HIE Lawyers & Vacuum Extractor Attorneys Discuss Vacuum Extractor Injuries
Vacuum Extraction Injuries | HIE Lawyers & Vacuum Extractor Attorneys Serving Clients Nationwide
A vacuum extractor is sometimes used in the delivery of a baby if, for example, the baby is in distress or the mother is losing the ability to push. It’s important that the extractor be placed properly on the head, or trauma to the baby’s head and brain can result. If the doctor pulls too hard, this can also be a potential cause of brain damage.
Operative vaginal delivery refers to a delivery in which the physician uses an instrument, such as a vacuum device, to assist in bringing the baby out of the birth canal. The vacuum extractor was developed in 1953 by a Swedish obstetrician who introduced a hollow, disc-shaped, stainless steel metal cup for vacuum assisted delivery. Suction tubing attached to the dome of the cup and a traction chain passed through the tubing. This cup quickly became the template for all subsequent vacuum extractor systems. By 1992, the number of vacuum assisted deliveries surpassed the number of forceps deliveries in the U.S., and by 2000, approximately two-thirds of operative vaginal deliveries were by vacuum.
A vacuum assisted delivery should only be attempted when a specific obstetric indication is present, although there is no absolute indication. The major indications for vacuum extraction include:
- There is a prolonged second stage of labor
- Fetal status is nonreassuring
- A maternal illness is present, such that “bearing down” or pushing efforts would be risky (e.g., maternal cardiac or neurological disease is present)
- The mother is exhausted
There are several instances in which vacuum extraction should never be performed. Contraindications for vacuum delivery include the following:
- The baby is less than 34 weeks gestation. There is a risk of fetal intraventricular hemorrhage at these ages.
- Prior scalp sampling or multiple attempts at fetal scalp electrode placement are contraindications because these procedures may increase the risk of cephalohematoma / cephalhematoma (bleeding under the skin of the head) or external bleeding from the scalp wound.
- In addition, fetal demineralization disease, connective tissue disorders, fetal bleeding diatheses, and suspected fetal-pelvic disproportion (CPD) are contraindications to vacuum extraction.
Techniques for Using the Vacuum Extractor
The vacuum extractor is applied to the fetus’s head, and the physician uses traction to extract the baby, typically during a contraction while the mother is pushing. The mother is placed in the lithotomy position (the mother’s feet are placed above or at the same level as the hips, often in stirrups) and assists throughout the process by pushing. The cup on the baby’s head uses suction to draw the skin from the scalp into the cup.
Correct placement of the cup directly over the flexion point (the sagittal suture, or top, center portion of head), about 3 cm in front of the baby’s fontanelle (soft spot), is critical to the success of the vacuum extractor. In addition, the maternal cervix must be fully dilated, the head engaged in the birth canal, and the head position known.
The most important technique for avoiding problems is to strictly adhere to the Food and Drug Administration’s recommendation that the vacuum device only be used when a specific obstetric indication is present. In addition, physicians should follow these guidelines:
- There must be correct cup placement. The cup must be placed over the flexion point. Misalignment of the cup leads to cranial deflexion or asymmetry as traction is applied, which impedes delivery because a larger part of the head (increased cranial diameter) is presented to the birth canal, and this is associated with a higher rate of scalp trauma. If the cup becomes dislodged, an injury can occur. Thus, the scalp must be examined to make sure there is no injury before reapplying the cup.
- The physician must know when to abandon the procedure. Physicians must be willing and able to abandon the vacuum extraction and promptly proceed to a C-section delivery when the vaginal delivery is not progressing normally. Although there often is a tendency to try to complete the delivery vaginally despite failed progress and / or multiple pop offs of the cup, it is essential to deliver the baby through the abdomen by a C-section when the baby is not readily delivered with vacuum assistance. An indicated vaginal delivery that could not be completed with vacuum assistance is unlikely to progress to a spontaneous vaginal delivery with a little more time, and delay can greatly increase the risk of injury or death.
Utilization of forceps is NOT indicated in the event of a failed vacuum extraction. The standard of practice is a quick delivery by C-section when vacuum extraction fails.
