The operation of the vacuum extraction of the fetus. Clinical guidelines. Operative delivery. Vacuum extraction of the fetus

Vacuum extraction of the fetus (lat. Vacuum - emptiness; extrahere - pull out) - an obstetric delivery operation for extracting a live fetus during childbirth using a special apparatus - a vacuum extractor, the cup of which is sucked to the presenting part of the fetus (head) due to air rarefaction.

In our country, vacuum extraction is used in 0.12-0.20% of all births and in recent times its use is becoming increasingly rare. The low percentage of vacuum extraction is explained by the expansion of indications for surgery caesarean section for the benefit of the fetus.

The device of the Malmstrom vacuum extractor (Fig. 25.34, a). The device is supplied with a set (7 pieces) of metal cups (caps) differing in diameter (from 15 to 60 mm). To extract the head of a full-term fetus, usually three large cups (40-60 mm in diameter) with a rounded smooth edge and a concave inner surface. There is a hole in the center of the cup covered with a thin metal plate that does not close the hole. A chain is attached to the plate, passed through rubber tube. The chain connects the cup to a metal tap that serves to secure the chain. There is a device with a vacuum gauge to create a negative pressure.

It is most advisable to use elastic (silicone, rubber) cups large sizes which are less traumatic for the fetus and for the mother.

To create a vacuum, devices with adjustable negative pressure have now been created (Fig. 25.34.6).

Indications for applying a vacuum extractor. Indications for vacuum extraction are:

1) weakness of labor activity, not amenable to drug therapy;

2) low transverse standing of the swept seam;

3) started acute hypoxia fetus.

The conditions for applying a vacuum extractor are:

1. Living fetus.

2. Full disclosure of the uterine os.

3. Absence of a fetal bladder.

4. Finding the fetal head in a wide or narrow part of the pelvic cavity.

5. Correspondence between the size of the small pelvis and the head of the fetus.

6. Accurate knowledge of topographic relationships in the small pelvis at the time of applying the vacuum extractor.

7. Empty bladder.

Contraindications to the imposition of a vacuum extractor are as follows:

1. Dead fetus.

2. Not full disclosure uterine os.

3. Hydrocephalus, anencephaly.

4. extensor presentation and high straight standing swept seam.

5. Anatomically (II-III degree of narrowing) and clinically narrow pelvis.

6. Deeply premature fetus.

7. high location heads (pressed, stands with a small or large segment at the entrance to the pelvis).

8. Diseases of the mother, requiring the exclusion of attempts (preeclampsia, preeclampsia, eclampsia, hypertonic disease, heart defects with symptoms of decompensation, etc.).

Preparation for the operation. The preparation is the same as for all vaginal surgeries.

Rice. 25.34.

BUT - appearance; b - diagram

Before surgery, the bladder is emptied with an elastic catheter. Inhalation and intravenous anesthesia are contraindicated, since the woman in labor must push during extraction. For pain relief, especially in primiparas, bilateral novocaine anesthesia of the pudendal nerves is shown, which also helps to relax the muscles of the perineum. Immediately before the operation, a vaginal examination is performed to clarify the obstetric situation.

When applying a vacuum extractor, the presence of an assistant, the presence of an anesthesiologist and a neonatologist who owns the technique of resuscitation of newborns are mandatory.

Operation technique. Right hand under the control of the fingers of the left hand, a cup No. 5-7 is inserted into the vagina with the side side, depending on the capacity of the vagina, the height of the perineum. It is very important to correctly fix the cup on the fetal head. Attaching the calyx in the area of ​​​​the small fontanelle contributes to the flexion of the head and the correct mechanism of childbirth. The location of the calyx on the border between the small and large fontanel promotes extension during traction. When fixing the cup on the side of the sagittal suture, an asynclic insertion of the head occurs (Fig. 25.35).

Rice. 25.35..

A - types of fixation: 1 - flexion (ideal), 2 - extensor, 3 - paramedial; b - localization of the cup of the vacuum extractor on the fetal head: 1 - in the region of the small fontanelle, 2 - in the region of the posterior angle large fontanel; 3 - paramedial location with asin-clitism.

