Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #8 Teacher’s Guide
Lesson Title: Vacuum Assisted Delivery/ Vacuum Materials:
Extraction Module, OB book, pens
Learning Targets:
At the end of the module, students will be able to: References:
1. Assess a woman who is experiencing a complication
of pregnancy. Silbert-Flagg , JoAnne and Pilliteri, Adele
2. Formulate nursing diagnoses that address the needs (2018) Maternal and Child Health Nursing, 8th
of a woman and her family experiencing a complication Edition. USA: Lippincott Williams and Wilkins
of pregnancy.
3. Identify expected outcomes to minimize the risks to a Cunningham, F. G., Leveno, K. J., Bloom, S.
L., Dashe, J. S., Hoffman, B. L., Casey, B. M.,
pregnant woman and her fetus when a sudden & Spong, C. Y. (2018). Williams Obstetrics
complication of pregnancy occurs as well as manage (25th ed.). USA: McGraw-Hill Education.
seamless transitions across differing healthcare
settings. Vacuum Assisted Delivery
A. LESSON PREVIEW/REVIEW
B. MAIN LESSON
VACUUM ASSSISTED DELIVERY/VACUUM EXTRACTION (p.1364)
DESCRIPTION INDICATIONS
Suction is created within a cup placed on the Vacuum extraction is reserved for fetuses who
fetal scalp such that traction on the cup aids have attained a gestational age of 34 weeks.
fetal expulsion. Maternal exhaustion
Vacuum extraction has advantages over Drug induced analgesia
forceps birth in that little anesthesia is Soft tissue resistance with failure to descend
necessary, thus leaving the fetus with less Predisposing maternal illness
respiratory depression at birth. Hemorrhage
Relative Cephalopelvic disproportion
Malposition
Malpresentation
Non reassuring fetal heart rate
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Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #8 Teacher’s Guide
CONTRAINDICATIONS PRE-REQUISITES OF THE PROCEDURE
Operator inexperience Procedure should be explained to the patient
Inability to assess fetal position and consent should be taken
High station (above 0 station) Emotional support and encouragement
Suspicion of cephalopelvic disproportion Lithotomy position.
Other presentations than vertex. Bladder should be emptied.
Premature fetus (<34 weeks). Antiseptic measures for the vagina, vulva and
Intact membranes perineum.
Vaginal examination to check pelvic capacity,
cervical dilatation, presentation, position,
station and degree of flexion of the head and
that the membranes are ruptured.
ADVANTAGES DISADVANTAGES
Regional Anesthesia is not required so it is Over natural birth is that more perineal
preferred in cardiac and pulmonary patient. lacerations may occur.
The ventouse is not occupying a space It causes a marked caput on the newborn head
beside the head as forceps. that may be noticeable as long as 7 days after
Less compression force (0.77 kg/cm2) birth.
compared to forceps (1.3 kg/cm2) so injuries Vacuum extraction should not be used as a
to the head is less common. method of birth if fetal scalp blood sampling
Less genital tract lacerations. was used because the suction pressure can
Can be applied before full cervical dilatation. cause severe bleeding at the sampling site.
It can be applied on non-engaged head. Vacuum extraction is not advantageous for
preterm infants because of the softness of the
preterm skull.
COMPLICATIONS
Maternal Fetal
Perineal, vaginal, labial, periurethral and Cephalohematoma.
cervical lacerations. Scalp lacerations and bruising
Cervical incompetence and future prolapse if Subgaleal hematomas-also known as a
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Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #8 Teacher’s Guide
used with incompletely dilated cervix. subgaleal hemorrhage, is a serious
Tears of the genital tract may occur. complication that occurs when blood
accumulates outside of the baby's skull
Examine the woman carefully and repair any tears to (extracranially)
the cervix or vagina, or repair the episiotomy. Intracranial hemorrhage.
Neonatal jaundice
Subconjunctival hemorrhage
Injury of sixth and seventh cranial nerves
Retinal hemorrhage
Fetal death
MANAGEMENT
PROCEDURE RATIONALE
1. Explain the procedure and ask for consent. Explaining the procedure to the client’s cooperation
and will lessen the apprehension.
