Massive subaponeurotic haemorrhage in infants born by vacuum extraction

The role of sonographic head circumference in the occurrence of subgaleal hemorrhage following vacuum delivery

OBJECTIVE

Subgaleal hemorrhage (SGH) is a severe neonatal morbidity that is associated with vacuum-assisted delivery (VAD). Large sonographic head circumference (sHC) was previously associated with complicated VAD. Nevertheless, the association of large sHC with SGH formation following VAD is underreported. We aim to evaluate the role of sonographic head circumference (sHC) with SGH formation following attempted VAD.

METHODS

A retrospective case-control study. Cases comprised singleton pregnancies for whom attempted VAD resulted in SGH with an sHC measured within 2 weeks from delivery. Controls were VAD deliveries which not resulted in SGH, with an sHC measured within 2 weeks from delivery. We matched controls in a 1:1 ratio by gestational age, parity and year of delivery.

RESULTS

Overall, 118 women were included in the SGH study group and were matched to 118 controls. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birth weight in the SGH group (median 3422 vs. 3195 grams, p = .001). sHC did not vary between groups (median 336 mm in SGH groups vs. 333, p = .08). Rate of sHC >90th and >95th percentile did not significantly differ between the groups (13.6% vs. 8.5%, 6.8% vs. 3.4%, p = .21, p = .37, for SGH vs. controls, respectively). In multivariate regression analysis, sHC was not found to be independently associated with SGH - aOR (95% CI) 1.004 (0.97-1.03). Receiver operating characteristic curves of sHC for SGH formation underlined an area under the curve of 0.58 (95% CI) (0.51-0.65).

CONCLUSIONS

sHC is not associated with SGH formation following VAD.

Neonatal subgaleal hemorrhage unrelated to assisted vaginal delivery: clinical course and outcomes

PURPOSE

The purpose of the study was to evaluate the occurrence of subgaleal hemorrhage (SGH) following non-assisted vaginal delivery (normal vaginal delivery or cesarean delivery), and to characterize associated factors, clinical course, and outcomes, compared to attempted assisted vaginal delivery (AVD)-associated SGH METHODS: A retrospective cohort study was conducted. All cases of SGH encountered following delivery of a singleton neonate at Hadassah, Hebrew University Medical Center during 2011-2018 were included. Maternal, fetal, intrapartum, and neonatal characteristics and outcomes were compared between AVD-related and non-AVD-related SGH groups.

RESULTS

The overall incidence of SGH was 4.5/1000 (369/82,256) singleton deliveries. The incidences of AVD- and non-AVD-related SGH were 44.6/1000 (350/7852) and 0.3/1000 (19/74,404) singleton deliveries, respectively. Ten (53%) of the 19 non-AVD-related SGH were diagnosed after vaginal delivery and 9 (47%) after an urgent cesarean section. SGH severity was mild, moderate, and severe in 68%, 16%, and 16% of the cases, respectively. SGH severity did not differ between the attempted AVD group and the non-AVD-related SGH group. A higher proportion of neonates with non-AVD SGH required phototherapy treatment than did those diagnosed with AVD-related SGH (56% vs. 24%, P = 0.003). Other neonatal outcomes, including Apgar scores, maximal bilirubin level, length of stay, and the rate of composite adverse outcomes, did not differ between the groups.

CONCLUSIONS

SGH, although rare, may be diagnosed after unassisted vaginal or cesarean delivery in the absence of an AVD attempt. We advocate continuing education for all medical staff who participate in peripartum and neonatal care, regarding the possible occurrence of non-AVD-related SGH.

Encephalopathy in neonates with subgaleal hemorrhage is a key predictor of outcome

BACKGROUND

Subgaleal hemorrhage (SGH) is reported to be associated with severe hemodynamic instability, coagulopathy, and even mortality. The importance of the presence or absence of neonatal encephalopathy in predicting SGH outcomes has not been explored. The aim of this study was to determine the relationship of clinical encephalopathy to short-term outcomes in neonates with SGH.

METHODS

Neonates ≥35 weeks gestation, diagnosed radiologically with SGH between 2010 and 2017, were included. Cases were divided into encephalopathic and non-encephalopathic. Demographic, clinical, and outcome data were compared between groups.

