Operative vaginal delivery

Authors
Elisabeth K Wegner, MD
Ira M Bernstein, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG
Disclosures: Elisabeth K Wegner, MD Nothing to disclose. Ira M Bernstein, MD
Nothing to disclose. Charles J Lockwood, MD, MHCM Consultant/Advisory Boards:
Celula [Aneuploidy screening (Prenatal and cancer DNA screening tests in
development)]. Vanessa A Barss, MD, FACOG Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group.
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All topics are updated as new evidence becomes available and our peer
review process is complete.
Literature review current through: Jul 2015. | This topic last
updated: Jun 26, 2015.
NEWER VERSION OF TOPIC MESSAGE
INTRODUCTION Operative vaginal delivery refers to a delivery in
which the operator uses forceps or a vacuum device to assist the
mother in transitioning the fetus to extrauterine life. The instrument is
applied to the fetal head and then the operator uses traction to extract
the fetus, typically during a contraction while the mother is pushing.
The first instrumental deliveries were performed to extract fetuses from
parturients who were at high risk of maternal mortality due to prolonged
and/or obstructed labor. In these cases, saving the mother's life took
precedence over possible harm to the fetus. The focus of these
procedures has changed as a result of modern obstetrical practices that
have drastically reduced the risk of intrapartum maternal mortality and
major morbidity. Decisions regarding use of instrumental delivery are
now based primarily upon the fetal/neonatal impact of these procedures
and are weighed against the alternative options of cesarean birth,
expectant management (prolonging the second stage), and
augmentation of contractions with oxytocin.
INCIDENCE In the United States, 3.5 percent of all deliveries are
accomplished via an operative vaginal approach [1]. The overall rate of
operative vaginal delivery has been diminishing, but the proportion of
operative vaginal deliveries conducted by vacuum assisted births has
been increasing and is more than four times the rate of forceps assisted
births. Forceps deliveries account for 1 percent of vaginal births and
vacuum deliveries account for about 4 percent of vaginal births.
In recent years, the success rate for operative vaginal deliveries has
been quite high (99 percent) [2]. This likely reflects appropriate choice

of candidates for this intervention. However, the wide range of operative

vaginal delivery rates (1 to 23 percent), both across and within
geographic regions in the United States, suggests that evidence based
guidelines for operative vaginal delivery are either inadequate or
randomly applied [3].
INDICATIONS An American College of Obstetricians and
Gynecologists (ACOG) practice bulletin outlined the following
indications for operative vaginal delivery (forceps or vacuum),
recognizing that no indication is absolute; cesarean delivery is also an
option in these clinical settings [4]:

Prolonged second stage of labor For nulliparous women, a

prolonged second stage has been defined as no progress
(descent, rotation) after 4 hours with epidural anesthesia and 3
hours without epidural anesthesia [5]. For multiparous women, a
prolonged second stage has been defined as no progress
(descent, rotation) after 3 hours with epidural anesthesia and 2
hours without epidural anesthesia.
In the past, shortening the second stage was an acceptable option,
independent of any specific maternal or fetal indications, because
early studies suggested the risk of fetal morbidity was higher when
the second stage of labor exceeded two hours. More recent
evidence does not support this practice. The ability of fetal heart
rate monitoring to identify the fetus who is not tolerating labor has
generally made the arbitrary termination of labor because of any
elapsed period of time unwarranted [4,6-9]. The maternal risks of
a prolonged second stage (eg, pelvic floor injury, postpartum
hemorrhage) appear to be increased but are more related to
instrumental intervention than the specific length of the second
stage [7-12]. (See 'Maternal complications' below.)

Nonreassuring fetal status Suspicion of immediate or potential fetal

compromise (eg, nonreassuring fetal heart rate pattern, abruption)
is an indication for use of forceps or vacuum when expeditious
vaginal delivery can be readily accomplished; otherwise, cesarean
delivery may be the safer and more effective option.

Maternal cardiac or neurological disease Forceps or vacuum can

be used to shorten the second stage of labor if the Valsalva
maneuver is contraindicated because of maternal cardiovascular
or neurologic disease, or if pushing is ineffective because of
maternal neurological or muscular disease.

PREREQUISITES The operator should be experienced in operative

vaginal delivery. This individual should determine the following
prerequisites prior to application of instruments (table 1) [4,13]:

The cervix is fully dilated.

The membranes are ruptured.

The head is engaged.

Fetal presentation, position, station, and any asynclitism are known.

The fetus must be in a cephalic presentation (unless the purpose is to
use forceps to assist in delivery of an after-coming head).
If fetal presentation or position is uncertain, intrapartum ultrasound
examination should be performed, as it is more accurate than digital
examination in this setting. Sonographic visualization of fetal intracranial
structures, including the cerebellum, orbits, and midline falx, can be
used to confirm fetal head position. In two studies, digital examination
incorrectly defined fetal head position in over 20 percent of cases about
to undergo operative vaginal delivery [14,15]. However, in a randomized
trial, ultrasound assessment of head position did not reduce maternal or
neonatal morbidity compared with standard clinical care [15].
Large infants, extreme molding, extension of the fetal head, pelvic
deformities, and asynclitism may falsely suggest engagement of the
vertex. In these cases, the leading bony part is at the ischial spines,
although the biparietal diameter has not passed through the pelvic inlet.
If ultrasound is not available, no more than one-fifth of the fetal head
should be palpable abdominally if the vertex is engaged [16].

