Design and Development of Atraumatic Vacuum Assisted Delivery Devices

Vacuum-Assisted Delivery (VAD) is an obstetric practice used to assist child delivery during the second stage of labour. During the procedure, the obstetric professional attaches the VAD device to the scalp of the foetus through suction and tractive force is then applied alongside maternal contractions to assist the baby’s passage through the delivery channel. VAD is more prevalent than obstetric forceps due to its ease of use, lower maternal morbidity and improved cosmetic outcome for the mother and her baby. However, safety concerns such as unintentional cup detachment or high vacuum, can lead to induced trauma to the foetus. Since its original inception, there have been limited efforts to evaluate the safety of VAD devices or optimise their design and operation. Here, an engineering approach to assess the devices’ failure modes is proposed to inform training, best obstetric practice and improved VAD design. An instrumented experimental recreation of VAD has been developed to achieve a comprehensive understanding of the mechanics of VAD devices and the associated trauma. It features an instrumented adaptation of a commercially available VAD device (the Kiwi® Omnicup™) connected to a tensile testing machine to simulate obstetric traction onto a head scalp model (fabricated using textile reinforced silicone). A pneumatic control system provides an actively controlled vacuum to the instrumented device. Optical markers, placed onto the scalp model, combined with a high-speed camera system provide tracking of scalp deformation during the mechanical simulation of an obstetric traction. Experimental factors such as traction speed, magnitude of vacuum imposed & changes to the design geometry of the VAD cup and pneumatic architecture including the consideration of frictional attributes of the maternal environment, were investigated. The results from the experimental studies show that a simulated obstetric VAD traction produces a characteristic response from which a number of key clinically relevant metrics can be determined and highlight the association of clinical factors and mechanical factors to device performance. The research informed on the conception of an atraumatic concept to prevent cup detachment. Upon evaluation of the technical and commercial feasibility of the concept, commercial and research opportunities were identified, which could help improve the performance of VAD devices, in the future

Simulation and beyond – Principles of effective obstetric training

Simulation training provides a safe, non-judgmental environment where members of the multi-professional team can practice both their technical and non-technical skills. Poor teamwork and communication are recurring contributing factors to adverse maternal and neonatal outcomes. Simulation can improve outcomes and is now a compulsory part of the national training matrix. Components of successful training include involving the multi-professional team, high fidelity models, keeping training on-site, and focussing on human factors training; a key factor in adverse patient outcomes. The future of simulation training is an exciting field, with the advent of augmented reality devices and the use of artificial intelligence

The Basic Surgical Skills course in sub-Saharan Africa: an observational study of effectiveness

Background: The Basic Surgical Skills (BSS) course is a common component of postgraduate surgical training programmes in sub-Saharan Africa, but was originally designed in a UK context, and its efficacy and relevance have not been formally assessed in Africa. Methods: An observational study was carried out during a BSS course delivered to early-stage surgical trainees from Rwanda and the Democratic Republic of the Congo. Technical skill in a basic wound closure task was assessed in a formal Objective Structured Assessment of Technical Skills (OSAT) before and after course completion. Participants completed a pre-course questionnaire documenting existing surgical experience and self-perceived confidence levels in surgical skills which were to be taught during the course. Participants repeated confidence ratings and completed course evaluation following course delivery. Results: A cohort of 17 participants had completed a pre-course median of 150 Caesarean sections as primary operator. Performance on the OSAT improved from a mean of 10.5/17 pre-course to 14.2/17 post-course (mean of paired differences 3.7, p < 0.001). Improvements were seen in 15/17 components of wound closure. Pre-course, only 47% of candidates were forming hand-tied knots correctly and 38% were appropriately crossing hands with each throw, improving to 88 and 76%, respectively, following the course (p = 0.01 for both components). Confidence levels improved significantly in all technical skills taught, and the course was assessed as highly relevant by trainees. Conclusion: The Basic Surgical Skills course is effective in improving the basic surgical technique of surgical trainees from sub-Saharan Africa and their confidence in key technical skills

Review of instrumental vaginal delivery at the Obafemi Awolowo University Teaching Hospitals Complex

Background: Instrumental vaginal delivery (IVD) is one of the signal functions of the basic emergency obstetric and newborn care. Some recent reviews point towards a sustained fall in the performance of this lifesaving procedure. With increasing caesarean section rates, institutional reviews of the practice of IVD are important to improve and sustain this art which is on the path of extinction.Objectives: To determine the IVD rate at the OAUTHC over a 5‑year period from January 2013 to December 2017 and to review the maternal and newborn outcomes.Methods: This was a retrospective review. Case records of parturients who had either forceps or vacuum delivery during the study period were retrieved and relevant information were extracted. Data analysis was done with IBM‑SPSS version 20.Results: There were 10,286 deliveries and 101 IVDs over the 5‑year period giving an IVD rate of 0.98%, with 0.41% for forceps and 0.57% for vacuum delivery. Seventy‑one case records were available for review. Mean maternal age was 27.21 ± 5.8 years and 31 (43.7%) of the parturients were primigravidae. Thirty‑nine (54.9%) were booked and 66 (93%) of the procedures were performed as emergencies. Senior residents conducted most (94.4%) of the procedures and poor maternal efforts in the second stage of labor was the most common indication (43.8%). All resulted in vaginal delivery with the most common maternal complication being genital tract laceration, most notably first and second‑degree perineal tears. Of the 66 livebirths, neonatal ward admission rate was 45.5%. There was an early neonatal death which followed a traumatic vacuum delivery.Conclusion and Recommendations: The IVD rate at OAUTHC is low, with higher preference for vacuum delivery. Appropriate case selection is evident, and poor maternal effort in second stage of labor remained the leading indication. The neonatal admission rate is high. Training and retraining of resident doctors is necessary towards increasing the conduct and ensuring better outcome.Keywords: Forceps delivery; instrumental vaginal delivery; maternal complications; neonatal outcomes; vacuum deliver

