Vacuum extraction of the fetus - extraction of a live fetus during childbirth using a special apparatus - a vacuum extractor, the cup of which is attached to the presenting part of the fetus (head) due to air rarefaction. Attempts during vacuum extraction of the fetus are not excluded.
In our country, vacuum extraction of the fetus is used in 0.12-0.2% of all births, and in recent times there is an increasingly rare use of it in connection with the expansion of indications for caesarean section in the interests of the fetus.
Indications
Indications for applying a vacuum extractor:
■ weakness of labor activity, not amenable to drug therapy;
■ low transverse position of the swept seam;
■ the onset of acute fetal hypoxia.
Conditions required for applying a vacuum extractor:
■ live fetus;
■ full disclosure of the uterine pharynx;
■ absence of a fetal bladder;
■ finding the fetal head in a wide or narrow part of the pelvic cavity;
■ correspondence between the size of the small pelvis and the head of the fetus;
■ exact knowledge topographic ratios in the small pelvis at the time of applying the vacuum extractor;
■ an empty bladder.
Contraindications
■ Dead fetus.
■ Incomplete opening of the uterine os.
■ Hydrocephalus, anencephaly.
■ Extension presentation and high straight standing of the sagittal suture.
■ Anatomically (II-III degree of narrowing) and clinically narrow pelvis.
■ Deeply premature fetus.
■ High location of the head (pressed, stands in a small or large segment at the entrance to the pelvis).
■ Maternal diseases that require the exclusion of attempts (preeclampsia, preeclampsia, eclampsia, hypertension, heart defects with decompensation, etc.).
Training
Before surgery, the bladder is emptied with an elastic catheter.
Inhalation and / in anesthesia are contraindicated, because. the woman in labor should push during extraction. For pain relief, especially in primiparas, bilateral novocaine anesthesia of the pudendal nerves is shown, which also helps to relax the muscles of the perineum. Immediately before the operation, a vaginal examination is performed to clarify the obstetric situation.
Intervention technique
With the right hand, under the control of the fingers of the left hand, a cup No. 5-7 is inserted into the vagina with the side side, depending on the capacity of the vagina and the height of the perineum. It is very important to correctly fix the cup on the fetal head. Attaching the calyx in the area of the small fontanelle contributes to the flexion of the head and the correct mechanism of childbirth. The location of the calyx on the border between the small and large fontanel promotes extension during traction. When fixing the cup on the side of the sagittal suture, an asynclic insertion of the head occurs.
After the cup is brought to the head, you need to make sure that the edges of the neck or the vaginal wall are not captured, then you should press the cup to the head and create a negative pressure of 520 mm Hg. Art. (0.7-0.8 kg/cm2). At the same time, under the cap of the calyx, a birth tumor (“hairpiece”) is formed on the head, due to which the calyx is held. Too much quick creation vacuum can cause the formation of cephalohematoma.
During traction, you can rotate the head in the right direction.
Before eruption of the parietal tubercles, a perineal dissection (median-lateral episiotomy) should be performed. When the parietal tubercles erupt, the calyx is separated from the head after the vacuum is eliminated. The head is then removed by hand. The duration of the operation should not exceed 15-20 minutes, because. the risk of bruising, the formation of cephalohematoma, and brain injury increases.
The inefficiency of vacuum extraction is observed in 1-27% of cases. After the operation of applying a vacuum extractor, especially if the operation was difficult, manual separation of the placenta and a control examination of the walls of the uterus to assess its integrity are indicated. In all cases, after vacuum extraction of the fetus, an examination of the cervix and vagina with the help of mirrors is shown, and if their integrity is violated, suturing is necessary.
Possible complications and their prevention
Complications during the operation of vacuum extraction can be observed both in the mother (ruptures of the perineum, vagina, small and large labia, clitoris, cervix and rarely - rupture of the lower segment of the uterus, bladder, symphysis), and in the fetus (abrasions and wounds on the head, cephalohematomas, intracranial hemorrhages, etc.).
To prevent bleeding in the afterbirth and early postpartum periods after vacuum extraction, the introduction of uterotonic agents is necessary:
Methylergometrine, 0.02% solution, i.v. 1 ml, once
Oxytocin IV drip 1 ml (5 U) in 500 ml of 5% dextrose solution or 0.9% sodium chloride solution, once.
Forecast
If this operation is performed correctly according to indications, taking into account contraindications, the prognosis is favorable.
