Ventouse

1. Introduction:
Ventouse is a vacuum device used to assist the delivery of a baby when the second stage of labour has not progressed adequately. It is an alternative to a forceps delivery and caesarean section. It cannot be used when the baby is in the breech position or for premature births. This technique is also called vacuum-assisted vaginal delivery or vacuum extraction (VE). The use of VE is generally very safe, but it can occasionally have negative effects on either the mother and the child.The ventouse (also known as a 'vacuum extractor') is a metal or rubber-type cup with tubing attached. The cup is applied to the crown of the baby's head, after which negative pressure (or a 'vacuum') is created, to enable the caregiver to 'pull' the baby down, as you 'push', for the baby to be born in the event of complications.

2. Types:
The different types of ventouse that are commonly used include:

2.1 Metal cup: This type of ventouse is made of metal, and can come as a large 'anterior
cup' and a smaller 'posterior cup'. Metal cups are associated with being more successful at delivering the baby when their head is higher in the birth canal, for more difficult births and where the baby's head is deflexed (head slightly extended rather than tucked in with chin on chest) or in aposterior position.A metal cup does not actually turn the baby as such (like forceps can), but the head will generally rotate on its own as it descends onto the woman's pelvic floor, in the same way as it would if the head descended unassisted. Metal cups are also capable of being used before the woman is fully dilated, and can be attempted if the baby is distressed, and the woman is more than 7 centimetres dilated. Metal cups produce what is called a 'chignon'. This is like a large swelling of the baby's scalp that mimics the shape of the ventouse cup. The formation of the chignon helps the cup to stay attached, and contributes to the higher success rates of the metal cups.It can cause the baby's head to be bruised (or possibly grazed) and tends to be made worse if the cup has slipped off during the procedure, and needs to be reapplied. The most common metal cups used over the years are the 'Bird's' and the 'Malmstrom' cups. These cups are attached to rubber or plastic tubing (to allow it to be attached to the suction so that the vacuum can be created), and also have a fine chain threaded up inside the tubing to attach to the cup. This allows the caregiver to apply more traction to be able to deliver the baby.

2.2 Semi-rigid cup: These cups are made from a type of flexible plastic and have gained
popularity because they are less likely to injure the baby's head, but are more successful than the soft cup. Their use would be similar to the metal cup. A commonly used semi-rigid ventouse is called the 'Mityvac' cup.

2.3 Soft cup: Soft cups are usually made of firm, but supple, rubber or silicone. They are
preferred for use when the baby's head is low in the woman's birth canal, and it is anticipated that the baby will come down relatively easily. Soft cups are associated with less injury to the baby's but are less likely to succeed if the baby's head is high or posterior and deflexed, because of the difficulty in being able to correctly apply them to the baby's crown, and the fact that they do not tend to create a 'chignon'. The soft cups tend to change shape, to follow the contour of the baby's head. This makes them more likely to slip off if the baby has a large

caput. The design also means that the degree of traction is significantly less, when compared to a metal cup. Soft cups appear to be associated with less trauma to the baby's head, but are less likely to achieve a vaginal delivery, especially with more difficult births. It is a bellshaped 6.5 cm diameter soft cup which is made of a firm but supple silastic material. Advantage: It produces symmetric, less cosmetically alarming caput succedaneum and less scalp abrasions. Disadvantage: It slips more than the metal cup but with less scalp injuries.

2.4 Malmstrom cup: A metal cup to its centre attached a metal chain passed through the
rubber tube. The other end of the chain is attached to a handle for traction.

2.5 Birds cup: The suction rubber tube is attached to the periphery of the cup while the
handle of traction is attached by a separate short metal chain to the centre of the cup.

3. Design:
3.1 Vacuum extraction instruments
Vacuum extraction (VE) instruments are constructed of varying materials including polyethylene or silastic plastic and stainless steel. Several features are found in all designs. These include the following: a) b) c) d) A mushroom-shaped vacuum cup of varying composition, diameter, and depth A fixed internal vacuum grid or guard within the vacuum cup A combined vacuum pump / handle or a vacuum port for a vacuum hose attachment A handle for traction

