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OPERATIVE VAGINAL DELIVERY

Raymond Sandler, MDAssociate ProfessorDirector Labor and Delivery

Loraine O’Neill RN, MPHChief System Patient Safety Officer,

Department of Obstetrics, Gynecology and Reproductive Science

The Icahn School of Medicine

at Mount Sinai

CONFLICT OF INTEREST DISCLOSURE STATEMENT

I don’t have financial interest or other relationships with the

industry relative to the topics being discussed.

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OBJECTIVES

a. Correctly identify the Flexion Point

b. Demonstrate the application of Kiwi Vacuum

c. Describe and give examples of Best Practices

d. Outline the elements of documentation required

OPERATIVE VAGINAL DELIVERY

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EngagementDescentFlexionDescentInternal RotationDescentExtensionDelivery VertexRestitution/External Rotation

Delivery of body

MECHANISMS OF LABOR

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Vacuum assisted vaginal delivery is all about‘RESTARTING’

the (stalled) mechanism of labor

descentengagementflexion

internal rotation

descent (cont.)

extension

external rotation

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Forceps

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Correct application:

The biparietal/bimalar application. The blades lie evenly against the fetal head and cover the space between the orbits and the ears.

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Correct application

The sagittal suture is perpendicular to the plane of the shanks.

The posterior fontanelle is 3cm from the plane of the shanks andequidistant from the sides of the blades.

No more than a fingertip will fit between the blade and the fetal head.9

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Follow the Curve of Carus with efforts at traction.

The Saxtorph-PajotManeuver to obtain the proper vector of traction.

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Correct application

The sagittal suture is perpendicular to the plane of the shanks.The posterior fontanelle is 3cm from the plane of the shanks and

equidistant from the sides of the blades.No more than a fingertip will fit between the blade and the fetal head.

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The flexion point may be located during vaginal examination by identifying the posterior fontanelle and then moving the finger anteriorly/posteriorly a distance of approximately 3 cm along the sagittal suture.

The tip of the finger will mark the flexion point.

Two observations are required:

– Distance from flexion point to posterior forchette.

– Degree of lateral displacement of the flexion point from the midline axis of the pelvis.

FLEXION POINT

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Mentoverticaldiameter

Suboccipito-bregmaticdiameter

Vacca, A., “Handbook on Vacuum Delivery”; 2003.

The Flexion Point

The flexion point is situated on the sagittal suture3 cm ant/post to the posterior fontanelle

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3cm

Flexion Point

The center of the vacuum cup should be placed overthe flexion point with the sagittal suture in the midline

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Location, Location, Location!

▶ Correct placement is KEY to your

▶ success and safety

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FLEXION POINTS TENDENCY TO STAY IN MIDLINE

Vacca, A. Handbook on Vacuum Delivery in Obstetrical Practice; 2003 16

Professor Aldo Vacca (1941-2014)

MODERN MANEUVERABLE CUP

Kiwi OmniCupClinical Innovations 18

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KIWI

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OmniCup®

A universal cup for all positions for easy insertion

A handle grip

Stalk graduated in cms

Pressure gauge

Pressure release .

KIWI

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Place tip of examining finger on flexion point

Calculate distance from flexion point to forchette by measuring distance from tip to where finger makes contact with forchette.

The distance from the tip of the middle finger to the proximal interphalangeal joint is5 - 6cm,

and to the metacarpophalangeal joint is 10 - 11 cm.

Distance Measurement

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Distance Measurement

OmniCup tubing has markings to assist the user in the location of these distances as shown in the figures.

These markings also help to identify how much progress is madeduring each contraction.

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The Importance of 6 and 11cm

“Vacuum by Numbers”

6 cm 11 cm

Vacca, A. Handbook on Vacuum Delivery in Obstetrical Practice; 2003 24

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POSTERIOR

10-11 cms25

Vacca, A. Handbook on Vacuum Delivery in Obstetrical Practice; 2003

Determining the Flexion Point Distance

2-3 cm4-5 cm

5-6 cm 8-9 cm

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Once contraction begins, rapidly raise vacuum to 450-600 mm Hg (green zone).

With each contraction ask the mother to push

Place finger on scalp next to cup to assess descent and potential slippage

Start traction in line of pelvic axis and perpendicular to cup

Procedure : Traction Triple Action

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Press against dome of cup with thumb of nonpulling hand and feel cup edge to help prevent ”pop off” from scalp.

Observe for descent.

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AXIS OF TRACTIONUpward traction should be delayed until the biparietaldiameter has reached the level of the pubic arch

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Between contractions check Fetal Heart Rate.

Do not pull if there is no contraction.

