Vacuum extraction / Forceps
        Main and The Obgyn Clinic of Hvidovre (danish)
        The use of forceps increases the risk of perineal, vaginal laceration and sphincter rupture.

        Operative delivery (10-15%) can be decreased by continuous support during upright or lateral position and avoiding epidural analgecia.

        Oxytocin in primiparus women with epidudral anaesthesia starting in the second state of labour can reduce the need for vaginal operative delivery. Operative intervention can be reduced if pushing is delayed 1-2 hours until the woman have a strong urge to push.

        There is an insufficient evidens to support the hypotesis that discontinuing epudiral analgecia reduce the incidens of operative vaginal delivery.

        Indication:
          Prolonged second stage of labour
        • Primigravidas: More than 3 hours with a regional anesthetic or more than 2 hours without a regional anesthetic.
        • Multiparas: More than 2 hours with a regional anesthetist or more than 1 hour without a regional anesthetic.
          ** if there is no maternal or fetal distress and the patient is not pushing during the whole second stage, the definition of prolonged second stage should be liberally extended.

          Maternal exhaustion
          Fetal distress
          Contraindications to maternal expulsive efforts:
          cardiac disease, previous retinal detachment, maternal vascular intracranial pathology - (increased intracranial pressure is hazardous i.e. severe preeclampsia).

        Special Indication:
          Cord prolapse with fully dilated cervix and the baby would appear to be delivered easily.
          For forceps
          Face presentation Aftercoming head (Kjelland or Piper) For vacuum
          Fetal distress in case of multiparas with almost fully dilated cervix (> 8 cm)

          Twin B, fetal distress when the head is still high

        What instrument should be used:
          Vacuum extraction more likely to fail to give cephalohaematona and retinal haemorrhage. Vacuum less likely to give maternal perinal and vaginal trauma. A five year follow-up did not show any significant different in the long term outcome for either mothers and infants whether the infant was delivered by operational vaginal delivery or Caesarean section.
          Vacuum followed by forceps increase the risk for neonatal trauma.

        Contraindications:
          Gestational age of < 34 weeks
          Suspected bleeding disturbances on the infants

        Conditions:
          Vacuum:
          cervix fully dilated and membranes ruptured Caput + 1, NOT PALPABLE OVER THE SYMPHYSIS extended caput succedeaneum often mistaken as caput is more distended than is actually the case.
          Check adequacy of the pelvis (contour of sacrum, prominence of the spine, the sub-pubic angle)
          Outlet forceps:
          Cervix should be fully dilated and caput at least at or on the perineum.
          Rotation does not exceed 45% the pelvic floor.
          Low forceps should be performed by an experienced operator. Skull is at station = +2 and not on the pelvic ± rotation.
          Mid forceps: (Vacuum is often preferable) the station is above 2 cm but head is engaged.

        Place of Instrumental Delivery
        If in doubt, vaginal delivery is feasible or potential fetal distress, vacuum/forceps should be performed in the operating room.

        Application of the Cup:
          In the midline towards the fetal occiput, 3 cm from anterior fontanelle in occiput posterior under symphysis and in other presentation place the cup posteriorly.

          Applied vacuum 0.2 kg/cm = (180 mmHg and insure there is no interposition tissue). The cup can thereafter be increased to 0.8 kg/cm (600 mmHG). The same should occur in the first contraction permit no more than 3(-5) contractions with uterine contractions (20 minutes or 2 episodes of breaking of suction any trial of vacuum).

          There is little evidence of increased maternal and neonatal morbibidity following failed vaginal delivery compared with immediate Caesarean section.

          This rule can be broken if slow delivery is performed to protect the perineum. If no fetal distress, vacuum can be discharged and the woman can deliver the head by pushing the head alone.

        References:
        (1) Johansen, RB. A randomised prospective study comparing the new vacuum extractor policy with forceps delivery. Br J Obstet Gynaecol. 1993 Jun;100(6):524-30.

        (2) Operative Vaginal Delivery. RCOG Guideline No. 26, October 2005

        (3) Vacca A. Handbook of vacuum extraction in obstetric practice. ISBN 0-340-54849-5.

        (4) Vacuum extraction versus forceps for assisted vaginal delivery Cochrane Review.

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