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Reducing the Medicolegal Risk of Vacuum Extraction

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Reducing the Medicolegal Risk of Vacuum Extraction Martin L. Gimovsky, MD Program Director, Newark Beth Israel Medical Center, Newark, NJ, and Clinical Professor of Obstetrics, Gynecology and Women’s Health, Mount Sinai School of Medicine, New York, NY Ji-Soo Han, MD Senior Resident in Obstetrics and Gynecology, Newark Beth Israel Medical Center, Newark, NJ The authors report no fi nancial relationships relevant to this article. The vacuum cup is applied to the fetal scalp over the sagittal suture about 6 cm distal to the anterior Martens ® Dowden Health Mediafontanel and 2 cm proximal to the posterior fontanel Kimberly © Copyright ReducingFor personal the usemedicolegal only risk of vacuum extraction IN THIS ARTICLE ❙ Factors that favor Focus on indications, informed consent, technique, success or portend and documentation to yield better outcomes failure Page 76 CASE Three hours of pushing tractor, which has replaced the forceps as the most commonly used approach ❙ Subgaleal hemor- C.A., age 29 years, is 40 weeks’ pregnant for operative vaginal delivery. Like the rhage, a deadly with her fi rst child. After an unremarkable forceps, the vacuum extractor has vocif- pregnancy, she arrives at the hospital for erous detractors as well as supporters. complication cervical ripening and induction of labor. Liberal use of cesarean section and ques- Page 78 Oxytocin is given, and labor progresses tions regarding the safety of operative uneventfully. When C.A.’s cervix is dilated vaginal delivery vis-à-vis cesarean sec- ❙ Traction efforts 8 cm, however, labor stalls. The physician tion have fueled the debate over its role reap a diminishing orders placement of a pressure catheter and in obstetric practice. return increases the dosage of oxytocin, and the Among the benefi ts of vacuum ex- Page 84 cervix dilates fully. Although C.A. pushes traction are its cost-effectiveness and well, the vertex descends only from +1 to shorter hospital stay (TABLE 1). It also +2 station (of 5 stations) after 3 hours. obviates the need for cesarean section, How would you manage this delivery? including repeat cesarean. Risks include an increased incidence of genital tract One option in C.A.’s case is operative trauma and a greater risk of fetal subga- vaginal delivery using the vacuum ex- leal hemorrhage. 74 OBG MANAGEMENT • June 2007 For mass reproduction, content licensing and permissions contact Dowden Health Media. We review 4 critical spheres of con- TABLE 1 cern in regard to vacuum extraction: Delicate balance: Risks and benefi ts 1. Patient selection of operative vaginal delivery 2. Informed consent 3. Technique WHO? BENEFIT RISK 4. Documentation Mother Cost-effective Increased incidence of genital Increased understanding of these as- Less blood loss tract trauma pects of vacuum extraction will improve Lower risk of febrile morbidity Possible damage to pelvic fl oor, outcomes for the patient and limit medi- Maternal preference with urinary and anal colegal risk. No need for cesarean incontinence In the case of C.A., the physician of- section or repeat cesarean fered 3 options: Shorter hospitalization and • Continue maternal expul- convalescence sive efforts to allow descent Fetus Fewer respiratory diffi culties Increased risk of subgaleal • Attempt delivery by at birth hemorrhage vacuum extraction Association with shoulder • Proceed to cesarean section on dystocia the basis of protracted descent. Risks and benefi ts were reviewed with the patient, who chose to deliver agement remain acceptable in contempo- by cesarean section. A 3,780-g infant in rary practice.3 Otherwise, a trial of vacu- occiput posterior position was delivered um extraction may be appropriate. safely. Vacuum extraction is particularly useful when the mother has diffi culty pushing because of exhaustion and the 1. Patient selection fetal head has descended enough that it Maternal and fetal distends the labia between contractions, indications as in outlet deliveries. Vacuum extraction may be justifi ed for FAST TRACK maternal or fetal indications.1,2 Maternal Fetal indications If the fetal heart rate indications include prolongation or arrest Fetal indications for operative vaginal of the second stage of labor, or the need delivery include distress, jeopardy, or a is reassuring, the to shorten the second stage, for reasons “nonreassuring” FHR tracing. Such a second stage such as maternal cardiac disease, com- tracing may include late and prolonged of labor need not plex congenital cardiovascular disorders, decelerations, baseline bradycardia or be limited and maternal exhaustion. tachycardia with or without variable decelerations, or, occasionally, a normal to 2 or 3 hours No defi nitive time limit baseline rate with diminished variability. for the second stage of labor There is more fl exibility today than in the past about what constitutes a “safe” Use vacuum or forceps? length of the second stage. Recommenda- The choice depends on which device tions concerning when the mother should would achieve delivery in the safest man- begin pushing—and for how long—have ner with the