IN AND. Kulakov, V.N. Serov
It was easy and without complications, and the baby was born healthy! But in reality, childbirth happens different situations which cannot be predicted in advance. Sometimes the second stage of childbirth, which is called straining, is delayed, and the baby still cannot be born. In some cases, there are signs that the child begins to suffer, not yet born. In such situations, operative aids in childbirth can help, one of which is the vacuum extraction of the fetus. Does this method negative consequences for newborns? Our today's article we fully devote to this topic.
Vacuum extraction of the fetus during childbirth is called surgery using a special device that helps to remove the baby from the birth canal by his head. This device is called a vacuum extractor. It consists of a manometer, an electric pump and a set of applicators (cups) on the head of the fetus.
The device itself was developed over 60 years ago. The principle of its operation is as follows: to create a negative pressure between the baby's head and the cup of the device superimposed on it in order to move the head along the birth canal to the exit.
What are the indications for the operation?
Vacuum extraction during childbirth is performed infrequently, because it requires strict indications. The most common indications are listed below:
- Weak labor activity in the laboring period (weak attempts), which is not amenable to the effects of drugs. As a result, the second stage of childbirth is delayed.
- The appearance of signs of the onset of acute hypoxia (lack of oxygen) of the baby in childbirth.
In order to be able to use a vacuum extractor in the pressing period, it is necessary that the uterine os be completely open, the fetus should be alive, and its head should already be in the pelvic cavity. In addition, the operation is performed with the active participation of the mother herself, because she needs to push at the moment when the doctor pulls up the baby's head with the help of a vacuum extractor. If a woman cannot push, then only the application of obstetric forceps can be used.
This benefit is not carried out in childbirth in those women who are contraindicated to push (in some cases, severe preeclampsia and a number of diseases). Such future mothers are shown planned or emergency C-section.
It is also impossible to perform an operation if there is a discrepancy between the size of the baby's head and the size of the mother's pelvis, in case of premature birth.
Another contraindication for vacuum extraction is the incorrect position of the fetal head, including when it is not pressed by the chin to the chest, but is in the extensor position.
Some nuances of the operation technique
After the doctors accompanying the woman during childbirth decide that it is necessary to help the baby to be born and use a vacuum extractor for this, it is necessary to once again conduct a vaginal examination and empty the bladder. Anesthesia is not required for a woman, she should feel good attempts. The only exceptions are those cases where epidural analgesia was performed in advance according to the available indications.
When conducting a vacuum extraction, a woman lies on her back with her legs wide apart, which are bent at the knees and hip joints, that is, just like with ordinary attempts. The doctor inserts a cup of a vacuum extractor into the vagina and fixes it in a certain place on the fetal head. Then, with the help of an electric pump, a negative pressure is created between the baby's head and the cup, the pressure value is monitored on the pressure gauge.
As soon as the pressure reaches the desired value, the doctor, holding on to the handle of the cup, pulls the child's head out. Mom is pushing at this moment, that is, the synchronism of the action of both the doctor and the mother is very important. The movement of the doctor's hand should be such that the head moves in the right direction along the bends of the birth canal. In the intervals between contractions, traction (sipping) of the head is not carried out.
After the parietal tubercles are born in the baby, the doctor carefully removes the cup of the apparatus from the head. Then the woman herself gives birth to the baby's head, the midwife or doctor helps her a little with her hands. The whole procedure is carried out very carefully to minimize the risk undesirable consequences vacuum extraction.
If during the procedure the cup slips off the baby's head, then it can be applied again, but only once. If the situation repeats or if there is no effect from the procedure, it is necessary to resort to applying forceps. Fortunately, this doesn't happen often.
It is laid down by nature in such a way that a child should be born on his own, without any benefits and outside help. Both doctors and mothers involuntarily think about whether vacuum extraction has a negative impact on the health of the baby? Yes, there are adverse effects of the procedure, but it is worth considering the following: firstly, the procedure is performed only according to strict indications, and secondly, the risk of an unfavorable outcome of childbirth without the use of vacuum extraction is sometimes much higher (when we are talking about acute fetal hypoxia in the second stage of labor).
We will talk with a neonatologist about whether babies who have undergone vacuum extraction in childbirth are born healthy.
Expert comment
- Ekaterina Vladimirovna, please tell us, does vacuum extraction during childbirth have any negative impact on the health of children? After all, initially doctors go for this operation in order to save the child's life and preserve his health?
In fact, the operation of vacuum extraction of the fetus during childbirth is used in situations where there is a threat to the life and health of the baby, it is too late to do a caesarean section, and the moment when obstetric forceps can be applied has not yet arrived. The state of health of children who were born by caesarean section, or at the birth of which the imposition of obstetric forceps was used, has been studied quite well. But there is very little data in the literature about the course of the neonatal period of babies who underwent vacuum extraction during childbirth. There is also no information about the health of these children (neurological outcome) in the future.
