• Explain the procedure to the woman and family and the reason for carrying it out, then gain conscent.
• Provides privacy
• Wash hands
• Evaluate the woman’s condition abdominally and vaginally to ensure that the conditions for carrying vacuum extraction are present.
• The doctor or midwife practicing vacuum extraction must be skilled and experienced.
• The baby is alive or fetal heart (FH) stopped during labor.
• The fetus must be a term baby.
• The presentation should be vertex.
• Ensure ruptured membranes
• Exclude CPD, caput succedenum, excessive moulding.
• Descent should be 1/5 or 0/5 on abdominal palpation.
• There must be good uterine contractions.
• Position of fetal head must be certain
• Full dilatation and effacement of the cervix (anterior lip may be an exception).
• Instruments must be in good working order.
• Adequate analgesia
• Make sure there is a backup doctor or midwife.
• Must be carried out in well equipped facility in case it fails or there must be proper referral system.

Mentions any 4

STEPS

• Prepare instruments: requirements for normal delivery, connect pump, tubing and cup, resuscitation requirements.
• Test vacuum on the palm to ensure it is effective in creating a vacuum.
• Position the woman in a lithotomy position (legs apart with knees flexed).
• Ensure bladder is empty. Catheterize if necessary.
• Perform V.E., confirm presentation and position.
• A local anaesthetic in form of pudendal block or an epidural analgesia is topped up if already in situ.If not available, infilteration of the perineum might suffice.
• Fetal heart rate should be monitored regularly.
• Gently pull down the perineum to make space for cup.
• Through V.E., locate the posterior fontanelle and gently place the cup on the flexion point of the fetal head i.e 2cm anterior to the posterior fontanelle.
• Pass a finger around the edge of the cup to ensure that none of the mother’s tissue has been caught under the cap.
• The vacuum in the cup is increased gradually to achieve close application to fetal head by squeezing the handle to raise the pressure to 100mmHg. or 0.2Kg/cm2.
• With achievement of vacuum and good contractions, traction is applied in a downwards and backwards direction, forwards and upwards, following the “curve of Caurus.”
• When contraction fades, reduce traction.
• As the next contraction begins, raise vacuum by 100mmHg to 400mmHg the maximum pressure should NEVER exceed 600mmHg or 0.8kg/cm2.
• Continue applying traction with contraction until the head has crowned,
• Encourage woman to breathe deeply when contractions stop.
• Encourage mother to push with contraction for the final part /of delivery.
• Release vacuum after crowning of head or pull downwards in the direction of normal delivery.
• Do not twist or turn cup or handle as this may lead to loss of vacuum and injury to baby’s scalp.
• Continue care as in normal delivery, reassure mother.
• Active management of third stage should be done.
• Check perineum for lacerations and repair.
• Manage equipments properly

N.B:  when contractions stop, reduce pressure by 100mmHg. do not allow pressure to remain at maximum levels (600mmHg) for more than 10 minutes.

A vacuum extractor has failed if:

• Fetal head does not advance with each pull.
• Fetus is not delivered with three pulls or no descent in 30 minutes.
• Cup pops off the head twice at the proper direction of pull with appropriate pressure.
• STOP the procedure and prepare for Caesarean section
• Record outcome of procedure

OBJECTIVE STATION: VACUUM EXTRACTION/INSTUMENTAL DELIVERIES

1. A vacuum extractor has failed if the following occurs EXCEPT

a. Fetal head does not advance with each pull.

b. The perineum is rigid

c. Fetus is not delivered with three pulls or no descent in 30 minutes.

d. Cup pops off the head twice at the proper direction of pull with appropriate pressure.

2. The following are conditions to be met before carrying out vacuum extraction EXCEPT

a. The fetus must be a term baby.

b. The presentation should be vertex.

c. Ensure intact membranes

d. Descent should be 1/5 or 0/5 on abdominal palpation.

3. During vacuum extraction, the cup should be placed at the …………………….. of  the fetal head

a. Extension point

b. Occiput

c. Flexion point

d. Anterior fontanelle

4. During the procedure, when contraction fades, 

a. Apply traction on the head

b. Reduce traction on the head

c. Rotate the head

d. Flex the head

 

5. The vacuum practitioner should not exceed a vacuum pressure of ………………… during vacuum extraction

a. 500mmHg

b. 400 mmHg

c. 600 mmHg

d. 700 mmHg

6. When the vacuum cup stays for more than10 minutes on the fetal scalp, it may cause

a. Sub periostal haemorrhage

b. Ruptured sinuses

c. Damage to the brain cells

d. Facial haematoma

7. During vacuum extraction, the vacuum can be released when 

a. The head has descended

b. The face is delivered

c. Restitution has takenplace

d. The head has crowned

8. The following are contra indications to the use of vacuum extraction except

a) No contractions

b) Incomplete cervical dilatation

c) Gestational age less than 37 weeks

d) Vertex presentation

9. Women who use epidural as a form of pain relief are at increased risk of having 

a) an instrumental assisted birth

b) obstructed labour

c) sepsis

d) intra partum eclampsia

10. In current obstetric, forceps are also used to assist 

a) To deliver an un engaged head

b) To withdraw the head up and out of the pelvis during caesarean section.

c) Delivery of a woman with shoulder dystocia

d) To deliver the buttocks in breech presentation

11. The cephalic curve is the curve on the flat surface of the obstetric forcep which when articulated

a) grasps the fetal chest without compression.

b) grasps the fetal neck without compression.

c) grasps the fetal head without compression.

d) grasps the frontal bone without compression.

12. Conditions to be met before forceps delivery are the following except

a) Full dilatation

b) Skilled practitioner

c) Adequate pelvis

d) Descent of 5/5

13. During forceps delivery, 

a) The forceps are inserted separately

b) The forceps are locked before inserting into vagina

c) The position of  fetal head  must not be known

d) The forceps should remain on fetal head after delivery of the head

14. After application of the forceps, the head should be pulled with contractions along the

a) Pelvic inclination

b) Curve of caurus

c) Station 0 of presenting part

d) Pubic arc

15. The midwife must be very vigilant during and after forcep delivery to detect major complications like ………………………..

a) Eclampsia

b) Ruptured uterus

c) Hyperglycaemia

d) Drop foot

 

MARKING GUIDE

1. B

2. C

3. C

4. B

5. C

6. A

7. D

8. D

9. A

10. B

11. C

12. D

13. A

14. B

15. B