Rigid-cup designs include the classic Malmstrm stainless steel vacuum cup and the various modifications of this instrument introduced since the 1960s. New rigid plastic cup extractors mimic the Malmstrm device. These were originally designed for use with deflexed or posterior positioned heads but now are becoming popular for all types of deliveries.[25] A recent trend in VE design is to incorporate the vacuum pump within the handle, avoiding the need for a separate vacuum tube and for the assistance of a birth attendant in producing vacuum. Soft-cup extractors include numerous disposable polyethylene or combined polyethylenesilastic cup designs that differ in largely inconsequential and clinically unimportant ways. The vacuum extractor was introduced by Malmstrom in 1954 to assist delivery by the application of traction to a metal suction cup attached to the fetal scalp. It consists of : a) A specially designed suction cup, smaller at the rim than above, which holds the scalp tight against the base of the cup. There are 3 cup sizes available 40 mm, 50 mm, and 60 mm. b) A hose connecting the suction cup to a suction pump. c) Intervening trap bottle and manometer d) A chain inside the hose connecting the suction cup to a crossbar for traction.

Various modifications have been made to this design. Birds modification of the suction cup allows better traction, while at the same time doing away with the need to thread the chain through the hose. The metal cup may be replaced by a soft silicone rubber cup, which is easier to manipulate and causes fewer fetal scalp injuries. Hand-held vacuum pumps and mechanical pumps with built-in regulators have further enhanced the safety of the procedure.

3.2 Description:
Vacuum extractor is composed of: a) A specially designed cup with a diameter of 3, 4, 5 or 6 cm. b) A rubber tube attaching the cup to a glass bottle with a screw in between to release the negative pressure. A manometer fitted in the mouth of the glass bottle to declare the negative pressure. c) Another rubber tube connecting the bottle to a suction piece which may be manual or electronic creating a negative pressure that should not exceed - 0.8 kg per cm2.

3.3 Vacuum Extraction Technique:

Appropriate technique is important when the vacuum extraction (VE) is used. The safety and success of vacuum-conducted extraction operations depend on the following: a) The accuracy of the initial cup application (i.e., cup center over flexion or pivotpoint) b) Case choice c) The traction technique, including degree of effort (number of tractions), vector of traction, method of applied force d) The fetal cranial position (including deflection) and fetal station at the time of application e) The cup design f) The fetopelvic relationship If the prerequisites for VE operation are met, informed consent is obtained. Thereafter, the position, station, and attitude of the fetal head are verified by pelvic examination and an instrument is chosen. To correctly insert and position the cup, a specific protocol is followed. The woman is placed in the lithotomic position and assists throughout the process by pushing. A suction cup is placed onto the head of thebe by and the suction draws the skin from the scalp into the cup. Correct placement of the cup directly over the flexion point, about 3 cm anterior from the occipital (posterior) fontanels, is critical to the success of a VE. Ventouse devices have handles to allow for traction. When the baby's head is delivered, the device is detached, allowing the accoucheur and the mother to complete the delivery of the baby. For proper use of the Ventouse, the maternal cervix has to be fully diluted, the head engaged in the birth canal, and the head position known. If the Ventouse attempt fails, it may be necessary to deliver the infant by forceps or caesarean section.

3.4 Indications for use of Ventouse:

3.4.1 Prolonged second stage of labor
Clinical studies before the 1970s suggested that the risk of fetal morbidity and mortality was higher with a prolonged second stage of labor; however, studies involving almost 36,000 parturient found no direct relationship between the length of the second stage and infant mortality or morbidity. These data indicate that a prolonged second stage, according to American College of Obstetricians and Gynaecologists (ACOG) criteria, is not an indication for immediate operative intervention unless the maternal or fetal status becomes bothersome or progress ceases. Do not ignore tardy progress. Poor progress requires caution because cranial malpositioning, deflection, asymmetries, or true feto-pelvic disproportion could be present. The safety of an extended second stage depends upon close maternal or fetal monitoring, with judicious intervention as required. Therefore, an extended second stage is a relative, but not absolute, indication for obstetric intervention.

3.4.2 Shortening of the second stage of labor

On occasion, shortening the second stage of labor is appropriate. Maternal disorders (eg, cardiac, cerebrovascular, or neuromuscular conditions) in which voluntary expulsive efforts are contraindicated or impossible exist. Additional situations that may lead to intervention include the vastly over diagnosed condition of maternal exhaustion or the uncommon instances of overly dense epidural analgesia.