After the cup is brought to the head, you need to make sure that the edges of the neck or the wall of the vagina are not captured, then you should press the cup to the head. The assistant connects the hoses from the cup and the vacuum apparatus and slowly (within 2-4 minutes) using a hand pump or a special apparatus creates a negative pressure of 520 mm Hg. Art. (0.7-0.8 kg/cm2). At the same time, under the cap of the calyx, a birth tumor (“hairpiece”) is formed on the head, due to which the calyx is held. Vacuuming too quickly can cause a cephalohematoma to form.

After creating a vacuum, you should once again check the correct position of the vacuum extractor cup on the head. After making sure that the cup is applied correctly, proceed to traction. The obstetrician places his fingers on the rubber hose directly at the cup itself (sometimes at a distance) and produces traction synchronously with attempts, respectively, the wire axis of the pelvis and the mechanism of childbirth (Fig. 25.36, 25.37). With the wrong direction of traction, the cup can come off and cause serious injury to the woman in labor. During traction, you can rotate the head in the desired direction.

Before eruption of the parietal tubercles, a perineal dissection (median-lateral episiotomy) should be performed. When the parietal tubercles erupt, the calyx is separated from the head after the vacuum is eliminated. The head is then removed by hand. The duration of the operation should not exceed 15-20 minutes, as the risk of bruising, the formation of cephalohematoma, and brain injury increases.

In case of slipping of the cup, it cannot be shifted more than 2 times due to the great trauma to the fetus. Slipping of the calyx indicates, as a rule, the wrong choice of the method of delivery. If the head is located high enough, sometimes you have to resort to a caesarean section. When it is in the pelvic cavity, it is necessary to apply forceps.

The inefficiency of vacuum extraction is observed in 1-27% of cases.

After the operation of applying a vacuum extractor, especially if the operation was difficult, manual separation of the placenta and a control examination of the walls of the uterus to determine its integrity are indicated. In all cases, after vacuum extraction of the fetus, an examination of the cervix and vagina with the help of mirrors is shown, and if their integrity is violated, suturing is necessary.

Rice. 25.36.

(a) and the beginning of traction (b)

Rice. 25.37..

For the prevention of bleeding in the aftermath and early postpartum periods intravenous administration of uterotonic agents (methylergometrine, oxytocin) is necessary.

Complications. Complications during the vacuum extraction operation can be observed from both the mother’s side (ruptures of the perineum, vagina, small and large labia, clitoris, cervix and rarely rupture of the lower uterine segment, Bladder, symphysis), and the fetus (abrasions and wounds on the head, cephalohematomas, intracranial hemorrhages, etc.).

When a vacuum extractor is applied for fetal hypoxia, 20.2% of children subsequently experience dysfunction of the central nervous system. The relationship of such disorders with the duration of vacuum extraction and the severity of asphyxia before surgery has been established.

If the extraction of the fetus during birth process occurs with the help of a special obstetric device - a vacuum preparation, then this process is defined in obstetrics as vacuum extraction. Consider the main indications for the use of this delivery procedure.

The need for a vacuum extractor

During labor, every woman in labor has a certain risk of perinatal fetal morbidity and death as a result of acute oxygen deficiency. Lack of oxygen can be observed during the entire process of delivery of a woman.

Unfortunately, the medical statistics are not very encouraging. Approximately 70% of all deaths of children during childbirth and before the onset of their 12 months occur due to traumatic brain injury received during labor and directly during childbirth.

Possible complications of vacuum extraction of the fetus are mechanical damage(ruptures of the vagina), perineum, large and small labia. On the part of the fetus, damage to the soft tissues of the head and profuse hemorrhage are possible.

Vacuum extraction of the fetus is the removal of the child from the birth canal using vacuum apparatus. This procedure is used if the second stage of labor is delayed, the child does not move through the birth canal or is under stress.

The vacuum apparatus consists of cups of different diameters and a pump (electric or manual). The first vacuum devices were with metal cups, now they mainly use plastic or silicone, which are less traumatic for the fetus.

The calyx is placed on the fetal head and negative pressure is gradually created in the apparatus, then during the contraction movements are made to help the extraction of the fetus, while the woman in labor is straining.

Pain relief is usually not used as it is necessary Active participation women in labor, but at the request of the mother, local anesthesia can be performed. Episiotomy (dissection of the perineum) with vacuum extraction is performed infrequently and mainly by primiparas.

