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Objective: To compare the efficacy, safety and cost-effectiveness of Manual vacuum aspiration (MVA) with Electrical vacuum aspiration (EVA) in the management of first trimester pregnancy loss., Methods: A single-centre randomized controlled trial (RCT) was conducted at Maternal and Child Health Centre (MCHC), Unit-I, Pakistan Institute of Medical Sciences (PIMS), Islamabad from April 2007-Dec 2008. A total of 176 cases with early pregnancy loss at < 12 weeks gestation, with a diagnosis of anembryonic pregnancy, incomplete, missed or septic induced abortion and molar pregnancy were randomly allocated to either MVA or EVA in the operation theatre., Results: A total of 176 women were included out of which 70 underwent EVA and 106 had MVA. Baseline characteristics were similar in the two groups except significantly higher gestational age and gestational sac diameter in MVA group. Majority of EVA were performed under general anaesthesia (95.7%) while majority of MVA were performed under paracervical block (60.3%). Complete evacuation was achieved in 89.6% with MVA vs 91.4% with EVA (p=0.691). MVA was superior in terms of significantly less blood loss (62.08 +/- 32.19 vs 75.71 +/- 35.53; p=0.008), shorter hospital stay (12.26 hours +/- 6.97 vs 19.54 hours +/- 7.95; p=0.000) and less hospital cost (Rs 1419.5 +/- 1337.620 vs Rs. 3222.5 +/- 1816.02; p=0.000). Post-operative pain assessment by visual analogue score (VAS) at 0 and 6 hours showed no significant difference (p=0.845 and p=0.157 respectively). The only complication was uterine perforation in 2 (2.4%) cases both belonging to EVA., Conclusion: MVA is a safe and effective alternative of conventional EVA. It is superior to EVA in terms of reduced cost and need for general anaesthesia and is thus useful at low resource setting with scarcity of electricity and general anaesthesia.

Instrumental deliveries are believed to be associated with increased maternal and, especially, fetal morbidity and mortality. Hence, it is less practiced in many developing countries. The aim of this retrospective study, conducted between 1 January 2007 and 31 December 2008, was to assess the prevalence, indications, neonatal wellbeing and maternal complications of instrumental deliveries. Of 3623 vaginal deliveries, 84 (2.3%) instrumental deliveries were conducted. The most common indication was a prolonged second stage of labour. Fetal wellbeing, measured by the Apgar score, was good and was similar in the group who had forceps delivery and that of the vacuum extraction delivery group. Maternal complications, usually minor, were vaginal and perineal tears. Instrumental delivery should be encouraged and taught in order to reverse the rising caesarean section rate.

Aim: To evaluate maternal and fetal complications resulting from the use of the Kiwi vacuum extractor and to compare them with those resulting from the use of forceps or spatula., Patients and Methods: Patients who had instrumental extraction between November 2006 and April 2007 were included in a unicentric retrospective study. Complications resulting from the use of Kiwi vacuum extractor and those of other instruments were compared., Results: One hundred and sixty-nine patients where included, 79 had extraction with Kiwi vacuum extractor. The two populations (women having extraction with Kiwi and woman having extraction with spatula or forceps) were similar in terms of maternal characteristics, progress of labour and delivery. The rate of episiotomies was significantly lower with KIWI (73.1% versus 94.4%; P=0.0001), as well as was postpartum haemorrhage rate (8.9 % versus 18.9%; P=0.04). No perineal tear of second or third degree occurred with Kiwi. Kiwi vacuum extractor was associated with a higher rate of shoulder dystocia (12.8% versus 6.7%, NS), but related fetal complication rates were similar in the two groups. The extraction failure rate was significantly higher with Kiwi (11.4% versus 4.4%; P=0.04), but cesarean section rate was similar for the two groups (1.3 % versus 4.4%)., Discussion and Conclusion: This study is the first comparing complications occurring after extraction with KIWI vacuum extractor to those occurring with other instruments. Although the results are limited by the retrospective nature of the study and the small size of the workforce, our study suggests that Kiwi vacuum extractor is associated with a lower rate of maternal complications and a rate of fetal complication similar to other kind of instruments. This instrument should be promoted and taught to younger patricians. Our study also revealed higher failure and shoulder dystocia rates. Larger studies are needed to better evaluate risks factor concerning these two complications in order to optimise the use of Kiwi vacuum extractor., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Objective: To summarize available data concerning vacuumextraction and it's use in the Czech Republic., Design: Review article., Methods: Compilation of published data from scientific literature., Conclusion: The rate of vacuumextraction use in the Czech Republic is one of the lowest in the world. Forceps is usually the preferred technique. The use of vacuumextraction is on the rise, the limiting factor is the fact that in Czech Republic it is not recommended in cases with presumed fetal distress. According to world literature, the preferred technique in cases where operative vaginal delivery is indicated should be vacuumextraction due to significantly lower risk of maternal trauma. An obstetrician should be familiar with both techniques--vacuumextraction and forceps. It up to him/her which instrument is used based on his/her own competency, experience and circumstances of the labour.