The fetal size has been estimated and clinical pelvimetry indicates
adequate mid and outlet pelvic dimensions, and no obstructions or
contractures exist.

Maternal anesthesia is satisfactory. Neuraxial anesthesia provides more

effective analgesia than pudendal block [17].

Maternal bladder is empty.


The patient consents to the procedure. The risks of the procedure
should be explained to the woman and documentation of the indication
and maternal and fetal assessments should be made in the medical
record [18]. The record should also document the informed consent
discussion (with specific risks, benefits, and alternatives delineated),
and that her questions were answered.

The option of performing an immediate cesarean delivery is available if

complications arise. Personnel for neonatal resuscitation are available,
if needed.
We do not give antibiotic prophylaxis as there is no convincing evidence
that it reduces infection in this setting [19].
Contraindications Most contraindications to instrumental delivery
are related to the potential for unacceptable fetal risks. Fetal prematurity
is a relative contraindication. Some other contraindications include
known fetal demineralizing diseases (eg, osteogenesis imperfecta), fetal
bleeding diatheses (eg, hemophilia, alloimmune thrombocytopenia),
unengaged head, unknown fetal position, malpresentation (eg, brow,
face), and suspected fetal-pelvic disproportion [20]. A nonreassuring
fetal heart rate pattern is not a contraindication to operative vaginal
delivery [4]. (See "Fetal blood sampling".)
In addition, vacuum devices should not be used to assist delivery prior
to 34 weeks of gestation because of the risk of fetal intraventricular
hemorrhage [4]. Prior scalp sampling or multiple attempts at fetal scalp
electrode placement are also relative contraindications to vacuum
extraction since these procedures may increase the risk of
cephalohematoma or external bleeding from the scalp wound [21-23].
Minimum and maximum estimated fetal weight There is no
consensus regarding the minimum and maximum estimated fetal
weights that should preclude operative vaginal delivery.
Upper threshold Instrumental delivery of the macrosomic infant may
be associated with an increased risk of injury. As an example, a study of
2924 macrosomic infants (birth weight >4000 g) found the risk of
persistent significant injury was higher after forceps than after
spontaneous delivery (relative risk [RR] 2.6) or cesarean birth (RR 4.2),
although the overall rate of persistent injury was low (0.3 percent) [24].
The risk of persistent injury at six months of age was seven-fold higher
among macrosomic infants compared with appropriate-for-gestationalage (AGA) controls (birth weight 3000 to 3999 g) and was related to
vaginal birth (operative or spontaneous). Persistent injury was not
observed in infants delivered by cesarean delivery.
The authors did not recommend a policy of elective cesarean birth for

macrosomia because it would necessitate 148 to 258 cesarean

deliveries to prevent a single persistent injury; avoidance of operative
vaginal delivery would require 50 to 99 cesarean births per injury
prevented. Furthermore, there is no precise method for determining
which mothers have macrosomic infants prior to delivery. (See "Fetal
macrosomia".)
A trial of labor and careful use of forceps or vacuum extraction are
acceptable for most fetuses suspected to be macrosomic [4]. Under
these circumstances, the obstetrician should be aware of the risk of
shoulder dystocia, especially when the second stage of labor is
prolonged. (See "Shoulder dystocia: Risk factors and planning delivery
of at risk pregnancies".)
Lower threshold As discussed above, vacuum devices should not
be used to assist delivery prior to 34 weeks of gestation (mean birth
weight 2500 g [25]) because of increased risks of fetal intraventricular
hemorrhage in premature infants. Premie sized forceps have been used
on fetuses as small as 1000 g [26].
There are no prospective randomized trials examining the impact of
prophylactic low forceps delivery in low birth weight infants.
Observational studies have reported conflicting findings. In 1965, the
Collaborative Study of Cerebral Palsy reported that prophylactic low
forceps delivery was associated with neurologic benefits in infants
between 1000 and 2500 g when compared to spontaneous vaginal or
cesarean deliveries [27]. However, this report was limited by the lack of
a rigorous statistical analysis.
Another study that performed immediate and later head ultrasound
examinations of 230 infants with estimated fetal weights of less than
1750 g observed that the overall incidence of cerebral hemorrhage was
the same after vaginal and cesarean deliveries (41 and 44 percent,
respectively) [28]. However, a lower incidence of hemorrhage was noted
after vaginal delivery with forceps (17 percent). More grades 3 to 4
hemorrhages were observed after vaginal birth without forceps and in
cesarean births following active phase labor compared to other modes
of delivery.
In contrast, several other studies have suggested an increased risk of
intraventricular hemorrhage with prophylactic low forceps [29-31] while
one report on 1065 infants between 1000 to 2500 g identified no
differences in neonatal outcome between the 394 infants delivered by
low forceps and the 671 that delivered spontaneously [26].
In summary, the evidence does not clearly identify a superior mode of
delivery in cephalic presenting low birth weight infants and very little
data address the very low birth weight infant. Reassuringly, larger trials