Vacuum extraction is applied under certain conditions: full opening cervix, no membranes, correct presentation fetus.

A similar vacuum extraction is the procedure for applying obstetric forceps. In principle, these interventions are interchangeable, but the vacuum is used more often, since not all doctors have the skills to use forceps. Cm." " ".

Indications for vacuum extraction of the fetus.

Vacuum fetal extraction is mainly used when it is necessary to urgently remove the baby. There are the following indications for vacuum extraction of the fetus.

Weakness of labor activity.

Fetal hypoxia, if an emergency caesarean section is not possible.

Endometritis in childbirth is an infection of the birth canal, accompanied by fever.

Preeclampsia of the middle and mild degree at mother.

The presence of an extragenital pathology in the mother (cardiovascular, pulmonary and other diseases), which requires the exclusion or reduction of the period of attempts.

There is a vacuum extraction and contraindications.

Extension insertion of the head - frontal, facial, anterior head presentation. To apply the vacuum, the child must be at the entrance to the small pelvis with the back of the head (occipital presentation).

The discrepancy between the size of the pelvis and the size of the fetal head.

Complications of pregnancy, requiring the complete exclusion of attempts. During vacuum extraction, the woman in labor must push, so when the attempts are completely turned off, forceps are used.

Vacuum fetal extraction: implications for mother and child.

With vacuum extraction of the fetus, less often than with the application of forceps, there are injuries to the mother, but injuries to the child occur more often. Most frequent consequences the extraction vacuum for the mother is the rupture of the birth canal. Also, the use of vacuum increases the risk of postpartum infectious complications.

The consequences of vacuum extraction of the fetus for a child can be damage to the scalp, difficult birth of the shoulders, hemorrhages in the eyes, hyperbilirubinemia ( elevated bilirubin or jaundice).

A serious consequence of vacuum extraction is intracranial hemorrhage, but it is extremely rare. More high probability hemorrhage premature babies, so they try not to use a vacuum in preterm birth.

After a vacuum, newborns often develop swelling on the head, which disappears within 48 hours and does no harm.

Often there is such an injury as cephalohematoma, in which a subcutaneous cavity filled with blood forms in the damaged area on the head. Small cephalohematomas go away on their own, in some cases it is required medical intervention(puncture).

Most of the damage in the child occurs when the cup of the device repeatedly slips off the fetal head, prolonged attempts to extract or apply excessive force during the procedure.

With regard to long-term effects such as cerebral palsy, epilepsy, delayed psychomotor development, the conducted studies did not prove their connection with instrumental methods of delivery (vacuum, forceps). These diseases are more associated with fetal hypoxia and some pregnancy complications.

In principle, vacuum extraction of the fetus is safe enough for the mother and child, if carried out according to the indications, taking into account all the conditions and observing the execution technique.

It will be about vacuum extraction of the fetus, and also about the consequences of this procedure.

During my pregnancy, on all ultrasounds, the doctor said that the child has a big head, but all the relatives are big-headed, so I didn’t really worry about this. My gynecologist was not worried either, the pelvis is wide, I have a normal face.

For a period of 40 weeks and 2 days, contractions began at 6 pm, by 12 am the interval was already 5 minutes and it was decided to go to the maternity hospital. In the maternity hospital, an examination, all related procedures, and now I'm already in the maternity block. The opening went slowly and painfully, they anesthetized with no-spoy, but apart from a terrible taste in the mouth, there was no point.

At 11 am next day we decided to pierce the bladder, but it successfully burst itself, the waters were green, they didn’t remove the CTG, terrible pain and the inability to even move because of the sensors on the stomach. As luck would have it, she gave birth on New Year's holidays, there was only one team, and there were many women in labor. The midwife showed me how to breathe correctly in order to push the child to the exit, which I did for the next few hours.

Closer to 5 pm, everyone realized that everything was useless, no matter how hard I tried, my baby didn’t want to be born at all. After the heartbeat began to worsen, a crowd of doctors gathered around me and it was decided to do something with me, since the child’s head was stuck in the birth canal and it was too late to do a cesarean.

At first they persuaded me to try better, but almost a day without sleep and hellish pain exhausted me so much that I no longer had any strength and the contractions weakened. It was decided to make an incision and vacuum extraction.

