Procedure for vacuum-assisted operative vaginal delivery
- James Greenberg, MD
James Greenberg, MD
- Associate Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
In 1953, the Swedish obstetrician, Tage Malmström, introduced a hollow disc-shaped stainless steel metal cup for vacuum assisted delivery . Suction tubing attached to the dome of the cup and a traction chain passed through the tubing. The Malmström cup quickly became the template for all subsequent vacuum extractor systems [2,3].
By the 1970s, the vacuum extractor virtually replaced forceps for assisted deliveries in northern European countries. However, in many English-speaking countries, including the United States and the United Kingdom, adoption of the vacuum device was slower . Nonetheless, by 1992, the number of vacuum assisted deliveries surpassed the number of forceps deliveries in the United States, and by 2000, approximately two-thirds of operative vaginal deliveries were by vacuum .
The technique for vacuum assisted operative delivery will be reviewed here. An overview of methods for operative vaginal delivery, including risks and outcomes, can be found separately. (See "Operative vaginal delivery".)
INDICATIONS AND CONTRAINDICATIONS
Indications — A vacuum assisted delivery should only be attempted when a specific obstetric indication is present [5,6]. The three major categories of indication are prolonged second stage of labor, nonreassuring fetal status, and maternal cardiac or neurological disease, but there is no absolute indication.
The indications and prerequisites for operative vaginal delivery are discussed in detail separately. (See "Operative vaginal delivery", section on 'Indications' and "Operative vaginal delivery", section on 'Prerequisites'.)
- Malmström, T. The vacuum extractor: An obstetrical instrument. Acta Obstet Gyncol Scand 1957; 36:5.
- Miksovsky P, Watson WJ. Obstetric vacuum extraction: state of the art in the new millennium. Obstet Gynecol Surv 2001; 56:736.
- Vacca, A. Vacuum-assisted delivery. OBG Manag 2004; Suppl:S1-7.
- Demissie K, Rhoads GG, Smulian JC, et al. Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis. BMJ 2004; 329:24.
- FDA Public Health Advisory. Need for caution when using vacuum assisted delivery devices. U.S. Food and Drug Administration: Center for Devices and Radiological Health: www.fda.gov/cdrh/fetal598.html.
- Johanson, RB. Instrumental vaginal delivery. Guidelines and Audit Committee of the Royal College of Obstetricians and Gynaecologists, 2001.
- Attilakos G, Sibanda T, Winter C, et al. A randomised controlled trial of a new handheld vacuum extraction device. BJOG 2005; 112:1510.
- Groom KM, Jones BA, Miller N, Paterson-Brown S. A prospective randomised controlled trial of the Kiwi Omnicup versus conventional ventouse cups for vacuum-assisted vaginal delivery. BJOG 2006; 113:183.
- Ismail NA, Saharan WS, Zaleha MA, et al. Kiwi Omnicup versus Malmstrom metal cup in vacuum assisted delivery: a randomized comparative trial. J Obstet Gynaecol Res 2008; 34:350.
- Johanson R, Menon V. Soft versus rigid vacuum extractor cups for assisted vaginal delivery. Cochrane Database Syst Rev 2000; :CD000446.
- Muise KL, Duchon MA, Brown RH. The effect of artificial caput on performance of vacuum extractors. Obstet Gynecol 1993; 81:170.
- Hofmeyr GJ, Gobetz L, Sonnendecker EW, Turner MJ. New design rigid and soft vacuum extractor cups: a preliminary comparison of traction forces. Br J Obstet Gynaecol 1990; 97:681.
- Hammarström M, Csemiczky G, Belfrage P. Comparison between the conventional Malmström extractor and a new extractor with Silastic cup. Acta Obstet Gynecol Scand 1986; 65:791.
- Ross MG, Fresquez M, El-Haddad MA. Impact of FDA advisory on reported vacuum-assisted delivery and morbidity. J Matern Fetal Med 2000; 9:321.
- Billings, RG. The physics of vacuum extraction. OBG Manag 2004; Suppl S7.
- Suwannachat B, Lumbiganon P, Laopaiboon M. Rapid versus stepwise negative pressure application for vacuum extraction assisted vaginal delivery. Cochrane Database Syst Rev 2012; :CD006636.
- Duchon MA, DeMund MA, Brown RH. Laboratory comparison of modern vacuum extractors. Obstet Gynecol 1988; 71:155.
- MISHELL D Jr, KELLY JV. The obstetrical forceps and the vacuum extractor: an assessment of their compressive force. Obstet Gynecol 1962; 19:204.
- Moolgaoker AS, Ahamed SO, Payne PR. A comparison of different methods of instrumental delivery based on electronic measurements of compression and traction. Obstet Gynecol 1979; 54:299.
- Laufe LE. Divergent and crossed obstetric forceps. Comparative study of compression and traction forces. Obstet Gynecol 1971; 38:885.
- Vacca A. Vacuum-assisted delivery: an analysis of traction force and maternal and neonatal outcomes. Aust N Z J Obstet Gynaecol 2006; 46:124.
- Baskett TF, Fanning CA, Young DC. A prospective observational study of 1000 vacuum assisted deliveries with the OmniCup device. J Obstet Gynaecol Can 2008; 30:573.
- Vacca A. Handbook of vacuum assisted delivery in obstetric practice, 2nd ed, Vacca Research, Brisbane, Australia 2003.
- Bofill JA, Rust OA, Schorr SJ, et al. A randomized trial of two vacuum extraction techniques. Obstet Gynecol 1997; 89:758.
- Kudish B, Blackwell S, Mcneeley SG, et al. Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol 2006; 195:749.
- Lund NS, Persson LK, Jangö H, et al. Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2016; 207:193.
- Johanson RB, Rice C, Doyle M, et al. A randomised prospective study comparing the new vacuum extractor policy with forceps delivery. Br J Obstet Gynaecol 1993; 100:524.
- Bofill JA, Rust OA, Devidas M, et al. Neonatal cephalohematoma from vacuum extraction. J Reprod Med 1997; 42:565.
- Ghidini A, Stewart D, Pezzullo JC, Locatelli A. Neonatal complications in vacuum-assisted vaginal delivery: are they associated with number of pulls, cup detachments, and duration of vacuum application? Arch Gynecol Obstet 2016.
- Verhoeven CJ, Nuij C, Janssen-Rolf CR, et al. Predictors for failure of vacuum-assisted vaginal delivery: a case-control study. Eur J Obstet Gynecol Reprod Biol 2016; 200:29.
- Bird GC. The importance of flexion in vacuum extractor delivery. Br J Obstet Gynaecol 1976; 83:194.
- Sadan O, Ginath S, Gomel A, et al. What to do after a failed attempt of vacuum delivery? Eur J Obstet Gynecol Reprod Biol 2003; 107:151.
- Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999; 341:1709.
- Revah A, Ezra Y, Farine D, Ritchie K. Failed trial of vacuum or forceps--maternal and fetal outcome. Am J Obstet Gynecol 1997; 176:200.
- INDICATIONS AND CONTRAINDICATIONS
- Extractor cup
- - Soft versus rigid
- - Bell versus mushroom shape
- - Occiput posterior position
- Patient preparation
- Determine the flexion point
- Place the cup
- Apply suction
- Exert traction
- FAILED PROCEDURES
- Risk factors
- REDUCING THE RISK OF COMPLICATIONS
- Confirm correct cup placement
- Avoid entrapping vaginal soft tissues
- Know when to abandon the procedure
- COMPLICATIONS AND OUTCOME
- SUMMARY AND RECOMMENDATIONS