2. Bladder should be emptied or need to be Bladder emptying helps in dislodging the shoulders.
catheterized.
3. Examine the woman, cervix must be fully dilated. When the cervix is not fully dilated, there's a
significant chance of injuring or tearing the cervix.
Cervical injury requires surgical repair and may lead to
problems in future pregnancies.
4. Determine the position of the fetal head. The anterior fontanelle is larger and forms a cross
The posterior fontanelle is smaller and forms a Y
*REMEMBER: Molding of the head makes
assessment difficult
Think about dystocia if the fetus will fit through the
pelvis
5. Equipment and vacuum needs to be ready Provides efficiency of the procedure and ensures that
no defective materials are used.
6. Application of the cup over the sagittal suture 3cm Flexion point: Proper application of the cup results in
in front of the posterior fontanelle. flexion of the fetal head when traction is applied
The cup is applied by compressing it in an Identification of the flexion point: (as shown below)
anteroposterior diameter and then introducing it into -It is situated 3 cm in front of the posterior fontanelle.
the posterior -Centre of the cup should be overlying the flexion
fourchette while protecting the maternal tissues and point. This placement promotes flexion, descent and
making space with the opposite hand. (as shown autorotation.
below)
If traction is directed from this point the fetal head is
flexed to the narrowest sub-occipitobregmatic
diameter(9.5 cm).
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Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #8 Teacher’s Guide
7. Gentle traction should be applied at right angles to To ensure that no maternal tissue is between the fetal
the plane of the cup. (as shown below) head and the vacuum cup.
This should be reconfirmed before each pull on the
vacuum and following any re-application or suggestion
of loss of contact during traction
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Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #8 Teacher’s Guide
8. Traction is usually applied at settings between 500 The vacuum pressure may or may not be released
and 600 mm Hg (0.6–0.8 kg/cm2 ). between contractions, to resting pressure settings of
between 100 and 200 mm Hg (0.1– 0.3 kg/cm2),
depending on the type of vacuum used.
9. No rotational force should be applied; the fetal Traction should always be in the direction of the
head may rotate on its own with descent. pelvic curve—initially downward and finally upward. A
common error is to attempt to extend the head
prematurely, thereby increasing the diameter that
must pass over the perineum and increasing the
likelihood of perineal trauma.
10. Apply traction with contractions and with maternal After every vacuum delivery, the newborn should be
expulsive efforts. observed to ensure that the expected swelling on the
head does not enlarge significantly and that there is
no evidence of developing hypovolemia, which might
occur with a
subgaleal hemorrhage.
Vacuum failure
Before undertaking any attempt at operative vaginal delivery, consider the risk of failure for vaginal
delivery and the potential for other complications, such as shoulder dystocia and postpartum
hemorrhage.
Ensure adequate assistance is present if such complications should occur.
Consider the fetal status before making your attempt to deliver the baby and the time necessary to
initiate a cesarean section if the procedure fails.
Under circumstances in which fetal well-being is suspect and/or the potential for success of an
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Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #8 Teacher’s Guide
operative vaginal delivery is in doubt, proceed directly to cesarean section, if available. If times
permits, consider transfer to the next level of care.
Whenever operative delivery is considered, a health care provider skilled in newborn resuscitation
should be present at the birth. This person’s sole responsibility must be the care of the newborn.
The vacuum procedure has failed when descent or delivery has not been accomplished.
The procedure should be abandoned at this point, and an alternate method of delivery should be
selected.
When to halt—beware
3 pulls over 3 contractions, no progress abandon procedure
3 pop-offs: after 1, reassess carefully before reapplying
After 20 minutes of application with no progress reassess
The above recommendations should be considered the maximal limits.
The incidence of scalp trauma is increased when the cup application is greater than 10 minutes
compared to less than 10 minutes.
It is imperative that some descent is observed with each pull.
