If the procedure is unsuccessful, the resulting options include cesarean delivery and expectant management.
Tip. Use both hands during the pull to more reliably detect a problem with cup attachment, thereby minimizing the possibility of detachment and subsequent scalp trauma (FIGURE).
Delivery is facilitated by use of both hands Left hand allows operator to safely ascertain the descent of the fetal head as well as the attachment of the cup.
Key points of technique
Perform a careful and thorough pelvic examination to determine fetal station, position, attitude, and synclitism.
The optimal cup placement is 2- to 3-cm proximal to the posterior fontanel or, alternatively, 5- to 6-cm distal to the anterior fontanel, assuming the fetal head is properly flexed.4 The correct point of flexion will result in the smallest diameter of the fetal head presenting to the birth canal and should minimize the force necessary to achieve delivery.
Use minimal vacuum to attach the cup to the fetal head. As the subsequent contraction develops, apply full vacuum with the hand device. Encourage maternal expulsive effort and use traction only in concert with pushing efforts. Three pushes facilitated with pulling may be achieved during a single contraction. Failure to bring about descent with the initial pull indicates potential failure with this approach and, in the absence of technical reasons for the failure, merits serious consideration of abandoning the procedure (TABLE 3).
In the event of failed delivery with VE, it is important to recognize that you should not make a second attempt with another instrument; the chance of success is low and the risk of injury is significantly increased.5
Carefully document the decision for VE and its implementation
The medical record is the most important witness to the event. Clearly record the following items, preferably as close in time to the decision/event as possible:
- the indication for the procedure
- the antecedent labor course
- maternal anesthesia
- personnel present
- instruments employed
- position and station of the fetal head
- force and duration of traction
- nature of the attempt
- immediate condition of the neonate, and any resuscitative efforts.
Closing reminders and advice
In preparing to discuss the patient’s preferences for delivery, understand clearly the risks and benefits of VE and develop a comfortable approach to sharing this information with your patient and her family. Also, if VE is selected, consider performing the procedure in the cesarean delivery room. This will serve to remind you to be mindful to abandon the procedure, if need be, at an appropriate point.
CASE: Resolved
You apply the vacuum extractor, and a small amount of vacuum demonstrates satisfactory attachment. On the second pull, the fetus easily delivers, and the Apgar scores are 8 and 8. The birthweight is 3,725 g. The vacuum-assisted delivery has resulted in the shortest delay in delivery and without adverse consequences for neonate or mother.
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