The Fundamentals of Safe Vacuum Delivery Course Workbook ... · LESSON THREE STEP 1. LOCATING THE...

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The Fundamentals of Safe Vacuum Delivery 7 HOURS | ONLINE TUTORIAL COURSE

With video tutorials by Aldo Vacca

LESSON THREELearn The Vacca 5-Steps Technique

CLASS WORKBOOK

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40 | THE FUNDAMENTALS OF SAFE VACUUM DELIVERY © VACCA ACADEMY .com

NOTES

LESSON THREE

LESSON OUTLINE

LEARN THE STEP-BY-STEP PROCEDURE OF VACUUM DELIVERY. BECOME FAMILIAR WITH THE TECHNIQUE AND PROCEDURAL STEPS COMMON TO ALL VACUUM DELIVERIES.

CONCEPTS • Locating the flexion point • Calculating cup insertion distance • Manoeuvrability of cups •

Choice of vacuum cup • Manoeuvring the cup • Method of traction • Finger tip and finger

thumb techniques • The descent & pelvic floor phase • Preventing cup detachment

Master the art of safe vacuum delivery

Provided the operator has been trained in the use of a posterior cup, flexing median applications may be achieved consistently in almost all posterior and transverse positions of the occiput.

LESSON THREE

READING


WHICH VACUUM EXTRACTOR CUP AND WHY?Use of ‘anterior’ cups should be restricted to non-rotational, low vacuum-assisted deliveries

(VAD). ‘Posterior’ cups should be selected for OP & OT rotational deliveries. The dome-

attached handles or tubing of the anterior cups limits their manoeuvrability within the lower

birth canal making it difficult or impossible for them to reach the flexion point when it is

displaced from the introitus in malpositions and deflexed or asynclitic attitudes of the head. On

the other hand, posterior cups can be manoeuvred towards the flexion point because the tubing

lies in the same plane as the body of the cup and does not impede its inward movement.

LESSON THREE

THE VACCA 5-STEPS TECHNIQUE OF VACUUM-ASSISTED DELIVERYAll vacuum-assisted deliveries, non-rotational and rotational are comprised of five steps with

only minor adaptation of technique depending on station and position of the fetal head.

Adherence to the Vacca 5-Steps Technique will allow the operator to standardise the method

and to concentrate on the surrounding clinical circumstances that may also influence the

outcome. Since resistance, and hence traction force, is greater when the head is passing

through the pelvic floor level, the recommendation is made that a VAD should be divided into

descent and pelvic floor phases.

Anterior cup

Posterior cup


LESSON THREE

STEP 1.

LOCATING THE FLEXION POINT - CALCULATING THE CUP INSERTION DISTANCEThe flexion point is located by identifying the posterior fontanelle with the middle finger and

moving the finger along the sagittal suture anteriorly an estimated distance of 3cm. Keeping

the tip of the finger on the flexion point, it is possible to calculate the cup insertion distance by

observing which part of the middle finger is resting on the maternal fourchette of the perineum

bearing in mind that the length from the tip to the knuckle of the middle finger is between 10-

11cm and to the middle joint of the finger, 5-6cm.

STEP 2.

HOLDING THE CUP - INSERTING THE CUP INTO THE VAGINAThe operator retracts the perineum with two fingers to form a space into which the cup is

inserted gently with one movement immediately following a contraction. If the cup being used

has a groove on its dome, insert the cup so that the groove is situated at the “12 O’Clock”

position to the mother’s pubic arch. The groove serves as a marker of auto-rotation of the head

in OP and OT rotational VADs

STEP 3.

MANOEUVRING THE CUP TOWARDS AND OVER THE FLEXION POINTThe cup is manoeuvred towards the flexion point using the two index fingers only. The operator

should twist his/her body such that the left elbow (for right handed people) is pointing to the

mother with the left index finger compressing the fetal caput. The index finger of the right hand

is placed on the curved rim of the cup nearest the operator and pushes the cup backwards

in the midline until the centre of the cup is judged to be over the flexion point. The distance

markers on the tube of the OmniCup at 6cm and 9cm assist the operator to know when the

centre of the cup has reached the calculated insertion distance.


