Re: vacuum extraction criteria

From: ainsron@msn.com
Fri Mar 10 11:52:50 2000

I was trained in my residency to use both forceps and vacuum and feel comfortable using either. I must say that over the years, I have gravitated towards using Vacuum over forceps because of its simplicity and ease of use, spontaneous rotation of a posterior presentation, ease of application with minimal anesthesia, etc., especially with the new silastic cups, as opposed to the rigid metal cups I trained with.

I am certainly aware of the risks and have a written handout discussing both forceps and vacuum that is given to my patients. Additionally, I discuss with the labor patient and her family why I am recommending delivery with vacuum or forceps, including the "marks" they leave on the babies and the small risk of long term damage and give them the alternative of C/S while encouraging them that the procedure I am recommending is generally safe and will be abandoned if it doesn't progress normally. You have to admit that the risk of major injury/death is quite small, the FDA report of 12 deaths and 9 serious injuries (5/year) in the period in question vs. a denominator of total vacuum assisted births (228,354 in 1995) comes out to ~1:45,000.

I am also acutely aware that even in the best of hands, there are no guarantees. A well-trained colleague of mine delivered the grandchild of another physician in our community, using the vacuum extractor and the baby suffered major neurologic consequences. The case is currently in litigation and was the focus of the 20/20 report in January 1999.

>At my hospital vacuums extractions are done, very infrequently but they
>are done. I have looked at them to see if it is something that I want
>to learn and frankly it looks to me sort of horrendous. Not that
>forceps is any better nor a difficult cesarean section. But anyway, the
>FDA published the following: In May 1998, the Food and Drug
>Administration (FDA) issued a public health advisory to all
>practitioners who deliver babies. The advisory, entitled "Need for
>Caution When Using
>Vacuum Assisted Delivery Devices," (1) was based on reports to the FDA
>of 12 deaths and 9
>serious injuries during vacuum deliveries in the preceding four years.
>In the 12 years before
>that period, much smaller numbers of such complications had been
>reported. The advisory
>noted the most serious complications of vacuum delivery -- subgaleal
>hematoma and
>intracranial hemorrhage -- and emphasized that vacuum devices should be
>used only for
> specific obstetrical indications.
>
>We must all agree that it is good to know how to apply well forceps and
>I imagine it must be good to also know how to apply well vacuum
>extractor for there will be instances when that will be your best
>option.
>
>Now finally I am getting close to my original question, which is, if you
>*only* use vacuums or even forceps in very selected instances, you will
>be doing so few that how do you learn how to use it or, after you became
>an *expert* in your residency, how do you maintain your expertise
>afterward with so little usage? That simple and silly question is it.
>Now, that was coupled with another angle which probably turned people
>off even more that the silly question. And that is that I think that
>many more vacuums and even forceps are used than "really" needed because
>so much epidurals are being used. Paul reported 80% epidurals at his
>hospital. And then as posted originally somebody has a terminal fetal
>distress in a patient with epidural and can not push the baby out. So
>we have sort of a an emergency that needs to be solved by the best
>method that the physician decides, but which are all terrible no matter
>which study you look into, and worse of all, this solution is a solution
>to a problem partially caused by us. ie, the epidural
>Do my patients use epidurals? Yes!!!!!! Frequently? Obviously not. I
>give them real informed consent which the anesthesiologists at my
>hospital hate (less income) and most get turned off and labor very
>well..
>
>Philosophically, I have grown into the idea that we physicians have
>instrumentalized, medicalized and messed with labor too much. Obviously
>I am talking about normal pregnancy and labor, not about they myriad of
>medical and obstetrical problems that do ensue, and truly they are many.
>
>This is too long, for whatever it's worth, I hope it is clear, courteous
>and not too low for the level of the listmembers.
>
>Carlos
>>

--
Ronald E. Ainsworth, MD



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