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INTERIM UPDATE
ACOG PRACTICE BULLETIN
Clinical Management Guidelines for Obstetrician–Gynecologists
NUMBER 219 (Replaces Practice Bulletin Number 154, November 2015)
Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the Committee on Practice Bulletins—
Obstetrics with the assistance of Alan M. Peaceman, MD.
INTERIM UPDATE: This Practice Bulletin is updated as highlighted to reflect the Prophylactic Antibiotics for the Prevention of
Infection Following Operative Delivery (ANODE) trial. The term “cesarean delivery” has been changed to “cesarean birth”
and the term "vaginal delivery" has been changed to "vaginal birth" throughout the document in accordance with the
reVITALize terminology.
Operative Vaginal Birth
Despite significant changes in management of labor and delivery over the past few decades, operative vaginal birth
remains an important component of modern labor management, accounting for 3.3% of all deliveries in 2013 (1). Use
of obstetric forceps or vacuum extractor requires that an obstetrician or other obstetric care provider be familiar with
the proper use of the instruments and the risks involved. The purpose of this document is to provide a review of the
current evidence regarding the benefits and risks of operative vaginal birth.
Background
Operative vaginal birth is used to achieve or expedite
safe vaginal birth for maternal or fetal indications.
Examples include maternal exhaustion and an inability
to push effectively; medical indications such as maternal
cardiac disease and a need to avoid pushing in the second
stage of labor; prolonged second stage of labor, arrest of
descent, or rotation of the fetal head; and nonreassuring
fetal heart rate patterns in the second stage of labor.
Operative vaginal birth is beneficial for women because
it avoids cesarean birth and its associated morbidities.
The short-term risks of cesarean birth include hemorrhage,
infection, prolonged healing time, and increased
cost. The long-term morbidities associated with cesarean
birth include the high likelihood of repeat cesarean birth,
the complications that can occur with labor after cesarean
birth, and the risks of placental abnormalities such as
placenta accreta. For the fetus showing signs of possible
compromise, successful operative vaginal birth can
shorten the exposure to additional labor and reduce or
prevent the effect of intrapartum insults (2). Often, operative
vaginal birth can be safely accomplished more
quickly than cesarean birth.
The rate of operative vaginal birth has decreased
over the past few decades, accounting for part of the
increase in cesarean birth rates in the United States. As
the rate of cesarean birth increased over the past two
decades, the rate of operative vaginal birth decreased
from 9.01% of all deliveries in 1992 to 3.3% of all
deliveries in 2013 (1). Nonetheless, operative vaginal
birth remains an important part of modern obstetric care
and in the appropriate circumstances can be used to
safely avoid cesarean birth. Operative vaginal deliveries
are accomplished by applying direct traction on the fetal
skull with forceps or applying traction to the fetal scalp
by means of a vacuum extractor (3). Various types of
forceps and vacuum extractors have been developed for
this purpose, and readers should refer to textbooks for
review of these instruments (4–6). Whichever instrument
is used, the indications for operative vaginal birth are the
same (Box 1).
Operative vaginal deliveries are classified by the
station of the fetal head at application and the degree of
rotation necessary for delivery (Box 2). In an evaluation
of the American College of Obstetricians and Gynecologists’
classification, investigators demonstrated that the
lower the fetal head and the less rotation required, the
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less the risk of injury to the woman and the fetus (7).
Before use of either forceps or vacuum extractor, an
assessment by the operator of the factors that contribute
to success and safety should be performed, including
estimated fetal weight, the clinical adequacy of the maternal
pelvis, the fetal station and position, and the adequacy
of anesthesia. Operative vaginal birth is contraindicated
if the fetal head is not engaged in the maternal pelvis or if
the position of the vertex cannot be determined.
Clinical Issues
Choice of Instruments
Forceps and vacuum extractors have low risk of complications
and are acceptable for operative vaginal birth.
The choice of whether to use vacuum or forceps and
which specific instrument to use is defined by the clinical
circumstances and operator preference based on experience
and training. Both types of instruments can be
effective in delivering the fetus and shortening the time
to delivery. Vacuum extraction is believed to be easier to
learn and may be used when asynclitism prevents proper
forceps placement. Use of forceps provides a more secure
application and is appropriate for rotation of the fetal
head to occiput anterior or occiput posterior position.
