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/cm2 (Yellow)
 check application of cup
 Increase vacuum to 0.8kg/cm2 (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
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.
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
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
Total number of births in Mbale Referral
Hospital
Standard Vaginal Delivery
C- Section
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan12
693
569
110
696
572
124
780
636
144
702
552
153
697
544
133
705
599
106
712
558
107
%
Jul
11
Aug11
Sep-11
Standard Vaginal
Delivery
569
572
636
C- Section
110
124
144
9
2
5
0
2
2
Breech
Vacuum delivery
Oct-11
552=78.6
3%
153=
21.79%
16=2.28
%
1=0.14%
Nov-11
Dec-11
Jan-12
544= 78.05%
599 =
84.98%
558 =78.3%
133=19.08%
106 = 15%
107 = 15%
15= 2.15%
9= 1.29%
27= 3.83%
21= 2.98%
26= 3.65%
22 = 3.08%