Purpose: The main goal of this study was to investigate the impact of parity and intrauterine fetal condition on vacuum extraction., Material and Methods: This study included 10742 newborns who were delivered during 2008 in obstetrics/gynecology clinics in Kosovo, Yugoslavia. One hundred fifty-eight of these were vacuum deliveries. Data were collected for indicators such as parity, maternal age, gestation duration, newborn vitality, and birth weight., Results: Vacuum extraction was used in 158 cases (1.47 %), of whom 116 (73%) were nulliparous and 42 (27%) were multiparous. In 121 cases (76.5%), vacuum extraction was performed in women with no history of abortion, and 101 (64%) of the women were aged 21-30 years. The main reason for vacuum extraction in 115 women (72%) was arrest (stasis) in the second stage of labor. Vacuum extraction was carried out at a gestational age of 34-40 weeks in 94 cases (59.5%). Amniotic fluid was clear in 125 cases (80%), and meconial amniotic fluid was seen in three cases (1.8%). Birth weight was > 3.5 kg in 77 infants (48.5%) and < 2.5 kg in seven (4.5%). Apgar score (AS) was 0-3 in 19 (12%), 4-7 in 129 (81.6%), and 8-10 in eight (6.4%) infants. In 91 cases (57.6%), newborn resuscitation was necessary and neonatal complications occurred in 11 cases (6.96%)., Conclusions: We conclude that vacuum extraction was performed mostly in nulliparous women aged 21-30 years. Most newborn infants had a birth weight of > 3.5 kg, the most frequent AS was 4-7, and newborn resuscitation was needed in most cases.

Vacuum extraction is one of the methods for assisted vaginal delivery. In this article the evolution of vacuum extraction in obstetrics is been discussed. Historical facts and data from the invention up to state-of-the-art vacuum systems in modern obstetrics are presented.

Ultrasound may play an important role in the management of labor and delivery. Induction of labor is a common obstetric intervention, performed in about 20% of pregnancies. Pre-induction cervical length, measured by transvaginal sonography, has been shown to have a significant association with the induction-to-delivery interval and the risk for cesarean section. In the management of labor there is extensive evidence that digital pelvic examination does not provide accurate assessment of the position and descend of the fetal head both during the first but also in the second stage of labor. Several recent studies using both two- and three-dimensional ultrasound have now described objective measures of progression of the fetal head during labor. In instrumental deliveries an important determinant of a successful and safe use of vacuum and forceps is the correct determination of the fetal head position and appropriate application of the instrument. However, ultrasound studies have shown that digital examination before instrumental delivery fails to identify the correct fetal position in a high proportion of cases. The use of ultrasound is of crucial importance in performing a safe operative delivery and can help in the prediction of whether a vaginal delivery would be successful., (2010 S. Karger AG, Basel.)

Objectives: The objectives of this study were to define the components of a skilled low-cavity non-rotational vacuum delivery (occiput anterior, vertex at station +2 or below and less than 45-degree rotation from midline) and to facilitate the transfer of skills from expert to trainee obstetricians., Design: Qualitative study using interviews and video recordings., Setting: Two university teaching hospitals (St Michael's Hospital, Bristol, and Ninewell's Hospital, Dundee)., Participants: Ten obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries., Methods: Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low-cavity vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and compared for consistency of interpretation. The experts reviewed the coded interviews and video data for respondent validation and clarification. The themes that emerged following the final coding were used to formulate a list of skills., Main Outcome Measures: Key technical skills of a low-cavity non-rotational delivery., Results: The final list included detailed technical skills required for conducting a low-cavity vacuum delivery. The combination of semi-structured interviews and simulation videos allowed the formulation of a comprehensive skills tool for future evaluation., Conclusion: This explicitly defined skills list could aid trainees understanding of the technique of low-cavity vacuum delivery. This is an important first step in evaluating clinical competence in intrapartum procedures.

The vacuum extractor, as opposed to other instruments, does not increase the fetal head diameter for vaginal delivery. Introduced half a century ago, this device is today widely used in many countries probably because of a learning-curve which is acquired quicker than for the forceps. Major benefits obtained are the flexion of the fetal head provided that the cup is correctly placed, and the compulsory rotation induced that is most useful in the conversion of occiput posterior or transverse to anterior positions. The limitations reside in the need for maternal effort at expulsion and in the fact that it is unsuitable for face presentations. Moreover, like other instruments, the vacuum extractor can be harmful and even dangerous to the mother and her fetus. Therefore, its indications and contra-indications must be respected, and its operative use mastered with as much precision as for the forceps.

The second stage of labor is a dynamic event that may require assistance when maternal efforts fail to effect delivery or when there are nonreassuring fetal heart tones. Therefore, knowing how to perform an operative vaginal delivery with forceps or vacuum is vital for family physicians who provide maternity care. Vacuum is rapidly replacing forceps as the predominant instrument, but each has advantages and disadvantages, including increased risk of maternal trauma with forceps and increased risk of neonatal cephalohematoma with vacuum. Use of a second instrument if the first one fails is associated with worse outcomes. Routine episiotomy in operative vaginal delivery is no longer recommended. The "ABCDEFGHIJ" mnemonic can facilitate proper use and application of the vacuum device and minimize risks, and practicing the techniques on mannequins can provide an introduction to the skills of operative vaginal delivery.