3.4.3 Presumed fetal jeopardy/fetal distress

While a potentially distressed infant is a classic indication for operative intervention, this is the setting in which extra caution is indicated. Operative heroics have no place in obstetric management. The means for diagnosis of presumed fetal jeopardy are imperfect, except in extreme instances such as fixed bradycardia or cord prolapsed. When prompt delivery is indicated, station and position of the fetal head, the feto-pelvic relationship, operator skill, and judgment of the degree of jeopardy dictate the mode of delivery. For most practitioners, cord prolapsed, abruption placenta, or persistent bradycardia at a high station, even at full dilation with an engaged head, are best managed by caesarean delivery. Nonetheless, expedited vaginal delivery using vacuum extraction (or forceps) is appropriate in carefully selected cases of rapidly progressing labor when pelvic adequacy is good, the parturient is willing and able to assist, and an experienced surgeon is present.

3.5 Ventouse delivery:

The ventouse is a round plastic or metal cap that attaches by suction to your baby's scalp. You'll have to put your legs in stirrups and then, once the Ventouse is in place, your obstetrician or midwife will pull on the handle attached to the Ventouse as you push through a contraction. Hopefully, this combined effort will help your baby be born. If your baby's born using a ventouse, it's likely they'll have an area of swelling on their head caused by a

build up of fluid, but this usually disappears within a day or so. Less commonly, they may have what's called a cephalhaematoma. It sounds terrifying, but it's essentially just a big blood blister, which will go away, although it can take several weeks. This bruising may make your baby jaundiced. There may also be some grazing, but this should also go within a few days. Ventouse is generally considered to be less painful and safer for women than forceps; plus, you may not require an episiotomy. But, if the Ventouse delivery fails, your doctor may decide to try again using forceps.

3.6 Vacuum Extraction versus Forceps :

Forceps operations have become less popular, and vacuum extraction (VE) procedures are more common in recent years. There is long-term debate concerning when assisted delivery is appropriate and which instrument (vacuum extractor or forceps), is best. Although the instruments are largely interchangeable for most applications there are factors favoring the use of one instrument over the other. Important factors include the following: 1. Anaesthesia: In general, low or outlet vacuum extraction (VE) operations are less uncomfortable for the mother than a forceps procedure from the same station. The metaanalysis reported by Johanson observed a significant reduction in the requirement for anaesthesia with VE operations in comparison with forceps deliveries. With a willing parturient, an uncomplicated VE can occasionally be performed with either a local, pudenda, or no anaesthetic. 2. Instrument failure: VE operations are more likely to fail than forceps procedures. The relative risk of failure with VE versus forceps operations is 1.69 (95% CI 1.31 to 2.19). The higher VE failure rate reflects a number of factors: poor instrument applications, incorrect vector of force in traction efforts, improper methods of applying traction, fetal malpositioning, poor choice of cases, and operator inexperience as well as the intrinsic inability of the vacuum extractor to exert as much force to the fetal head as forceps. The higher failure rate for VE operations is of concern in light of recent data regarding the risks of sequential instrument use when the application of forceps may follow a VE failure. In general, as mentioned above, infants from sequential instrument deliveries have worse outcomes than those delivered either by a caesarean delivery or by a vaginal procedure that was successful on the first attempt. 3. Maternal injury: Any instrumental delivery is associated with an increased risk of perineal/rectal injury versus the incidence of these complications following either a spontaneous or a caesarean delivery. A consistent finding is an increased incidence of perineal tears following forceps as opposed to VE deliveries 4. Fatal fetal injury: A study reported by Towner and coworkers collected mode of delivery and birth injury data from several large populations. The report by Demissie and coworkers includes information from total United States births for 1995-8 (n= 11,939,388) as well as data from New Jersey (375,351). These large numbers permit statistical evaluation of mortality information as most other studies have too restricted numbers due to the low incidence of fatal injury. These data indicate that delivery by VE is least as safe as forceps delivery with fatal complications in both cohorts statistically similar. Other fetal injuries include the following: Facial nerve (VII) palsies are more common following forceps operations (4.5 per 1,000) than VE procedures (0.46 per 1,000). However, these injuries are uncommon, virtually always transitory and thus not of great clinical import.

In the Towner series, infants delivered by VE had a significantly higher rate of intracranial haemorrhage (ICH) (including subdural and other cerebral bleeds), brachial plexus injuries, convulsions, and central nervous system depression versus infants delivered spontaneously. VE neonates are also more likely to need mechanical ventilation after delivery than spontaneously delivered infants. However, in the Towner report, which included 584,340 total deliveries, no significant differences were reported in the risk for the more severe neonatal injuries, including ICH, between infants delivered by caesarean delivery during labor (0.25 per 1,000) and infants delivered by either VE (0.15 per 1,000) or forceps (0.26 per 1,000) alone.