If these limits are approached, progress does not occur or there is evidence of scalp trauma, the
procedure should be abandoned.
Check for Understanding
The instructor will prepare questions that can enhance critical thinking skills. Students will work by themselves
to answer these questions and write the rationale for each question.
1. The following are indications of Vacuum Assisted Delivery, EXCEPT:
A. Drug induced analgesia
B. Relative Cephalopelvic disproportion
C. Malposition
D. Premature fetus
E. Malpresentation
2. The following are advantages of Vacuum Assisted Delivery, EXCEPT:
A. Regional Anesthesia is not required so it is preferred in cardiac and pulmonary patient.
B. Less genital tract lacerations
C. Should be applied only at full cervical dilatation
D. Can be applied before full cervical dilatation
3. The following are disadvantages of Vacuum Assisted Delivery, EXCEPT:
A. The ventouse is not occupying a space beside the head as forceps
B. It causes a marked caput on the newborn head that may be noticeable as long as 7 days after birth.
C. Vacuum extraction should not be used as a method of birth if fetal scalp blood sampling was used because
the suction pressure can cause severe bleeding at the sampling site.
D. Vacuum extraction is not advantageous for preterm infants because of the softness of the preterm skull.
4. The following are maternal complications of Vacuum Assisted Delivery, EXCEPT:
A. Perineal, vaginal, labial, periurethral and cervical lacerations.
B. Cervical incompetence and future prolapse if used with incompletely dilated cervix.
C. Tears of the genital tract may occur.
D. Injury of sixth and seventh cranial nerves
5. Application of the cup over the sagittal suture ____ in front of the posterior fontanelle.
A. 4 cm B. 3 cm C. 5 cm D. 1 cm
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Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #8 Teacher’s Guide
6. Gentle traction should be applied at _____ angles to the plane of the cup.
A. Left B. Right
C. Transverse D. Side
7. Traction is usually applied at settings between __________.
A. 700 to 800 mmHg B. 200 to 300 mmHg
C. 500 and 600 mmHg D. 300 to 400 mmHg
8. The following are indication of a Vacuum Failure, EXCEPT:
A. Ensure adequate assistance is present if such complications should occur.
B. Consider the fetal status before making your attempt to deliver the baby and the time necessary to initiate a
cesarean section if the procedure fails.
C. The vacuum procedure has failed when descent or delivery has not been accomplished.
D. The procedure should be abandoned at this point, and an alternate method of delivery should be selected.
E. It is imperative that some descent is observed with each pull.
9. Assuming fetopelvic disproportion and malpresentation have been ruled out, vacuum extraction
delivery may be appropriate when:
A. Shoulder dystocia occurs
B. Fetal head is rotated 45° from the midline
C. Need to speed delivery for a small preterm baby
D. Failure to descend
10. The following are signs that Vacuum Assisted Delivery should be stop, EXCEPT:
A. The vacuum procedure has failed when descent or delivery has not been accomplished
B. 3 pulls over 3 contractions, no progress abandon procedure
C. After 20 minutes of application with no progress
D. The incidence of scalp trauma is increased when the cup application is greater than 10 minutes compared
to less than 10 minutes.
ADDITIONAL NOTES FOR TEACHERS
ANSWERS and RATIONALE
1. The following are indications of Vacuum Assisted Delivery, EXCEPT:
A. Drug induced analgesia
B. Relative Cephalopelvic disproportion
C. Malposition
D. Premature fetus
E. Malpresentation
ANSWER: D
RATIONALE: Premature fetus is a part of contraindication for Vacuum Assisted Delivery because before 34
weeks of gestation is due to perceived increased risk of birth injuries.
2. The following are advantages of Vacuum Assisted Delivery, EXCEPT:
A. Regional Anesthesia is not required so it is preferred in cardiac and pulmonary patient.
B. Less genital tract lacerations
C. Should be applied only at full cervical dilatation
D. Can be applied before full cervical dilatation
ANSWER: C
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Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #8 Teacher’s Guide
RATIONALE: Vacuum Assisted Delivery can be applied before full cervical dilatation on Forceps assisted
delivery it should be applied only when the client is on full cervical dilatation.