Background: Vacuum extraction is a common technique of assisted vaginal delivery. Traditionally, it has been recommended that the pressure is increased slowly in a stepwise procedure; some have advocated rapid increases in pressure., Objectives: To assess the efficacy and safety of rapid versus stepwise negative pressure application for assisted vaginal delivery by vacuum extraction., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008)., Selection Criteria: Randomized controlled trials and quasi-randomized controlled trials of rapid compared with stepwise increase in negative pressure application of vacuum extraction., Data Collection and Analysis: Two authors independently assessed trial quality and extracted data., Main Results: One trial of 94 women was included. Duration of vacuum procedure was reduced in rapid application group (mean difference -6.10 minutes, 95% confidence interval -8.83 to -3.37). There were no significant differences in detachment rate, degree of perineal tears, Apgar score less than seven at one and five minutes, umbilical venous pH less than 7.2, scalp laceration greater than a quarter, cephalhematoma and number of tractions., Authors' Conclusions: The rapid negative pressure application for vacuum assisted vaginal birth reduces the duration of the procedure whilst there is no evidence of differences in maternal and neonatal outcome. Due to a small number of participants in the single included trial, the evidence is limited and either policy may be employed until further controlled trials provide conclusive evidence of benefit from one or other method.

Objective: To determine the maternal and perinatal outcomes associated with delivery by the rigid plastic OmniCup vacuum delivery device., Methods: We conducted a prospective observational study of 1000 consecutive vacuum-assisted deliveries using the OmniCup vacuum device in singleton pregnancies. The relationship of the cup application to the flexion point was independently observed after delivery and related to the neonatal outcome, including scalp trauma., Results: Of the 1000 women, 70% were nulliparous and 30% parous (> or = para 1). In 87.1% of the women, vacuum-assisted delivery was completed; spontaneous or forceps delivery occurred in 10.9%, and Caesarean section was performed in 2%. The vacuum was applied for < or = 10 minutes in 97.4% of deliveries, < or = 3 pulls were required in 95.6%, and < or = 25 lb traction force was required in 85.7% of cases. There was a statistically significant relationship between unfavourable cup applications (deflexing and paramedian) and scalp trauma in infants born to nulliparous women (P < 0.01). Four cases of neonatal intracranial hemorrhage (0.4%) were identified, and three of these infants were subsequently neurodevelopmentally normal. There was one subgaleal hemorrhage., Conclusions: There is a relationship between unfavourable cup application during vacuum assisted delivery and neonatal scalp trauma in infants born to nulliparous women.

Objective: To compare maternal morbidity after Thierry's spatulas or vacuum-assisted deliveries., Patients and Methods: Retrospective study, at the French hospital la Conception, in Marseilles. All successful instrumental deliveries between November 2003 and May 2005 were reviewed, that is to say 264. Univariate and multivariate analysis were performed comparing maternal morbidity in the two groups. The primary outcome measure was perineal trauma. Secondary outcomes were blood loss and duration of hospitalization., Results: Among the 264 deliveries, there were 96 vacuum deliveries and 168 Thierry's spatulas extraction. Thierry's spatulas were use more often in nulliparous patient (<0.001). Patients in the group of Thierry's spatulas have a higher rate of epidural analgesia (p=0.05), a longer duration of first (p=0.002) and second stage of labor (p=0.03). There was no difference in incidence of sphincter tears between women who underwent Thierry's spatulas and those who underwent vacuum delivery with respective incidence of 4.2 and 3.2% (p=0.67). There was a significant difference in post-partum hemoglobin value with a higher blood loss in the group of Thierry's spatulas (<0.001). Mean duration of hospitalization was longer in the group with Thierry's spatulas (5.6 days) than in the group who underwent vacuum delivery (4.7 days) (p<0.001)., Discussion and Conclusion: Incidence of third degree tears was similar between the vacuum and Thierry's spatulas group. Deliveries with vacuum are associated with less blood loss and a shorter hospitalization stay.

After centuries of use in obstetrics, have forceps and vacuum deliveries become a dying art? Contemporary trends in operative vaginal delivery show increasing numbers of vacuum deliveries and decreasing numbers of forceps deliveries worldwide. Primary drivers of such trends include concerns over neonatal and maternal safety as well as fewer clinicians skilled in forcep use. Current literature reports a comparable efficacy rate for the two instruments, as well as a decrease in maternal morbidity compared with cesarean section. It has also been suggested that the neonatal morbidity once associated with operative vaginal delivery may actually be a function of an abnormal labor process itself, rather than a consequence of an operative vaginal intervention. Both the American College and the Royal College of Obstetricians and Gynecologists continue to support the use of both vacuum and forceps and strongly encourage residency programs to incorporate the teaching of these skills into their curricula.

