Implementation of Vacuum Assisted Delivery in the Mbale Region of Uganda Sean Watermeyer Presented 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 : Application  Assess position of fetal head by feeling sagital suture line and fontanelles  Identify posterior fontanelle

Procedure : Application  Explain to mother  Apply largest possible cup  Place centre of cup 1-2cm anterior to the posterior fontanelle

Procedure : Application  Insert gently and apply to flexion point  Check application  Check no maternal soft tissue in rim of cup

Procedure : Application  create a vacuum of 0.2kg/cm 2 (Yellow)  check application of cup  Increase vacuum to 0.8kg/cm 2 (Green)  check application of cup  Ask the patient to tell you when next contraction starts

Procedure : Application

Procedure : Traction Triple Action  With each contraction ask the mother to push  Place finger on scalp next to cup to assess descent and potential slippage  start traction in line of pelvic axis and perpendicular to cup

Procedure : Traction

 Between contractions check FH and application of cup  Do not pull if no contraction  Decide if episiotomy indicated  Continue pulls for maximum of 20 minutes

Procedure : Traction

Procedure : Action When head is delivered release the vacuum and remove cup. Deliver baby in normal way.When head is delivered release the vacuum and remove cup. Deliver baby in normal way.

Failed vacuum extraction  Classify as ‘failed’ if  Fetal head does not advance with each pull  Baby undelivered after maximum of 20 minutes  Cup slips off the head twice at proper direction of pull with maximum negative pressure  Consider an alternative procedure caesarean section or symphysiotomy

Complications Maternal Lower genital tract injuriesLower genital tract injuries  Fetal  Localised scalp oedema (Caput and chignon)  Scalp abrasions and lacerations  Cephalo-haematoma  Neonatal jaundice  Intracranial bleeding-rare

Where expert neonatal review not available  Careful observation-increasing swelling  Serial Packed Cell Volume (PCV) check, Serum Bilirubin (SB)  Cephalo haematoma spontaneously 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-11Aug-11Sep-11Oct-11Nov-11Dec-11 Jan- 12 % Total number of births in Mbale Referral Hospital Standard Vaginal Delivery C- Section

Jul 11 Aug- 11Sep-11Oct-11Nov-11Dec-11Jan-12 Standard Vaginal Delivery =78.6 3%544= 78.05% 599 = 84.98%558 =78.3% C- Section = 21.79%133=19.08%106 = 15%107 = 15% Breech952 16=2.28 %15= 2.15%27= 3.83%26= 3.65% Vacuum delivery2021=0.14%9= 1.29%21= 2.98%22 = 3.08%