However, tension should be maintained between contractions

Decide if episiotomy indicated

Procedure : Traction

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For maximum efficiency and best results, direct pull perpendicularto cup.

Exercise caution. Pendulum or rocking movements from side to side may also increase predisposition to “pop off” and should NOT be done.

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Correct technique should enhance the normal processes of labor and should not depend on traction alone to effect delivery of the baby.

The key is to locate the flexion point and place the vacuum cup properly over it.

The flexion point is situated on the sagittal suture 3 cm in front of the posterior fontanelle.

The center of the cup should correspond to the flexion point so that traction in the line of the pelvic axis will promote flexion and correct asynclitism.

Summing Up

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B. Anterior parietal bone precedes the sagittal suture. The anterior parietal bone is more easily palpated than the posterior parietal bone. This is Anterior Asynclitism.

C. Posterior parietal bone precedes the sagittal suture. The posterior parietal bone is more easily palpated than the anterior parietal bone. This is Posterior Asynclitism.

A. The sagittal suture is lowermost in the pelvis. Each parietal bone is equally palpated by the examining hand. This is Synclitism.

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Location, Location, Location!

▶ Correct placement is KEY to your

▶ success and safety

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Importance of the Flexion Point

Flexing Median Application

Flexing Paramedian Application35

Importance of the Flexion Point

Deflexing Median Application

Deflexing Paramedian Application36

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Pulls, Pop-offs and Progress

What is a pull?

– Traction over the course of a contraction with maternal expulsive effort

(1 contraction = 3 pushes =1 pull )

What is a pop-off?

– Cup detachment with traction after successful application

– Maximum 2-3

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DO NOT TWIST, TORQUE, OR USE EXCESSIVE FORCE.

DO NOT REAPPLY IF CUP HAS BEEN “POPPED OFF” 3 TIMES

DO NOTS!!

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SUCCESS!!

Progress

– 1st pull flexion of head and some descent

– 2nd pull head to the pelvic floor

– 3rd pull delivery of head complete or imminent

– Should not exceed 15-20 minutes total application time

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Classify as ‘failed’ if

Fetal head does not advance with each pull Baby undelivered after maximum of 3 pulls.

Cup pops off the head 3x at proper direction of pull with maximum negative pressure

Proceed to Cesarean section

NO FORCEPS!

FAILURE!!

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Contraindications to VAVD

Unengaged head

Position unknown

Live fetus with bone demineralization or bleeding disorder

Fetus less than 34 weeks GA

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RECAP

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CONFLICT OF INTEREST DISCLOSURE STATEMENT

I don’t have financial interest or other relationships with the

industry relative to the topics being discussed.

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Prerequisites-Provider

Current privileges to perform:

operative vaginal deliveries

cesarean deliveries

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Prerequisites for VAVD

• Cervix fully dilated and retracted

• Membranes ruptured• Engagement of fetal

head• Position of the fetal head

has been determined• Fetal weight estimation

performed• Pelvis thought to be

adequate for vaginal delivery

• Adequate anesthesia• Maternal bladder has

been emptied• Patient has agreed after

being informed of the risks and benefits of the procedure

• Willingness to abandon trial of operative delivery and back-up plan in place in case of failure to deliver

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Only one instrument (Forceps OR Vacuum)

Vacuum not before 34 weeks

OVD not indicated

EFW >4000g in diabetic womenEFW >4500g in non-diabetic women

Procedure abandoned after 3 pop offs, or no descent after 3 pulls

Vacuum is considered to have been used if the pressure dial needle is pumped up to the green or red zones.

Best Practices

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Contraindications:

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A. Failed instrument intervention: Do not switch attempts between vacuum

extractor and then attempt forceps or vice versa

B. Operator inexperience

C. Gestational age less than 34.0 weeks

D. Cephalopelvic disproportion as indicated by failure or arrest of descent with

adequate trial of labor and/or evidenced by significant caput or overlapping fetal

cranial sutures.

E. Breech, face, brow, transverse or unknown presentation

F. Fetus with a known bone demineralization condition (osteogenesis) or

bleeding disorder (alloimmune thrombocytopenia, hemophilia or Van

Willebrand’s disease)

G. Inability to achieve proper positioning of the cup on the flexion point

H. Inadequate trial of labor

The following should be done PRIOR to operative vaginal deliveries:

a. A huddle by the attending, resident, delivery nurse, charge nurse, and anesthesiologist must occur.

b. The L&D charge nurse has been informed and confirms that an operating room is currently available to use should the instrumental delivery be unsuccessful.

c. Pediatric personnel have been notified.

d. Document discussion was made with patient regarding the mode of delivery including risk/benefits and alternatives.