do not demonstrate any increase in neurologic injury with the use of low
forceps in low birth weight infants, and a role for low forceps in clinically
indicated situations would appear reasonable in this population. (See
"Delivery of the preterm low birth weight singleton fetus".)
Two forceps are available which are smaller in dimension than standard
forceps and are intended for use in the low birth weight or very low birth
weight populations. "Baby" Elliot and "baby" Simpson forceps are
among these instruments. Unfortunately, we were unable to identify any
published studies or manufacturer guidelines regarding the estimated
fetal weights or gestational ages at which these instruments might be
most useful.
ALTERNATIVES Possible alternatives to operative vaginal delivery
are cesarean birth, expectant management (possibly with delayed
pushing, maternal rest, change in maternal position, reduction in
neuraxial anesthesia, emotional support), and augmentation of
contractions with oxytocin. The choice depends upon the clinical
situation, taking into account factors such as whether the fetal heart rate
pattern is nonreassuring, the quality and frequency of contractions,
estimated fetal size, and fetal position. (See "Overview of normal labor
and protraction and arrest disorders" and "Shoulder dystocia: Risk
factors and planning delivery of at risk pregnancies".)
TRIAL OF INSTRUMENTAL DELIVERY Although one can never be
certain of a successful outcome, an operative vaginal delivery should
only be considered when the likelihood of success is high, given there
may be a higher rate of birth trauma after failed attempts at operative
delivery [4,32,33]. As an example, in one study, the rates of subdural or
cerebral hemorrhage, facial nerve injury, convulsions, central nervous
system depression, and mechanical ventilation were higher in infants
delivered by cesarean birth after a failed instrumental delivery than in
those delivered by cesarean with no prior attempt at operative vaginal
delivery (table 2) [34]. However, other studies have not shown adverse
effects from failed operative vaginal delivery as long as cesarean
delivery followed promptly [35]. No randomized trials have been
performed comparing a trial of instrumental vaginal delivery (vacuum
extraction or forceps) to immediate cesarean delivery for women with
failure to progress in the second stage of labor.
Multiple variables have been associated with an increased risk of failed
operative delivery; two common causes are occiput posterior position
and macrosomia [32,36-42]. Other purported factors include one fifth of
the head palpable abdominally, the presenting part only as far as the
ischial spines, excessive molding of the fetal head, protracted labor, and
maternal obesity [32].
CLASSIFICATION OF FORCEPS DELIVERIES ACOG redefined the
classification of forceps delivery in 1988 to better reflect the degree of
difficulty and attendant risk (eg, lower fetal station and smaller degrees
of head rotation are associated with reduced maternal and fetal injury

[43]) [4]. The criteria for different types of forceps deliveries are as
follows [4]:

Outlet forceps The application of forceps when the scalp is visible at

the introitus without separating the labia, the fetal skull has reached the
pelvic floor, the sagittal suture is in anteroposterior diameter or a right or
left occiput anterior or posterior position, the fetal head is at or on the
perineum, rotation does not exceed 45 degrees.

Low forceps The application of forceps when the leading point of the
fetal skull is 2 cm or more beyond the ischial spines (ie, at least +2 cm
station; the maximum possible distance beyond the ischial spines using
this system is 5 cm), but not on the pelvic floor. Low forceps have two
subdivisions: (a) rotation is 45 degrees or less (left or right occiput
anterior to occiput anterior, or left or right occiput posterior to occiput
posterior), and (b) rotation more than 45 degrees.

Midforceps The application of forceps when the head is engaged, but

the leading point of the skull is higher than +2 cm station.
Under very unusual circumstances, such as the sudden onset of severe
fetal or maternal compromise, application of forceps above +2 cm
station may be attempted while simultaneously initiating preparations for
a cesarean delivery in the event the forceps maneuver is unsuccessful.
Under no circumstances, however, should forceps be applied to an
unengaged presenting part or when the cervix is not completely dilated
[4].
CHOICE OF INSTRUMENT The choice of instrument is determined
by level of training with the various forceps and vacuum equipment.
Factors that might influence choice are the availability of the instrument,
the degree of maternal anesthesia, and knowledge of the risks and
benefits associated with each instrument. Differences between the two
instruments in the types and rates of maternal and fetal morbidity are
reviewed below (see 'Data from comparative trials' below).
In general, vacuum delivery is probably safer than forceps for the
mother, while forceps are probably safer than vacuum for the fetus.
Vacuum devices are easier to apply, place less force on the fetal head,
require less maternal anesthesia, result in less maternal soft tissue
trauma, and do not affect the diameter of the fetal head compared to
forceps. Fetal head rotation may occur secondary to fetal extraction.
By comparison, the advantages of forceps are that they are unlikely to
detach from the head, can be used on premature fetuses or to actively
rotate the fetal head, result in less cephalohematoma and retinal

hemorrhage, and do not aggravate bleeding from scalp lacerations.