I heard about this method, but I never thought that I would try it on myself. I won't go into details, there is a lot of information on the web. As a result, I had an episio and pulled out the head with a suction cup, while another doctor pressed me from above on my stomach, since the head was already almost at the exit and I didn’t have to pull hard. I didn’t even feel any manipulations, everything is done in a fight, and there it’s no longer clear what and where it hurts. On my second push, my baby was born. Weight 3240 and head circumference 36 cm. Apgar score 7/8. Neonatologists first said 8/8, but the gynecologist was indignant "what are you saying, the waters there were like a swamp!"

When they showed me my baby I started roar out loud and ask his forgiveness for not being able to give birth to him normally.

The first days the child's head was stretched out like a zucchini, a bruise on the top of the head reminded of a vacuum, but by the time he was discharged, he had almost gone. On the 2nd day they did an ultrasound and said that there were no consequences.

During the first months, the hypoxia also made itself felt, the baby cried a lot, did not allow him to touch his head.

From all the experiences, milk naturally disappeared and I practically began to hate myself, I couldn’t give birth, I still can’t feed, what kind of mother am I. Most likely due to postpartum depression.

Now the child is almost 10 months old, he is developing normally, everything corresponds to his age, but problems are revealed over time. With the growth of the head, the deformation of the skull became noticeable, since it was subjected to great pressure during childbirth, and the resulting neurological problems, such as excitability, poor sleep, hypertonicity, and so on. We have already done 4 courses of massage and are undergoing treatment with an osteopath. The prognosis is good, the main thing is to engage and not let it take its course.

Of course, I don’t wish anyone to experience this, but childbirth is an unpredictable process and anything can happen, the main thing is not to waste time and be sure to observe the child with experienced doctors, of whom, unfortunately, there are fewer and fewer in our time, since such births without consequences are not pass.

To everyone who is waiting, easy delivery and healthy babies!

In the event that the efforts of a woman are not enough for a successful delivery, then they use alternative ways: caesarean section, childbirth with forceps or vacuum extractor. Most expectant mothers are not familiar with the devices used in obstetrics, and therefore are afraid of their use. But the tools are applied in cases where it is justified and ignoring the problem can lead to undesirable consequences for both mother and child.

When are tongs or a vacuum extractor used?

These medical instruments are justified to be used if the cervix is ​​fully open and the widest part of the child's head has already passed into the area under pubic bone. This placement of the fetus indicates that it will successfully pass through pelvic bones, and forceps or a vacuum extractor should be used in order to stretch the soft tissues of the perineum without unnecessary injury.
If the child's skull has not yet reached the mother's pelvis, then instrumental intervention is not justified and can be harmful - a head injury is possible. With this arrangement and weak labor activity, the method of caesarean section is more often used.

With a long 2nd stage of labor or fetal distress, 2 types of auxiliary instruments for delivery are used: a vacuum extractor and obstetric forceps.

Vacuum extractor: the mechanism of action of the tool. Consequences of application and features of use

The tool consists of a bowl, a flexible hose and a mechanism that provides pressure (up to 0.8 kg / cm2).

There are several types of vacuum extractor: with a metal cup (Mallstrom extractor), with a rigid polyethylene bowl and soft silicone ( disposable). Cups with front and rear fixation of the tube have also been developed. This allows you to create a vacuum acentrically and successfully apply them depending on the position of the child's head.

FROM modern medicine disposable flexible silicone cups are predominantly used.

How is a vacuum extractor used?

The procedure is carried out in stages:

● the cup is inserted into the woman's vagina;
● a vacuum is created using a tool;
● traction behind the child's head;
● Removing the bowl from the newborn's head.

The bowl of the vacuum extractor in a vertical-lateral position is inserted and fixed on the child's head. Then the instrument is correctly positioned: the bowl is attached closer to the leading point on the child's head, avoiding the fontanelles. After confirming the correct position of the bowl, a negative pressure is created.

The fixation stage should be carried out with the utmost care: it is unacceptable to attach the bowl to soft tissues mother's body.

When choosing a direction, it is important to take into account the biomechanism of childbirth: the wire point of the child's head moves along the wire axis of the mother's pelvis. When deviating from such a trajectory, bowl distortion and separation of the instrument from the surface of the fetal head are possible.

