministry of Health and to the patient, medical practitioners are reluctant to divulge all the details of adverse events to the patient.

Serious head injury in young children: Birth trauma versus non-accidental head injury

Birth injury of the skull and central nervous system can be a complication of a difficult delivery, especially following forceps or vacuum-assisted delivery. Birth trauma of the head can also mimic the appearance of a non-accidental head injury and is therefore an important differential diagnosis. We report on two young infants with serious head injuries. The difficult differential diagnosis birth trauma versus non-accidental head injury is discussed and the necessity for cooperation between clinicians, forensic doctors and specialized neuroradiologists is emphasized.

Resident Duty-Hour Restrictions and Their Effect on Operative Experience in Obstetrics and Gynecology

Background/Aims: To determine the effect of duty-hour restrictions on the operative experience of obstetrics and gynecology residents. Methods: Operative numbers were obtained from graduates of Mayo Clinic (Rochester, Minn., USA) and Good Samaritan Hospital (Cincinnati, Ohio, USA). Mean operative numbers between graduates in 2007 and 2003 were compared. The following procedures were evaluated: spontaneous vaginal delivery, forceps-assisted vaginal delivery, vacuum-assisted vaginal delivery, cesarean delivery, surgery on antenatal patients, amniocentesis, total abdominal hysterectomy, total vaginal hysterectomy, laparotomy, incontinence or pelvic floor surgery, operative laparoscopy, hysteroscopy, cervical conization, and surgical sterilization. The number of procedures performed (total and as the primary surgeon) were evaluated. We analyzed each institution’s residents separately. Results: At Mayo Clinic, the 2007 graduates performed significantly fewer conizations than the 2003 graduates (p = 0.006). At Good Samaritan Hospital, the 2007 graduates performed significantly more vacuum-assisted vaginal deliveries (p = 0.002), cesarean deliveries (p = 0.002), and sterilizations (p < 0.001) than the 2003 graduates. The above findings were unchanged when evaluating procedures for which the resident was the primary surgeon. Conclusion: Duty-hour restrictions have not adversely affected the operative experience of obstetrics and gynecology residents. No significant differences in the number of the spontaneous vaginal deliveries, abdominal hysterectomies, or vaginal hysterectomies performed were observed.

Risk factors for severe perineal injury during childbirth: a case-control study of 60 consecutive cases

The study aimed to evaluate the current risk factors for severe perineal tears in a single university-affiliated maternity hospital. An obstetric database of 31 784 consecutive women who delivered from January 2007 to December 2009 was screened for cases of third-degree or fourth-degree perineal tears. Four controls, matched by time of delivery, were selected for each case of third- or fourth-degree perineal tear. Maternal and obstetric parameters were analyzed and compared between the study and control groups. Sixty women (0.25% of all vaginal deliveries) had a third-degree (53 women) or a fourth-degree (seven women) perineal tear. The control group comprised 240 matched vaginal deliveries without severe tears. Primiparity, younger maternal age, Asian ethnicity, longer duration of second stage of labour, vacuum-assisted delivery and heavier newborn birth weight were significantly more common among women who had third- or fourth-degree perineal tears. Of the variables that were found to be statistically significant in the univariate analysis, only primiparity (OR = 2.809, 95% CI: 1.336-5.905), vacuum delivery (OR = 10.104, 95% CI: 3.542-28.827) and heavier newborn birth weight (OR = 1.002, 95% CI: 1.001-1.003) were found to be statistically significant independent risk factors for severe perineal trauma. Identification of women at risk may facilitate the use, or avoidance, of certain obstetric interventions to minimize the occurrence of childbirth-associated perineal trauma.

Don't Get Lost in the Vacuum: Clarifying the Nurse's Role During Vacuum-Assisted Deliveries

Don't Get Lost in the Vacuum: Clarifying the Nurse's Role During Vacuum-Assisted Deliveries

Rapid versus stepwise application of negative pressure in vacuum extraction-assisted vaginal delivery: a multicentre randomised controlled non-inferiority trial

To evaluate whether the application of rapid negative pressure for vacuum-assisted delivery is as effective and safe as the stepwise method. Randomised controlled trial. Six centres, including university, secondary and tertiary hospitals, in Thailand. In total, 662 women were randomised to rapid and stepwise groups, with 331 women in each group. Vacuum extraction was performed by applying a metal cup (Malmstrom) connected to an electric pump to the fetal head. The stepwise method consisted of four incremental steps of 0.2 kg/cm² every 2 minutes to obtain a final negative pressure of 0.8 kg/cm². In the rapid method the negative pressure of 0.8 kg/cm² was applied in one step in < 2 minutes. Success rate of vacuum extraction, vacuum cup detachment rate, duration of vacuum extraction, and maternal and neonatal complications. There were no significant differences in detachment rates (RD 0.3%, 95% CI -3.1 to 2.4). The overall success rates were identical, at 98.2%. There were significant reductions in the time between applying the vacuum cup and attaining maximum negative pressure (MD -4.6 minutes; 95% CI -4.4 to -4.8 minutes), and in the time between applying the cup and delivery (MD -4.4 minutes; 95% CI -4.8 to -4.0 minutes). There was a significantly higher rate of perineal suture in the rapid method group (RD 4.5%; 95% CI 1.1-8.2). There were no significant differences in maternal and fetal morbidities. Rapid negative pressure vacuum extraction could be performed as effectively and safely as the stepwise method, in a shorter period of time.