Table. Incidence of Fetal Intracranial Haemorrhage (n=584,340)

Mode of Delivery Caesarean delivery with no labor

Incidence of ICH 1 per 2,750

Spontaneous vaginal delivery

1 per 1,900

Caesarean delivery during labor

1 per 907*

Vacuum-assisted vaginal delivery

1 per 860*

Forceps-assisted vaginal delivery

1 per 664*

Caesarean delivery after failed vacuum or forcepsassisted delivery *Differences not statistically significant

1 per 334

3.7 Positive aspects:

a. b. c. d. An episiotomy may not be required. The mother still takes an active role in the birth. No special anaesthesia is required. The force applied to the baby can be less than that of a forceps delivery, and leaves no marks on the face. e. There is less potential for maternal trauma compared to forceps and caesarean section.

3.8 Negative Aspects:

a. The baby will be left with a temporary lump on its head, known as a chignon. b. There is a possibility of cephalhaematoma formation, or subgaleal haemorrhage.

3.9 Complications of Vacuum Extraction or Ventouse

Complications usually occur due to improper use of the Ventouse, such as use in circumstances where it is contraindicated, incorrect application, use of excessive negative pressure, overlong application of the suction cup on the fetal scalp, and not taking care to avoid cervical or vaginal tissue from entering the cup. 3.9.1 Maternal Complications Maternal trauma and other complications are less common and may be less severe with Ventouse than with forceps delivery. Maternal complications may include a. b. c. d. e. f. g. Perineal pain during delivery. Perineal injuries. Hematomas. Postpartum haemorrhage. Pain in the immediate postpartum period. Urinary retention. Urinary and fecal incontinence.

3.9.2 Fetal Complications Fetal complications may include: a. Chignon or caput formation on the scalp, which looks like a lump, and usually resolves in 2 to 3 days. b. Scalp bruising. c. Subgaleal hematoma bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis causing a boggy mass to develop over the scalp. d. Intracranial haemorrhage.

e. Cephalhaematoma. f. Increased chance of retinal haemorrhage. g. Skull fracture.

4. Conclusion:
The vacuum extractor is an effective and safe device for assisted vaginal delivery and an important addition to the obstetrical armamentarium. Treat this instrument with respect in order to maximize the possibilities of its success while limiting the risks of maternal and fetal injury. The following conclusions are derived from an analysis of the literature, as interpreted by the authors. The level of recommendations follows that prompted by the ACOG and is based on the highest level of evidence found in the data. The level of recommendation that follows each statement parallels that promoted by the ACOG and is based on the highest level of evidence found in the data. Recommendations are graded according to the following categories:

consistent scientific evidence. Level B: Recommendations are based on limited or inconsistent scientific evidence. Level C: Recommendations are based primarily on consensus and expert opinion. Recommendation type A: Serious fetal injuries, while possible with either the VE or forceps, are rare. Recommendation type B: Intracranial haemorrhage may result from the events of labor, leading to the dystopia requiring operative intervention rather than being due to the instrument assisting delivery. This assumes medically appropriate use of the instrument. A second stage of labor that is considered prolonged by standard criteria alone is no longer an absolute indication for immediate operative delivery. The small but real risk for SG haemorrhage following extraction operations emphasizes the absolute requirement for a cautious approach to VE operations and involvement of the paediatrician to assure appropriate postoperative observation of suspect cases. Perineal trauma has the potential to injure pelvic nerves or facial support or disrupt the anal sphincter, resulting in permanent pelvic floor dysfunction; however, the implications of maternal birth canal injuries from spontaneous and instrumentally assisted deliveries remain unsettled. These data, while incomplete, prompt care in all deliveries and special caution in instrumental deliveries to limit the performance of episiotomy and to avoid

perineal injury when possible. The likelihood of serious infant injury probably is increased when either the forceps or a vacuum extractor is attempted following a failed operation with the alternative instrument. Sequential instrument use is restricted to selected cases conducted by highly experienced surgeons only.
Recommendation type C: Trials of instrumental delivery following an adequate trial of labor continue to have a place in clinical practice. However, these trials are appropriate only in the hands of the experienced, in situations when the possibility of success is believed to be high, and only when concomitant preparations for a possible cesarean delivery are underway.