RESULTS

Of 54,048 live births, 56 had SGH, of them 13 (23%) had encephalopathy. When compared to the non-encephalopathic neonates, encephalopathic neonates had lower Apgar scores, lower hemoglobin, lower platelet count, longer neonatal intensive care unit stay, two (15%) deaths, and four (31%) required blood transfusion. No non-encephalopathic infant with SGH died or required blood transfusion. Notably, on magnetic resonance imaging (MRI), a majority of subgaleal collections had either no or minimal blood products.

CONCLUSIONS

In the absence of encephalopathy, SGH is not associated with adverse short-term outcome. Neurological assessment is likely to identify infants at higher risk for adverse outcome. The absence of MRI signal consistent with blood in subgaleal collection warrants further research.

Risk factors associated with subgaleal hemorrhage in neonates exposed to vacuum extraction

INTRODUCTION

Subgaleal hemorrhage (SGH) is a life-threatening neonatal condition that is strongly associated with vacuum assisted delivery (VAD). The factors associated with the development of SGH following VAD are not well-established. We aimed to evaluate the factors associated with the development of SGH following attempted VAD.

MATERIAL AND METHODS

A retrospective case-control study of women who delivered at a tertiary university-affiliated medical center in Jerusalem, Israel, during 2009-2018. Cases comprised all parturients with singleton pregnancies for whom attempted VAD resulted in neonatal SGH. A control group of VAD attempts was established by matching one-to-one according to gestational age at delivery, parity and year of delivery. Fetal, intrapartum and vacuum procedure characteristics were compared between the groups.

RESULTS

In all, 313 (89.5%) of the 350 attempted VAD were nulliparous. Baseline maternal and fetal characteristics were similar between the groups except for higher neonatal birthweight in the SGH group. In multivariate logistic regression analysis, only six independent risk factors were significantly associated with the development of SGH: second-stage duration (for each 30-minute increase, adjusted odds ratio [OR] 1.13; 95% confidence intervals [CI] 1.04-1.25; P = .006), presence of meconium-stained amniotic fluid (adjusted OR 2.61; 95% CI 1.52-4.48; P = .001), presence of caput succedaneum (adjusted OR 1.79; 95% CI 1.11-2.88; P = .01), duration of VAD (for each 3-minute increase, adjusted OR 2.04; 95% CI 1.72, 2.38; P < .001), number of dislodgments (adjusted OR 2.38; 95% CI 1.66-3.44; P < .001), and fetal head station (adjusted OR 3.57; 95% CI 1.42-8.33; P = .006). Receiver operating characteristic curves showed that VAD duration of ≥15 minutes had a 96.7% sensitivity and 75.0% specificity in predicting SGH formation, with an area under the curve equal to .849.

CONCLUSIONS

Vacuum duration, the number of dislodgments, the duration of second stage of delivery, fetal head station, the presence of caput succedaneum and the presence of meconium were found to be independently associated with SGH formation.

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.

Subgaleal haemorrhage in the newborn: A call for early diagnosis and aggressive management

Subgaleal haemorrhage (SGH) is an important cause of preventable morbidity and mortality in the neonate. Its increased prevalence in recent years has coincided with the rise in the number of births assisted by vacuum extraction. Three deaths in Australia within the last 7 years have been the subject of two coronial inquests. Subsequent coronial reports have highlighted that neonatal death from SGH can be prevented if appropriate attention is paid to identification of risk factors, early diagnosis, close observation and aggressive treatment. To prevent unnecessary deaths, all involved in the care of the baby after birth need to be aware of the importance of prompt diagnosis, monitoring and early treatment of SGH.

Neonatal subgaleal hemorrhage

Subgaleal hemorrhages, although infrequent in the past, are becoming more common with the increased use of vacuum extraction. Bleeding into the large subgaleal space can quickly lead to hypovolemic shock, which can be fatal. Understanding of anatomy, pathophysiology, risk factors, differential diagnosis, and management will assist in early recognition and care of the infant with a subgaleal hemorrhage.

Risk factors associated with subaponeurotic haemorrhage in full-term infants exposed to vacuum extraction

OBJECTIVES

To determine obstetric and neonatal risk factors associated with subaponeurotic haemorrhage (SAH) in infants exposed to vacuum extraction.

DESIGN

A prospective observational study.

SETTING

In the labour room, operation theatre, postnatal wards and neonatal intensive care unit (NICU) of a tertiary teaching hospital.