A vaginal birth is more likely to be achieved with
forceps than with vacuum extractors; however, forceps
are more likely to be associated with third- and fourthdegree
perineal tears. In a review of randomized trials
comparing forceps deliveries with vacuum deliveries, the
authors found that when all deliveries were considered,
use of vacuum was more likely to fail as the instrument
of delivery compared with forceps (relative risk [RR],
0.65; 95% confidence interval [CI], 0.45–0.94). Forceps
were more likely to be associated with third- and fourthdegree
perineal tears (RR, 1.89; 95% CI, 1.51–2.37),
with no difference in the occurrence of neonatal cephalohematomas
(RR, 0.64; 95% CI, 0.37–1.11) (8). In
another study that analyzed longer-term outcomes, no
difference in urinary incontinence or anal sphincter dysfunction
was found after 5 years in women who had
deliveries by forceps versus vacuum extractor (9). Vacuum
extraction has been discouraged for gestational age
less than 34 weeks, although a safe lower limit for gestational
age has not been established (10–12).
Technique
Few specific aspects of operative vaginal birth technique
have been studied. Nonetheless, it is reasonable to
perform many parts of the procedure based on traditional
teaching and longstanding experience. A full list of
prerequisites for an operative vaginal birth is presented
in Box 3. In addition, the reason for the procedure, alternatives,
and risks involved should be discussed with the
patient and agreement obtained.
Box 1. Indications for Operative Vaginal
Delivery
c Prolonged second stage of labor
c Suspicion of immediate or potential fetal
compromise
c Shortening of the second stage of labor for
maternal benefit
Data from Royal Australian and New Zealand College of
Obstetricians and Gynaecologists. Instrumental vaginal delivery.
College Statement C-Obs 16. East Melbourne, Australia:
RANZCOG; 2012. Available at https://ranzcog.
edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Wom-
en%27s%20Health/Statement%20and%20guidelines/C-
linical-Obstetrics/Instrumental-Vaginal-Birth-(C-Obs-16)Review-March-2016.pdf?ext5.pdf.
Retrieved June 9, 2015.
Box 2. Criteria for Types of Forceps
Deliveries
Outlet forceps
c Fetal scalp is visible at the introitus without separating
the labia.
c Fetal skull has reached the pelvic floor.
c Fetal head is at or on perineum.
c Sagittal suture is in an anteroposterior diameter
or right or left occiput anterior or posterior
position.
c Rotation does not exceed 45 degrees.
Low forceps
c Leading point of the fetal skull is at station +2 cm
or more and not on the pelvic floor.
c Without rotation: Rotation is 45 degrees or less
(right or left occiput anterior to occiput anterior, or
right or left occiput posterior to occiput posterior).
c With rotation: Rotation is greater than 45 degrees.
Midforceps
c Station is above +2 cm but head is engaged.
Adapted from Royal Australian and New Zealand College
of Obstetricians and Gynaecologists. Instrumental
vaginal delivery. College Statement C-Obs 16. East Melbourne,
Australia: RANZCOG; 2012. Available at http-
s://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-
MEDIA/Women%27s%20Health/Statement%20and%
20guidelines/Clinical-Obstetrics/Instrumental-VaginalBirth-(C-Obs-16)-Review-March-2016.pdf?ext5.pdf.
Retrieved
June 9, 2015.
e150 Practice Bulletin Operative Vaginal Birth OBSTETRICS & GYNECOLOGY
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Before applying traction with either forceps or
a vacuum extractor, it is important to confirm appropriate
placement. For vacuum extraction, the cup should be
placed 2 cm anterior to the posterior fontanelle and
centered over the sagittal suture, ensuring that no
maternal tissue is included. For forceps, the application
should be checked to ensure that the sagittal suture is
aligned with the shanks, that the posterior fontanelle is
one finger breadth above the shanks, and that the
lambdoid sutures are equidistant from the forceps blades.