Objectives: The aim of our study was to define the influence of mode of delivery in term breech presentation on the Apgar score and transfert in neonatal care unit using our university hospital protocol., Material and Method: We conducted a retrospective study. The study included 568 singleton term pregnancies during the period January 1996 to December 2005. The main selection criteria were Apgar score and transfert in neonatal care unit., Results: Analysis of the Apgar scores at 1.5 and 10min and transfer in neonatal care unit do not show any statistical difference., Conclusion: The absence of a difference in neonatal prognosis is to allow vaginal delivery to be carried out. To carry on with the teaching of obstetrical manoeuvres makes it possible to avoid pointless surgical intervention and a bad maternofoetal prognosis in the event of an unexpected breech presentation.

Objectives: When all the breech conditions for the acceptance of a vaginal breech birth are present, we occasionally practise a total breech extraction for non frank breech presentations. Similarly, for frank breech presentations, instead of using the fetal leg as tractor, we sometimes apply the vacuum extractor on the breech presentation in order to perform the first step of the total breech extraction. The vacuum extractor is not traumatic for the fetus and enable a quick extraction. This study was conducted to describe the technique we use in our ward., Patients and Methods: A retrospective study including every singleton delivery with a breech presentation and a tried and assisted vaginal delivery using the vacuum extractor in our maternity ward from 1994 to 2004. A descriptive analysis of maternal, fetal and obstetrical elements has been carried out., Results: Twenty-eight deliveries were indexed. In each case, a vaginal delivery was performed. Neonatal outcomes were satisfactory with a five minutes Apgar score always higher than 7. In all 96.5% of the extractions were realized under pelvic level +2. The main indication of extraction (78.5%) was a second stage of labour which was too long., Conclusion: Obstetricians should know several techniques to accept and to manage breech deliveries. Indications for assisted vaginal delivery using the vacuum extractor in frank breech presentation are unusual, concerning delay in the second stage with an engaged foetus. This technique may avoid some cesarean sections. Nevertheless vaginal breech delivery try should be happening with great caution and with a strict patient's eligibility.

Objectives: Cesarean section has largely replaced the role of difficult midcavity instrumental deliveries. The aim of this study was to determine the trend in trials of instrumental delivery as well as the maternal and fetal factors associated with successful and failed trial of instrumental deliveries., Setting: North Middlesex University Hospital, a teaching hospital in London., Study Design: A retrospective review of trials of instrumental delivery in theatre involving singleton term pregnancies between 2000 and 2005., Results: Of the 114 trials, 82 (40 forceps and 42 vacuum extraction) were successful. Women who had successful trials were similar in age (27.8+/-5.9 vs. 27.1+/-5.4 yrs), gestation (40.5+/-2.1 vs. 40.5+/-1.1 wks) and parity (0.4+/-1.2 vs. 0.3+/-1.6) when compared to those who were unsuccessful (p>0.05). The two groups also had similar birth weight (3.6+/-0.7 vs. 3.7+/-0.4 kg) and duration of second stage (164.9+/-12.0 vs. 162.8+/-16.0 min) (p>0.05). Babies born following failed trial of instrumental deliveries were more likely to be acidotic (p=0.014) but admission to Special Care Baby Unit was similar in both groups. Women who had failed trials of instrumental delivery were more likely to have post-partum hemorrhage (802.7+/-100.0 vs. 425.4+/-120.0 ml) and pyrexia (15.6% vs. 6.1%) (p<0.05). Trial of instrumental delivery was twice as likely to fail if occipito-posterior and three times more likely to succeed if the presenting part was visible (p<0.05). However, 25% of babies had presenting parts well below the ischial spines but still had instrumental deliveries in theatre and 80% of this subgroup were delivered by junior trainees. Although 71.9% of trials of instrumental delivery were successful, many were relatively uncomplicated and did not necessarily require delivery in theatre., Conclusion: Unsuccessful trials are associated with maternal rather than neonatal morbidity. The shortening of duration training as well as reduction of working hours in the United Kingdom has led to obstetric trainees being less experienced in conducting instrumental deliveries. Thus, many junior trainees may prefer to conduct relatively uncomplicated instrumental deliveries in theatre. Appropriate training and senior staff input would help reduce this.

Background: As an alternative to electric vacuum aspirations (EVA), there is an increasing interest in using manual vacuum aspiration (MVA)., Objective: To compare the safety, efficacy and acceptability of MVA with those of EVA for first-trimester abortion., Search Strategy: We searched MEDLINE, EMBASE, Cochrane Library and Chinese Biomedical Database in all language, together with reference lists of retrieved papers., Selection Criteria: Randomised controlled trials comparing MVA with EVA for first-trimester abortion were included. The outcomes are complete abortion rate, uterine perforation rate, blood loss, pain perception and acceptability., Data Collection and Analysis: Two reviewers independently extracted the data. Results from the trials were combined to calculate relative risks (RRs) or risk differences for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes, together with 95% CIs., Main Results: Ten trials were included, involving 1660 women. Generally, the methodological quality was poor. There were no statistically significant differences, comparing MVA with EVA, in complete abortion rate (RR 1.00; 95% CI 0.99-1.02) and participants' satisfaction (RR 1.02; 95% CI 0.87-1.20). In participants with less than 50 days of gestational age, less blood loss (WMD -1.84; 95% CI -2.45 to -1.23) and less severe pain perception (RR 0.04; 95% CI 0.01-0.12) were reported during the MVA procedure, whereas the operation time was shorter (WMD 0.32; 95% CI 0.02-0.63) in the EVA procedure., Author's Conclusions: There is some evidence that MVA is as effective and acceptable as EVA and might be safer than EVA.