LESSON THREE

STEP 4.

CREATING THE VACUUM - AND EXCLUDING MATERNAL TISSUE ENTRAPMENTInducing and maintaining the vacuum: The cup should be held in place over the flexion point

with the left index finger while the vacuum is created, otherwise it may slip outwards towards

the introitus. The recommended vacuum pressure of 60-80kPa (450-600mmHg) may be

achieved rapidly in one step. However, if the operator is not confident that the cup has been

placed correctly, it may be advisable to pause when a vacuum of 20kPa (150mmHg) has been

reached to check the application and that vaginal tissue has not become trapped under the

cup. The vagina and labia minora are at greatest risk of being caught beneath the vacuum cup

when the fetal head is stationed at or near the outlet of the pelvis because at these low levels

the vagina sweeps around the front of the head to its attachments to the perineal body at the

introitus.

STEP 5.

METHOD OF TRACTION - FINGER TIP AND FINGER THUMB TECHNIQUESStandard method of traction: Traction for VAD is a two-handed exercise, one hand providing

the traction, the other monitoring descent and controlling the force applied to the fetal

head. The non-pulling hand has six functions: to check maternal expulsive forces; to monitor

progress; to control applied traction force; to prevent complete detachment; to assist with axis

traction; to act as a rotary point in auto-rotation. The pulling hand has three functions: to provide

the required traction using fingertips only; to direct traction along the axis of the pelvis and to

pull only with contractions and maternal expulsive effort.

* PULL ONLY DURING A UTERINE CONTRACTION AND WHILE THE MOTHER IS PUSHING. DO NOT PULL IF THE MOTHER IS NOT PUSHING!

LESSON ONE


The number of pulls should be defined as the number of contractions during which expulsive effort and traction occur. If the mother prefers to push two or more times during one contraction, this should be counted as one pull.

THE ‘F INGER-TIP’ POSITION OF THE PULLING HANDVacuum devices that incorporate a traction bar should be held with the bar cradled in the

distal interphalangeal joints of the fingers. Sufficient traction for delivery of the baby can be

generated in most cases simply by flexing the fingers. The ‘finger-thumb’ position of the non-

pulling hand: The thumb of the non-pulling hand should be placed on the dome of the cup

to provide counter-pressure when required and the index finger should rest on the scalp to

monitor progress and control descent.

DIRECTION OF TRACTIONThe axis of the pelvis forms a curve that bends through 90º from inlet to outlet. For practical

purposes, optimal diameters of the head will be presenting during vacuum extraction when

the flexion point descends slightly behind the axis of the pelvis to keep the mid-point of the

mento-vertical diameter aligned with the axis. For this reason, traction should be directed more

posteriorly (towards the floor) to achieve the best fit of the head within the cavity of the pelvis

at any given level. As the head descends, the direction of pull gradually moves upwards until

the mid-point of the head emerges from beneath the symphysis at crowning.

VACUUM DELIVERY SHOULD BE CONSIDERED A TWO-PHASE PROCEDUREIn a prospective study of vacuum delivery in nulliparous mothers using a vacuum device that

incorporated a traction force indicator, higher levels of traction force and a greater number of

pulls were recorded in the majority of cases during the pelvic floor and perineal phase of the

procedure than during the descent phase. The explanation may be that at this level the widest

part of the fetal head is negotiating the narrowest and most resistant part of the birth canal.

For this reason, a vacuum delivery should be considered as a two-phase procedure, namely, a

‘descent’ phase and a ‘pelvic floor & perineal phase’.

