Vacuum-assisted Delivery Research Articles

I355 The technique of vacuum-assisted delivery

I355 The technique of vacuum-assisted delivery

Congenital duplication of the superior sagittal sinus and parietal encephalocele after vacuum extraction delivery

A newly-born infant with a congenital dural and bony defect and an associated short-segmented duplication of the superior sagittal sinus suffered from herniation and infarction of parietal brain tissue secondary to vacuum extraction. This ultimately led to the formation of a subgaleal cerebrospinal fluid (CSF) collection. Initial operative closure of the encephalocele was performed by attaching a galeal flap to the periostium surrounding the congenital defect. As the bony defect developed characteristics of a growing fracture later on, dural repair, transplantation of a split-bone flap and, finally, the insertion of a ventriculoperitoneal shunt became necessary. This case affirms that stringent indication and cautious usage of vacuum-assisted delivery is strongly recommended, especially in view of the possibility that undetected congenital cranial, vascular and/or cerebral alterations may be present.

Do Vacuum-Assisted Deliveries Cause Intracranial Vessel Injuries?

Vacuum-assisted deliveries are fairly commonly used in obstetrical practice. Most newborns who have a vacuum-assisted delivery undergo extracranial birth traumas that have no residual consequences. Vacuum-assisted deliveries that complicate intracranial vascular infarction are rarely reported. We present 2 cases of intracranial vessel infarction after vacuum-assisted deliveries. One newborn, with scalp erosion, showed an unusual left middle cerebral artery infarct, and the other, with a severe subgaleal hematoma, had a venous thrombosis. Before the diagnosis, made using brain ultrasonography, neither had specific observable neurological symptoms. In conclusion, vacuum-assisted deliveries should be given special attention, especially when they are combined with a severe extracranial birth trauma.

Episiotomy and perineal repair practices among obstetricians in Greece

Objective To assess current preferences regarding episiotomy and management of obstetric perineal injuries used by obstetricians in Greece, and to assess the impact of evidence-based information on everyday practices. Methods A questionnaire survey of obstetricians regarding episiotomy use and the management of obstetric perineal injuries. Results Fifty-one percent of obstetricians reported routinely performing an episiotomy during a normal vaginal delivery in primiparous women and 89% reported performing an episiotomy during vacuum-assisted deliveries. Forty-two percent of the respondents performed lateral, 44% mediolateral, and 14% midline episiotomies. Following an obstetric anal sphincter tear, half of the respondents recommended a vaginal delivery, regardless of bowel symptoms. There was significant heterogeneity of practices regarding the repair techniques of all obstetric perineal injuries. Conclusion The majority of obstetricians prefer to perform routine mediolateral and lateral episiotomies, for both normal and operative vaginal deliveries. The adoption of evidence-based information should be implemented while considering working and cultural backgrounds.

Operative vaginal deliveries in Zaria, Nigeria

Operative vaginal deliveries are frequent features of obstetrics practice in tertiary levels of care even in developing countries. It is essential to review these practices in order to assess their benefits or otherwise to safe motherhood in resource limited settings. Labor records on operative vaginal delivery cases and matched controls who had spontaneous vaginal deliveries between January 1997 and December 2001 at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, were analyzed with respect to mode of delivery, indication for operative vaginal delivery, anesthesia use, fetal 5-min Apgar score, birth weight, fetal, and maternal complications. Of 7,327 deliveries at the center in the study period, 262 (3.6%) were by operative vaginal deliveries. Forceps delivery was most frequently performed (55.7%), while vacuum delivery was found to be in increased use (38.2%). Embryotomy procedures were performed selectively (6.1%). Operative vaginal deliveries were more commonly employed on primigravida (78.6%) compared to multiparas and the most common indication was delayed second stage of labor. Forcep- and vacuum-assisted deliveries were both associated with maternal and newborn complications. There was no significant difference in the use of anesthesia between forceps and vacuum deliveries. Operative vaginal delivery rates in this center are comparable to other centers as are the possible complications. Making these procedures safer will improve safe motherhood in settings where there are performed.