POPULATION

All infants born in the hospital with a history of exposure to vacuum extraction.

METHODS

A prospective observational study carried out over a 26-month period. All eligible infants were examined at birth and during the first 24 hours of life.

MAIN OUTCOME MEASURES

A diagnosis of SAH was based on detection of a tender fluctuant scalp swelling that crossed the skull suture lines of infants.

RESULTS

Of 10,066 infants born in the hospital during the study period, 338 (3.4%) had exposure to vacuum extraction. SAH was detected in 71 (21.0%) of them. Forward multivariate logistic regression analysis showed that five factors were significantly associated with development of SAH: maternal nulliparity (adjusted odds ratio [OR]: 4.0; 95% confidence intervals [CI]: 1.6, 10.0), failed vacuum extraction (adjusted OR: 16.4; 95% CI: 2.0, 135.6), Apgar score of less than 8 at 5 minutes of life (adjusted OR: 5.0; 95% CI: 1.7, 15.2), marks of vacuum cup over the sagittal suture (adjusted OR: 4.4; 95% CI: 1.9, 10.2) and marks of leading edge of vacuum cup at <3 cm away from the anterior fontanel of infants' heads (adjusted OR: 6.0; 95% CI: 1.7, 21.0).

CONCLUSION

Maternal nulliparity, placement of vacuum extraction cup over the sagittal suture at a distance too close to infant's anterior fontanel and failed vacuum extraction predisposed infants to develop SAH.

Neonatal Subgaleal Hemorrhage and Its Relationship to Delivery by Vacuum Extraction

Subgaleal hemorrhage is a rare condition of the neonate often associated with instrumental delivery. It is a potentially fatal condition that is often underreported and underdiagnosed. The vacuum extractor is being advocated as the instrument of first choice for assisted vaginal delivery, but appears to be associated with an increased incidence of subgaleal hemorrhage. It is widely believed that the vacuum cup will dislodge before causing serious fetal trauma. Because of the ease of application, vacuum extractors could be used potentially in circumstances in which forceps would not be attempted, allowing an operator of average experience to perform rotational deliveries. The worrisome increase in the incidence of subgaleal hemorrhage associated with vacuum extraction leads to the issuance of warnings from governmental authorities in Canada and the United States. This review discusses the anatomy of this lesion, etiology, clinical presentation, management, and possible prevention.

Neonatal subgaleal hematoma causing brain compression: report of two cases and review of the literature

OBJECTIVE AND IMPORTANCE

Neonatal subgaleal hematomas (SGHs) are infrequent but underdiagnosed collections of blood beneath the galea, often caused by vacuum delivery. With massive bleeding into the subgaleal space, exsanguination and hypovolemic shock can cause death in 20 to 60% of newborn infants. We report the first two known patients with extracranial cerebral compression caused by SGH. Also, the surgical evacuation of neonatal SGH has not been described previously.

CLINICAL PRESENTATION

One patient was a full-term boy who was delivered via vacuum extraction after an uncomplicated pregnancy. Within a few hours, he developed an expanding fluid collection of the scalp and disseminated intravascular coagulation and shock requiring intubation, inotropic support, and blood transfusions. His head circumference grew from 33 cm at birth to 42 cm. He became progressively lethargic and developed posturing movements. Computed tomography of the head revealed a massive SGH causing gross overlapping of the cranial sutures and diffuse cerebral edema. The other patient was a full-term boy delivered via cesarean section after an unsuccessful attempt at vacuum extraction and forceps delivery. The initial head circumference was 34 cm. Within a few hours, he developed an expanding fluid collection of the scalp and became progressively lethargic with posturing. Magnetic resonance imaging of the head revealed a massive SGH with cranial compromise and diffuse cerebral edema.

INTERVENTION

Both children had radiographic features indicative of elevated intracranial pressure as well as neurological decompensation. The first patient was taken to the operating room, and the hematoma was evacuated through a small scalp incision. Initially, approximately 150 ml of blood was removed, and a Jackson-Pratt drain diverted another 200 ml of blood during the next 2 days. The infant made a good recovery. In the second case, the patient remained too unstable for operative intervention and died.

CONCLUSION

Extracranial cerebral compression represents another way by which neonatal SGH may jeopardize the infant's life. Management consists of measures to correct hypovolemic shock and disseminated intravascular coagulation, as well as surgical intervention to control elevated intracranial pressure.

