Instrumental vacuum assisted delivery in obstructed labor – time for AI in the birth team 

 Background: Operative assistance in late obstructed labor is a delicate mission. Emergency caesarean delivery implies risk for severe maternal surgical complications, whereas vaginal assistance by vacuum extraction may harm the fetus. The associated risk for severe fetal outcome during vacuum assisted delivery, such as intra cranial haemorrhage, asphyxia, or seizures, is approximately 2-4 %. The situation for the birth team is difficult. Aiming to increase fetal safety the research team, together with the Royal Institute of Technology, has invented a digital vacuum extraction handle. 

Aim: The digital extraction handle has been studied in vacuum assisted deliveries at the Karolinska Institute campus South and the Karolinska University hospital since 2013. The aims were to investigate the extraction force profile in association to fetal outcome and operator´s skill for future improvement in patient safety. 

Results: The data is novel, as traction force has never been studied in a clinical setting. The vacuum cup used on the fetal head allows higher traction forces than earlier anticipated; 450 Newton (N) compared to the earlier suggested 216 N. Operators systematically underestimate applied force to the feal head and high level of force is associated with the need of neonatal intensive care (>221 Newtonsminutes) as well as intra cranial haemorrhage, severe asphyxia, and seizures (>340 Newtonminutes). Obstetricians trained with the digital extraction handle experience fewer new-borns with severe outcome (0.9 vs 4 %). 

Conclusion and future: To implement AI as a supportive technique can strengthen the skill, awareness, and objective documentation, with little risk to harm, can increase the fetal safety of the vacuum assisted procedure. The observations described in the present study could be one step towards such a development. Further epidemiological studies on long-term outcomes for the children, and studies on pathophysiology of brain damage associated to traction force in on-going.