A Prospective Observational Study of 1000 Vacuum Assisted Deliveries With the OmniCup Device

ObjectiveTo determine the maternal and perinatal outcomes associated with delivery by the rigid plastic OmniCup vacuum delivery device. MethodsWe conducted a prospective observational study of 1000 consecutive vacuum-assisted deliveries using the OmniCup vacuum device in singleton pregnancies. The relationship of the cup application to the flexion point was independently observed after delivery and related to the neonatal outcome, including scalp trauma. ResultsOf the 1000 women, 70% were nulliparous and 30% parous (≥ para 1). In 87.1% of the women, vacuum-assisted delivery was completed; spontaneous or forceps delivery occurred in 10.9%, and Caesarean section was performed in 2%. The vacuum was applied for ≤10 minutes in 97.4% of deliveries, ≤3 pulls were required in 95.6%, and ≤ 25 lb traction force was required in 85.7% of cases. There was a statistically significant relationship between unfavourable cup applications (deflexing and paramedian) and scalp trauma in infants born to nulliparous women (P ≤ 0.01). Four cases of neonatal intracranial hemorrhage (0.4%) were identified, and three of these infants were subsequently neurodevelopmentally normal. There was one subgaleal hemorrhage. ConclusionsThere is a relationship between unfavourable cup application during vacuum assisted delivery and neonatal scalp trauma in infants born to nulliparous women.

Morbidité maternelle immédiate après extraction instrumentale par spatules de Thierry et par ventouse obstétricale

ObjectiveTo compare maternal morbidity after Thierry's spatulas or vacuum-assisted deliveries. Patients and methodsRetrospective study, at the French hospital la Conception, in Marseilles. All successful instrumental deliveries between November 2003 and May 2005 were reviewed, that is to say 264. Univariate and multivariate analysis were performed comparing maternal morbidity in the two groups. The primary outcome measure was perineal trauma. Secondary outcomes were blood loss and duration of hospitalization. ResultsAmong the 264 deliveries, there were 96 vacuum deliveries and 168 Thierry's spatulas extraction. Thierry's spatulas were use more often in nulliparous patient (<0.001). Patients in the group of Thierry's spatulas have a higher rate of epidural analgesia (p=0.05), a longer duration of first (p=0.002) and second stage of labor (p=0.03). There was no difference in incidence of sphincter tears between women who underwent Thierry's spatulas and those who underwent vacuum delivery with respective incidence of 4.2 and 3.2% (p=0.67). There was a significant difference in post-partum hemoglobin value with a higher blood loss in the group of Thierry's spatulas (<0.001). Mean duration of hospitalization was longer in the group with Thierry's spatulas (5.6days) than in the group who underwent vacuum delivery (4.7days) (p<0.001). Discussion and conclusionIncidence of third degree tears was similar between the vacuum and Thierry's spatulas group. Deliveries with vacuum are associated with less blood loss and a shorter hospitalization stay.

Mediolateral Episiotomy Reduces the Risk for Anal Sphincter Injury During Operative Vaginal Delivery