Controversies in the use of the vacuum extractor

Operative pelvic delivery is an important component of obstetrical care. Vacuum extraction assumes a prominent role, and when appropriately performed, has been proven safe and effective. However, controversies continue to exist. Historical background and review of the latest literature are presented to delineate these issues and promote consensus and direct research to continue to provide the safest means of delivery for the mother and baby.

Forceps delivery

This chapter reviews the role for instrumental delivery in current practice and gives a critical account of current techniques of operative vaginal delivery by forceps. Important issues, including case choice, documentation, forceps application, avoidance of complications, and training and education are included.

[Obstetrical vacuum: a modern instrument]

Contrary to the forceps, the vacuum extractor has clearly progressed in the last years. The use of the vacuum extractor increases in every developed countries, certainly because of an easier learning than forceps. Furthermore, maternal after-effects of the delivery like sphincters injuries and anal incontinence seem to be less frequent with vacuum extractor than with forceps. For these reasons the American College of Gynecologists and Obstetricians (ACOG) recommend a large use and a priority teaching of this fetal extraction instrument. The technical aspects of use of the vacuum extractor are developed in this article, and personnel results are added as commentaries.

Vacuum extraction in modern obstetric practice: a review and critique

The practice of obstetric vacuum extraction is controversial. This article discusses several issues concerning vacuum extraction including maternal and fetal injury risks, failure rates, indications and technique. Recently published articles on these topics are presented and summarized. Throughout this review, vacuum extraction is evaluated against its principal alternatives, forceps and cesarean delivery.

Impact of FDA advisory on reported vacuum-assisted delivery and morbidity

OBJECTIVE

In May 1998 the US Food and Drug Administration (FDA) issued a health advisory reporting neonatal injuries/deaths following vacuum delivery and encouraged voluntary reports of future adverse events. We compared FDA reports of vacuum delivery adverse events prior to and following the advisory.

METHODS

The FDA database (MAUDE) was searched for vacuum deliveries using brand name, manufacturer name, and procedure "string searches." Cases were sorted by report date, source, and manufacturer. Neonatal morbidity was quantified as deaths and life-threatening or nonlife-threatening events.

RESULTS

A total of 80 reported adverse cases were identified after duplicate cases were consolidated. Twenty-five were reported to the FDA prior to the 1998 advisory and 55 in the immediate 6-month period following the advisory. There was a 22-fold increase in reported events from five events/year prior to the advisory to an estimated 110 events/year following the advisory. The distribution of reporting sources changed significantly following the advisory with increased "manufacturer" (8-43%) and decreased "voluntary" reports (56-20%). All major brand names were represented. During the 6 months following the FDA advisory there were 10 neonatal deaths, 30 life-threatening events, 12 nonlife-threatening events, and three equipment-related reports. Infant deaths were due to intracranial or subgaleal hematomas. Injuries included skull fracture, scalp abrasions, and cephalohematomas.

CONCLUSIONS

The FDA advisory was associated with a 22-fold increase in the rate of reported adverse events. This increase in reporting likely represents both enhanced awareness of complications as well as an increase in vacuum-related adverse neonatal sequelae. As vacuum delivery is associated with greater neonatal morbidity/ mortality than was previously recognized, the adage that the vacuum is "designed to come off before infant damage occurs" appears unsubstantiated. It is recommended that manufacturers quantify the suction and traction capabilities of present and new proposed vacuum cup designs.

Subgaleal haemorrhage: risk factors and neurological and developmental outcome in survivors