Unlabelled: The aim of the study is to investigate the benefits and the limits in using the soft cup vacuum extractor on the fetal scalp during the caesarean section., Material and Methods: The prospective study includes 19 cases of caesarean sections (group A), with vacuum assisted delivery using the soft cup vacuum extractor on the fetal scalp (diameter 6 cm) and 25 cases (group B) of caesarean sections with usual, manual extraction of the head assisted by fundal compression. All of the patients had undergone a planned caesarean section on term in absence of uterine activity and preserved amniotic membranes., Results: Our results doesn't show differences in the Apgar score on the first and 5-th minute in the newborns of the two groups. The duration of the scalp traction was significantly shorter (30 +/- 4 sec) in comparison to the classical manual extraction (53 +/- 21 sec). The mean duration for applying the vacuum cup was 10 sec and 25 sec for tractions. The total blood loose and total duration of the caesarean sections were shorter than in the control group. The applied traction with the vacuum cup was sufficient for head extraction and there was no need for additional fundal compression. In conclusion we consider that the extraction of the fetal head in high position in caesarean section with vacuum extractor is an easy, non traumatic and rapid method which can put away the need of rough and prolonged fundal compression and its consequences.

Objective: To investigate whether the accuracy of vacuum cup placement can be improved by intrapartum ultrasound assessment of the fetal head position during the second stage of labor prior to vacuum extraction for prolonged second stage., Methods: 50 women undergoing vacuum extraction for prolonged second stage were randomly allocated to either digital examination (n=25) or digital examination together with transabdominal intrapartum ultrasound (n=25) prior to vacuum extraction by the attending obstetrician. The distance between the centre of the chignon and the flexion point was then measured by a midwife immediately after delivery. The flexion point was defined as 6 cm posterior to the anterior fontanelle or 3 cm anterior to the posterior fontanelle., Results: There were no statistically significant differences in the demographic data, duration of labor, incidence of induction/augmentation, and intrapartum complications between the two groups. The mean distance between the centre of the chignon and the flexion point was 2.1+/-1.3 cm in the group with digital examination and ultrasound assessment and 2.8+/-1.0 cm in the group with digital examination alone. The difference in the mean distance between the two groups was statistically significant (p=0.039)., Conclusion: Intrapartum transabdominal ultrasound assessment of the fetal head position during the second stage of labor improves the accuracy of vacuum cup placement during vacuum extraction for prolonged second stage.

Approximately one in ten deliveries in the Western world is an instrumental vaginal delivery. Like other surgical operations, instrumental vaginal delivery has its complications, and the operator is obliged to critically appraise the indication for the procedure and the background risk factors, and communicate effectively with the woman. Also, it calls for team work. The safe approach to instrumental delivery should therefore be similar to that adopted for other surgical operations in terms of preoperative assessment, intraoperative precautions and postoperative care. Safe practice in instrumental delivery addresses the various types of error that may occur, and places a strong premium on operator skills, competence, and familiarity with the particular instrument. This chapter reviews good practice in the conduct of instrumental delivery, highlights what could go wrong, and outlines interventions that could reduce the incidence of harm. Issues relating to communication and consent as well as training and documentation are discussed. Indications for abandonment are outlined, and the importance of situational awareness is emphasized. Safe practice tips are amply provided.

The vacuum extractor Kiwi OmniCup (Clinical Innovations, Muray, Utah, USA) has been developed to provide several advantages. This is a complete system with an integral hand-held vacuum operated by the obstetrician. This is also a single use instrument, which may reduce the risk of potential transmission of infections and the logistic of sterilization process. Further potential benefits of this system include the smaller overall equipment size and the ability to measure traction force. However, the data about its efficiency remain conflicting. The first works demonstrated very high successful rate of vaginal delivery, whereas two recent randomized studies showed that the Kiwi Omnicup was less efficient than currently used vacuum extractor. It appears to be as safe as conventional a device for both mother and newborn. However, further additional data remain necessary needed to complete its evaluation.