Sexual function, delivery mode history, pelvic floor muscle exercises and incontinence : a cross-sectional study six years postpartum

Background: There is controversy over the effect of mode of delivery, pelvic floor muscle exercises (PFME), incontinence and sexual function. Aim: To investigate the relationship of sexual function with delivery mode history, PFMEs and incontinence. Methods: This was a cross-sectional postal survey of women, six years post-partum, who had given birth in maternity units in Aberdeen, Birmingham and Dunedin and had answered a previous questionnaire. Each sexual function question was analysed separately by ANOVA. Results: At six years post-index delivery, 4214 women responded, of whom 2765 (65%) answered the optional ten sexual function questions. Although there was little association between delivery mode history and most sexual function questions, women who had delivered exclusively by caesarean section scored significantly better on the questions relating to their perception of vaginal tone for their own (P-value < 0.0001) and partner's (P-value 0.002) sexual satisfaction, especially when compared with women who had had vaginal and instrumental deliveries. Women who reported that they were currently performing PFME scored significantly better on seven questions. Women with urinary or faecal incontinence scored significantly poorer on all sexual function questions. Conclusions: Mode of delivery history appeared to have minimal effect on sexual function. Current PFME performance was positively associated with most aspects of sexual function, however, all aspects were negatively associated with urinary and faecal incontinence.The original study was supported by Wellbeing and the Health Research Council of New Zealand and the follow-up study by the Health Services Research Unit, which is core funded by a grant from the Chief Scientist Office of the Scottish Executive Health Department

A Review of Pneumatic Actuators Used for the Design of Medical Simulators and Medical Tools

International audienc

Birth by vacuum extraction

Background: In Sweden, vacuum extraction (VE) is used in almost every tenth woman to facilitate vaginal birth. VE is an important obstetric instrument that is used when shortening of the second stage of labor is necessary. VE has been associated with increased neonatal morbidity such as extracranial and cranial injuries. The outcome of the VE depends on the right selection of patients and how the VE is performed. Despite its common use, little is known about the performance of VEs, how many extractions fail, and if failure is dangerous for the child. It is also unclear whether VE delivery has negative long-term consequences for the child. Materials and Methods: In Study I, we investigated clinical performance as described in medical records in 596 VE deliveries and compared this with recommendations in local practice guidelines for VE. Detailed data on performance was collected from six different delivery units, each contributing with information about 100 VEs performed in 2013. In Study II, we investigated if women delivered by VE receive adequate pain relief and the risk factors associated with not receiving pain relief. We identified 62,568 women delivered by VE between 1999 and 2008 in the Swedish Medical Birth Register (SMBR). In Study III, the aim was to investigate the incidence of failed VEs, risk factors for failure, and neonatal morbidity in failed VEs. We collected information on singleton pregnancies delivered at term (>36+6) by either a successful VE (n=83,671) or a failed VE (n= 4747) from the SMBR. Failed VE was defined as a VE attempt with a subsequent cesarean section (CS), the use of forceps, or both. In Study IV, the aim was to investigate if birth by VE affects cognitive development as indicated by school performance at sixteen years of age. We identified 126,032 infants born as singletons without major congenital malformations, in a vertex presentation at a gestational week of 34 or more, with Swedish-born parents, and delivered between 1990 and 1993 in the SMBR. These children were followed up at sixteen years of age in the school grade registry containing all final grades in compulsory school. Results: Clinical performances in VEs were mostly conducted according to evidence-based safe practice; however, in a few cases, inappropriate and potentially harmful performance was used. In 6% of all extractions, more than six pulls were used to deliver the infant, and in 2.3% the procedure took more than 20 minutes. Fourteen extractions (2.3%) were conducted from a high station in the maternal pelvis. The local practice guidelines on VE were incomplete and were not updated or evidence-based. Every third woman was delivered by VE without potent pain relief. VE failure occurred in 5.4% of cases. Identified risk factors for failure were for example nulliparity, fetal malposition, and mid-pelvic extractions. Failure with the extractor was associated with increased risks of subgaleal hematoma, convulsions, and low Apgar scores but not intracranial hemorrhage in the infant. Children delivered by VE had significantly lower mean mathematics test scores and mean merit grades than children born vaginally without instruments, after adjustment for major confounders. Infants delivered by emergency cesarean section had similar results as children delivered by VE. Conclusion: Improvements in the clinical performance of VEs can be accomplished, and practice guidelines need to be improved to support safe and evidence-based practice in VE procedures. In addition, more women should receive pain relief prior to the extraction. Failed VE can be dangerous for the child, and risk factors for failure should be closely evaluated prior to the extraction to avoid this dangerous situation. In the case of failure, a subsequent CS should be performed. Birth by VE has marginal negative effects on final school grades at 16 years of age compared with children born by spontaneous vaginal delivery. Similar marginal effects were found in children delivered by emergency CS, indicating that these lower grades are rather due to difficult labor occurring prior to birth and not to the instrument itself