To identify the risk factors associated with subgaleal haemorrhage and to assess the long-term neurological and developmental morbidity in survivors, data were prospectively collected over 5 years on 69 newborns with subgaleal haemorrhage from a cohort of 23,353 live and term deliveries, giving an incidence of subgaleal haemorrhage of 3.0 per 1000 live and term births. Multivariate analysis of risk factors associated with subgaleal haemorrhage on univariate analysis showed that prolonged second stage of labour (OR = 9.02; 95% CI 6.15-17.51), fetal distress (OR = 5.05; 95% CI 2.67-11.12), vacuum delivery (OR = 7.17; 95% CI 5.43-10.25), forceps delivery (OR = 2.66; 95% CI 1.78-5.18), and birthweight (OR = 2.20; 95% CI 1.54-6.56) significantly influenced the occurrence of subgaleal haemorrhage. When the effects of prolonged second stage of labour, fetal distress, birthweight and gestational age were controlled for, the odds of harbouring subgaleal bleed following vacuum delivery were, respectively, OR = 7.80 (95% CI 5.45-11.61), OR = 6.15 (95% CI 3.71-10.84), OR = 5.01 (95% CI 2.78-9.63) and OR = 7.65 (95% CI 4.73-16.65). Among the 69 newborns with subgaleal haemorrhage, ten (14%) died and twelve (20%) of the 59 survivors were lost to follow-up. Of the remaining 47 survivors, three (6%) died during follow-up of diseases unrelated to the bleed, leaving 44 survivors, none of whom had either neurological deficit or developmental delay. The study concludes that subgaleal haemorrhage in neonates is the result of birth trauma associated with difficult instrumental delivery. Newborns with subgaleal haemorrhage who survive the acute episode of the bleed show no evidence of subsequent long-term neurological deficit or developmental delay.

Neonatal subgaleal haematoma: associated risk factors, complications and outcome

OBJECTIVE

To describe the obstetric and perinatal factors, in particular the method of delivery, associated with development of a subgaleal haematoma (SGH) and to determine the outcome of survivors with this type of birth trauma.

METHODOLOGY

Perinatal and obstetric data were retrospectively reviewed for 37 infants admitted to the neonatal unit of the sole tertiary paediatric referral hospital in Western Australia with an SGH, over a 24 year period from 1970 to 1993. These data were compared to data for all Western Australian births. The long-term outcome was obtained through medical and private paediatric records for 26 of these infants.

RESULTS

All except one of the neonates had instrumental deliveries; 89% had a vacuum extractor applied to the head at some stage of delivery compared to 10% of the general population of births in Western Australia. There was also a significantly increased risk of failure of attempted vacuum extraction. Of the cases where a vacuum extraction was attempted, 45% also had forceps applied to the head. Coagulopathy was associated with the severity of the SGH. There was also a high frequency of occurrence (40%) of associated head trauma such as intracranial haemorrhage, skull fracture and cerebral oedema, as well as neonatal encephalopathy (73%). The occurrence of these associated features did not correlate significantly with the severity of SGH. Minor complications of SGH included jaundice and facial bruising. There was an excess mortality associated with SGH; however, the long-term outcome for neonatal survivors with this disorder was good. None of the cases studied subsequently developed cerebral palsy or intellectual disability, and minor neurological sequelae only were documented in four infants.

CONCLUSIONS

SGH is an uncommon type of birth trauma, and is associated with delivery or attempted delivery by vacuum extraction. The most commonly associated clinical problems were hypovolaemia and coagulopathy. The long-term outcome for neonates with this condition is good.

Subaponeurotic haemorrhage in the 1990s: a 3-year surveillance

A 3-year survey of subaponeurotic haemorrhage (January 1991 to December 1993) in a tertiary referral centre in Hong Kong revealed that the incidence of this life-threatening condition was 6.4 per 1000 ventouse-associated deliveries, which is 60-fold more common than with other modes of childbirth. We highlight a lesser known phenomenon of marked male predominance (male to female ration 8:1). Three of 18 (17%) infants with subaponeurotic haemorrhage died. Severe subaponeurotic haemorrhage with a decrease in venous haematocrit >25% of the baseline value at birth and requiring urgent blood transfusion in the first 12 h, in association with significant birth asphyxia with arterial cord blood pH <7.20 and 1-min Apgar score < or = 3 were the most important risk factors for death. A worrying feature was the silent presentation of occult subaponeurotic haemorrhage in two of the fatal cases. Frequent monitoring of haematocrit, early and rapid restoration of blood volume and prompt commencement of cardiac inotropes are the keys to the management of this condition, which should be suspected in all ill newborn infants subjected to the ventouse applicator.

A randomised prospective study comparing the new vacuum extractor policy with forceps delivery

OBJECTIVE

To compare assisted vaginal delivery by forceps with delivery by vacuum extractor, where a new vacuum extractor policy was employed which dictated the cup to be used in specific situations.

DESIGN

Multicentre randomised controlled trial.

SETTING

Four district general hospitals in the West Midlands.

SUBJECTS

Six hundred-seven women requiring assisted vaginal delivery, of whom 296 were allocated to vacuum extractor delivery and 311 to forceps.