A meta-analysis of randomized trials found that forceps were less likely
to fail to achieve vaginal birth than vacuum (RR 0.65, 95% CI 0.45-0.94;
7 trials, 2419 participants), but with more maternal trauma [44]. The
authors suggested use of vacuum extraction when a relatively easy
procedure is anticipated (eg, occipito-anterior position with no signs of
relative cephalopelvic disproportion).
Vacuum A meta-analysis of eight trials involving 1076 women
compared soft (silicone, plastic, rubber) vacuum extractor cups to rigid
(metal, plastic) ones [44]. Soft cups were more likely to fail in achieving
vaginal delivery (OR 1.63, 95% CI 1.17-2.28). However, there were
fewer scalp injuries and cephalohematomas with the soft cup and no
differences between groups in regard to maternal injury. The authors
concluded that metal or rigid cups were more suitable for occiput
posterior, transverse, and difficult occiput anterior deliveries, whereas
the soft cup was appropriate for uncomplicated deliveries.
Two randomized prospective trials compared conventional vacuum
devices to the Kiwi Omnicup. Both showed a statistically significant
higher failure rate with the Kiwi Omnicup compared to conventional
vacuum: failure rates in one trial were 30.1 and 19.2 percent,
respectively [45], and in the other trial, failure rates were 34 and 21
percent, respectively [46].
Forceps A detailed discussion of the hundreds of types of
instruments available for forceps delivery is beyond the scope of this
review. In general, the instrument selected should have cephalic and
pelvic curves appropriate to the size and shape of the fetal head,
maternal pelvis, and planned procedure. Midpelvic deliveries are
facilitated by an instrument that can be used with a traction handle (eg,
Bill's axis traction handle) and a sliding lock is helpful when there is
asynclitism. Simpson type forceps tend to fit a long molded head, Elliott
or Tucker-McLane type forceps are better suited to a round unmolded
head, and Kielland forceps are useful for rotations because of their
minimal pelvic curve and sliding lock (picture 1A-F).
Spatula An unarticulated forceps (ie, Thierry spatula) has become
popular in many European, African, and Latin American countries [47].
Outcome data are limited, but maternal and neonatal complication rates
appear to be similar to, or slightly higher than, rates with other
instruments [48,49].
Odon device A novel alternative instrument, the Odon device, was
developed by the World Health Organization (WHO) for use in areas
that have limited or no access to cesarean birth. The Odon device is
undergoing the first phase of testing for safety and feasibility in
Argentina and rural South Africa [50]. It is a low-cost device made of
film-like polyethylene material that creates a sac filled with air that
surrounds the entire head and enables extraction when traction is
applied. It has the potential to be safer and easier to apply than

forceps/vacuum extractor for assisted deliveries. Videos showing

application of the device and fetal extraction are available online
(www.odondevice.org).
APPLICATION
Forceps Appropriately applied forceps grasp the occiput anterior
(OA) fetal head such that:

The long axis of the blades corresponds to the occipitomental diameter

(figure 1)

The tips of the blades lie over the cheeks (figure 2)

The blades are equidistant from the sagittal suture, which should bisect
a horizontal plane through the shanks

The posterior fontanelle should be one finger breadth anterior to this

plane

Fenestrated blades should admit no more than one finger breadth

between the heel of the fenestration and the fetal head

No maternal tissue has been grasped.

Rotation, when needed, is performed between contractions. These
deliveries are more difficult and associated with a higher risk of
maternal and fetal complications than simple traction applied to the nonor minimally rotated vertex. Forceps application and rotation when the
fetal vertex is not directly OA is beyond the scope of this topic review.
To reduce the risk of laceration, forceps are disarticulated and removed
when expulsion is certain, but before the widest diameter of the fetal
head passes through the introitus. The vertex can then be delivered
with no or minimal maternal assistance.
Vacuum The procedure for vacuum extraction is discussed in detail
separately. (See "Procedure for vacuum assisted operative vaginal
delivery".)
Traction Traction with forceps (or vacuum) should be steady (not
rocking) and in the line of the birth canal. Traction should be exerted
with each contraction and in conjunction with maternal expulsive efforts;
the forceps can be relaxed between contractions to reduce fetal cranial
compression. In most cases, progress is noted with the first or second
pull and delivery occurs by the third or fourth pull [51]. The procedure

should be abandoned if descent does not occur with appropriate

application and traction.
An observational study of 560 vacuum assisted deliveries using an
omnicup vacuum device with a traction force indicator found that 86
percent of extractions occurred with 11.5 kg (25 lbs) or less traction and
14 percent with greater than 11.5 kg traction [52]. A similar series found
that neonatal scalp abrasion and cephalhematoma were more common
in infants born with traction greater than 11.5 kg [53].
SEQUENTIAL ATTEMPTS ACOG has suggested that multiple
attempts at operative vaginal delivery using different instruments
(vacuum, different types of forceps) be avoided due to the greater
potential for maternal and/or fetal injury [4]. Population-based data have
shown increased maternal and neonatal risks from sequential
application of vacuum and forceps [34,54-56], while a few small studies
have not demonstrated increased risk, but these may be limited by their
study sizes [35,57].
In one large study, the incidence of subdural or cerebral hemorrhage in
infants delivered by vacuum and forceps, vacuum alone, or forceps
alone was approximately 21, 10, and 8, per 10,000 births, respectively
[34]. These findings were corroborated by another analysis based upon
state-wide birth certificate data [54], and a study on asymptomatic term
infants who underwent routine magnetic resonance imaging within 48
hours of birth [55]. Nine of 111 asymptomatic infants had subdural
hematomas with the highest proportion in the group exposed to failed
vacuum followed by successful forceps delivery (five subdural
hematomas among 18 infants). In addition, three subdural hematomas
occurred in 49 infants spontaneously delivered from vertex presentation
and one subdural hemorrhage occurred after a failed vacuum delivery.
No subdurals were noted in the remaining infants (25 infants delivered
by cesarean, 4 delivered by forceps, 13 delivered by vacuum, and 1
delivered by cesarean after failed forceps). All hematomas had resolved
without clinical sequelae when reevaluated four weeks later. However,
two other small studies did not show adverse effects from sequential
use of vacuum and forceps, even when vaginal delivery was not
achieved [35,57].
For the mother, sequential use of vacuum and forceps has been
associated with increased rates of third/fourth degree lacerations and
postpartum hemorrhage [56].
We feel sequential delivery may be appropriate in rare, carefully
selected cases, as long as none of the indications for abandonment of
operative delivery are present. We would not consider it a sequential
delivery in situations where proper placement of forceps cannot be
achieved or a vacuum device fails to achieve suction and no traction
has been applied and then a second instrument is used (see 'When to
abandon the procedure' below).
WHEN TO ABANDON THE PROCEDURE The decision to proceed