Objective: Having studied intrapartum translabial ultrasound (ITU) to define easily obtainable sonographic criteria during maternal pushing, we used it dynamically immediately before vacuum extraction to determine its use in predicting successful operative vaginal delivery., Methods: In a pilot study, maternal and fetal landmarks were determined sonographically during maternal pushing from a mid-sagittal translabial insonation using a curved array transducer in women delivering singleton fetuses in cephalic presentation spontaneously. With this transducer placed infrapubically ('infrapubic plane'), easily obtainable landmarks and signs were: (i) the 'infrapubic line', perpendicular to the long axis of the pubic joint and extending dorsally from its inferior margin in a mid-sagittal plane, (ii) the widest fetal head diameter and its movement with regard to the infrapubic line during pushing, and (iii) the 'head direction' with respect to the long axis of the symphysis. A three-dimensional reconstruction from a computed tomographic (CT) dataset of a normal female pelvis was then used to quantify accurately the spatial relationship between the infrapubic line and the anatomical landmarks. Finally, 20 pregnant women in spontaneous term labor with normal singleton fetuses in cephalic presentation and clinical indication for vacuum extraction were studied by ITU immediately before operative vaginal delivery., Results: CT reconstruction demonstrated the infrapubic line to be 3 cm cranial to the parallel interspinous plane. Eleven of the 20 vacuum deliveries with the 'head-up' sign (head pointing ventrally) and objective descent of the fetal head below the infrapubic line, both noted at the height of pushing, resulted in successful ('simple' or 'moderately difficult') operative delivery. Lack of descent or lack of passage below the infrapubic line and horizontal or downward head direction were poor prognostic signs., Conclusions: ITU provides objective information on the dynamics of the second stage of labor, head station and head direction. ITU may be used to assess the prognosis for operative vaginal delivery., (Copyright (c) 2006 ISUOG.)

Objectives: To establish the true prevalence of clinically recognisable and occult obstetric anal sphincter injuries (OASIS)., Design: Prospective interventional study., Setting: Busy district general hospital., Sample: Two hundred and fifty-four women having their first vaginal delivery over a 12-month period were invited. Two hundred and forty-one (95%) participated and 208 (86%) attended follow up., Methods: Women had a clinical examination at delivery by the accoucheur and repeated by an experienced research fellow immediately after delivery. All identified OASIS were verified and repaired by the duty specialist registrar or consultant. Endoanal ultrasound was performed immediately postpartum prior to suturing and repeated seven weeks later., Main Outcome Measures: Prevalence of recognised and occult anal sphincter injuries., Results: Fifty-nine (24.5%) women sustained OASIS. The prevalence of OASIS increased significantly from 11% to 24.5% when women were re-examined. Of these, 30 occurred in deliveries by midwives who missed 26 (87%) and 29 following deliveries by doctors who missed 8 (28%) injuries. All clinically apparent OASIS were also identified on endoanal ultrasound. In addition, three (1.2%) women had an occult anal sphincter injury. Two of these occult sphincter injuries were isolated to the internal anal sphincter (IAS) and would not usually be clinically detectable., Conclusions: OASIS occur more frequently than previously reported. Many remain undiagnosed and are subsequently classified as occult when identified on anal endosonography. Genuine occult injuries are rare. Training in perineal anatomy and recognition of OASIS needs to be enhanced in order to increase detection of OASIS and minimise the risk of consequent anal incontinence.

Objective: To provide guidelines for operative vaginal birth in the management of the second state of labour., Options: Nonoperative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth., Outcome: Reduced fetal and maternal morbidity and mortality., Evidence: MEDLINE and Cochrane databases were searched using the key words "vacuum" and "birth" as well as "forceps" and "birth" for literature published in English from january 1970 to June 2004. The level of evidence and quality of recommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination., Recommendations: (1) Nonoperative interventions such as one-to-one support, partogram use, oxytocin use, and delayed pushing in women using epidurals will decrease need for operative birth (I-A). (2) Manual rotation may be used alone or in conjunction with instrumental birth with little or no increased risk to the pregnant women or the fetus (III-B). (3) Routine episiotomy is not necessary for an assisted vaginal birth (II-1E). (4) When operative intervention in the second stage of labour is required, the options, risks, and benefits of vacuum, forceps, and Caesarean section much be considered. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other (II-B). (5) Failure of the chosen method, vacuum and/or forceps, to achieve delivery of the fetus in a reasonable time should be considered an indication for abandonment of the method (III-C). (6) Adequate clinical experience and appropriate training of the operator are essential to the safe performance of operative deliveries. Hospital credentialing boards should grant privileges for performing these techniques only to an appropriately trained individual who demonstrates adequate skills (III-C)., Validation: The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.

Purpose: Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is now a common procedure for ulcerative colitis (UC). Moreover, it has been reported that fertility is preserved in women who undergo this procedure, many of whom can experience normal delivery., Methods: We assessed the perinatal outcomes and changes in anal function in four women, aged from 27 to 35 years, who gave birth after undergoing IPAA for UC. Pregnancies were confirmed 15-111 months after IPAA, three women had full-term pregnancies, and one gave birth after 31 weeks' gestation., Results: Cephalic delivery with a vacuum extractor was used for one patient, and another underwent cesarean section. The other two patients experienced normal delivery. None of the patients needed artificial insemination and none had any symptoms of intestinal obstruction during their pregnancy. After delivery, two patients suffered a transient increase in bowel frequency and soiling, which gradually resolved., Conclusions: Although transient anal dysfunction occurred in the puerperal period, there were no changes in anal function during pregnancy. Therefore, there are no factors directly prohibiting pregnancy and vaginal delivery in women who undergo IPAA for UC.