MAIN OUTCOME MEASURES

Delivery success rate, maternal perineal and vaginal injuries, maternal anaesthetic requirements, neonatal scalp and facial injuries.

RESULTS

Of the vacuum extractor group, 85% were delivered by the allocated instrument compared to 90% in the forceps group (odds ratio (OR) 0.64; 95% confidence intervals (CI) 0.4-1.04). However, more women in the vacuum extractor group were delivered vaginally (98%) than in the forceps group (96%). There were significantly fewer women with anal sphincter damage or upper vaginal extensions in the vacuum extractor group (11% vs 17%, OR 0.6; 95% CI, 0.38-0.97). There were significantly fewer women in the vacuum extractor group requiring epidural or spinal anaesthetics (25.4% vs 32.7%, OR 0.69; 95% CI 0.49-0.99) or general anaesthetics (1% vs 4%, OR 0.17; 95% CI 0.04-0.76). Although there were significantly more babies in the vacuum extractor group with cephalhaematomata (9% vs 3%, OR 3.3; 95% CI 1.4-7.4) there were fewer babies in the vacuum extractor group with other facial injuries. There were three babies in the forceps group with unexplained neonatal convulsions.

CONCLUSIONS

Assisted vaginal delivery using the new vacuum extractor policy is associated with significantly less maternal trauma than with forceps. Further studies are required to assess neonatal morbidity adequately.

Vacuum extraction, bone injury and neonatal subgaleal bleeding

In a population of 27 flemish newborns with subgaleal bleeding encountered within a period of 6 years, we studied the obstetrical, clinical and radiological data. In contrast with controversial findings from the available literature, there is little doubt that difficult, often elective vacuum extraction is the main cause of this neonatal emergency. Disturbances in haemostasis, when documented, were attributed to focal intrahaematoma consumption, except for one boy who presented with haemophilia and neonatal subgaleal bleeding. Conventional X-ray examination continues to be of importance for the documentation of suture diastasis, fissures and fractures. CT scan reveals both the amount of extra-osseous bleeding, the degree of bone displacement and injury as well as the type and extent of associated intracranial damage. Subgaleal haemorrhage rarely hides a growing synchrondrosal rupture.

A randomized prospective study comparing delivery with metal and silicone rubber vacuum extractor cups

OBJECTIVE

To determine the relative benefits and complications of assisted vaginal delivery with metal and silicone rubber vacuum extractor cups.

DESIGN

Prospective randomized controlled study.

SETTING

A busy referral maternity hospital in Kathmandu, Nepal.

SUBJECTS

101 women were assigned to delivery with the Silc-cup and 98 to delivery with the metal cup.

MAIN OUTCOME MEASURES

Success rate at achieving delivery with the assigned instrument and incidence of neonatal trauma. Analysis was by 'intention to deliver' with women remaining in their original group regardless of the eventual mode of delivery.

RESULTS

Randomization resulted in two groups of women similar in respect of age, parity, gestation and indication for delivery. The overall success rate was similar for the two instruments (Silc-cup 85% and metal cup 87%). The Silc-cup was more likely to fail if there was excessive caput (seven failures compared with one in the metal cup group). The frequency of clinically significant maternal trauma was low in both groups. There were fewer babies with clinically significant scalp trauma in the Silc-cup group (22%), compared with the metal cup group (37%).

CONCLUSIONS

The data indicate a greater tendency for the Silc-cup to fail when excessive caput is present but that metal cups are associated with increased scalp injuries.

Long-term neurological sequelae following vacuum extractor delivery

Two hundred and ninety-five children delivered by vacuum extractor (VE) 10 years ago were studied to determine if they had an increased incidence of neurological abnormality; 302 children delivered spontaneously in the same hospital looked after by the same doctors in the same year matched for maternal age, gestational age and birthweight were used as controls. Fine- and gross-motor control, perceptual integration and behavioural maturity were screened by 4 tasks selected from the Quick Neurological Screening Test. Intelligence assessment was based on scholastic performance, speech ability and ability of self-care as commented by teachers and parents. Similar scorings were found between the 2 groups. Mental subnormality or severe neurological abnormality was found in 3 children delivered by VE and in 3 children delivered spontaneously and there was no evidence that it was birth-related.