LESSON ONE


DESCENT PHASE & PELVIC FLOOR PHASE OF VADThe descent phase is that part of a VAD from the time of cup application until the widest diameters of

the head descend to the pelvic floor. At this stage, the cup will be visible in or near the introitus. The

pelvic floor & perineal phase is that part of a VAD from the time the cup is visible at the introitus to

complete delivery of the fetal head. Dr Aldo Vacca recommended that 3 pulls for the descent phase

and 3 pulls for the pelvic floor and perineal phase should be considered acceptable limits provided that

some progress is observed with each pull and traction is not excessive – the ‘3 + 3 pulls’ rule.

AUTO-ROTATION OF THE FETAL HEADBird demonstrated that in OP and OT positions of the fetus, if the cup was applied over the flexion

point and if axis traction was applied, rotation to OA will occur in about 90% of VADs. The rotation is an

auto- rotation and occurs independently of the operator just as internal rotation occurs spontaneously

during the process of normal labour. However, to achieve correct cup applications in malpositions of the

head the operator must use and know how to use one of the more manoeuvrable posterior cups. Failed

rotations, like difficult or failed VADs, are often the result of incorrect applications of the cup.

TECHNICAL ASPECTS 1There is no evidence that the vacuum pressure per se is injurious to the fetal scalp but the recommended

range is shown here. The working level of vacuum should be achieved rapidly as there are no benefits

to a slow reduction of negative pressure. The practice of decreasing the pressure level between

contractions has been shown to be of no benefit for the infant, nor is leaving it up harmful. A check for

maternal tissue entrapment should always be made; and while this is easily performed when the head is

low, it is usually impossible to palpate around the complete perimeter of the cup in OP & OT positions.

TECHNICAL ASPECTS 2Some progress should occur with each pull. Initially, in malpositions, this progress may simply be flexion

of the head on the first pull, followed by some rotation and descent. For reasons already discussed,

the pull should be directed posteriorly to achieve axis traction. Since the greatest resistance to descent

will be encountered at the pelvic floor level, cup detachments usually occur here. Detachments are

injurious to the fetal scalp and should be limited to two. Correct traction technique will prevent most

cup detachments. Limit the number of pulls (see 3 + 3 pulls rule) and the duration of the procedure to 20

minutes.

* IF VACUUM DELIVERY HAS NOT BEEN COMPLETED AFTER 10 MINUTES IN A MULTIPARA AND 15 MINUTES IN A NULLIPARA, OPERATORS SHOULD CAREFULLY REASSESS WHETHER FURTHER TRACTION ATTEMPTS ARE WARRANTED. IF THE DURATION EXTENDS BEYOND 20 MINUTES THE PROCEDURE SHOULD BE DISCONTINUED AND THE BABY DELIVERED BY CAESAREAN SECTION UNLESS THE FETAL HEAD HAS DESCENDED TO THE LEVEL OF THE PERINEUM.


LESSON THREE

* AN ASSISTANT, NOT THE OPERATOR, SHOULD SUPPORT THE PERINEUM AS THE HEAD IS DELIVERING

Correct application of the cup and traction directed along the axis of the pelvis should prevent the majority of the detachments. Complete detachment may be prevented by exerting counter-pressure on the cup with the finger-thumb technique during traction and by ceasing to pull when the contraction passes and the mother stops pushing

DETACHMENT OF THE CUP

Traction is discontinued between all contractions. Traction is discontinued if an audible

‘hiss’ is heard signalling loss of vacuum and imminent cup detachment (pop-off). Incorrect

application of the cup, pulling too hard and pulling in the wrong direction are common causes

of cup detachment. Detachment may injure the scalp and should not be regarded as a safety

mechanism of the vacuum extractor. If detachment occurs, the cup should be reapplied only if

the operator is convinced that the cause of the detachment is not cephalopelvic disproportion

and that the scalp has not been injured. If detachment recurs or if the head fails to descend

with traction the procedure should be abandoned and the delivery completed by caesarean

section except when the detachment occurs at the outlet. Forceps applied at outlet station to

complete the delivery are unlikely to injure the infant.

