Contraindications for Vacuum-Assisted Vaginal Delivery
Vacuum-assisted vaginal delivery is contraindicated in cases of suspected cephalopelvic disproportion, as this can lead to significant maternal and fetal complications. 1
Absolute Contraindications
- Gestational age <34 weeks due to increased risk of intracranial hemorrhage in premature infants 2
- Non-cephalic presentations (breech, face, brow) 3
- Suspected cephalopelvic disproportion 1
- Unengaged fetal head (station above +0) 4
- Known fetal bleeding disorders or demineralizing bone diseases 2
- Previous fetal scalp blood sampling or application of fetal scalp electrode during labor 2
Relative Contraindications
- Deflexion attitude of the fetal head as this increases risk of vacuum extraction failure 4
- Occiput posterior position due to higher failure rates and increased risk of maternal and neonatal complications 4
- Estimated fetal weight >4000g as this is associated with higher failure rates 4
- Maternal coagulation disorders due to increased risk of maternal hemorrhage 5
- Previous fetal scalp injury or cephalohematoma observed during labor 4
Specific Clinical Scenarios Where Vacuum Should Be Avoided
- During cesarean delivery to disimpact the fetal head, as this can cause significant fetal injury including intracranial and subgaleal hemorrhage 2
- In women with afibrinogenemia or severe hypofibrinogenemia where vacuum-assisted delivery should be avoided due to increased bleeding risk 5
- In cases of maternal hepatitis C with high viral load, where invasive procedures including vacuum extraction should be avoided to reduce vertical transmission risk 5
- When the fetal head is impacted during breech presentation, as vacuum extraction has shown higher failure rates and worse neonatal outcomes compared to proceeding directly to cesarean section 3
Safety Considerations When Using Vacuum
- Continuous electronic fetal heart rate monitoring is essential during operative vaginal delivery 1, 2
- Proper training in vacuum application techniques is crucial to minimize risk of injury 2
- Avoid using vacuum as a lever to disimpact the fetal head as this is dangerous 2
- Be prepared to abandon the procedure if initial attempts are not successful, as multiple failed attempts increase neonatal morbidity 6
- Have immediate access to facilities for cesarean delivery in case of vacuum failure 7
Pitfalls to Avoid
- Exceeding recommended application time or number of pop-offs increases risk of neonatal injury 8
- Applying vacuum when the position of the fetal head is not properly identified can lead to failed extraction and complications 4
- Using vacuum in situations where forceps might be more appropriate, such as when rapid delivery is needed for fetal distress 7
- Attempting vacuum extraction without proper training or experience, which increases risk of complications 7, 8
By carefully assessing for these contraindications before attempting vacuum-assisted vaginal delivery, clinicians can reduce the risk of maternal and neonatal complications while preserving this valuable technique for appropriate clinical scenarios.