Objective: The objective of this study is to compare the relative safety of 2 techniques for surgical abortion late in the second trimester.Study design Retrospective review of patients who underwent surgical abortion at >or=20 weeks' gestation at our hospital from June 1996 through June 2003. Records were reviewed to determine whether the technique used was dilation and evacuation or intact dilation and extraction. Subsequent pregnancies at our hospital were identified, and obstetric outcomes were recorded. Categorical data were compared with Fisher exact test and chi(2) analysis. Continuous data were compared with Mann-Whitney U test., Results: Three hundred eighty-three patients met inclusion criteria. Intact dilation and extraction was performed in 120 cases, and dilation and evacuation was used in 263. Intact dilation and extraction was associated with higher parity, later gestational age, and more preoperative cervical dilation. There was no difference in procedure time or estimated blood loss in the 2 groups. Complications occurred in 19 cases (5.0%), and occurred with similar frequency in the 2 groups. We identified 62 subsequent pregnancies. There were no second-trimester miscarriages. Spontaneous preterm birth occurred in 2 of 17 (11.8%) pregnancies in the intact dilation and extraction group, compared with 2 of 45 (4.4%) in the dilation and evacuation group (P=.30)., Conclusion: Outcomes appear similar between patients undergoing dilation and evacuation and intact dilation and extraction after 20 weeks' gestation. Subsequent obstetric outcomes are similar between the 2 groups. The technique for surgical abortion should be determined by the physician on the basis of intraoperative factors.

Objective: To evaluate the clinical performance of a hand-held vacuum delivery system., Methods: Between December 1999 and September 2000, a prospective audit was undertaken of all vacuum deliveries performed at Derby City General Hospital., Results: In this period, 3296 deliveries occurred, of which 317 (9.6%) were by vacuum. Of these, data were collected on 300 (94.6%), 78 deliveries with the hand-held vacuum and 222 with standard vacuum. There were no differences in the demographic profiles, indication, gestational age at delivery, or birth weights between the two groups (P >.05 in all instances). In all types of delivery, nonrotational and rotational, the hand-held vacuum performed comparably to its contemporaries with no increase in delivery "failures" being noted. There were no differences in the extent or frequency of maternal injuries between the instruments, and other than transient scalp abrasions, there were no significant fetal injuries., Conclusion: The hand-held vacuum delivery system is a functionally effective addition to the practitioners' "armory," providing an alternative to the standard metal and silastic cups.

During a study of 108 vacuum assisted deliveries, a fetal hand was detected in the pelvic space between the head and maternal sacrum in seven of the procedures. The larger presenting diameters resulting from the compound fetal presentations were reflected in a greater number of pulls and higher traction forces recorded during the deliveries. In all cases, extraction of the hand facilitated the completion of birth without causing serious injury to the fetus or maternal perineum. It is recommended that a digital examination to detect the presence of a fetal hand in the sacral space should become a part of standard vacuum delivery practice.

Failure rates for vacuum extraction of between one in 16 and one in 600 have been reported. Most studies report that unexpected failure carries a greater risk to both mother and fetus. The aim of this study was to determine factors that were likely to predict success or failure in trials of vacuum extraction. At the Port Moresby General Hospital, 59 trials of vacuum extraction were performed between 1 December 1997 and 30 November 1999. These cases were analysed according to whether vacuum extraction was achieved with more than or less than three pulls, or an alternative method of delivery was required to effect delivery Factors that were predictive of failure were: (i) Highlands origin of the mother; (ii) longer duration of the second stage of labour; (iii) severe moulding of the fetal head; (iv) cup detachments and deflexing cup applications; and (v) operator persisting with the procedure after three pulls. The cervix being less than fully dilated when the trial was commenced was not associated with a higher risk of failure, nor was it associated with a significantly higher risk of cervical trauma. Perinatal death and serious fetal scalp trauma were associated with deflexing cup applications, making more than three pulls and failed vacuum extractions.

Unsuccessful vacuum extraction, cup detachment and failed anterior rotation in occipitoposterior positions are commonly associated with obstetric factors that are avoidable or correctable. These factors include the preferential use of soft vacuum cups, incorrect cup applications and attempts to deliver with the vacuum extractor before the cervix is completely dilated. Evidence from randomized trials demonstrates that soft cups cause fewer cosmetic effects and scalp lacerations than rigid cups. Soft cups do not reduce the incidence of cephalhaematomas nor have they been shown to provide any advantage over rigid cups for the prevention of subgaleal haemorrhage. Clinically significant subgaleal haemorrhage and intracranial injury are almost always preceded by difficult vacuum extraction. Although the vacuum extractor is less likely than forceps to injure the mother's genital tract and anal sphincters at delivery, no significant differences have been demonstrated between the instruments in terms of subsequent urinary or bowel disturbances., (Copyright 2002 Elsevier Science Ltd.)

