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Vacuum Extraction Injury

The use of vacuum extractor devices has outpaced forceps in the belief that vacuum extraction deliveries are safer. While vacuum extractions are safer than forceps deliveries, they still have their complications. Soft cups have largely replaced firm metal cups because they are easier to use and result in fewer injuries to the foetal scalp. The biggest problem with the use of vacuum extractors is that they frequently detach when pulling on the devices so that sometimes little progress is made. They are used in cases of maternal stalling in the second phase of labour and with situations of a non-reassuring heart rate in the foetus.

The types of vacuum extractors include a metal cup variety, which is a mushroom shaped device with a centrally attached chain that connects to a detachable handle. The handle is used to apply traction and a peripherally applied vacuum connector connects the vacuum. There is a higher success rate with metal cups and it is more easily placed than soft cups. They do have a chance of causing increased scalp injuries in the foetus so they are not much used.

Soft cup extractors cause fewer injuries to the foetal scalp but they do have a higher failure rate. They often pop off the foetal scalp during traction. An electrical or manual pump can be used and monitored as to how much suction is being applied. These extractors can be disposable or washable. The cup is bell shaped or funnel-shaped. There is a newer mushroom-shaped device out there that incorporates the features of both a soft and metal cup.

A vacuum extractor is used whenever the second stage of labour has stalled out and when there is foetal distress during labour. An infant at 34 weeks or less is not a candidate for vacuum extraction due to having a soft skull with many open areas to the brain. Some doctors believe that vacuum extraction can be applied before complete cervical dilatation. As usual, the risks of using the vacuum extraction should be weighed against the advantages. The risks and benefits of other delivery procedures need to be done.

In the vacuum extraction procedure, the patient must empty her bladder and lie down in the dorsal lithotomy position. Anaesthesia is optional. The cup is inserted into the vagina and placed on the foetal scalp. Care must be obtained to avoid enclosing the cervix within the cup. The suction is applied to the acceptable levels and traction is applied in order to get the foetal head out. If the fetus is separated from the cup, the foetus should be examined for injury before an attempt is made to replace the cup. The cup is disengaged when the head is at the perineum.

There are maternal and foetal complications associated with having vacuum extraction. The maternal complications are the same, regardless of the type of vacuum extractor is used. In foetuses, there can be a subgaleal haemorrhage, which is a serious foetal complication. It happens in 1-3.8 percent of vacuum extractions. The scalp is boggy and there is swelling of the scalp that crosses the suture lines. The baby can develop pallor, hypovolemia, anaemia and tachycardia.

The other complication is a cephalhematoma. It occurs in an average of 6 percent of all deliveries assisted by vacuum procedure. Intracranial haemorrhage occurs in one out of every 850 vacuum deliveries, compared to happening in one out of 1900 deliveries unassisted with vacuum extraction. This, however, does not show any differences when compared to normal deliveries. Retinal haemorrhages are more common in vacuum deliveries but this may be because the deliveries are prolonged and retinal haemorrhages are associated with long labours. Caesarean sections after prolonged deliveries show the same rate of retinal haemorrhages.

There can be transient lateral rectus paralysis in the neonate in vacuum-assisted deliveries. This occurs about 3 percent of the time and is less often in forceps deliveries. The paralysis always goes away by itself so it is rarely of clinical significance. Vacuum procedures in delivery have not been found to affect the neurological or intellectual capabilities of the infant.

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