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Fetal injury associated with routine vacuum use during cesarean delivery

Published:February 25, 2008DOI:https://doi.org/10.1016/j.ajog.2007.12.009
      The use of a vacuum device as a routine procedure at the time of repeat cesarean delivery was associated with major fetal intracranial hemorrhage. In the absence of clear evidence of benefit, the routine use of vacuum extraction at the time of cesarean delivery is not justified, given its potential for serious fetal injury.

      Key words

      Occasional fetal injury associated with vacuum-assisted vaginal delivery is well described.
      • Simonson C.
      • Barlow P.
      • Dehennin N.
      • et al.
      Neonatal complications of vacuum-assisted delivery.
      However, no information exists regarding such injuries occurring when a vacuum device is used at the time of cesarean delivery. We report the first description of serious fetal injury associated with this delivery technique.

      Case Report

      A 42-year-old gravida 3, para 1 woman underwent scheduled repeat cesarean delivery at term. Immediately prior to delivery maternal hypotension was noted secondary to spinal anesthetic and ephedrine was administered. The fetal heart rate immediately prior to incision was noted to be 100 beats per minute. The fetal head was delivered with the use of a soft silastic vacuum device. No attempts had been made to deliver the head manually prior to use of the vacuum. The delivery was difficult, and 2 popoffs occurred. The obstetrician then extended the incision and accomplished delivery with the third application of the vacuum. Apgar scores were 6 and 8 at 1 and 5 minutes.
      A cephalohematoma and subgaleal hemorrhage were diagnosed and the infant’s condition deteriorated. Seizure activity was noted and a computed tomography scan revealed a cerebellar, subarachnoid, and intraparenchymal hemorrhage with mass effect resulting in ventriculomegaly. Subsequent imaging studies demonstrated encephalomalacia secondary to the infarction from the intracranial hemorrhage.

      Comment

      This case was identified during a quality improvement–directed review of adverse perinatal outcomes in our hospital system. Given the absence of active labor or prenatal trauma and Apgar scores inconsistent with asphyxia, the difficult vacuum delivery and the nature and location of the extra- and intracranial hemorrhage identified postnatally, it appears likely that the injury occurred as a result of the difficult vacuum delivery.
      The use of either forceps or a vacuum device to assist in delivery of the fetal head at cesarean delivery is a well-established and accepted part of obstetric practice when the delivery is found to be difficult and atraumatic manual delivery is not possible.
      • Hankins G.D.V.
      • Clark S.L.
      • Cunningham F.G.
      • Gilstrap L.C.
      Operative obstetrics.
      However, we have recently noted a trend with some practitioners in a small number of facilities toward the routine use of a vacuum device during cesarean delivery.
      Cesarean deliveries carry increased risks to the mother, compared with vaginal delivery, but are often justified to avoid trauma to the fetus. Similarly, operative vaginal delivery is sometimes safer for a mother than cesarean delivery but carries well-described risks of fetal trauma. There is no clear rationale for routinely and electively subjecting a mother/baby pair to the risks of both cesarean delivery and vacuum delivery. More importantly, neither the benefit nor the safety of routine vacuum use at the time of cesarean delivery has ever been established in the medical literature. The few case reports and very small descriptive series that exist do not support improved outcomes and lack the power to detect uncommon but serious complications.
      • Pelosi M.A.
      • Apuzzio J.
      Use of the soft, silastic obstetric vacuum cup for delivery of the fetal head at cesarean section.
      • Arad I.
      • Linder N.
      • Bercovici B.
      Vacuum extraction at cesarean section—neonatal outcomes.
      Moreover, the prolongation of the incision to delivery time assisted with vacuum use has been shown to increase the risk of neonatal depression when compared with traditional cesarean delivery technique.
      • Arad I.
      • Linder N.
      • Bercovici B.
      Vacuum extraction at cesarean section—neonatal outcomes.
      In the absence of clear evidence of benefit, the authors feel that the routine use of vacuum extraction at the time of cesarean delivery is not justified, given its potential for serious fetal injury. Given a similar lack of evidence-based support for the routine use of forceps during cesarean, such devices should also be limited to situations in which atraumatic manual delivery of the head is not possible.

      References

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        • Barlow P.
        • Dehennin N.
        • et al.
        Neonatal complications of vacuum-assisted delivery.
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        • Hankins G.D.V.
        • Clark S.L.
        • Cunningham F.G.
        • Gilstrap L.C.
        Operative obstetrics.
        in: Appleton & Lange, Norwalk, CT1995: 318
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        • Apuzzio J.
        Use of the soft, silastic obstetric vacuum cup for delivery of the fetal head at cesarean section.
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        • Bercovici B.
        Vacuum extraction at cesarean section—neonatal outcomes.
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