Today, we take a look at an option that is offered to families as an alternative to a cesarean. While at first read, it may not be something you are willing to consider, once you are in the situation, using a forceps or a vacuum may be something you will be grateful you read up on when all things were calm.
One must weigh the benefits and the risks of these instrument deliveries with the benefit of a vaginal birth. Once you choose a cesarean birth, your future birth choices are going to be restricted by various players: your own beliefs, your care provider, and your birth place.
Definitions: Forceps/Vacuum Extraction
The two blades of the forceps are individually inserted, the posterior blade first, then locked. The position on the baby's head is checked. The fetal head is then rotated to the occiput anterior position if it is not already in that position. An episiotomy may be performed if necessary. The baby is then delivered with gentle (maximum 30 lbf Newton) traction in the axis of the pelvis.
The cervix must be fully dilated and retracted and the membranes ruptured. The urinary bladder should be empty, perhaps with the use of a catheter. The woman is placed on her back, usually with the aid of stirrups or assistants to support her legs. A mild local or general anesthetic is administered (unless an epidural anesthesia has been given) for adequate pain control. Ascertaining the precise position of the fetal head is paramount, and though historically was accomplished by feeling the fetal skull suture lines and fontanelles, in the modern era, confirmation with ultrasound is essentially mandatory.
The accepted clinical standard classification system for forceps deliveries according to station and rotation was developed by ACOG and consists of:
• Outlet forceps delivery, where the forceps are applied when the fetal head has reached the perineal floor and its scalp is visible between contractions. This type of assisted delivery is performed only when the fetal head is in a straight forward or backward vertex position or in slight rotation (less than 45 degrees to the right or left) from one of these positions.
• Low forceps delivery, when the baby's head is at +2 station or lower. There is no restriction on rotation for this type of delivery.
• Midforceps delivery, when the baby's head is above +2 station. There must be head engagement before it can be carried out.
High forceps delivery is not performed in modern obstetrics practice. It would be a forceps-assisted vaginal delivery performed when the baby's head is not yet engaged.
Vacuum Extraction (VE) aka Ventouse
The woman is placed in the lithotomy position and assists throughout the process by pushing. A suction cup is placed onto the head of the baby 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) fontanelle, 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 dilated, the head engaged in the birth canal, and the head position known.
In recent decades, the VE has progressively replaced forceps as the instrument of choice for many practitioners.
Why was it developed? What was it supposed to treat? Has it been effective: as in, has the incidence decreased because of the intervention/procedure/test?
Egyptian, Greek, Roman, and Persian writings and pictures refer to forceps that were originally used for extraction following fetal demise to save the mother’s life.
The credit for the invention of the precursor of the modern forceps to be used on live infants goes to Peter Chamberlen of England (circa 1600) though. Modifications have
led to more than 700 different types and shapes of forceps. In 1745, William Smellie described the accurate application to the occiput, rather than the previously performed pelvic application, regardless of the position of the head. In 1845, Sir James Simpson developed a forceps that was designed to appropriately fit both cephalic curvatures and pelvic curvatures. In 1920, Joseph DeLee further modified that instrument and advocated the prophylactic forceps delivery. In an era in which many women labored and delivered under heavy sedation, forceps deliveries became common.
Typically, forceps are used when a singleton fetus in the cephalic position fails to progress or when delivery needs to be expedited in the second stage of labour because of fetal distress.
Forceps had a profound influence on obstetrics, as it allowed for the speedy delivery of the baby in cases of difficult or obstructed labor. Over the course of the 19th Century, many practitioners attempted to redesign the forceps, so much so that the Royal College of Obstetrics and Gynecologists' collection has several hundred examples.
In the last decades, however, with the ability to perform a cesarean section relatively safely, and the introduction of the ventouse or vacuum extractor, the use of forceps and training in the technique of its use has sharply declined.
Ventouse/Vacuum Extraction (VE)
VE has a long history. The initial applications of vacuum techniques in deliveries began in the 18th century, derived from the ancient technique of cupping. However, designing a vacuum-based instrument for obstetric use proved difficult. A successful extraction required the development of techniques for the transvaginal application of a cup to the fetal head (and occasionally, in premodern times, the buttocks) as a means to apply traction, and the ability to periodically reinforce the vacuum due to inevitable imperfections of the seal.