with operative vaginal delivery is ongoing and decided moment by

moment based on assessment of the success of the various steps in
the procedure. Operative vaginal delivery should be abandoned if it is
difficult to apply the instrument, descent does not easily proceed with
traction, or the baby has not been delivered within a reasonable time
(eg, 15 to 20 minutes) [16]. Some experts have recommended
abandoning the procedure after three pulls. A cohort study found that 82
percent of completed operative deliveries occurred with one to three
pulls, and that pulling more than three times was associated with infant
trauma in 45 percent of such deliveries [58]. Based on these data, it
seems prudent to abandon the procedure if good instrument placement
is followed by no progress in descent over three attempts. If descent
has occurred and delivery is clearly imminent, then proceeding with
instrumental delivery after three pulls may be appropriate and less
morbid than a cesarean delivery of an infant with its head on the
perineum.
The operator should not be fixated on affecting a vaginal delivery. It is
essential that the operator be willing to abandon a planned or attempted
operative delivery and have the ability to perform a cesarean birth if
evaluation or reevaluation of the clinical status shows that an
instrumental delivery is contraindicated (eg, the fetal head is not
engaged, the position is uncertain, the procedure is not succeeding).
It is important to remember to examine the mother for possible tissue
trauma after a failed attempt at operative delivery, as well as after
successful attempts.
OUTCOME AFTER FAILED PROCEDURES A secondary analysis of
an observational study of women who underwent second stage
cesarean delivery compared outcomes of infants delivered abdominally
after a failed attempt at operative vaginal delivery (n = 640) with those
who underwent cesarean delivery without such attempts (n = 2549) [59].
Overall, a failed operative delivery was associated with significantly
higher rates of umbilical pH <7.0 (4.7 versus 1.7 percent), Apgar score
3 at 5 minutes (1.7 versus 0.6 percent), seizures in the first 24 hours of
life (0.9 versus 0.1 percent), and hypoxic ischemic encephalopathy
(HIE) (1.1 versus 0.1 percent).
The authors attributed these differences, at least in part, to the higher
proportion of nonreassuring fetal heart rate tracings as the indication for
cesarean in the attempted operative vaginal delivery group (18 versus
14 percent); unfortunately, the indications for attempted instrument
delivery were not reported. There was no evidence of fetal cranial
trauma in neonates with HIE, which suggests that the HIE was related
to the nonreassuring fetal status rather than trauma. This hypothesis is
supported by the observation that significant differences in neonatal
outcome did not occur when the instrumental procedures were
performed for indications other than a nonreassuring tracing (eg,
dystocia); however, the number of adverse events in these settings was

small, with a wide confidence interval around the odds ratio. This study
did not report outcomes of pregnancies in which attempted operative
vaginal delivery was successful; incorporating these data might change
the overall results reported for attempted operative vaginal delivery and
impact conclusions about the safety of attempting this procedure. Data
from randomized trials which include outcomes of all women
undergoing attempted operative vaginal delivery are needed before one
can conclude that a failed instrumental delivery has any adverse
neonatal effects.
RISKS Maternal and fetal complication rates depend on a number of
factors, which are not entirely independent. These include parity,
forceps/cup position, head position at application, and station.
Data from comparative trials The risks associated with operative
vaginal delivery need to be evaluated with respect to appropriate control
groups and reasonable alternative procedures. This was illustrated by a
study assessing the incidence of intracranial hemorrhage related to
labor and mode of delivery in 583,340 singleton infants born to
nulliparous women in California (table 3) [34]. The rate of subdural or
cerebral hemorrhage associated with vacuum extraction was equivalent
to that associated with forceps use or cesarean delivery during labor,
but higher than after spontaneous delivery or a cesarean delivery
performed prior to labor. This suggests that the intrapartum indication
for intervention was the major risk factor for this complication, rather
than mode of delivery. (See "Clinical manifestations and diagnosis of
intraventricular hemorrhage in the newborn".)
Comparative data on the risks of instrumental delivery are illustrated by
the following examples from large studies:

A meta-analysis of 10 trials comparing vacuum with forceps delivery

found vacuum deliveries were associated with less maternal soft tissue
trauma (OR 0.41, 95% CI 0.33-0.50), required less general and regional
anesthesia, and resulted in fewer cesarean deliveries [60]. However,
use of a vacuum device was less likely to result in successful vaginal
delivery than forceps. The lower cesarean delivery rate after attempted
vacuum extraction was likely due to follow-up trial of forceps, whereas
failed forceps typically resulted in a cesarean delivery. Patient selection
may have also been a factor; the vacuum approach may have been
used in patients more likely to deliver with minimal assistance.
Neonates delivered by vacuum extraction had more neonatal
cephalohematoma (OR 2.38) and retinal hemorrhages (OR 1.99) than
those delivered by forceps [60]. These problems generally are not
associated with long-term complications (see 'Maternal complications'
below).

