What information should be included when obtaining consent for vacuum delivery?

Informed Consent for Vacuum Delivery

When obtaining consent for vacuum-assisted delivery, you must discuss the procedure's nature and technique, significant maternal and fetal risks (including scalp trauma, intracranial injury, and maternal soft tissue trauma), benefits of avoiding prolonged second stage or cesarean section, alternatives including forceps or cesarean delivery, and the possibility of procedure failure requiring instrument change or cesarean section. 1, 2, 3

Core Information That Must Be Provided

Procedure Description and Technique

• Explain what vacuum extraction involves: placement of a suction cup on the fetal head to assist delivery during contractions and maternal pushing 4, 5
• Describe the specific technique planned: cup type (soft vs rigid), placement location on fetal head, and maximum number of pulls (typically limited to three per guidelines) 6, 7
• Clarify the clinical indication: why vacuum delivery is recommended for this specific patient (e.g., prolonged second stage, fetal distress, maternal exhaustion, or contraindication to pushing) 5

Material Risks and Complications

Fetal/Neonatal Risks

• Scalp trauma is the most common complication and must be discussed, as vacuum extractors are more likely than forceps to cause scalp injuries including cephalohematoma and scalp lacerations 8, 7
• Subgaleal hemorrhage, though rare, is a serious complication that can be life-threatening and occurs more frequently with non-compliant technique (11% vs 0% with guideline compliance) 6
• Intracranial injury risk must be mentioned, as vacuum extraction may be associated with increased rates of intracranial trauma compared to forceps 8
• Need for neonatal resuscitation occurs in approximately 14-35% of cases depending on technique compliance 6

Maternal Risks

• Soft tissue trauma including perineal lacerations, though generally less than with forceps 8
• Increased blood loss at delivery, particularly with non-compliant technique (438 mL vs 388 mL with compliance) 6
• Pain and discomfort during the procedure 3

Alternatives and Their Risks

• Forceps delivery: more difficult to apply, requires better analgesia, associated with increased maternal soft tissue trauma and facial injuries, but may have lower scalp trauma rates 8, 7
• Cesarean section: discuss risks including bleeding, infection, organ damage, venous thromboembolism, and implications for future pregnancies 3
• Expectant management risks: prolonged second stage complications, birth asphyxia if fetal distress present 5

Procedure Limitations and Failure

• Possibility of failed vacuum extraction requiring instrument change to forceps or proceeding to cesarean section (occurs in 4-13% of cases) 6
• Abandonment criteria: if delivery not imminent after three pulls or cup detachment occurs multiple times, procedure must be stopped 6, 7

Process Requirements

Timing and Environment

• Information must be provided early, ideally during prenatal care or at minimum when the decision for operative delivery is made, not immediately before the procedure unless emergency circumstances exist 1
• Allow adequate time for the patient to process information and ask questions in a non-pressured environment 2

Who Obtains Consent

• The physician performing the procedure or an appropriately trained individual who can answer questions accurately must obtain consent 2, 3
• If a trainee will perform the procedure, specific consent may be required with disclosure of additional risks from inexperience 2, 9

Patient-Centered Communication

• Tailor information to what this particular patient would regard as relevant when making the decision 1
• Use plain language the patient can understand, avoiding medical jargon 1
• Provide information in the patient's language using professional interpreters if needed, not family members 3, 9
• Ask if the patient has questions at the end of the explanation and address them fully 1

Documentation Requirements

Record the following in the medical record: 1, 2, 3

• Specific risks, benefits, and alternatives explained
• Patient questions asked and responses provided
• Any patient-specific concerns or risk factors discussed
• Patient's agreement to proceed with the procedure
• Urgency level and timing considerations

Critical Pitfalls to Avoid

• Never minimize pain or discomfort expectations or withhold information because it might make the patient anxious 2
• Do not obtain consent immediately before the procedure in the delivery room for non-emergency situations 1
• Do not force detailed explanations on patients who explicitly decline information, but document this and explain the consequences of not having full information 1
• Ensure the patient understands that consent is ongoing and can be withdrawn at any time without penalty 2
• Identify patient-specific risk factors such as coagulopathy or anticoagulant therapy that may increase procedural risk 2