<p>Vacuum Bundle Background and Information (As adapted from Dr. Peter Cherouny’s Lecture Series)</p><p>What causes birth trauma?</p><p>– Large fetuses</p><p>– Operative vaginal deliveries (esp midpelvic & combined); Vacuum Assisted deliveries</p><p>Forceps Deliveries</p><p>– Vaginal breech delivery</p><p>– Inappropriate use of pitocin</p><p>– Abnormal/excessive traction</p><p>– Inadequate assessment of fetal status</p><p>What are the risks of vacuum use?</p><p>To the baby:</p><p>– Scalp laceration: From 15-40% neonates have cosmetic scalp trauma, related to application time, related to improper placement (off midline), rare long term sequelae </p><p>– Retinal hemorrhage: Approx 38% of Vacuum instrumented infants, rare long term sequelae </p><p>– Cephalohematoma: 14-16% of Vacuum instrumented infants, hyperbilirubinemia likely results from blood products reabsorbed after cephalohematoma; most are benign.</p><p>– Subgaleal hemorrhage: 2.6-4.5% of Vacuum instrumented infants, may be associated with serious long term sequelae and/or death, possibly associated with technique</p><p>– Intracranial hemorrhage: May be associated with serious long term sequelae and/or death, possibly associated with technique.</p><p>– Hyperbilirubinemia: </p><p>Maternal trauma:</p><p>– Perineal injury</p><p>– Hematoma formation</p><p>– Possible association with pelvic floor injury</p><p>1 Summary:</p><p>– Serious complication of Vacuum device in approximately 5% of vacuum attempts</p><p>– Patients need to be aware of these risks</p><p>“Given the maternal and fetal risks associated with operative vaginal delivery, it is important that the patient be made aware of the potential complications of the proposed procedure”</p><p>Operative vaginal delivery. ACOG Technical Bulletin No. 17. June, 2000</p><p>Quality Care in Obstetrics Birth Trauma related to Vacuum Delivery</p><p>Effect of Delivery on Neonatal Injury</p><p>Method Death ICH Other* SVD 1/5,000 1/1,900 1/216 C/S labor 1/1,250 1/952 1/71 C/S after OVD 1/333 1/38 C/S no labor 1/1,250 1/2,040 1/105 VD alone 1/3,333 1/860 1/122 Forceps alone 1/2,000 1/664 1/76 Vacuum and forceps 1/1,666 1/280 1/58</p><p>*Facial nerve/brachial plexus injury, convulsions, central nervous system depression, mechanical ventilation</p><p>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;341:1709–1714 </p><p>How we cause birth trauma with the vacuum application</p><p>– Unnecessary procedure: Prolonged second stage alone is not an indication for immediate delivery, maternal exhaustion can be managed by maternal rest.</p><p>– High risk procedure: Low chance of success, “trial” of operative vacuum delivery, combination procedure with forceps, gestational age less than 34 weeks.</p><p>– Inadequate skill of provider: Provider need be credentialed in the procedure, provider must know the definitions of the different types of vacuum delivery, rocking movements should not be used.</p><p>2 – Unknown fetal parameters: Estimated fetal weight is critical to the procedural risks, station and position of the fetus must be known, resuscitation team not available.</p><p>– Prolonged application or multiple pop-offs: Cephalohematoma directly correlated with application time, multiple pop-offs are associated with CPD, fetal injury and failed procedure.</p><p>– No alternative delivery options available: Cesarean section not readily available, there is a 3-5% unsuccessful rate of delivery, fetal concern often arises during the procedure</p><p>Vacuum Bundle (5 Bundle Components, recommended 100% review) </p><p>1. Alternative labor strategies considered:</p><p>Including passive descent, resting between pushes, open glottis pushing, avoiding length of second stage parameters if Mom and infant reassuring.</p><p>2. Prepared patient</p><p>Informed consent discussed and documented</p><p>3. High probability of success</p><p>EFW, fetal position and station known</p><p>4. Maximum application time and number of pop-offs predetermined </p><p>Decided upon by the team and supported by manufacturing guidelines and ACOG/AWHONN consensus documents.</p><p>5. Exit strategy available </p><p>Cesarean and resuscitation team available</p><p>3</p>