A population-based analysis of singleton births in the United States

provided crude morbidity/mortality data for over 11 million unassisted,
forceps assisted, and vacuum assisted births (table 4) [61]. Vacuumassisted deliveries were associated with significantly lower rates of birth
injury, seizures, and assisted ventilation than forceps-assisted
deliveries, after adjustment for confounders; neonatal death rates were
equivalent.
State-based data for California and New Jersey are shown in the tables
(table 5 and table 6) [34,61]. Although patients contained in these
reports might represent a biased sample, relative to the choice of tool
for operative vaginal delivery, it seems likely that this is a reasonable
representation of injuries to be expected with the application of the
different tools, given current clinical indications for different types of
operative vaginal delivery.
Maternal complications
Short-term Short-term maternal risks from instrumental delivery
include pain at delivery, perineal pain at 24 hours, lower genital tract
lacerations and hematomas, urinary retention and incontinence,
anemia, anal incontinence, and rehospitalization [62-67]. A randomized
trial reported at least one adverse maternal outcome (periurethral/labial
laceration, vaginal laceration, 3rd or 4th degree laceration, vulvar or
vaginal hematomas, or cervical lacerations) occurred in 48 percent of
forceps, 36 percent of silastic vacuum extractor, and 22 percent of
Mityvac vacuum extractor deliveries [68]. Severe maternal trauma is
primarily associated with rotational and midforceps operations [43,69];
direct bladder injury, ureteral lacerations/transections, and uterine
rupture have been reported in such cases [70].
Although maternal complications can occur with spontaneous delivery,
they are more likely to be associated with vacuum or forceps delivery.
This was illustrated by a retrospective review of 50,210 vaginal
deliveries and a cohort study of 87,267 vaginal deliveries in which the
rates of third and fourth degree lacerations were: spontaneous delivery
(2 percent), vacuum extraction (10 to 11 percent), and forceps delivery
(17 to 20 percent) [71,72].
Additional maternal morbidities occur when episiotomy is performed at
the time of the operative vaginal delivery. These morbidities include an
increased risk of postpartum hemorrhage and perineal infection, and a
greater need for moderate or strong analgesia [73].
Most studies show performing an episiotomy (midline [74,75] or
mediolateral [76,77]) appears to increase, rather than decrease, the risk
of perineal trauma [74-78] when employed in association with operative
vaginal deliveries. As an example, a study that calculated odds ratios
(OR) for severe perineal laceration in nulliparous women undergoing
various types of delivery reported [75]:


Vacuum extraction without episiotomy (OR 9.4)

Forceps delivery without episiotomy (OR 23.2)

Vacuum extraction with episiotomy (OR 34.7)

Forceps delivery with episiotomy (OR 41.8)

Similar results have been reported in multiparous women.
However, one large cohort study found that mediolateral episiotomy
during operative vaginal delivery protected against anal sphincter injury
[79]. Of note, the only randomized trial comparing routine versus
restrictive episiotomy did not show a difference in outcomes, including
anal sphincter tear or postpartum hemorrhage [80].
Rates of third and fourth degree lacerations have decreased over
several decades in the US [81]. Observational data suggest that more
than 50 percent of this reduction can be accounted for by decreased
use of forceps and episiotomy [82]. The effects of episiotomy are
discussed in more detail separately. (See "Approach to episiotomy".)
Fetal position also has an impact on the risk of maternal trauma during
delivery [83-85]. The rate of rectal injury is higher for instrumental
delivery from the occiput posterior (OP) compared with the occiput
anterior (OA) position (for forceps delivery: 72 versus 54 percent; for
vacuum delivery: 33 versus 27 percent) [83]. A logistic regression model
adjusting for a number of factors showed that OP was four times more
likely than OA to be associated with anal sphincter injury; the
unadjusted rates of anal sphincter injury for the OP and OA positions
were 42 and 22 percent, respectively [84].
It should be noted that surgical trauma is intrinsic to all cesarean
deliveries. Although spontaneous vaginal delivery is less traumatic for
the mother than operative vaginal delivery, the latter is associated with
less short-term maternal morbidity than cesarean delivery. As an
example, a retrospective analysis of 358 midforceps and 486 cesarean
deliveries reported febrile morbidity followed 25 percent of cesareans,
but only 4 percent of forceps deliveries, and all cases of
thromboembolism occurred in women who underwent cesarean delivery
[86]. Unexpected cervical and vaginal lacerations and episiotomy
extensions occurred in 45 percent of forceps deliveries, while 21
percent of women delivered by cesarean had an unexpected
hysterotomy extension.
Long-term Long-term maternal sequelae from operative delivery are
primarily related to potential disturbances in urinary and anal function,
such as urinary incontinence, fecal incontinence, pelvic organ prolapse,
and, occasionally, fistula formation. As an example, a trial that randomly
assigned 75 women to forceps or vacuum delivery and surveyed them