A multicentre randomized trial comparing delivery with a silicone rubber cup and rigid metal vacuum extractor cups

A total of 258 women requiring assisted delivery where vacuum extraction was thought to be suitable were randomly allocated to delivery with a new silicone rubber cup or metal vacuum extractor cups. There was a tendency for the silicone rubber cup to effect delivery more quickly and to cause less scalp trauma, but to fail to effect delivery on more occasions than metal cups. However, none of these differences was statistically significant. There were no statistically significant differences in the rates of birth canal trauma, maternal blood loss, or neonatal jaundice. The silicone rubber cup produced a cosmetically more acceptable chignon than the metal cups. The introduction of vacuum extractors with silicone rubber cups into obstetric units should be encouraged.

Skull subcutaneous emphysema--a rare complication of vacuum extraction and scalp electrode

A full-term newborn infant with severe subcutaneous emphysema of the skull as a complication of vacuum extraction and scalp electrode wound is reported. We hypothesize that detachment of subcutaneous tissue and transmission of the negative pressure associated with the vacuum extraction resulted in entry of air through the scalp electrode wound.

Vacuum extractor: a safe instrument?

One thousand five hundred and twenty-six records of deliveries with vacuum extractor in 1982 and 1983 in the Hong Kong University Department of Obstetrics and Gynaecology were reviewed. Vacuum extractor was found to be easy and safe to use even by inexperienced house-staff. Vacuum extractor was especially useful in the delivery of malpositioned fetal heads because of its mechanism of allowing autorotation. Its advantage of not occupying extra space in the pelvis was most beneficial to the relatively smaller Chinese pelvis. Maternal injury was uncommon. Fetal scalp injury like cephalhaematoma was not uncommon but serious scalp injury was infrequent. Perinatal mortality rate attributed to the instrument was low (0.6/1,000). However, in order to achieve safety to the mother and fetus, strict rules in application of the vacuum extractor must be observed.

Portsmouth operative delivery trial: a comparison vacuum extraction and forceps delivery

A total of 304 women, for whom operative delivery was considered necessary in the second stage of labour, were randomly assigned to delivery by vacuum extraction or forceps. Of those allocated to forceps a higher proportion of babies were actually delivered with the allocated instrument; however, the caesarean section rate was also higher in this group. Maternal trauma, use of analgesia and blood loss at delivery were significantly less in the group allocated to vacuum extraction. Vacuum extraction did, however, appear to predispose to an increase in mild neonatal jaundice. More serious neonatal morbidity was rare in both groups and the trial was of insufficient size to rule out a clinically important differential effect of the two instruments on these measures of outcome. Another trial is now needed to address this still open question more rigorously.

Cephalhematoma in the newborn

A chart survey of 139 newborns with cephal hematoma showed the majority were associated with primiparity, forceps delivery, or prolonged labor. The complications included jaundice, central nervous system symptoms, localized in fection, anemia and subdural hematoma. Neo natal jaundice was frequently associated. Under lying skull fractures were found in 7.1 per cent of the 84 infants in whom skull x-rays were taken, a lower incidence than that reported by others.

Perinatal coagulopathies complicating fetal blood sampling

In a neonatal postmortem histological study of scalp stabs made with a fetal blood sampling blade the aponeurosis was punctured in up to 38% of cases even when it was more than 2 mm deep. This and other indirect and direct evidence discussed suggest that five of the seven reported cases of major bleeding after fetal blood sampling in labour were due to blood clotting defects and that these should be considered urgently in the management of future cases.

Massive scalp haemorrhage after fetal blood sampling due to haemorrhagic disease

Massive subaponeurotic haematoma occurred in a baby after suture of bleeding scalp blood sampling stabs made before delivery. Eighteen hours after delivery blood samples showed marked prolongation of the prothrombin time. The condition was successfully treated with vitamin K(1) and blood transfusion.

Hematologic and biochemical studies of Turkish children with pica. A presumptive explanation for the syndrome of geophagia, iron deficiency anemia, hepatosplenomegaly and hypogonadism

The present study clearly indicates the presence of iron deficiency anemia in Turkish children with long standing pica for soil and clay. Most of the patients described had marked growth retardation and a lag in bone age. As explanation, the cations in soil and clay seem to enter into an ion exchange retention reaction with dietary iron, zinc and perhaps other trace metals, resulting in the typical complex of deficiency symptoms.