A vacuum extraction is likely to be successful when there is accurate cup application, appropriate traction technique, a favorable flexed cranial position plus a low station (baby is fairly ready to be born) at the time of application, use of the most appropriate cup design, and absence of CPD.
When the baby is in the occiput anterior position (baby’s head is first, down in pelvis, and slightly off center), only mild traction (pressure) is required, and a soft, bell-shaped vacuum cup should be used. Soft cups result in less injury. The rigid mushroom-style cup is used for deliveries likely to require greater traction forces.
When the baby is in the occiput posterior position (baby is head first in pelvis, facing forward and slightly to the right or left, as if looking out the thigh), a rigid cup without a rigid stem that was designed just for this purpose should be used.
Gentle traction along the axis of the pelvic curve (down then up) in concert with maternal pushing is the proper technique. The scalp can be damaged if the handle is actively twisted to rotate the head.
Vacuum assisted procedures should be limited to the following:
- Three contractions for the descent phase (the part of the procedure from the time of cup application until the fetal head is descended to the outlet of the pelvis)
- Three contractions for the outlet extraction phase
- 2 to 3 pop offs of cup
- A total time of 15-30 minutes. Total time is from the very start of the procedure until the baby is extracted.
- It is important to note that low birth weight and premature fetuses have more delicate bones and soft tissue and are very prone to injury. The extraction pressures applied to these infants should be significantly reduced to avoid trauma and injury.
Vacuum Extractor Injuries
The vacuum extractor has been scrutinized in recent years. The FDA stated its concerns in a Public Health Advisory on vacuum assisted delivery devices:
“This is to advise you that vacuum assisted devices may cause serious or fatal complications… While no instrumented delivery is risk free, we are concerned that some health care professionals who use vacuum assisted delivery devices, or those who care for these infants following delivery, may not be aware that the device may produce life-threatening complications.”
It is the responsibility of the physician to inform the mother of the risks of a vacuum extraction. In addition, the physician must ensure that the instrument is used appropriately and that the mother and infant are properly monitored both during and after birth.
Indeed, it is crucial for standards of care to be followed at all times during vacuum extractor use. Permanent damage can result if the physician has a poor technique or uses the wrong type of cup. There should be no twisting of the neck or head, no excessive pulling, and no pulling for longer than 10-15 minutes. Improper use of a vacuum extractor can result in the following injuries:
- Skull fractures
- Retinal hemorrhages
- Brachial plexus / Erb’s palsy. This occurs when the brachial plexus (group of nerves to the arms and hands) is injured. It frequently occurs in births involving shoulder dystocia (difficulty delivering the baby’s shoulders). As a result of this type of injury, the baby cannot flex and rotate her arm. Sometimes the injury resolves itself; however, if the nerve is torn, there may be permanent damage.
- Brain hemorrhages or bleeds. A serious complication of a vacuum extraction is a subgaleal brain hemorrhage. In this case, the vacuum ruptures a vein which bleeds into a space between the scalp and skull. This condition is life threatening with a mortality rate as high as 20%. About 90% of all subgaleal hemorrhages are related to vacuum extraction. This type of bleeding is most likely to occur with excessive force, prolonged cup application, or if forceps are also used (which is contrary to the medical standard of care.) This often leads to neurological impairments and cerebral palsy.
- Cerebral palsy, seizures and other forms of brain damage.
Legal Help for Vacuum Extraction Injuries Such As Hypoxic Ischemic Encephalopathy (HIE)
It is imperative that the baby be very closely monitored during labor and delivery. A vacuum extractor may only be used when obstetrical indications are present. Due to the potential for severe injury, it is critical for the physician to be very skilled in vacuum extraction technique and follow all standards of care. Failure to follow guidelines and standards of care is negligence. If this negligence leads to injury in the baby, it is medical malpractice.
If your child was born using a vacuum extractor and sustained permanent damage, the national law firm of Reiter & Walsh ABC Law Centers can help. Our nationally recognized attorneys have many years of experience in handling complex vacuum extraction cases. We can help you understand your legal rights and we’ll help you obtain the compensation you and your child deserve. Contact Reiter & Walsh ABC Law Centers for a free review of your case: 888-419-2229.
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