Index of Suspicion in the Nursery

A term appropriate-for-gestational age male infant who was born by vacuum-assisted vaginal delivery to a 31-year-old G1P0 woman presents to the emergency department at 8 days of age after his mother noted a swelling on his scalp. The mother's prenatal laboratory results, including group B Streptococcus status, were negative. Delivery was complicated by prolonged rupture of membranes greater than 24 hours and development of preeclampsia. The neonate had an uneventful nursery course and was discharged after 72 hours. At 6 days after birth, the mother noted swelling of the scalp in the occipital area that spontaneously resolved, but another similar lesion developed in the right parietal region, progressively increasing in size. The mother reports normal urine output and bowel movements and denies any fever, irritability, lethargy, decreased oral intake, or feeding difficulties. She states that the child has been exclusively breastfeeding since birth. On physical examination, the infant is afebrile, vital signs are stable, and the only pertinent finding is a 1.5×1.5-cm edematous and erythematous lesion over the right parieto-occipital area that is oozing yellowish material and a 0.5-cm lesion at the level of the lambdoid suture that has a crusted scab. The baby is admitted to the inpatient unit for further management with parenteral antibiotics and to rule out sepsis. On admission to the inpatient unit, the complete blood count is within normal limits, and blood, cerebrospinal fluid (CSF), and scalp wound cultures are sent. A complete review of the maternal obstetrics …

Hematoma subgaleal crónico en un lactante. Presentación de un caso

Neonatal subgaleal hematomas are under-diagnosed collections of blood beneath the galea, often caused by certain obstetric procedures such as use of forceps or vacuum. They generally have low volume and often resolve spontaneously. Occasionally, they can achieve a large volume and may endanger the live of the affected newborns. Rarely, they become chronic and exceptionally they may require surgical treatment. We report the case of a child under one year of age who was referred to our department because of a subgaleal hematoma secondary to vacuum-assisted delivery that required surgical treatment.

Visual Diagnosis: Perceived Fevers and Back Pain in a 1-week-old Infant

1. Delia L. Gold, MD* 1. *Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH. A 7-day-old female infant presents to the emergency department with the complaints of perceived back pain and subjective fevers. Her mother also describes unexplained skin color changes to her infant's back and shoulders. For the past 2 days, the mother had noticed that her infant was fussy and would cry when her back was touched. She has no other systemic symptoms, no sick contacts, and no known history of trauma. The mother has no reported history of methicillin-resistant Staphylococcus aureus infection or colonization. This is the first time the mother has sought medical attention for her baby since discharge from the newborn nursery. The child was born by vacuum-assisted vaginal delivery at 39 weeks' gestation and weighed 3.8 kg. Labor had been induced because of maternal preeclampsia. Meconium-stained amniotic fluid was present on delivery. Apgar scores were 3 and 8 at 1 and 5 minutes, respectively. The infant did not require resuscitation and was admitted directly to the newborn nursery, where she stayed for 3 days. The mother had adequate prenatal care and no serologic evidence of prenatal infections. Of note, because the mother had one prior spontaneous abortion, she had received Rho (D) immune globulin during this pregnancy. Physical examination reveals an afebrile, irritable infant. Examination of the skin demonstrates a warm, confluent, blanching, erythematous, and somewhat purpuric area covering the upper third of her back (Fig. 1). Areas of induration are scattered over the patient's upper back and posterior axillae (Fig. 2). Shotty lymphadenopathy is noted in both axillae. The rest of the physical examination findings are unremarkable. Figure 1. Warm, confluent, blanching, erythematous, and somewhat purpuric area covering the upper third …

A Linear Fracture and Meningitis Associated with Non-Infected Cephalohematoma in a Neonate

We present a neonate with cephalohematoma complicated by a linear skull fracture and Staphylococcus epidermidis meningitis. Clinicians, especially neonatologists, should be aware that a cephalohematoma in the newborn infant with a history of vacuum-assisted delivery could be the origin or trigger point of the infection either as sepsis, meningitis or osteomyelitis. The utmost importance of screening studies should be emphasized in order to be aware of the pathogenic potential of cephalohematomas.

Neonatal Pneumomediastinum and the Spinnaker-Sail Sign

A male infant was born at 40 weeks of gestation by vacuum-assisted vaginal delivery. Mild respiratory distress with expiratory grunting and subcostal retraction was noted 1 hour after birth. Arterial oxygen saturation remained at more than 95% without the administration of supplemental oxygen. Chest radiography performed 6 hours after birth (Panel A) showed the spinnaker-sail sign, consisting of a large, wedge-shaped opacity extending from the right hemidiaphragm to the superior mediastinum (white arrows), representing thymic tissue displaced from its usual location by a collection of gas under pressure (black arrows). Axial computed tomography of the chest revealed air trapped between . . .