3. The following are disadvantages of Vacuum Assisted Delivery, EXCEPT:
A. The ventouse is not occupying a space beside the head as forceps
B. It causes a marked caput on the newborn head that may be noticeable as long as 7 days after birth.
C. Vacuum extraction should not be used as a method of birth if fetal scalp blood sampling was used because
the suction pressure can cause severe bleeding at the sampling site.
D. Vacuum extraction is not advantageous for preterm infants because of the softness of the preterm skull.
ANSWER: A
RATIONALE: The ventouse is not occupying a space beside the head as forceps is part of advantages of
Vacuum Assisted Delivery.
4. The following are maternal complications of Vacuum Assisted Delivery, EXCEPT:
A. Perineal, vaginal, labial, periurethral and cervical lacerations.
B. Cervical incompetence and future prolapse if used with incompletely dilated cervix.
C. Tears of the genital tract may occur.
D. Injury of sixth and seventh cranial nerves
ANSWER: D
RATIONALE: Injury of the sixth and seventh cranial nerves are part of fetal complications of Vacuum Assisted
Delivery.
5. Application of the cup over the sagittal suture ____ in front of the posterior fontanelle.
A. 4 cm
B. 3 cm
C. 5 cm
D. 1 cm
ANSWER: B
RATIONALE: Proper application of the cup results in flexion of the fetal head when traction is applied. It is
situated 3 cm in front of the posterior fontanelle.
6. Gentle traction should be applied at _____ angles to the plane of the cup.
A. Left
B. Right
C. Transverse
D. Side
ANSWER: B
RATIONALE: Gentle traction should be applied at the RIGHT angles to the plane of the cup this is to ensure
that no maternal tissue is between the fetal head and the vacuum cup.
7. Traction is usually applied at settings between __________.
A. 700 to 800 mmHg
B. 200 to 300 mmHg
C. 500 and 600 mmHg
D. 300 to 400 mmHg
ANSWER: C
RATIONALE: Traction is usually applied at settings between 500 to 600 mmHg. The vacuum pressure may or
may not be released between contractions, to resting pressure settings of between 100 and 200 mm Hg (0.1–
0.3 kg/cm2), depending on the type of vacuum used.
8. The following are indication of a Vacuum Failure, EXCEPT:
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Care of Mother and Child At-Risk or
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Module #8 Teacher’s Guide
A. Ensure adequate assistance is present if such complications should occur.
B. Consider the fetal status before making your attempt to deliver the baby and the time necessary to initiate a
cesarean section if the procedure fails.
C. The vacuum procedure has failed when descent or delivery has not been accomplished.
D. The procedure should be abandoned at this point, and an alternate method of delivery should be selected.
E. It is imperative that some descent is observed with each pull.
ANSWER: E
RATIONALE: Choice E is not part of the indication for a vacuum failure but a warning to stop Vacuum Assisted
Delivery
9. Assuming fetopelvic disproportion and malpresentation have been ruled out, vacuum extraction
delivery may be appropriate when:
A. Shoulder dystocia occurs
B. Fetal head is rotated 45° from the midline
C. Need to speed delivery for a small preterm baby
D. Failure to descend
ANSWER: B
RATIONALE: Fetal head is rotated 45 degrees from the midline is appropriate because there is a possibility
that vacuum assisted delivery will be successful.
10. The following are signs that Vacuum Assisted Delivery should be stop, EXCEPT:
A. The vacuum procedure has failed when descent or delivery has not been accomplished
B. 3 pulls over 3 contractions, no progress abandon procedure
C. After 20 minutes of application with no progress
D. The incidence of scalp trauma is increased when the cup application is greater than 10 minutes compared
to less than 10 minutes.
ANSWER: A
RATIONALE: The vacuum procedure has failed when descent or delivery has not been accomplished is a part
of Vacuum Assisted failure.
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