“Reducing the medicolegal risk of vacuum extraction,” by Martin L. Gimovsky, MD, and Ji-Soo Han, MD
Drs. Gimovsky and Han describe a case in which a patient who was pregnant with her first child underwent labor augmentation at term to achieve complete dilation. She then progressed over 3 hours from+1 to+2 station. At that point, she was offered the following options: (1) continue to push, (2) vacuum extraction, or (3) cesarean section on the basis of “protracted descent.” She opted for cesarean delivery, and the fetus was successfully delivered from occiput-posterior position.
Is it within the standard of care to offer the option of additional pushing to a patient with a fetus in occiput-posterior position who has already pushed for 3 hours to advance 1 station? If so, how does one evaluate progress and account for the expected caput and molding? Was this a mid-pelvic delivery? Dennen’s Forceps Deliveries1 states that operative vaginal delivery from occiput-posterior position may be at a higher station than anticipated, and Obstetrics Forceps2 describes delivery of a crowning fetus in occiput-posterior position in a primiparous patient as “mid-pelvic.”
Was the patient Drs. Gimovsky and Han describe a “marginal” or “poor” candidate for vacuum extraction? According to Table 2 in their article, she would have been a marginal candidate based on her primiparous status and the occiput-posterior position of the fetus, but she would have been a “poor” candidate based on her protraction disorder in the second stage.
Drs. Gimovsky and Han state that “all risks” must be discussed with the patient. Did they discuss the 1% to 3.8% risk of subgaleal hemorrhage and its associated 2.7% to 22.8% risk of death? Is it within the standard of care to offer such a patient vacuum extraction?
Russ Jelsema, MD
Grand Rapids, Mich
Dr. Gimovsky responds:
Fetal position was unknown until time of C-section
We appreciate Dr. Jelsema’s thoughtful comments. The appropriate duration of the second stage of labor is controversial and has generated diverse opinions.1,2 Time limits should serve to remind both patient and practitioner that the process has been prolonged, and that alternatives to expedite delivery may be warranted.3
In the case Dr. Han and I presented within our article, the occiput-posterior position was detected at the time of cesarean section and so did not affect the patient’s management leading up to that point. We did not recommend vacuum extraction, but only suggested it as an option. Given the clinical diagnosis of protracted descent, the patient’s primigravid status, and the unrecognized position of the fetal head, we agree that this patient was a marginal choice at best for operative vaginal delivery. Either continued pushing or cesarean section was a more appropriate choice.
However, practitioners should also recognize the wide range of patient preferences regarding mode of delivery. The apportionment of risk for a woman undergoing childbirth is a personal choice that should be made in conjunction with her physician’s recommendations.