So, the first post talked about one form of operative delivery, a low forceps assisted vaginal delivery. This post is going to be about a vacuum assisted vaginal delivery.
It was about 2:30pm. I"d been on call the night before, and I was just on the verge of being able to leave the hospital, after having been there since 6am the previous morning. I wandered to L&D to say bye to the attending of the day, and one of the midwives (my favorite midwife, actually, so we"ll call her Favorite Midwife, or just FM) came up to me and asked for my help with one of her patients. This patient was Spanish speaking only. In trying to deliver her first baby, she"d been pushing for 2 hours, and she"d become exhausted.
I go to assess her, and there was enough molding in the baby"s skull (the skull becomes deformed by the forces of labor and the pelvis. In this baby"s case, the sutures in the skull were overlapping each other, making it difficult to feel the baby"s position) that I couldn"t really tell the position with certainty. I tried to feel for an ear, but couldn"t quite get there. There did, however, seem to be adequate space to deliver the baby. I thought the baby was LOA with a significant asynclitism (baby"s head kind of turned off to one side). Because it was a private midwife patient, FM was there to assist me. There weren"t any residents available (it was a busy day on labor and delivery, and the residents were all in other deliveries or the c/s in the back) to do the vacuum, anyway, so I didn"t bother calling one to ask if they wanted to do the vacuum. Besides, it"s kind of nice to get to actually do a procedure I"m always letting the residents do anyway.
I discussed the options with the mom through the interpreters. The options were: 1) C/S now. 2) attempt at forceps (which I didn"t recommend because I"m not great at using forceps to correct an asynclitic head, although it certainly can be done) 3) Vacuum.
The patient agreed to a vacuum assisted delivery. The first vacuum I was handed was malfunctioning and could not hold any suction. I applied the second vacuum, waited for a contraction, and asked the patient to push as I started to pull. Some patients get to the point where they can"t focus, they can"t push because they"re too scared and too exhausted. The interpreters (also family members) were yelling. This was just too much. After about 5 minutes of trying to get this to work, the vacuum broke. It"s just a plastic thing and one of the plastic connections broke. But seeing the vacuum break made the mom totally freak out. The mom was yelling in Spanish. The family members/interpreters were yelling. The father was yelling, "I don"t care about the baby, just save my wife!" It was total chaos.
So I stopped.
I waited.
The baby was fine. The tracing was fine. There was no reason we couldn"t wait. But a vacuum assisted delivery requires more help from the mom than a forceps assisted delivery, and there was no way the mom was going to be able to cooperate while she was freaking out. I looked at FM and kind of sighed. She smiled and gave me a little hug. It gave me hope that I would get out of the delivery and out of the hospital eventually.
After probably 3 minutes of freaking out (although it seemed like 30), the mom had stopped yelling, the interpreters stopped yelling, and the father stopped yelling. I told everybody, "We are not going to be able to deliver this baby with all of this yelling. I need you all to know that everything"s going just fine. The baby is just fine, mom is just fine. But I need her to listen to me. I need everybody else to be quiet. Only one person should talk at a time, and we need everything to be calm for this to work. Otherwise, we should move towards a c-section now."
That seemed to quiet everybody down. With less chaos in the room, mom was much more able to cooperate and push when the contractions came and I pulled. After pulling the baby down a bit, I was better able to adjust the vacuum to correct for the asynclitic head, and the baby delivered without much further ado. She required an episiotomy, mostly just because of the operative delivery, but it was performed by FM and did not extend into the sphincter or the rectum. It should heal just fine.
The mom was very grateful afterwards, and the father gave me a hug. Really the mom did almost all of the work, I just gave her a little hand.
The thing is, never underestimate the value of calm. Calm is key. The previous delivery was easy because of the calm. This delivery was difficult because of the chaos.
I go to assess her, and there was enough molding in the baby"s skull (the skull becomes deformed by the forces of labor and the pelvis. In this baby"s case, the sutures in the skull were overlapping each other, making it difficult to feel the baby"s position) that I couldn"t really tell the position with certainty. I tried to feel for an ear, but couldn"t quite get there. There did, however, seem to be adequate space to deliver the baby. I thought the baby was LOA with a significant asynclitism (baby"s head kind of turned off to one side). Because it was a private midwife patient, FM was there to assist me. There weren"t any residents available (it was a busy day on labor and delivery, and the residents were all in other deliveries or the c/s in the back) to do the vacuum, anyway, so I didn"t bother calling one to ask if they wanted to do the vacuum. Besides, it"s kind of nice to get to actually do a procedure I"m always letting the residents do anyway.
I discussed the options with the mom through the interpreters. The options were: 1) C/S now. 2) attempt at forceps (which I didn"t recommend because I"m not great at using forceps to correct an asynclitic head, although it certainly can be done) 3) Vacuum.
The patient agreed to a vacuum assisted delivery. The first vacuum I was handed was malfunctioning and could not hold any suction. I applied the second vacuum, waited for a contraction, and asked the patient to push as I started to pull. Some patients get to the point where they can"t focus, they can"t push because they"re too scared and too exhausted. The interpreters (also family members) were yelling. This was just too much. After about 5 minutes of trying to get this to work, the vacuum broke. It"s just a plastic thing and one of the plastic connections broke. But seeing the vacuum break made the mom totally freak out. The mom was yelling in Spanish. The family members/interpreters were yelling. The father was yelling, "I don"t care about the baby, just save my wife!" It was total chaos.
So I stopped.
I waited.
The baby was fine. The tracing was fine. There was no reason we couldn"t wait. But a vacuum assisted delivery requires more help from the mom than a forceps assisted delivery, and there was no way the mom was going to be able to cooperate while she was freaking out. I looked at FM and kind of sighed. She smiled and gave me a little hug. It gave me hope that I would get out of the delivery and out of the hospital eventually.
After probably 3 minutes of freaking out (although it seemed like 30), the mom had stopped yelling, the interpreters stopped yelling, and the father stopped yelling. I told everybody, "We are not going to be able to deliver this baby with all of this yelling. I need you all to know that everything"s going just fine. The baby is just fine, mom is just fine. But I need her to listen to me. I need everybody else to be quiet. Only one person should talk at a time, and we need everything to be calm for this to work. Otherwise, we should move towards a c-section now."
That seemed to quiet everybody down. With less chaos in the room, mom was much more able to cooperate and push when the contractions came and I pulled. After pulling the baby down a bit, I was better able to adjust the vacuum to correct for the asynclitic head, and the baby delivered without much further ado. She required an episiotomy, mostly just because of the operative delivery, but it was performed by FM and did not extend into the sphincter or the rectum. It should heal just fine.
The mom was very grateful afterwards, and the father gave me a hug. Really the mom did almost all of the work, I just gave her a little hand.
The thing is, never underestimate the value of calm. Calm is key. The previous delivery was easy because of the calm. This delivery was difficult because of the chaos.
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