Controversies in the use of the vacuum extractor

The Association between the Number of Vacuum Pop-Offs and Adverse Neonatal Outcomes

OBJECTIVE

Obstetrical vacuum manufacturers have long recommended a maximum of two to three pop-offs be allowed before abandoning the procedure. However, there is a paucity of evidence on the safety of vacuum-assisted vaginal delivery in relation to the number of pop-offs to support this recommendation. Our objective was to examine whether the number of pop-offs in a vacuum-assisted vaginal delivery was associated with adverse neonatal outcomes.

STUDY DESIGN

This is a retrospective cohort study of women who underwent a trial of a vacuum-assisted vaginal delivery at a single tertiary care institution between October 2005 and June 2014. Maternal and fetal factors associated with the number of pop-offs were examined in bivariable analyses. Multivariable analyses were performed to determine the independent association of the number of pop-offs with adverse neonatal outcomes.

RESULTS

Of the 1,730 women who met inclusion criteria, 1,293 (74.7%) had no pop-offs, 240 (13.9%) had one pop-off, 128 (7.4%) had two pop-offs, and 69 (4.0%) had three or more pop-offs. Neonatal scalp/facial lacerations, intracranial hemorrhage, seizures, central nervous system depression, and neonatal intensive care unit admission were all associated with the number of pop-offs in bivariable analyses. In multivariable analyses, compared to no pop-offs, having any vacuum pop-offs was associated with an increased odds of adverse neonatal outcomes. However, there was not a consistent dose-response relationship.

CONCLUSION

While having vacuum pop-offs in a vacuum-assisted vaginal delivery was associated with an increased risk of adverse neonatal outcomes, there did not appear to be a dose-dependent association with the number of pop-offs.

KEY POINTS

· There are no specific guidelines on how many pop-offs can be allowed before abandoning a vacuum-assisted vaginal delivery.. · Having any vacuum pop-offs was associated with an increased risk of adverse neonatal outcomes.. · There was no dose-dependent association between number of pop-offs and adverse neonatal outcomes..

Duration of Operative Vaginal Delivery and Adverse Obstetric Outcomes

OBJECTIVE

This study aimed to evaluate whether the number of vacuum pop-offs, the number of forceps pulls, or the duration of operative vaginal delivery (OVD) is associated with adverse maternal and perinatal outcomes.

STUDY DESIGN

This is a secondary analysis of a multicenter observational cohort of women who underwent an attempted OVD. Women were stratified by the duration of OVD and the number of pop-offs (vacuum) or pulls (forceps) attempted. Severe perineal lacerations, failed OVD, and a composite adverse neonatal outcome were compared by the duration of OVD and number of pop-offs or pulls.

RESULTS

Of the 115,502 women in the primary cohort, 5,325 (4.6%) underwent an attempt at OVD: 3,594 (67.5%) with vacuum and 1,731 (32.5%) with forceps. After adjusting for potential confounders, an increasing number of pop-offs was associated with an increased odds of the composite adverse neonatal outcome. However, an increasing duration of vacuum exhibited a stronger association with the composite adverse neonatal outcome. Similarly, the number of forceps pulls was less strongly associated with the composite adverse neonatal outcome compared with the duration of forceps application.

CONCLUSION

The duration of OVD may be more associated with adverse neonatal outcomes than the number of pop-offs or pulls.

Early Blood Transfusion and Resolution of Disseminated Intravascular Coagulation Associated with Massive Subgaleal Hemorrhage

A male infant delivered to a primipara woman following vacuum applications. He was vigorous at birth, with small caput and scalp bruising. His head was enlarging; he became pale with respiratory distress. Subgaleal hemorrhage (SGH) was suspected. His hematocrit was noted to be 26.2 percent prior to transfusion of O, Rh-negative blood (40 mL/kg). Moderate disseminated intravascular coagulation (DIC) was noted at 12 hours of age. Posttransfusion of fresh frozen plasma (FFP), his condition became stable, and DIC gradually resolved. Head magnetic resonance imaging did not show intracranial hemorrhage. Although one episode of seizures was noted, electroencephalogram was normal. With the application of obstetric vacuum, we recommend that the neonatal health care professionals frequently evaluate the infant's condition. In light of developing fluctuant subgaleal fluid associated with pallor, anemia, metabolic acidosis, and respiratory distress, immediate blood transfusion is warranted. In the presence of DIC, transfusion of FFP is beneficial.

Late preterm gestation: physiology of labor and implications for delivery

The late preterm infant represents a significant portion of preterm deliveries. Historically, this cohort has been referred to as near-term, which may not address adequately the increased perinatal morbidity these neonates experience. The changing demographics of pregnant women also are increasing the number of inductions in this gestational age group. More women with chronic hypertension, diabetes, and other chronic medical problems are getting pregnant, and often these pregnancies may require induction during this gestational age. The increasing numbers of multi-fetal gestations also have an average gestational age at delivery in this range of 34 to 36.6 weeks. Preeclampsia is another factor that can lead to delivery and induction during this gestational age. This article discusses some of the physiologic causes behind late preterm deliveries.

Primary nonmedically indicated cesarean section ("section on request"): evidence based or modern vogue?

Cesarean section, initially described as an emergency operative procedure for delivering moribund parturients, is now advocated by many as a routine technique with major advantages over vagi-nal delivery. In fact, it has been suggested that labor and vaginal delivery are no longer the desired consequence of pregnancy, a conclusion that reflects perceived medical advantages and patient and physician convenience. This article systematically reviews the various medical implications to the mother and infant of this procedure in the hope of facilitating a more rational approach to this spreading and controversial phenomenon.