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The following should be confirmed PRIOR to delivery and be part of the documentation for all operative vaginal delivery:

a. The cervix is fully dilated.

b. Estimated fetal weight has been documented and confirmed.

c. Confirmation that the pelvis is clinically adequate.

d. Confirmation that the fetal station is between +2 and +5 station between contractions.

e. Confirmation of fetal head position when the instrument is initially placed.

f. Maternal analgesia is addressed.

g. The urinary bladder is emptied immediately before applying the instrument.

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Nurse’s Role

Empty bladder

Ensure equipment ready for peds

Call out time

Ensure fetal heart monitoring

Assist patient to push as instructed by provider

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Debrief - To evaluate efficiency of event, address any systems issues, commend a good performance

Disclose - Explains event to parents

Document - Can explain what information is required for appropriate documentation

Following Delivery

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Collect cord blood gases

Examine baby's head immediately after birth for scalp injury and note cup application site.

Inspect scalp regularly if difficulty was experienced to exclude bleeding into the subgaleal space.

Reassure parents that chignon should disappear in a matter of hours and that marks from cup should leave no traces after a few days.

Reexamine baby within 24 hours to check the application site of vacuum cup

Following Delivery

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Maternal

• Lower genital tract injuries

Fetal

Localised scalp edema(Caput and chignon)

Scalp abrasions and lacerations

Cephalo-hematoma

Neonatal jaundice

Intracranial bleeding-rare

Complications

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Minor Complications

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Major Complications

Subgaleal or intracranial hemorrhage

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Documentation

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1.Content of counseling provided to the patient during verbal informed consent process including alternative labor strategies.

2. Estimated fetal weight, predetermined number of applications, fetal position, caput, molding, acynclitism, attitude, station, and cervical dilation.

3. Indication for vacuum extractor application and type of instrument used.

4. Steps taken to confirm proper placement of the cup.

5. Number of applications, duration of traction, number of pulls and pop-offs total length of time applied, results and maximum pressure.

Documentation cont:

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6. Notation that excess traction was not employed (or document exact traction force by using the Kiwi MT) and any additional maneuvers employed for delivery.

7. Any analgesia provided

8. Any neonatal trauma noted with disclosure of any neonatal injury to parents.

9. Availability of neonatal resuscitation and anesthesia/surgical teams

10. If deviation from guidelines, give detailed progress note of medical rationale is highly suggested.

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Key Points

Team effort

Involve the patient

Documentation

Follow up

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BIBLIOGRAPHY

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Aiken CE, Aiken AR, Brockelsby JC, Scott JG. Factors influencing the likelihood of instrumental delivery success. Obstet

Gynecol 2014;123:796–803.

Billings, R. G. (February 2004). The physics of vacuum extraction. Supplement to OBG

Evers EC, Blomquist JL, McDermott KC, Handa VL. Obstetrical anal sphincter laceration and anal incontinence 5–10

years after childbirth. Am J Obstet Gynecol 2012;207:425.e1–6

Fitzgerald MP, Weber AM, Howden N, Cundiff GW, Brown MB. Risk factors for anal sphincter tear during vaginal delivery.

Pelvic Floor Disorders Network. Obstet Gynecol 2007;109:29–34.

Kudish B, Blackwell S, Mcneeley SG, Bujold E, Kruger M, Hendrix SL, et al.. Operative vaginal delivery and midline

episiotomy: a bad combination for the perineum. Am J Obstet Gynecol 2006;195:749–54

McQuivey, R.W., Vacuum-assisted delivery: a review. Journal of Maternal-Fetal and Neonatal Medicine, 2004, 16:171-

179.

Perez, A., Cutting Your Legal Risks with Vacuum Assisted Deliveries. OB Management, 1999; March; 22-36.

Sartore A, De Seta F, Maso G, Pregazzi R, Grimaldi E, Guaschino S. The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gyne-col 2004;103:669–73.

Vacca, A. Vacuum-Assisted Delivery. Improving patient outcomes and protecting yourself against litigation. OBG Management supplement. February, 2004

Vacca, A. Handbook on Vacuum Delivery in Obstetrical Practice; 2003

Werner EF, Janevic TM, Illuzzi J, Funai EF, Savitz DA,Lipkind HS. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol 2011; 118:1239–46

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ACOG Technical Bulletin Technical Bulletin #197, Operative Vaginal Delivery (2000). Reaffirmed 2008.

ACOG Practice Bulletin #154, Operative Vaginal Delivery Nov. 2015

Kiwi Package insert

Public Health Advisory: Need for Caution When Using Vacuum assisted Delivery Devices. Center for Devices and Radiological Health, US Dept. of Health and Human Services; May 21 1998