Injury to the anal sphincter during childbirth is accepted as a major risk factor for fecal incontinence in women. As many as 50% of women with such injury report fecal incontinence, due mainly to a persistently defective sphincter. Risk factors for anal sphincter injury during operative vaginal delivery were examined in a population-based observational study of 7478 Dutch women who had forceps delivery and 21,254 who delivered by vacuum extraction. Cases were taken from a validated Dutch national obstetrical database for the years 1994–1995. Partial sphincter injuries were included. Anal sphincter injury occurred in 646 women delivered with vacuum extraction (3.0%) and in 348 of those who had forceps delivery (4.7%). Risk factors for anal sphincter injury during delivery aided by vacuum extraction included primiparity, higher fetal birth weight, an occipitoposterior position, and the duration of the second stage of labor. Induction of labor did not appear to alter the risk. Mediolateral episiotomy during vacuum extraction had a highly protective effect, lowering the risk of a third-degree perineal tear by nearly 90% (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.09–0.13). The number of mediolateral episiotomies needed to prevent 1 anal sphincter injury after vacuum-assisted delivery was 12.4. Significant risk factors for anal sphincter damage in forceps deliveries included primiparity, occipitoposterior position, and higher fetal birth weight. The duration of second-stage labor was not a significant risk factor. As with vacuum extraction, induced labor carried no added risk. Mediolateral episiotomy correlated with a considerable reduction in the risk of anal sphincter damage (OR, 0.09; 95% CI, 0.07–0.11). The number of episiotomies needed to prevent a single sphincter injury during forceps delivery was 5.0 (95% CI, 4.4–5.7). The investigators conclude that mediolateral episiotomy should be routinely performed during operative vaginal deliveries in order to avoid injuring the anal sphincter.

Community-acquired methicillin-resistant Staphylococcus aureus pneumonia

Community-acquired methicillin-resistant Staphylococcus aureus is increasingly recognized as an important pathogen causing skin and soft tissue infections. We report a case of severe necrotizing pneumonia caused by community-acquired methicillin-resistant S. aureus in a peripartum woman. This case illustrates that community-acquired methicillin-resistant S. aureus must be considered as a potential pathogen in severe community-acquired pneumonia.

Kiwi Omnicup versus Malmstrom metal cup in vacuum assisted delivery: A randomized comparative trial

To compare the success, clinical outcomes, and maternal and neonatal complications between the Kiwi Omnicup and the Malmstrom metal cup in vacuum assisted delivery. This was a prospective randomized comparative trial. Women who required vacuum assisted vaginal delivery were randomized into the Kiwi Omnicup (KO) group and the Malmstrom metal cup (MM) group. The vacuum assisted deliveries were conducted according to hospital protocol. Details of the procedure and delivery outcomes including success and complications were analyzed. One hundred and sixty-four women were recruited - 85 were assigned to vacuum assisted delivery using the KO and 79 the MM. One hundred percent delivery success was achieved with no significant differences between the two instruments in terms of maternal morbidity (P = 0.66). Six women in the MM group sustained post delivery complications in comparison to five in the KO group. Three babies were diagnosed with birth asphyxia in each group. More babies in the MM group were admitted to the Neonatal Intensive Care Unit (NICU) (10 babies versus 5 babies) and suffered complications (14 versus 12 babies), compared to the KO group, although the difference was not statistically significant. There were no intrapartum or neonatal deaths and of those admitted to the NICU, all were discharged within a week without any serious consequences. Kiwi Omnicup is an effective alternative to the currently available Malmstrom metal cup for vacuum assisted delivery with no increase in maternal or neonatal morbidity or mortality.

Neonatal subgaleal hemorrhage: Clinical presentation, treatment, and predictors of poor prognosis

Neonatal subgaleal hemorrhage (SGH) is a rare but potentially lethal medical emergency. The objective of the present retrospective study was to clarify the clinical presentation, management, and factors associated with morbidity and mortality. The records of all newborns from January 1995 to December 2004 were reviewed for evidence of SGH, based on the presence of a fluctuating hemorrhagic mass that crossed suture lines and extended toward the neck. Characteristics were compared between those with a poor or a good outcome. Forty-two newborns with SGH were identified, 77% having had an instrumental delivery. The incidence was 0.6/1000 deliveries and 4.6/1000 vacuum-assisted deliveries. Thirteen patients (31%) had a poor outcome (five died, four had epilepsy, three with severe auditory dysfunction, two with cerebral palsy, and one with renal vein thrombosis). The group with the poor outcome had significantly more patients who had been transferred from other hospitals (P < 0.001). Those with a poor outcome had significantly more hypotension (P < 0.001) and seizures (P < 0.05). Laboratory findings associated with a poor outcome included anemia, coagulopathy, metabolic acidosis, and renal impairment. Other predictors of a poor prognosis included skull bone fracture, the need for pressors, blood transfusion, ventilator support, intensive care unit admission, and a longer hospital stay. SGH may be associated with serious complications and death. The condition must be recognized promptly and monitored closely. Those with poor prognostic factors should be referred for intensive care, treated aggressively, and followed in the long term.