Six years ago, my colleagues and I conducted an analysis of the birth histories of children who underwent vacuum extraction during childbirth, and also tracked future fate» about a third of the babies examined at the first stage. The work was carried out on the basis of one of the maternity hospitals in the city of Arkhangelsk. At the first stage of work (maternity hospital), 100 histories of the development of newborns were studied. At the second stage (polyclinic), we were able to monitor in detail the health status of 35 babies up to one year of age.
- What can you say about the health of babies at the stage of the maternity hospital, based on the results of your work?
We received the following data:
Every second child who has undergone vacuum extraction during childbirth requires primary or resuscitation care immediately after birth. However, it cannot be said that this is the result of the vacuum extraction procedure itself. Still, the intervention was carried out to a greater extent in cases where there were signs of fetal hypoxia during childbirth, that is, the child was already suffering.
Various violations muscle tone and reflexes - this is the main neurological pathology of children, noted at the stage of the maternity hospital. So, at birth, about 90% of babies have impaired muscle tone, and 21% of children have impaired reflexes. By discharge, these figures become more positive: 75% and 5%, respectively.
More than half of newborns after vacuum extraction have hemorrhages of various localization and varying degrees of severity. These include hemorrhage under the periosteum of the bones of the skull (cephalohematoma), hemorrhages under the muscular helmet of the head, into the scalp and into the skin of the face.
- Ekaterina Vladimirovna, how many children who have undergone vacuum extraction in childbirth are discharged home?
Most of the children are discharged home from the maternity hospital, but 16% of children required transfer to the neonatal pathology department, 2% of babies - to the neonatal intensive care unit for further examination and treatment. Only a tenth of the babies discharged home do not have any diagnosis at discharge, that is, they went home practically healthy.
- Does the health of babies improve by the end of the first year of life according to your work?
Unfortunately, we were not able to follow all the children different reasons. Of the 100 children of the first stage, only 35 turned out to be at the second stage of the work. This is what we got: by their first birthday, most children who underwent vacuum extraction during childbirth are removed from the dispensary register of a neurologist and orthopedist. But three children out of 35 by the age of one were still registered with a neurologist with rather serious diagnoses.
- Thank you for the conversation!
Take the test This test is FOR WOMEN ONLY. How do you feel physically? Let's check this with a test proposed by Portuguese experts. It will help you determine your level of well-being.Vacuum extraction of the fetus is the extraction of the child from the birth canal using a vacuum apparatus. This procedure is used if the second stage of labor is delayed, the child does not move through the birth canal or is under stress.
The vacuum apparatus consists of cups of different diameters and a pump (electric or manual). The first vacuum devices were with metal cups, now they mainly use plastic or silicone, which are less traumatic for the fetus.
The calyx is placed on the fetal head and negative pressure is gradually created in the apparatus, then during the contraction movements are made to help the extraction of the fetus, while the woman in labor is straining.
Anesthesia is usually not used, since the active participation of the mother is necessary, but at the request of the mother, local anesthesia can be performed. Episiotomy (dissection of the perineum) with vacuum extraction is performed infrequently and mainly by primiparas.
Vacuum extraction is used under certain conditions: full opening of the cervix, absence of membranes, correct presentation of the fetus.
A similar vacuum extraction is the procedure for applying obstetric forceps. In principle, these interventions are interchangeable, but the vacuum is used more often, since not all doctors have the skills to use forceps. Cm." " ".
Indications for vacuum extraction of the fetus.
Vacuum fetal extraction is mainly used when it is necessary to urgently remove the baby. There are the following indications for vacuum extraction of the fetus.
Weakness of labor activity.
Fetal hypoxia, if an emergency caesarean section is not possible.
Endometritis in childbirth is an infection of the birth canal, accompanied by fever.
Preeclampsia of moderate and mild degree in the mother.
The presence of an extragenital pathology in the mother (cardiovascular, pulmonary and other diseases), which requires the exclusion or reduction of the period of attempts.
There is a vacuum extraction and contraindications.
Extension insertion of the head - frontal, facial, anterior head presentation. To apply the vacuum, the child must be at the entrance to the small pelvis with the back of the head (occipital presentation).
The discrepancy between the size of the pelvis and the size of the fetal head.
Complications of pregnancy, requiring the complete exclusion of attempts. During vacuum extraction, the woman in labor must push, so when the attempts are completely turned off, forceps are used.