five years postpartum reported 47 percent had some degree of urinary

incontinence and 20 percent had loss of bowel control "sometimes" or
"frequently" [87]. The long-term rates of morbidity were similar
regardless of the instrument used to assist delivery. This study was
limited by the lack of a control group of women who underwent
cesarean delivery following a dysfunctional labor.
Any increase in risk of long-term maternal morbidity from different types
of operative vaginal delivery cannot be accurately quantitated and
compared because of the lack of adequate randomized trials with
appropriate control groups. The most appropriate control group when
evaluating sequelae of operative vaginal delivery is probably cesarean
delivery during dysfunctional labor because prelabor cesarean delivery
and spontaneous vaginal delivery are not possible alternatives to
instrumental delivery in the setting of labor complications. Data from
longitudinal cohort studies suggest that cesarean delivery after full
dilation is associated with less urinary incontinence, anal incontinence,
and prolapse symptoms than operative vaginal delivery, but these
differences were not consistently statistically significant [88,89]. The
relationships between method of delivery and long-term risk of pelvic
relaxation and urinary and fecal incontinence are discussed in detail
separately. (See "Effect of pregnancy and childbirth on anal sphincter
function and fecal incontinence" and "Urinary incontinence and pelvic
organ prolapse associated with pregnancy and childbirth".)
Risk of recurrent operative vaginal delivery Mode of delivery after
a previous operative vaginal delivery has not been extensively
evaluated. A three-year follow-up study that surveyed women who had
undergone a successful, term, operative vaginal delivery in the second
stage reported 42 of 54 (78 percent) women achieved vaginal delivery
in the subsequent pregnancy and 3 of the 54 (5.6 percent) women had
another instrumental delivery [90]. Another study of nulliparas who
underwent operative vaginal delivery for their first birth observed 4.7
percent had a repeat operative vaginal delivery in their subsequent
delivery [91].
Neonatal complications
Short-term Postdelivery, the neonatal care provider should be
informed that the birth was attempted or assisted by vacuum or forceps.
Since a serious complication, such as a subgaleal hematoma, can
occur within hours of delivery, it is important that the infant care
providers be informed by either a reliable charting method or direct
notification. A prospective study that follows 79 term infants after
vacuum assisted delivery found all delivery related complaints were
identified within the first 10 hours of life [92].
The short-term complications to the fetus from operative vaginal
delivery are usually caused by head compression and traction on the
fetal intracranial structures, face, and scalp, but may be caused by
suboptimal instrument placement [93]. The most serious complication is

intracranial hemorrhage. The relative frequency of intracranial

hemorrhage according to type of delivery and labor status was best
illustrated in a study of 583,340 singleton infants born to nulliparous
women in California (table 5) [34]. Similar trends have been reported by
others [94]. Other complications include: bruises, abrasions and
lacerations, facial nerve palsy, cephalohematoma, retinal hemorrhage,
subgaleal hemorrhage, and skull fracture [16,95].
Virtually all of these complications can also occur in the course of a
spontaneous vaginal delivery, but the incidence is lower than with
instrumental delivery. The reported incidence of each complication
varies widely and depends on a number of factors, such as the
equipment used (metal, plastic, vacuum, forceps), fetal station, and the
experience of the operator.

Vacuum-assisted deliveries The incidence of serious neonatal

complications with vacuum extraction is approximately 5 percent
[96]. Torsion and traction of the vacuum cup can cause fetal scalp
abrasions and lacerations, separation of the scalp from underlying
structures leading to cephalohematoma, subgaleal hematoma (26
to 45 per 1000 vacuum deliveries [4]), intracranial hemorrhage,
hyperbilirubinemia, and retinal hemorrhage (figure 3) [34,52,97]. In
general, the incidence of retinal hemorrhage is higher for vacuumassisted than for spontaneous vaginal or cesarean deliveries (75,
33, and 7 percent, respectively) [98]. These hemorrhages typically
resolve without sequelae within four weeks of birth.
Cephalohematoma, in particular, is more common after vacuumassisted extraction than forceps delivery (approximately 15 versus
2 percent) (table 6) [60,61,68]. A study of 913 term newborns who
were successfully delivered using a vacuum device, and who had
a skull x-ray and head ultrasound, reported skull fracture in 46 (5
percent) [99]. All of the fractures were linear (nondepressed) and
no infant was symptomatic.
Death from intracranial hemorrhage has been reported. The Food and
Drug Administration (FDA) issued an advisory (May 21, 1998) regarding
the possibility of two major life-threatening complications following use
of vacuum assisted devices: (1) subgaleal hematoma (ie, collection of
blood between the aponeurosis covering the scalp and the periosteum;
blood can extend across suture lines and beneath the scalp and into the
neck) and (2) intracranial hemorrhage (subdural, subarachnoid,
intraventricular, and/or intraparenchymal hemorrhage) [100]. The FDA
also recommended these devices be used only when a specific
obstetric indication is present and when five criteria could be met (table
7).
Shoulder dystocia also appears to be more common with vacuum-

assisted than forceps deliveries [61,101]. This is likely the reason that
vacuum-assisted deliveries are at higher risk of brachial plexus injury
than forceps-assisted deliveries or cesarean delivery [94].