Neonatal Complications of Vacuum-Assisted Delivery

Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, Royal Brisbane Women’s Hospital, the University of Queensland, Brisbane, Australia Financial Disclosure Dr. Vacca, is the co-designer of the Kiwi “Omni-Cup” Cup (Clinical Innovations, Murray, Utah) and is on the Speaker’s Bureau for Clinical Innovations.

Postpartum Labial Adhesions

Labial adhesions are common in young girls and menopausal women. Topical estrogen is the first line of therapy for these adhesions. Based on a systematic literature review, postpartum labial adhesions are uncommon in clinical practice. They are not painful but can prevent patients from resuming normal sexual activity. Topical estrogen therapy is an ineffective treatment option for adhesions in this setting. Surgical division under local anesthesia is usually effective. A 29-year-old women presented at 6 weeks after an uncomplicated vacuum-assisted delivery for a routine postpartum evaluation. Examination revealed a 5-mm labial adhesion connecting her left and right labia minora. Division under local anesthetic resulted in a complete recovery within 3 days. Postpartum labial adhesions can usually be surgically divided under local anesthetic with complete and rapid recovery.

Neonatal Complications of Vacuum-Assisted Delivery

Simonson, Colin MD; Barlow, Patricia MD; Dehennin, Nathalie MD; Sphel, Marianne MD; Toppet, Veronique MD; Murillo, Daniel MD; Rozenberg, Serge MD Author Information

Fetal Pulse Oximetry and Cesarean Delivery

ABSTRACT More than 5 years ago the Food and Drug Administration approved, conditionally, the OxiFirst Fetal Oxygen Saturation Monitoring System as an adjunct to electronic fetal monitoring. The goal of monitoring was to gain more knowledge of the condition of the fetus by continuously monitoring oxygen saturation when there is a nonreassuring fetal heart rate pattern. The sensor is inserted through the dilated cervix following membrane rupture, and positioned against the fetal face. This randomized trial, conducted at 14 university-based clinical centers, was designed as a means of learning whether adjunctive fetal oximetry lessens the need for cesarean delivery. Participants were nulliparous women with a singleton fetus in cephalic presentation at 36 or more weeks' gestation. The 5341 women in the study were randomized to either “open” fetal pulse oximetry with oxygen saturation values displayed to the clinician, or “masked” oximetry in which the results were hidden. Overall rates of cesarean delivery were 26.3% for the open group and 27.5% for masked monitoring, not a significant difference. The respective operative delivery rates were 7.1% and 7.9% for a nonreassuring fetal heart rate pattern; and 18.6% and 19.2% for dystocia, Findings were similar for the 2168 women in whom a nonreassuring fetal heart rate pattern was identified before randomization. There were no significant differences between the open and masked groups in the rates of forceps or vacuum-assisted delivery, even after excluding women who had labor induced. The relative risk of cesarean delivery associated with knowing the fetal oxygen saturation was 0.96 (95% confidence interval, 0.87–1.04). Neither maternal nor infant complications differed significantly in incidence between the study groups. The sensitivity, specificity, positive predictive value, and negative predictive value of a nonreassuring fetal heart rate pattern for low oxygen saturation (defined as less than 30% for 2 consecutive minutes) were, respectively, 87%, 19.5%, 35%, and 75%. One-fourth of fetuses with a normal heart rate pattern exhibited low oxygen saturation. This large-scale study failed to demonstrate that knowledge of intrapartum fetal oxygen saturation significantly lowers the rate of cesarean delivery or improves infant outcomes. The findings emphasize the need to rigorously evaluate new technologies.