James Young Simpson, the Edinburgh professor of obstetrics already famous for his forceps design, introduced the first successful obstetric VE in 1849. His "air tractor" was most likely derived from breast pump and consisted of a metal syringe attached to a soft rubber cup. The device was placed against the fetal head, the syringe was evacuated, and traction was then applied to the neck at the base of the cup and the infant extracted. This device did prove marginally successful, but technical problems existed, illustrating the difficulties facing the inventors of such devices.
VE has gained popularity as it is seemingly easy to use, requires less anesthesia/analgesia, has lower maternal morbidity, and is commonly believed to be safe. Less fortunately, the importance of correct VE technique and of the potential risks of the procedure are less well recognized. Large differences are observed in the popularity of instrumental delivery and of the specific type of instrument used in varying parts of the United States. This reflects the biases introduced by original training, the inherent conservatism of practitioners in embracing different techniques, and the absence of fixed guidelines for instrumentation.
- Evidence suggests that forceps are associated with less failure than vacuum extraction (table).
- The American College of Obstetrics and Gynecology has recommended training in instrumental delivery to control and reduce the rates of caesarean section.
- Delivery by forceps is also quicker than by vacuum extraction, which may be of critical importance with fetal distress.
- Women who have instrumental vaginal deliveries typically have a shorter hospital stay and fewer readmissions than women who have caesarean sections.
- A Cochrane meta-analysis found that women who experienced vaginal delivery were less anxious about their babies and more satisfied with the birth than women who had a caesarean section. Women who had a vaginal delivery were also more likely to breast feed, have more positive reactions to their infants immediately after birth, and interact with them more at home.
In the immediate post partum period forceps have been associated with increased perineal and vaginal trauma and a greater requirement for analgesia compared with vacuum extractors.
These findings were confirmed by another study, which also found that cervical laceration, post partum infection and other complications, and prolonged hospital stay were more common in women who had forceps delivery compared with those who had vacuum assisted delivery.
- Pain in the perineum — the tissue between your vagina and your anus — after delivery
- Lower genital tract tears and wounds
- Difficulty urinating or emptying the bladder
- Short-term or long-term urinary or fecal incontinence
- Anemia — a condition in which you don't have enough healthy red blood cells to carry adequate oxygen to your tissues — due to blood loss during delivery
- Injuries to the bladder or urethra — the tube that connects the bladder to the outside of the body
- Uterine rupture — when the baby breaks through the wall of the uterus into the mother's abdominal cavity
- Weakening of the muscles and ligaments supporting your pelvic organs, causing pelvic organs to slip out of place (pelvic organ prolapse). While most of these risks are also associated vaginal deliveries in general, they're more likely with a forceps delivery.
Vacuum Extraction (VE)/Ventouse PROS
- Easier to learn / Ease of Placement (easier to place than forceps)
- Less maternal genital trauma
- Fewer neonatal craniofacial injuries
- Some investigators have suggested that vacuum-assisted vaginal delivery results in less bowel incontinence compared to forceps delivery; most likely, this is due to potential for more vaginal trauma with forceps. The forceps-assisted vaginal delivery is more likely to result in vaginal tears that partially involve or even completely transect the anal sphincter and rectal lining. This type of injury is referred to as a fourth-degree laceration and can be associated with long-term anal sphincter dysfunction, resulting in occasional leakage of stool or gas.
- Vacuum extraction exposes the baby to less traction in comparison to forceps delivery. One study found that vacuum extraction exerted approximately 40% less force to the baby's head than forceps delivery. Although vacuum delivery may be associated with development of a bruise on top of the baby's head, the forceps may cause similar injuries and may result in more serious nerve or skull injuries.
Vacuum Extraction (VE) / Ventouse CONS
- When the second stage of labor has been prolonged, it is common to find that the baby's head has a significant amount of swelling at the presenting point. Although this is a normal part of labor, if the swelling is significant, it may be difficult to obtain an optimal application of the cup against the baby's head and the cup may become detached. Improper placement of the vacuum cup may also result in detachment.
- Vacuum traction should be applied only during contractions; therefore, vacuum-assisted vaginal delivery may be slower than forceps delivery. Forceps delivery may be performed with very little maternal effort, while vacuum-assisted delivery requires maternal participation.
- Several large trials comparing the success of forceps delivery with that of vacuum-assisted delivery confirmed that forceps are more often successful in delivering the baby.
- It has been well documented that the risk of serious bleeding inside the baby's skull is greater with vacuum than forceps. Due to the pressure of the suction cup applied to the baby's head, a particular type of serious bleeding, though rare, is more common with and unique to vacuum delivery
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