DETACHMENT OF THE CUP MAY OCCUR FOR THE FOLLOWING REASONS:

• deflexing or paramedian cup applications

• incorrect traction technique, pulling too hard, in the wrong direction or with a rocking motion

• not providing counter-pressure on the cup with the thumb during traction

• upward traction before the midpoint of the head has passed beneath the pubic arch

• not allowing sufficient time for the resistant perineum to stretch over the advancing fetal head, especially if episiotomy is not performed

• large caput succedaneum (with soft cups)

• maternal tissue or scalp electrode trapped under the cup

• inadequate vacuum pressure or faulty equipment.


WATCH THE LESSON VIDEO AND FOLLOW ALONG WITH THIS WORKBOOK.

WHEN YOU SEE THIS ICON, PAUSE THE VIDEO.Draw and label each diagram.

GO TO

WWW.VACCAACADEMY.COM

LESSON THREE

VIDEO

NOTES

NOTES


LESSON THREE


Operators should avail themselves of every opportunity to practise the digital distance technique for cup insertion whenever vaginal examinations are performed in labour until they become familiar and confident with the method.

LESSON THREE

ACTIVITIES


LESSON THREE

* IT IS IMPORTANT TO FOLLOW THE SAME FIVE PROCEDURAL STEPS FOR ALL PROCEDURES, AND NOT TO COMPLICATE MEASURES BY CHANGING TECHNIQUE BETWEEN BIRTHS.

ACTIVITY ONE

DR ALDO VACCA DEFINED THE FIVE SIMPLE STEPS COMMON TO ALL VACUUM PROCEDURES.

DESCRIBE THE FIVE PROCEDURAL STEPS COMMON TO ALL TYPES OF VACUUM DELIVERY.

NOTES

ONE

TWO

THREE

FOUR

FIVE


LESSON THREE

ACTIVITY TWO

Operators should avail themselves of every opportunity to practise the digital distance technique for cup insertion whenever vaginal examinations are performed in labour until they become familiar and confident with the method.

STUDY THE IMAGE, LABEL AND DESCRIBE THE STEPS WHEN LOCATING THE FLEXION POINT AND CALCULATING THE CUP INSERTION DISTANCE.

* IN DEFLEXED OP POSITIONS THE DISTANCE TO THE FLEXION POINT MAY BE 8-9CM. IN OA POSITIONS ONE MAY EXPECT A DISTANCE OF 5-6CM.

NOTES


ACTIVITY THREE

STUDY THE IMAGE, LABEL THE FLEXION POINT AND MARK WHERE CUP MOVEMENT IS RESTRICTED. CIRCLE THE CORRECT CUP TO BE USED IN THIS CASE.

EXPLAIN THE IMPLICATIONS OF CUP CHOICE AND APPLICATION IN CLINICAL PRACTICE.

NOTES

LESSON THREE

* BEFORE APPLYING THE CUP TO THE FETAL HEAD, SCALP ELECTRODES, PULSE OXIMETERS AND INTRAUTERINE PRESSURE DEVICES SHOULD BE REMOVED SINCE THEY TAKE UP VALUABLE SPACE OR MAY INTERFERE WITH THE PROCESS OF DESCENT OR AUTOROTATION OF THE FETAL HEAD


LESSON THREE

ACTIVITY FOUR

STUDY THE IMAGE, LABEL AND DESCRIBE THE STEPS WHEN MANOEUVRING THE CUP OVER THE FLEXION POINT.

* THE NEWER LIGHT-WEIGHT DISPOSABLE PLASTIC DEVICES ARE EASILY SUPPORTED BY THE PERINEUM AND DO NOT NEED EXTERNAL SUPPORT THUS FREEING BOTH OF THE OPERATOR’S HANDS TO MANOEUVRE THE CUP.