Objective: To determine the risk of neonatal and maternal disease associated with the sequential use of vacuum and forceps compared with spontaneous vaginal delivery., Study Design: Using Washington state birth certificate data linked to hospital discharge records, we compared 3741 vaginal deliveries by both vacuum and forceps, 3741 vacuum deliveries, and 3741 forceps deliveries to 11,223 spontaneous vaginal deliveries., Results: Compared with spontaneous vaginal deliveries, deliveries by sequential use of vacuum and forceps had significantly higher rates of intracranial hemorrhage (relative risk [RR], 3.9; 95% confidence interval [CI], 1.5 to 10.1), brachial plexus (RR, 3.2; 95% CI, 1.6 to 6.4), facial nerve injury (RR, 13.3; 95% CI, 4.7 to 37.7), seizure (RR, 13.7; 95% CI, 2.1 to 88.0), depressed 5-minute Apgar score (RR, 3.0; 95% CI, 2.2 to 4.0), assisted ventilation (RR, 4.8; 95% CI, 2.1 to 11.0), fourth-degree (RR, 11.4; 95% CI, 6.4 to 20.1 among multiparous women) and other lacerations, hematoma (RR, 6.2; 95% CI, 2.1 to 18.1 among multiparous women), and postpartum hemorrhage (RR, 1.6; 95% CI, 1.3 to 2.0). The relative risk of sequential vacuum and forceps use was greater than the sum of the individual relative risks of each instrument for intracranial hemorrhage, facial nerve injury, seizure, hematoma, and perineal and vaginal lacerations., Conclusion: Sequential use of vacuum and forceps is associated with increased risk of both neonatal and maternal injury.

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.

The author was asked to provide an expert assessment of the case histories of 28 patients delivered by vacuum extraction. At the start of the extraction the foetal head level was at station 0 or above in 25 of the patients. In 12 cases the duration of extraction exceeded 14 min and in 7 of the cases it exceeded 19 minutes with a maximum of 45 minutes. Nine of the infants died, 11 suffered cerebral damage, 4 had brachial plexus injury and 1 had both cerebral damage and plexus injury. In 17 cases a causal relation between the unfavourable outcome and the vacuum extraction seemed plausible. During the past 40 years several studies of patients who have undergone high pelvic vacuum extractions have been published; cerebral damage of the infants often occurred. The risk of shoulder dystocia resulting in brachial plexus injury is considerably increased in case of a large infant and mid pelvic or high pelvic delivery. In the paediatric literature a number of authors describe cerebral lesions caused by high pelvic vacuum extraction. High pelvic vacuum extraction is still occasionally practiced in the Netherlands; it is a hazardous technique and should be replaced by caesarean section.

Vacuum extractors have replaced forceps for many situations in which assistance is required to achieve vaginal delivery. Compared with metal-cup vacuum extractors, soft-cup devices are easier to use and cause fewer neonatal scalp injuries; however, they detach more frequently. Vacuum extractors can cause neonatal injury. These devices should be employed when indicated, usually for a nonreassuring fetal heart tracing or failure to progress in the second stage of labor. Complications may be minimized if the physician recognizes contraindications to the use of vacuum extraction. Complete documentation is essential.

The traditional treatment of arrest of internal rotation of fetal head is forceps. We describe a maneuver for assisted internal autorotation of fetal head with vacuum extractor. We have used this approach in 30 parturients. No neonatal or maternal complications were noted.

Objective: To determine the optimal dosage and dosing interval for the use of misoprostol administered vaginally for pre-operative cervical dilatation., Design: Prospective double-blind randomised study., Setting: Fertility Control Centre, National University Hospital, Singapore., Methods: Women were randomly allocated to either the 200 microg or the 400 microg misoprostol group. Vacuum aspiration was performed at either three or four hours after the insertion of misoprostol tablets. Using Hegar's dilatator, degree of cervical dilatation before operation was measured. Other parameters assessed included the amount of additional dilatation required (if it was < Hegar 8), pre-operative and intra-operative blood loss, and associated side effects., Results: For the 200 microg misoprostol group, only seven (23.3%) achieved a dilatation of > or = 8 mm compared with 29 women (96.7%) in the 400 microg misoprostol group. The odds ratio was 95.3 (95% CI 10.9-830.9) for 400 microg misoprostol for successful pre-operative cervical dilatation of > or = 8 mm. The mean cervical dilatation for 400 microg and 200 microg misoprostol was 8.2 mm and 6.4 mm, respectively (P < 0.001). The use of 400 microg misoprostol with an evacuation interval of three hours appears to be the optimal dosage and evacuation time interval. Increasing the time interval beyond three hours did not confer any additional advantage on the rate of successful cervical dilatation but was instead associated with an increase in side effects such as vaginal bleeding, lower abdominal pain and the appearance of products of conception at the cervical os. However, besides vaginal bleeding, no significant differences in the frequency of these side effects were demonstrated., Conclusion: This first report on the comparison of differing dosages and time intervals to determine the optimal dosage treatment schedule shows that the vaginal application of 400 microg misoprostol for at least three hours is optimal for pre-operative cervical dilatation before vacuum aspiration in first trimester nulliparae.