Amniotic-Fluid Embolism and Medical Induction of Labor: A Retrospective, Population-Based Cohort Study

Amniotic-fluid embolism is a rare complication of delivery, the cause of which is unknown. It remains one of the major causes of maternal deaths in developed countries. This population-based cohort study sought to clarify the association between amniotic-fluid embolism and medical induction of labor in a cohort of 3 million hospital deliveries taking place in several regions of Canada in the years 1991-2002. Rates of amniotic-fluid embolism were 6.0 per 100,000 singleton deliveries and 14.8 per 100,000 multiple-birth deliveries, for an odds ratio (OR) of 2.5 (95% confidence interval [CI], 0.9-6.2). Only singleton births were analyzed further. Of 180 affected singleton births, 24 were followed by the mother's death, for a case-fatality rate of 13%. There was no apparent increase over time in amniotic-fluid embolism for either total cases or fatal cases. Medical induction of labor nearly doubled the risk of amniotic-fluid embolism; the adjusted OR was 1.8 (95% CI, 1.3-2.7). For fatal cases the crude OR was 3.5 (95% CI, 1.5-8.4). Other factors associated with an increased risk of amniotic-fluid embolism included a maternal age of 35 or above, cesarean delivery, instrumental vaginal delivery, polyhydramnios, cervical laceration, uterine rupture, placenta previa, placental abruption, eclampsia, and fetal distress. Advanced maternal age nearly doubled the risk, whereas young maternal age strongly protected against amniotic-fluid embolism. Forceps-assisted vaginal delivery carried a higher risk than did vacuum-assisted delivery. Even after adjusting for these risk factors and also for year of delivery, medical induction of labor nearly doubled the risk of amniotic-fluid embolism. Neither elderly primigravidity nor grand multiparity was a risk factor. These findings indicate that inducing labor medically increases the risk of amniotic-fluid embolism. It is important for parturients and their physicians to be aware of this association, even if the small increase in absolute risk is unlikely to alter a decision to induce labor if appropriate clinical indications are present.

Water Birth, More Than a Trendy Alternative: A Prospective, Observational Study

Water birth has become increasingly popular, particularly in German-speaking countries. The relevant literature provides some basis for thinking that the overall outcome may be comparable to—or even superior to—that of traditional methods. However, few prospective observational studies have been done. The present study was planned to prospectively study the effects of water birth on maternal and fetal outcomes in low-risk parturients seen at a tertiary obstetrical unit. A total of 513 women who requested a water birth in the years 1998–2002 were eligible for the study. All of them had a singleton pregnancy after 37 weeks' gestation with a cephalic presentation and a normal fetal cardiotocogram. The study group included 89 women (17% of the total) who delivered in water. Serving as controls were 133 women who had a normal vaginal delivery following temporary immersion; 146 who delivered without any immersion; and 145 who had either cesarean section or a forceps- or vacuum-assisted vaginal delivery. These groups were comparable in most demographic and obstetrical respects. After being offered an enema, the woman was permitted to enter the tub at any time, but preferably when the cervix was about 5 cm dilated. Soaps and other bath products were not recommended. The fetal heart rate was continuously monitored. Oxytocin was infused as needed if cervical dilation failed or, alternately, membrane rupture was initiated. Patients' wishes for pain relief were fully respected, but immersion ceased if an epidural block was needed. A midwife brought the infant to the surface within seconds of birth and then clamped and cut the umbilical cord. Significantly fewer women in the study group than in the temporary immersion and operative delivery control groups required additional analgesia. The first stage of labor lasted significantly longer in control cases than in women having water delivery. Women in all the control groups had a significantly prolonged second stage of labor. More pathological cardiotocograms were recorded in all control groups during the second stage of labor. More control women received IV oxytocin and uterine relaxants. Significantly more episiotomies were made in all control groups than in the study group, but there were more first- and second-degree perineal lacerations in the water group. None of the study patients had a third-degree laceration. Mean birth weights were similar in all groups, but infants whose mothers had operative delivery had low 1-minute APGAR scores. The operative delivery group had lower arterial pH values, and all control groups had significantly lower venous pH measurements. There were no group differences in rates of admission to neonatal intensive care. No significant group differences were found in hemoglobin or hematocrit values as estimated in the third trimester and during the first stage of labor. There were no cases of postpartum infection that could be ascribed to water delivery. When limited to low-risk parturients, water delivery appears to be safe and not associated with adverse fetal or maternal outcomes. Continuous intrapartum observation and fetal monitoring are essential, and more studies are needed to confirm the safety of this practice.

