Implementation of Vacuum Assisted Delivery in the Mbale Region of Uganda

Sean WatermeyerPresented by Fred Chemuko with help from Carol Porter  

Pontypridd Overseas Networking Trust (“PONT”) is a charity which has been successfully delivering Health Care and Educational projects in the Mbale region of Uganda for 10 years. 

A recent visit by an obstetrics team from the charity has highlighted the significantly increased maternal and child morbidity and mortality arising from obstructed labour which is rife in Uganda and the developing world in general

A significant contributing factor identified in Mbale is the lack of relatively simple interventions to assist normal vaginal birth

. One such intervention not available currently available is the use of “Kiwi” vacuum extraction cups – essentially a suction cup that is placed on the babys head with an attached handle that allows traction to be applied to help with delivery

Introduction of “Kiwi” would allow local midwives to improve outcomes in cases of obstructed labour and could deliver significant health gains in the Mbale community

How does KIWI work?

Procedure : ApplicationProcedure : Application

Assess position of Assess position of fetal head by feeling fetal head by feeling sagital suture line and sagital suture line and fontanellesfontanelles

Identify posterior Identify posterior fontanellefontanelle

Procedure : ApplicationProcedure : Application

Explain to motherExplain to mother

Apply largest possible Apply largest possible cupcup

Place centre of cup Place centre of cup 1-2cm anterior to the 1-2cm anterior to the posterior fontanelleposterior fontanelle

Procedure : ApplicationProcedure : Application

Insert gently and apply to flexion pointInsert gently and apply to flexion point

Check application Check application

Check no maternal soft tissue in rim of cupCheck no maternal soft tissue in rim of cup

Procedure : ApplicationProcedure : Application

create a vacuum of 0.2kg/cmcreate a vacuum of 0.2kg/cm22 (Yellow)(Yellow)

check application of cupcheck application of cup

Increase vacuum to 0.8kg/cmIncrease vacuum to 0.8kg/cm22 (Green) (Green)

check application of cupcheck application of cup

Ask the patient to tell you when next contraction Ask the patient to tell you when next contraction

startsstarts

Procedure : ApplicationProcedure : Application

Procedure : TractionProcedure : TractionTriple ActionTriple Action

With each With each contractioncontraction ask the mother to ask the mother to pushpush

Place finger on scalp next to cup to assess Place finger on scalp next to cup to assess descent and potential slippage descent and potential slippage

start start tractiontraction in line of pelvic axis and in line of pelvic axis and perpendicular to cupperpendicular to cup

Procedure : TractionProcedure : Traction

Procedure : TractionProcedure : Traction

Between contractions check FH and Between contractions check FH and application of cupapplication of cup

Do not pull if no contractionDo not pull if no contraction

Decide if episiotomy indicatedDecide if episiotomy indicated

Continue pulls for maximum of 20 minutesContinue pulls for maximum of 20 minutes

Procedure : TractionProcedure : Traction

Procedure : ActionProcedure : Action• When head is delivered release the vacuum and When head is delivered release the vacuum and

remove cup. Deliver baby in normal way. remove cup. Deliver baby in normal way.

Failed vacuum extractionFailed vacuum extraction

Classify as Classify as ‘failed’‘failed’ if if Fetal head does not advance with each pullFetal head does not advance with each pull Baby undelivered after maximum of 20 Baby undelivered after maximum of 20

minutesminutes Cup slips off the head twice at proper Cup slips off the head twice at proper

direction of pull with maximum negative direction of pull with maximum negative pressurepressure

Consider an alternative procedure Consider an alternative procedure caesarean section or symphysiotomycaesarean section or symphysiotomy

ComplicationsComplications

MaternalMaternal• Lower genital tract Lower genital tract

injuriesinjuries

FetalFetal Localised scalp oedema Localised scalp oedema

(Caput and chignon)(Caput and chignon) Scalp abrasions and Scalp abrasions and

lacerationslacerations Cephalo-haematomaCephalo-haematoma Neonatal jaundiceNeonatal jaundice Intracranial bleeding-rareIntracranial bleeding-rare

Where expert neonatal review not Where expert neonatal review not availableavailable

Careful observation-increasing swellingCareful observation-increasing swelling Serial Packed Cell Volume (PCV) check, Serial Packed Cell Volume (PCV) check,

Serum Bilirubin (SB)Serum Bilirubin (SB)

Cephalo haematoma spontaneously Cephalo haematoma spontaneously resolves within 2-4 weeks !resolves within 2-4 weeks !

The Study A 1 year control trial study is proposed in the Mbale region of Uganda between the use and non use of “Kiwi” vacuum extraction for the assisted delivery of women in obstructed labour in community health centres.

The plan is to introduce the “Kiwi” in 3 regional rural health centres and compare outcome with a control population of 3 regional rural health centres where the “Kiwi” will not be introduced. .

In addition, the “Kiwi” will be introduced into obstetric practice within the main regional referral hospital, Mbale for women in obstructed labour. An 18 month follow up of a cohort of women delivering at the hospital is proposed

The first 6 months will look at a cohort of women and babies when the Kiwi is not available, the following 12 months when the Kiwi has been introduced. The primary outcome measure following the introduction of the “Kiwi” will be avoidance of caesarean section

Early results

Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11Jan-

12

%

Total number of births in Mbale Referral Hospital 693 696 780 702 697 705 712

Standard Vaginal Delivery 569 572 636 552 544 599 558

C- Section 110 124 144 153 133 106 107

Jul 11

Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12

Standard Vaginal Delivery 569 572 636

552=78.63% 544= 78.05%

599 = 84.98% 558 =78.3%

C- Section 110 124 144153=

21.79% 133=19.08% 106 = 15% 107 = 15%

Breech 9 5 216=2.28

% 15= 2.15% 27= 3.83% 26= 3.65% Vacuum delivery 2 0 2 1=0.14% 9= 1.29% 21= 2.98% 22 = 3.08%