Tractions should be performed synchronously with attempts and not exceed 4 times; when the cup slips, it can be reapplied again, but no more - the risk of injury to the fetus increases.

During the procedure, an episiotomy is used. With successful extraction of the newborn, the cup is removed, gradually reducing the pressure.

If an attempt at vacuum extraction fails, then conditions arise for childbirth with obstetric forceps.

Complications after vacuum extraction in mother and child

During childbirth with the use of a vacuum extractor for the mother, there are risks of rupture of the soft tissues of the small, large labia, vagina, perineum, clitoris.
The child can get the following complications:
● cephalohematomas;
● injury to the soft tissues of the head;
● hemorrhages.
The silicone bowl of the vacuum extractor is the safest type to use.

Contraindications to the use of a vacuum extractor. When is a tool banned?

There are a number of contraindications, in the presence of which delivery using this instrument is unacceptable. These include:
● dead fetus;
● high straight standing of the child's head;
● frontal or facial insertion of the head;
● incomplete opening of the cervix;
● breech (low) presentation;
● miscarriage (delivery before 30 weeks);
● extragenital or obstetric pathology, which involves the exclusion of the 2nd stage of labor.

Indications for vacuum extraction and prerequisites for the procedure

Indications for the procedure can be from the side of the woman in labor, and from the side of the fetus.

For a future mother, the prerequisite for the procedure may be pregnancy pathologies that require a reduction in the 2nd period of labor:

● septic, infectious diseases, accompanied high temperature;
● weakness of labor activity in the 2nd stage of labor.

A vacuum extractor should be used if fetal distress is observed (in the 2nd stage of labor) and there is no possibility to perform a caesarean section.

Conditions for performing the vacuum extraction procedure:

● living child;
● full disclosure of the cervix;
● lack of fetal bladder;
● anatomical correspondence in the size of the birth canal and head of the child;
● the head should be in the small pelvis of the woman in labor.

Obstetric forceps. Tool structure, types

Obstetric forceps - a medical instrument made of metal, shaped like tweezers. They consist of 2 parts, each of them includes a spoon, a handle and a lock. Spoons are designed with curvature in mind and serve to girth the head; the handle is designed for traction. Depending on the type of lock, there are several types of tongs. On the territory of the Russian Federation, the Simpson-Fenomenov tool is used.
Classification of the instruments used depending on the location of the fetus: there are low cavity (typical) forceps - for applying to the child's head, located in the narrow part of the pelvic cavity, and atypical - when located in the wide part.

Why are forceps used during childbirth?

In modern obstetrics, the instrument is used for delivery if:
● missed time for caesarean section;
● diagnosed with severe preeclampsia, not amenable to treatment;
● weak attempts, generic activity not amenable to medical correction;
● the woman in labor has extragenital pathologies requiring to exclude attempts;
● there is acute fetal hypoxia.
Contraindications for childbirth with forceps are considered large fruit and prematurity.

Indications for the use of obstetric forceps

The imposition of forceps during childbirth is used if:

● the fetus is alive;
● the cervix is ​​fully dilated;
● amniotic sac missing;
● the size of the head of the child and the birth canal of the woman correspond;
● the head of the fetus is located in the narrow part of the pelvic cavity of the woman in labor.

Complications and postoperative rehabilitation after childbirth with the use of forceps

During the rehabilitation period:

● control examination of the uterus in order to verify its integrity;
● monitoring the work of the pelvic organs;
● prevention of inflammatory processes.

Which is better: vacuum extractor or tongs?

There are many stories about how the fetus was damaged by pulling it with forceps during childbirth. The fears of a woman who worries about her child are quite natural. If the pregnancy proceeds with pathologies, then anxiety increases: will such instruments be used and how dangerous is it?

The safety of using the extractor and forceps largely depends on the experience and skills of the doctor.
For a child, the imposition of a bowl can result in a hematoma and swelling of the tissues, and the use of forceps is fraught with cuts.
Vacuum extraction involves less pain relief for the woman in labor, soft tissue ruptures are less common, and rehabilitation is easier.
Efficiency for accelerating labor is approximately the same.

If there are indications for the use of forceps or a vacuum extractor, you should carefully choose a specialist who will take delivery, because the choice and success of using tools depend on his skills, experience and knowledge.