NOTES


LESSON THREE

ACTIVITY FIVE

WHY IS IT IMPORTANT TO CHECK FOR AND EXCLUDE MATERNAL TISSUE?

NOTES

ACTIVITY SIX

WHAT IS THE RECOMMENDED NEGATIVE VACUUM PRESSURE?

NOTES


LESSON THREE

ACTIVITY SEVEN

HOW CAN ONE DETERMINE THAT CUP APPLICATION IS CORRECT?

NOTES

* WHEN THE OPERATOR IS SATISFIED THAT THE CUP HAS BEEN POSITIONED CORRECTLY AND BEFORE THE ONSET OF THE NEXT CONTRACTION, THE APPLICATION IS CHECKED BY IDENTIFYING THE ANTERIOR FONTANELLE AND CONFIRMING THAT THE DISTANCE ALONG THE SAGITTAL SUTURE TO THE NEAREST PART OF THE CUP IS AT LEAST 3CM WITH THE SUTURE LINE PASSING UNDER THE MIDDLE OF THE CUP.


LESSON THREE

ACTIVITY EIGHT

Traction should be performed as a two-handed exercise with both hands working in unison.

EXPLAIN THE METHOD OF TRACTION AND THE FUNCTIONS OF THE NON-PULLING HAND.

NOTES


LESSON THREE

ACTIVITY NINE

DRAW A DIAGRAM SHOWING DIRECTION OF TRACTION OF THE INITIAL PULL FOR OCCIPITO-POSTERIOR AND OCCIPITO-TRANSVERSE POSITIONS.

EXPLAIN WHY TRACTION IS DIRECTED IN THIS WAY.

NOTES


LESSON THREE

ACTIVITY TEN

STUDY THE IMAGE AND LABEL THE KEY CONCEPTS REGARDING METHOD OF TRACTION.

DESCRIBE THE KEY CONCEPTS REGARDING METHOD OF TRACTION

NOTES


LESSON THREE

* THE MAJORITY OF CUP DETACHMENTS OCCUR WHEN THE CUP IS VISIBLE AT OR PASSING THROUGH THE VAGINAL INTROITUS. AT THIS STAGE OF THE PROCEDURE, THE WIDEST DIAMETERS OF THE FETAL HEAD, FOLLOWING SOME SIX CENTIMETRES BEHIND THE CUP, ARE AT THE LEVEL OF THE MOTHER’S RESISTANT PELVIC FLOOR AND STRONG TRACTION MAY CAUSE THE CUP TO DETACH. THERFORE IT IS IMPORTANT TO ALLOW SUFFICIENT TIME FOR THE RESISTANT PERINEUM TO STRETCH OVER THE ADVANCING FETAL HEAD, ESPECIALLY IF EPISIOTOMY IS NOT PERFORMED.

* IF SUPPORT OF THE PERINEUM WITH A HAND IS PRACTISED DURING DELIVERY OF THE HEAD, AN ASSISTANT SHOULD BE INSTRUCTED TO PERFORM THIS TASK, AS IT IS IMPERATIVE THAT THE FINGER-THUMB TECHNIQUE IS MAINTAINED UNTIL THE HEAD HAS CROWNED.

ACTIVITY ELEVEN

The majority of cup detachments occur when the cup is visible at or passing through the vaginal introitus.

EXPLAIN THE NEED TO BE PATIENT DURING THE PELVIC FLOOR AND PERINEAL PHASE.

NOTES


LESSON THREE

ACTIVITY TWELVE

Correct application of the cup and traction directed along the axis of the pelvis should prevent the majority of the detachments. Complete detachment may be prevented by exerting counter-pressure on the cup with the finger-thumb technique during traction and by ceasing to pull when the contraction passes and the mother stops pushing WHAT ARE THE WAYS TO HELP PREVENT CUP DETACHMENT?

NOTES

ASSESSOR’S COMMENTS


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