lowest risk of fetal injury. evolved from a strict time limit to a fo- With the vacuum, force is exerted direct- cus on progression. If the fetal heart rate ly on the fetal scalp and only secondarily (FHR) tracing is reassuring, the second on the fetal skull. This puts fetal vessels stage no longer needs to be limited to 2 that traverse the subgaleal space at risk or 3 hours. On the contrary, if the patient for injury (FIGURE, page 78). With for- is still able and willing to push, changes ceps, force is exerted directly on the fetal in positioning and further expectant man- skull and mitigated by the petrous bone. CONTINUED www.obgmanagement.com June 2007 • OBG MANAGEMENT 75 Vacuum extraction TABLE 2 perience of the operator. You must be familiar with the instrument and tech- Factors that predict success— or failure—of vacuum extraction nique before making any attempt to as- sist delivery. An inability to accurately When a woman fi ts overlapping categories, assess fetal position or station, feto- the decision to use vacuum extraction—or pelvic proportion, adequacy of labor, not—may be a judgment call* engagement of the fetal head, or any GOOD CANDIDACY degree of malpresentation (including minor degrees of defl exion) is a contra- Multiparous indication to a trial of operative vaginal Term pregnancy delivery. Occiput anterior position, well-fl exed Vacuum extraction should be re- Wide subpubic arch served for fetuses at more than 34 weeks’ gestation because of the increased risk of Compliant intracranial hemorrhage associated with MARGINAL CANDIDACY prematurity. Primiparous All decisions involving vacuum ex- traction should be made with caution. Post-term The adequacy of the pelvis, estimated Occiput posterior position fetal size, and any suggestions of feto- Average subpubic arch pelvic disproportion are of particular signifi cance.3 Gestational diabetes Arrest disorders in second stage POOR CANDIDACY 2. Informed consent Protraction disorders in second stage Elicit the patient’s desires Thorough discussion with the patient Narrow subpubic arch and her family—to explain the reason- FAST TRACK Uncertain position of fetal head ing behind the clinical decision to use the Reserve vacuum Defl exion or asynclitism vacuum extractor and delineate the al- ternatives—is paramount. Moreover, the extraction for Anticipated large-for-gestational-age infant patient should be encouraged to actively fetuses at more Poor maternal compliance participate in this discussion. than 34 weeks’ * When faced with a good indication in a marginal Among the alternatives to vacuum candidate, we recommend delivery in a “double set- extraction are expectant observation gestation because up” situation in which preparations are made for both vacuum extraction and cesarean section. If the vacuum and expedited delivery by cesarean sec- of the increased risk can be properly applied, the fi rst application of traction tion. Because patients increasingly are is crucial. We will only proceed if signifi cant descent requesting elective cesarean section in of intracranial hem- is achieved. If the fetal head (not the scalp) can be orrhage associated advanced a full station, then we proceed cautiously. the absence of obvious obstetric indica- If not, ready access to cesarean section allows for tions, this option should receive extra with prematurity completion of the delivery in a timely manner. attention. Most women still consider vaginal Little or no force is exerted on the fetal delivery an important milestone of fe- scalp, lessening the risk of traumatic in- male adulthood. When safety concerns jury such as potentially fatal subgaleal arise and the situation makes vaginal hemorrhage. delivery unwise, many women experi- Indications and contraindications ence disappointment and postpartum for vacuum extraction are similar, but depression over their “failed” attempt not identical, to those for forceps de- at vaginal delivery. These perceptions livery (TABLE 2).2,3 The most important need to be addressed in discussions with determinant for either device is the ex- the patient. 76 OBG MANAGEMENT • June 2007 The risk–benefi t equation TABLE 3 Vacuum extraction lessens the risk of Vacuum extraction can injure the fetus maternal lacerations, either of the lower genital tract in the case of obstetric for- DIRECT INJURY ceps, or of the cervix and lower uterine Cephalhematoma segment in the case of cesarean section. Intracranial hemorrhage (parenchymal, subdural, intraventricular, subarachnoid) In addition, vacuum extraction can be performed comfortably in the absence of Nerve injury regional anesthesia. Scalp laceration, abrasion, ecchymoses, necrosis Skull fracture Avoiding cesarean section can produce multiple benefi ts Subgaleal hemorrhage Another maternal benefi t of vacuum ex- INDIRECT INJURY traction is the decreased need for cesarean Anemia, hyperbilirubinemia section. A reduction in the primary cesar- ean rate also lowers the need for repeat ce- Brachial plexus injury sarean section, which can be more techni- Scalp infection or abscess cally challenging than primary C-section SOURCE: O’Grady et al31 due to the presence of dense scar tissue and intra-abdominal adhesions.
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