Indications for operative delivery
The choice of delivery method depends on numerous factors and concurrent complications:
- Threatened, incipient, or complete uterine rupture.
- Premature rupture of membranes with no response to labor induction.
- Footling presentation.
- Active genital herpes with vulvovaginal lesions and a ruptured membrane interval of less than 6 hours.
- Combined indications: a combination of multiple factors posing a threat to the mother or fetus (e.g., post-term pregnancy combined with an unfavorable medical history or maternal age over 35 years).
Prerequisites and preparation
Strictly defined conditions are required to perform the surgical intervention:
- Main requirement: presence of a live and viable fetus (exceptions include life-threatening maternal conditions such as placental abruption or uterine rupture).
- Preparation for elective surgery: fasting for 12 hours prior to the procedure and a morning cleansing enema.
- Emergency preparation: includes Foley catheterization of the bladder, mandatory auscultation of the fetal heart rate on the operating table, and prophylaxis of Mendelson's syndrome (administration of sodium citrate and gastric emptying as indicated).
Anesthesia and management of blood loss
Patient safety is ensured by modern methods of anesthesia and infusion therapy:
- Anesthesia: regional anesthesia is the method of choice. General endotracheal anesthesia is used when regional anesthesia is contraindicated or impossible, while local novocaine infiltration is used extremely rarely.
- Infusion therapy: baseline administration of crystalloids and colloids. In massive blood loss, fresh frozen plasma and packed red blood cells are used.
- Autologous blood donation and reinfusion: pre-operative plasma harvesting via plasmapheresis or the use of cell saver devices for intraoperative collection, washing, and return of the patient's own red blood cells.
Risks, safety, and specifics
Any surgical intervention involves specific nuances and precautionary measures:
- Surgical risks: technical errors (e.g., inadequate uterine incision) can lead to birth injuries.
- Surgical team protection measures: when working with patients from risk groups (HIV, hepatitis, syphilis), wearing protective goggles or face masks, as well as double gloves or cut-resistant gloves, is mandatory.
- Operating environment: standardly, the procedure is performed in an obstetric inpatient facility by a specialist; however, in extreme conditions where the mother's life is threatened, it may be performed in an atypical setting while maintaining asepsis.
Briefly: answers to topical questions
What are the indications for vacuum extraction of the fetus?
Indications for fetal vacuum extraction include the following obstetric conditions:
- Uterine inertia refractory to medical therapy.
- Low transverse arrest of the sagittal suture.
- Incipient acute fetal hypoxia.
- Maternal diseases requiring immediate delivery at the end of the second stage of labor.
- Difficulty delivering the fetal head during a cesarean section (caesarean section).
What conditions are mandatory for performing vacuum extraction of the fetus?
Strict adherence to the following mandatory conditions is necessary for the safe performance of fetal vacuum extraction:
- Live fetus.
- Full cervical dilatation.
- Ruptured amniotic sac.
- Location of the fetal head in the narrow cavity of the lesser pelvis or at the transition from the wide to the narrow cavity, with the sagittal suture approaching the anteroposterior diameter.
What are the contraindications for vacuum extraction of the fetus?
Contraindications to the application of a vacuum extractor are divided into fetal and maternal pathologies:
- Dead fetus.
- Incomplete cervical dilatation.
- Hydrocephalus, anencephaly.
- Face presentation (praesentatio facialis).
- Extremely premature fetus.
- High station of the fetal head (caput).
- Severe maternal diseases requiring the elimination of pushing efforts (preeclampsia, eclampsia, hypertension, heart disease with signs of decompensation).
What are the main steps of the fetal vacuum extraction procedure?
Fetal vacuum extraction involves preparation, equipment inspection, and the execution of key clinical steps:
- Assessment of the situation immediately prior to the intervention via vaginal examination (examinatio vaginalis).
- Insertion of the vacuum extractor cup under strict manual control using fingers in the vagina to ensure a tight seal and prevent entrapment of maternal soft tissues.
- Creation of negative pressure (vacuum) and a brief pause.
- Application of traction strictly synchronized with uterine contractions and the axis of the birth canal.
In what direction is traction applied during fetal vacuum extraction?
The direction of traction during fetal vacuum extraction is determined by the axis of the birth canal and depends on the type of presentation:
- Anterior presentation of occipital presentation: first, traction is directed downwards until the suboccipital region reaches the pubic symphysis, then forwards until the delivery of the head.
- Posterior presentation of occipital presentation: first, traction is directed downwards until the area of the anterior fontanelle reaches the pubic symphysis, then backwards after the suboccipital region reaches the coccyx.
- Sinciput presentation: traction is performed towards the operator to bring the forehead under the pubic bone, then forwards to deliver the occipital tuberosity.
Preoperative preparation plan: 12 hours of fasting, enema in the morning, Foley catheter, and regional anesthesia as a safety standard.
Class and exam questions
What are the main conditions for performing the operation?
The primary condition is the presence of a live and viable fetus. Exceptions are critical, life-threatening situations for the mother (uterine rupture, placental abruption).
Which anesthesia method is preferred?
Regional anesthesia (epidural, spinal, or combined) is considered the method of choice. General anesthesia with endotracheal intubation is used less frequently, when regional anesthesia is not feasible.
What is the essence of automated blood reinfusion?
A special device collects the patient's blood lost during surgery, thoroughly washes the red blood cells, and returns them back into the bloodstream.
What else to study on this topic
- Combined indications for post-term pregnancy and IVF
- Prevention of Mendelson's syndrome in emergency intervention
- Methods of intraoperative automated autologous blood reinfusion
- Management specifics for patients from infection risk groups
- Controversial issues of abdominal delivery at extremely early gestational ages
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