Neonatal Complications of Vacuum-Assisted Delivery

To assess systematically the extent of neonatal complications in a cohort of vacuum-assisted deliveries, identify risk factors associated with the occurrence of these complications, and to evaluate the usefulness of skull X-ray and transfontanellar ultrasonography after vacuum extraction. We reviewed a cohort of 1,123 attempted vacuum extractions of singletons performed between January 2000 and December 2004. During this period, a systematic screening using transfontanellar ultrasonography and skull X-ray was performed after vacuum extraction. Among 913 successful vacuum-assisted, full-term deliveries, 25.7% were admitted to the neonatal intensive care unit. Scalp edema, cephalhematoma, and skull fracture were assessed by cranial radiography and were present in, respectively, 18.7%, 10.8%, and 5.0% of cases. Intracranial hemorrhage occurred in eight cases (0.87%). Nulliparity, a vacuum attempt at mid station, an extraction requiring more than three tractions, and dislodgment of the cup were associated with these complications but had a low predictive value. Severe neonatal complications associated with vacuum extraction are uncommon. Systematic X-ray and ultrasonographic examination led to the discovery of asymptomatic complications. Because the clinical significance of these complications is unknown, we do not recommend them as routine screening tools. II.

Successful term pregnancy following MR-guided focused ultrasound treatment of uterine leiomyoma

Term vaginal delivery after magnetic resonance-guided focused ultrasound therapy (MRgFU) for symptomatic uterine leiomyoma. A 38-year-old nulligravida underwent MRgFU treatment per study protocol for a solitary 9 x 10 x 10 cm uterine myoma and conceived 18 months following the procedure. She was counseled on the unknown implications of MRgFU during subsequent pregnancy. Myoma size increased significantly during gestation. At 39 weeks, she underwent indicated labor induction with vacuum-assisted vaginal delivery of a healthy male infant. In one pregnancy following MRgFU, there were no associated antepartum or intrapartum obstetrical complications.

Effects of epidural lidocaine analgesia on labor and delivery: A randomized, prospective, controlled trial

BackgroundWhether epidural analgesia for labor prolongs the active-first and second labor stages and increases the risk of vacuum-assisted delivery is a controversial topic. Our study was conducted to answer the question: does lumbar epidural analgesia with lidocaine affect the progress of labor in our obstetric population?Method395 healthy, nulliparous women, at term, presented in spontaneous labor with a singleton vertex presentation. These patients were randomized to receive analgesia either, epidural with bolus doses of 1% lidocaine or intravenous, with meperidine 25 to 50 mg when their cervix was dilated to 4 centimeters. The duration of the active-first and second stages of labor and the neonatal apgar scores were recorded, in each patient. The total number of vacuum-assisted and cesarean deliveries were also measured.Results197 women were randomized to the epidural group. 198 women were randomized to the single-dose intravenous meperidine group. There was no statistical difference in rates of vacuum-assisted delivery rate. Cesarean deliveries, as a consequence of fetal bradycardia or dystocia, did not differ significantly between the groups. Differences in the duration of the active-first and the second stages of labor were not statistically significant. The number of newborns with 1-min and 5-min Apgar scores less than 7, did not differ significantly between both analgesia groups.ConclusionEpidural analgesia with 1% lidocaine does not prolong the active-first and second stages of labor and does not increase vacuum-assisted or cesarean delivery rate.