Vacuum fetal extraction: implications for mother and child.
With vacuum extraction of the fetus, less often than with the application of forceps, there are injuries to the mother, but injuries to the child occur more often. The most common consequences of vacuum extraction for the mother are ruptures of the birth canal. Also, the use of vacuum increases the risk of postpartum infectious complications.
The consequences of vacuum extraction of the fetus for a child can be damage to the scalp, difficult birth of the shoulders, hemorrhages in the eyes, hyperbilirubinemia (increased bilirubin or jaundice).
A serious consequence of vacuum extraction is intracranial hemorrhage, but it is extremely rare. A higher likelihood of hemorrhage in premature babies, so they try not to use a vacuum in preterm birth.
After a vacuum, newborns often develop swelling on the head, which disappears within 48 hours and does no harm.
Often there is such an injury as cephalohematoma, in which a subcutaneous cavity filled with blood forms in the damaged area on the head. Small cephalohematomas go away on their own, in some cases medical intervention (puncture) is required.
Most of the damage in the child occurs when the cup of the device repeatedly slips off the fetal head, prolonged attempts to extract or apply excessive force during the procedure.
As for the long-term consequences, such as cerebral palsy, epilepsy, psychomotor retardation, the studies have not proven their connection with instrumental methods of delivery (vacuum, forceps). These diseases are more associated with fetal hypoxia and some pregnancy complications.
In principle, vacuum extraction of the fetus is safe enough for the mother and child, if carried out according to the indications, taking into account all the conditions and observing the execution technique.
In modern obstetrics, the need to ensure the safety of childbirth is increasing. Previously, obstetric forceps were widely used for this, now they have been replaced by a new procedure. Vacuum extraction of the fetus is a manipulation using a low-pressure (“suction”) device that is applied to the presenting part during childbirth. Its use helps with the development of weakness of the birth forces, prolonged labor and other obstetric pathologies, when the child cannot be born on his own.
It has been proven that, compared with obstetric forceps, vacuum extraction is easier, requires less anesthesia, is less traumatic for mother and child, and is safer. However, the use of this procedure is limited due to the growing number of indications for caesarean section, the constant development of new devices, the lack of reliable statistics and full-fledged clinical studies.
Preparation for the procedure
Vacuum extraction of the fetus can only be performed by a doctor experienced in such manipulation. The woman must sign a voluntary informed consent. If the intervention is planned in advance, the doctor should:
- explain the need for the procedure;
- discuss with the patient the risks and benefits of this method compared to caesarean section;
- answer all questions.
If the procedure becomes necessary only during childbirth, such explanations are given in an abbreviated form. Therefore, if it is possible to use manipulation, it is better to first familiarize yourself with its features.
- the fetal membranes opened, the waters receded;
- the head is inserted into the small pelvis;
- the neck is completely dilated;
- the bladder is emptied or catheterized.
If it is not known whether the head, buttocks or legs are present, in addition to obstetric research, this is easy to find out using ultrasound. In this case, the sensor is placed in the vagina or on the perineum and directly during the first stage of labor makes it possible to quickly and safely determine the presenting part, as well as to determine the features of attaching the vacuum extractor cup.
The procedure can be performed without anesthesia, however, epidural anesthesia is most often used (how it is performed, we).
Indications
Manipulation can be performed only if there are certain indications, in other cases, a caesarean section is preferable. There are no absolute conditions for its use. The most common indications are the following conditions:
- protracted;
- acute fetal hypoxia;
- the need to shorten the second stage of labor to preserve the health of the mother.
All these indications are relative, and under the same conditions, a caesarean section can be performed. Therefore, the decision on the method of delivery should be made by an experienced doctor.
Protracted second stage of labor
In this case, vacuum extraction is carried out according to relative indications. For nulliparous women, this condition is determined in the absence of the fetus moving through the birth canal for 4 hours with the use of epidural anesthesia and 3 hours without it. In patients giving birth, this time is reduced by 2 hours.
This increases the likelihood of postpartum hemorrhage, chorioamnionitis and perineal injury. The degree of risk of pathology for the newborn is less pronounced.
Carrying out the procedure
In women with rates approaching the above, active surveillance is used. If the birth process is still going on, and the baby's heartbeat does not suffer, stimulation with oxytocin can be used. With the exhaustion of the birth forces or violations of the child's condition, vacuum extraction or a caesarean section is indicated.
Acute fetal hypoxia
This condition requires immediate medical care(what is the danger of pathology, read). With prolapse of the umbilical cord, persistent slowing of the heartbeat, tight attachment or placenta accreta, this method is prohibited. In these situations, caesarean section is preferable.