Forceps-assisted deliveries Short-term complications resulting from

forceps deliveries include skin markings and lacerations, external
ocular trauma, intracranial hemorrhage, subgaleal hematomas,
hyperbilirubinemia, retinal hemorrhage, lipoid necrosis, nerve
injury, skull fractures, and death [20,34,96,102]. Facial palsies
(table 6) [94,102] and depressed skull fractures [102], in particular,
are more common with use of forceps than vacuum devices; both
complications can also occur after a non-instrumental delivery.
Long-term Acute fetal injuries with potential long-term sequelae
include intracranial hemorrhage (subdural, subarachnoid,
intraventricular and/or intraparenchymal hemorrhage) [103] and
neuromuscular injury; however, these sequelae are rare.
Developmental outcome appears to be equivalent for both forceps and
vacuum assisted births. In one trial, 313 maternal-infant pairs were
randomly assigned to delivery by forceps or vacuum extraction and
followed for five years [87]. There was no difference in child
development between the groups. Another randomized trial of 300
women delivered by forceps or vacuum evaluated the infants at nine
months of age and found no differences in infant testing results, such as
hearing or vision [104]. Both of these trials lacked a comparison to
infants delivered spontaneously or by cesarean delivery. A third trial
compared neurodevelopmental outcome at age 5 for children born by
successful instrumental vaginal delivery, failed instrumental delivery,
and cesarean delivery in the second stage of labor [105].
Neurodevelopmental morbidity was low with no significant differences
among the three groups, but the study was underpowered.
One of the few follow-up evaluations comparing outcome at school age
after operative or spontaneous delivery among 3413 five year-olds
found no differences in cognitive testing [106]. This series included 1192
forceps deliveries, of which 114 were midforceps. Another study
compared the neurological outcome of 295 10-year-old children
delivered by vacuum extraction with that of 302 children delivered
spontaneously in the same hospital by the same doctors and matched
for maternal age, gestational age, and birthweight [107]. Both groups
had similar results for tests of fine and gross motor control, perceptual
integration, behavioral maturity, scholastic performance, speech ability,
and self-care. In addition, a national cohort study of 126,032 sixteen
year olds born as nonanomalous vertex singletons 34 weeks of
gestation to Swedish-born parents noted that those delivered by
vacuum extraction had slightly lower mean mathematics test scores

than children born vaginally without instruments after adjustment for

major confounders, but similar scores to those born by intrapartum
cesarean delivery [108].
Lastly, a cohort study of almost 25,000 births did not find any
association between forceps delivery and adult epilepsy [109].
USE OF VACCUM OR FORCEPS AT CESAREAN DELIVERY (See
"Management of deeply engaged and floating fetal presentations at
cesarean delivery".)
SUMMARY AND RECOMMENDATIONS

For each patient, the risks and benefits of operative vaginal delivery
need to be balanced against those for cesarean delivery and less
invasive interventions. Situations where operative vaginal delivery may
be preferable to cesarean delivery or less invasive interventions include
prolonged second stage of labor despite intervention with less invasive
measures, nonreassuring fetal status where expeditious delivery is
desirable, and maternal cardiac or neurological diseases where pushing
(Valsalva) needs to be avoided. Nonmedically indicated shortening of
the second stage is not an indication for operative vaginal delivery. (See
'Indications' above.)

Before resorting to an operative vaginal delivery, the clinician should

ensure that prerequisites are met (eg, head is engaged, membranes
ruptured, presentation and position known, anesthesia is satisfactory,
the fetus is of appropriate gestational age and size, maternal bladder is
empty) and there are no contraindications (eg, malpresentation, fetal
bleeding diathesis). (See 'Prerequisites' above.)

Forceps deliveries are classified as outlet, low, or mid, depending on the

fetal station and degree of head rotation. (See 'Classification of forceps
deliveries' above.)

There is inadequate evidence upon which to base a recommendation

for use of either vacuum or forceps for all circumstances when operative
vaginal delivery is attempted. In general, vacuum devices are easier to
apply, place less force on the fetal head, require less maternal
anesthesia, and do not increase the diameter of the fetal head
compared to forceps. By comparison, the advantages of forceps are
that they are unlikely to detach from the head, can be sized to a
premature cranium, may be used for a rotation, and do not aggravate
bleeding from scalp lacerations. (See 'Choice of instrument' above.)
Vacuum should not be applied to fetuses less than 34 weeks of

gestation.
For women who are to undergo an operative vaginal delivery at greater
than 34 weeks and have a high likelihood of success (eg, outlet
procedure), we suggest use of vacuum over forceps because of lower
maternal morbidity (Grade 2C). When success is uncertain, primary use
of forceps may reduce the morbidity associated with combined
sequential instrumental delivery. (See 'Choice of instrument' above and
'Sequential attempts' above.)

Vacuum assisted deliveries are associated with an increased risk of

neonatal cephalohematomata and retinal hemorrhage compared with
forceps or spontaneous deliveries. These complications generally
resolve without sequelae. Forceps assisted deliveries cause
significantly more acute maternal injury and fetal facial nerve injury than
vacuum assisted operative deliveries or spontaneous deliveries. (See
'Risks' above.)

The decision to proceed with operative vaginal delivery is ongoing and

decided moment by moment based on assessment of the success of
the various steps in the procedure. Operative vaginal delivery should be
abandoned if it is difficult to apply the instrument, descent does not
easily proceed with traction, or the baby has not been delivered within a
reasonable time (eg, 15 to 20 minutes) or after three pulls with no
progress. (See 'When to abandon the procedure' above.)

It is unclear whether a failed attempt at operative vaginal delivery

followed by cesarean delivery is associated with a poorer neonatal
outcome than cesarean delivery without the attempt. (See 'Outcome
after failed procedures' above.)

1
2
3

Although short-term neonatal morbidity varies between procedures,

developmental outcome appears to be equivalent for both forceps and
vacuum assisted births. (See 'Neonatal complications' above.)
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