A randomised controlled trial of two instruments for vacuum‐assisted delivery (Vacca Re‐Usable OmniCup and the Bird anterior and posterior cups) to compare failure rates, safety and use effectiveness

Most previous trials of vacuum-assisted delivery have been in settings with high rates of instrumental vaginal delivery (8-12%) and high rates of failure to deliver with the intended instrument (20-30%). Over the past 20 years, vacuum-assisted delivery rates at the Port Moresby General Hospital have been 3-4% with failure rates of <3%. The objective is to compare the failure rates of two vacuum extractor instruments, the Vacca Re-Usable Omnicup and the Bird Vacuum delivery system (anterior and posterior cups). Port Moresby General national referral and teaching Hospital (PMGH), Papua New Guinea. Two hundred consecutive women requiring assisted delivery, June-December, 2007. When a woman required an assisted delivery, she was randomised into either the Vacca Re-Usable Omnicup (Clinical Innovations Inc.) or Bird anterior or posterior metal cup (depending upon the position of the vertex). One hundred women were randomised to each vacuum device. Statistical analysis was on 'an intention-to-treat' basis. The main outcome measure was the successful completion of the delivery with the allocated instrument. Secondary outcomes were maternal trauma (episiotomy and trauma to the maternal genital tract), significant scalp trauma (sub-galeal haemorrhage or serious abrasion) and fetal and neonatal outcomes (Apgar score less than seven at 5 minutes, days spent in the Special Care Nursery and neonatal death). Failure rates for both Omnicup (2/100) and Bird metal cups (6/100) were not statistically different (RR 1.05, 95% CI 0.99-1.12; P = 0.17). Rates of maternal trauma and fetal scalp trauma were similar in both groups. Both the Vacca re-useable Omnicup and the Bird metal cups are very effective instruments to achieve successful assisted delivery and equally so. Failures and problems were associated with not applying the vacuum cup to the flexion point on the fetal scalp and the mechanical faults with vacuum equipment devices.

Ultrasound-guided needle aspiration of epidural hematoma in a neonate after vacuum-assisted delivery

Epidural hematoma (EDH) is a rare complication of vacuum-assisted delivery in neonates. Although the standard treatment of EDH is surgical evacuation via craniotomy, it is an invasive procedure in neonates, and less invasive methods may be favored for hematoma evacuation. We report a case of 5-day-old infant with a massive EDH, cephalohematoma, and a depressed fracture, which were secondary to a vacuum-assisted delivery and cured by ultrasound-guided needle aspiration and drainage. Neonatal EDH may be different from adult counterpart in that the former is more liquefied and is amenable to needle aspiration than the latter. Although needle aspiration is a blind procedure, addition of transcranial ultrasound not only ensures safety by visualizing the tip of the needle but also makes real-time evaluation of the residual hematoma volume possible.

Prolonged time to pregnancy is associated with a greater risk of adverse outcomes

Births with known time to pregnancy (TTP) during the period 1989-2007 (n=17,114) were analyzed to investigate associations between TTP and pregnancy outcome among couples that conceived spontaneously. The adjusted odds ratio (95% confidence interval) for poor neonatal health, including low Apgar score, low umbilical vein pH, and need for neonatal intensive care, was 1.51 (1.09-2.09) in women who had a TTP of 25-36 months and 1.60 (1.18-2.19) in women who had a TTP of >or=37 months compared with women with a TTP of 0-6 months.

680: Vacuum use during term cesarean delivery and rate of NICU admission

Vacuum-assisted cesarean delivery (VACD) may permit a smaller uterine incision to reduce the risk of lacerating the uterine vessels. We sought to determine whether VACD increased the rate of neonatal intensive care unit (NICU) admission.

Index of Suspicion in the Nursery

A term infant girl is born via vacuum-assisted vaginal delivery to a 28-year-old G1P0, now P1, rubella-nonimmune woman who has otherwise unremarkable serology results. Membranes ruptured approximately 6 hours prior to delivery and Apgar scores are 6 and 8 at 1 and 5 minutes, respectively. She is admitted to the neonatal intensive care unit at 35 hours of age for desaturations to 80% on room air associated with bottle feeding. She has a weak cry at birth for which supplemental blow-by oxygen is administered briefly. Subsequently, she has adequate oxygen saturations and is transferred to the mother when desaturations recur with feeding attempts. A nasogastric (NG) tube is placed without difficulty. Chest radiograph and complete blood count findings are unremarkable. Blood is drawn and antibiotics initiated until blood culture is negative at 48 hours. Upper gastrointestinal contrast study yields normal results without evidence of tracheoesophageal fistula or malrotation. Cardiac evaluation, including echocardiography, does not reveal anatomic abnormality. Results of head ultrasonography, brain magnetic resonance imaging, and electroencephalography are within normal limits. No desaturations occur with gavage feeding. Upon repeat attempt at oral feeding, the infant exhibits lack of appropriate suck and swallow coordination and persistent desaturations …