However, even in severe cases, everything is decided depending on specific situation and experience of the doctor.
Maternal illnesses
Some diseases of a woman require a reduction in the period of attempts. These include heart, lung and brain diseases, pathology of the neuromuscular system, spinal cord, myopia and others.
Vacuum extraction in such cases is performed when the presenting part is lowered so that the procedure can be done quickly and safely.
Contraindications
Absolute contraindications:
- the lack of experience of the doctor;
- the inability to properly apply the vacuum extractor cup;
- lack of standard indications;
- unknown position or presentation;
- suspicion of a discrepancy between the size of the pelvis of the mother and the head of the fetus;
- breech, facial or frontal presentation;
- suspicion of blood diseases or bone demineralization in a child.
Relative contraindications:
- insufficient descent of the head;
- gestational diabetes;
- large fruit ().
Manipulation
To carry out the manipulation, a special apparatus is used - a vacuum extractor. It is a hard or soft plastic bowl in which a vacuum is created using a pump or a special hose, connected to a pull handle.
The safety and success of the method depend on the exact location of the cup over the center of the presenting part, the anatomy of the pelvis, the traction technique, and the design of the apparatus. After obtaining informed consent, the doctor inserts the cup into the birth canal and sets it correctly. The center should be at an imaginary point above the midline of the sagittal (median) cranial suture, approximately 6 cm from the anterior fontanelle and 3 cm from the posterior. The edges of the cup should be located at a distance of 3 cm from the anterior fontanel and at the edge of the back. Then low pressure (100-150 mmHg) is applied to check if maternal tissue has entered the bowl.
Kiwi Vacuum Extractor
After checking cup placement, the doctor creates a full vacuum (450-600 mmHg) and makes tractions (movements) simultaneously with uterine contractions. The direction of the pull changes as the fetal head passes through the birth canal. An attempt at traction without concomitant uterine contractions most often fails.
During the relaxation period between attempts and contractions, the vacuum can be maintained or reduced to 200 mm Hg. Art. Both of these methods are considered equally safe.
During traction, the doctor places the other hand into the vagina, positioning thumb on the cup, the rest - on the head of the fetus. This helps to correctly guide the baby through the birth canal and notice the detachment of the edges of the vacuum extractor in time. All movements should be smooth and not performed "through force", as this increases the risk of damage to the scalp. After removing the head, the pressure in the bowl is normalized and the vacuum extractor is removed. Not recommended. Prophylactic use of antibiotics is also not required.
Usually 2-3 stages of traction are used, and the entire vacuum extraction of the fetus takes about 15 minutes.
If the fetal head does not advance, the doctor’s efforts do not bring results, the cup repeatedly slips if it is correctly applied, it is necessary to interrupt the procedure and perform a caesarean section (types, methods of the operation are described).
Consequences for mother and child
Complications of vacuum extraction of the fetus cannot be considered in isolation, they must be compared in frequency and severity with other methods (obstetric forceps, caesarean section). Most often there is a birth injury, and the most severe complication is intracranial hemorrhage. This condition occurs extremely rarely, but in 20% of cases it is accompanied by a fatal outcome. Vacuum extraction can lead to the death of a child in 0.1-3 cases per 1000 procedures.
Possible negative consequences for the child:
- subcutaneous hemorrhage;
- damage to the scalp;
- paralysis of the facial nerve;
- retinal hemorrhage;
- skull fracture.
Vacuum extraction of the fetus does not lead to differences between children born in the usual way, or with the use of this manipulation. During the first 18 years of life, they have the same indicators of development, growth, speech, school performance and neurological condition.
The consequences for the mother are less serious than when using forceps or caesarean section. However, sometimes they still occur, the frequency of which is 5-30%, especially with injuries in previous births or an episiotomy performed before vacuum extraction.
Conclusion
Vacuum extraction of the fetus is an effective and safe method of assisting women in childbirth if it is used by an experienced doctor. After the birth of a child with the help of such manipulation, he is closely monitored so as not to miss signs of intracranial hemorrhage. For the mother, the main danger is perineal injury, which in the future can lead to dysfunction of the anal sphincter.
To reduce the risk of injury, it is necessary to reduce the number of stretches to 3-4 times, the number of accidental cup detachments to 2-3 times, total time procedures - up to 20 minutes. It is not recommended to use obstetric forceps after unsuccessful use of a vacuum extractor, in this case, a caesarean section is preferable. Finally, with any obstacles or difficulties, it is necessary to abandon such manipulation.