A full description of operative vaginal birth techniques
are detailed elsewhere (4–6).
Episiotomy
Episiotomy should not be performed routinely for all
operative vaginal deliveries. Use of episiotomy has
significantly decreased among all deliveries; decreasing
from 60.9% in 1979 to 24.5% in 2004, with a similar
decrease in episiotomy rates with operative vaginal birth
(13). In the past, routine mediolateral episiotomy was
often recommended with operative vaginal birth to lessen
the chance of marked perineal stretching and damage to
the underlying pelvic muscles (5). More recently, a randomized
clinical trial compared routine episiotomy with
selective episiotomy for operative vaginal birth (14).
Although the study was underpowered and no distinction
was made between mediolateral and midline episiotomy,
it found no significant differences between the groups
with regard to anal sphincter tears, neonatal trauma, or
urinary or fecal incontinence.
There are no data to support the use of routine
episiotomy with operative vaginal birth. Routine episiotomy
with operative vaginal birth is not recommended
because poor healing and prolonged discomfort have
been reported with mediolateral episiotomy (15) and
because of the association of midline episiotomies with
increased risk of injury to the anal sphincter and extension
into the rectum (16). Several retrospective studies
have found an association between midline episiotomy
and anal sphincter trauma with operative vaginal birth
(17) and a lower risk of anal sphincter injury when mediolateral
episiotomy was used instead of midline episiotomy
with delivery by forceps or vacuum extraction
(18, 19). Thus, when episiotomy is indicated with forceps
or vacuum delivery, mediolateral episiotomy may have
a lower risk of anal sphincter injury than midline episiotomy,
but it is associated with an increased likelihood of
long-term perineal pain and dyspareunia (15).
Maternal Complications of Operative
Vaginal Birth
Research into the complications of operative vaginal
birth has been hampered by a number of confounders and
potential biases, including the level of experience of the
operators, changes in practice and definitions over time,
the small number of patients studied under similar
circumstances, and the inability to achieve statistical
power to answer relevant questions. Outcomes of
operative vaginal deliveries should not be compared
with those of spontaneous vaginal deliveries, but rather
with second stage cesarean birth because cesarean birth is
the clinical alternative.
Operative vaginal birth has been recognized as a risk
factor for anal sphincter injury, but it is difficult to
separate its contribution to these injuries from other
clinical factors associated with its use. Other clinical
factors include prolonged second stage of labor, fetal
size, maternal age and obesity, shoulder dystocia, and
episiotomy. In one study that controlled for these other
clinical factors, forceps use was still associated with
a sixfold increase in the risk of third- and fourth-degree
perineal tears, and vacuum extractor use was still
associated with a twofold increase compared with
patients who had a spontaneous delivery (20). However,
in another study of 109 primiparous women with second
stage arrest who completed symptom questionnaires at 1
year postpartum, the 53 women with successful operative
vaginal birth did not differ in pelvic floor function or
sexual function scores from those who had a cesarean
birth (21). In addition, one study reported that many of
Box 3. Prerequisites for Operative
Vaginal Birth
c Cervix fully dilated and retracted
c Membranes ruptured
c Engagement of the fetal head
c Position of the fetal head has been determined
c Fetal weight estimation performed
c Pelvis thought to be adequate for vaginal birth
c Adequate anesthesia
c Maternal bladder has been emptied
c Patient has agreed after being informed of the
risks and benefits of the procedure
c Willingness to abandon trial of operative vaginal
birth and back-up plan in place in case of failure
to deliver
Adapted from Royal Australian and New Zealand College
of Obstetricians and Gynaecologists. Instrumental
vaginal delivery. College Statement C-Obs 16. East Melbourne,
Australia: RANZCOG; 2012. Available at http-
s://www.ranzcog.edu.au/doc/instrumental-vaginaldelivery.html.
Retrieved June 9, 2015.
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Unauthorized reproduction of this article is prohibited.
the morbidities attributed to operative vaginal birth were
present antenatally to a greater or similar degree. Specifically,
among 108 patients with operative vaginal birth, the
reported prevalence of urinary incontinence was not different
at 6 weeks and 1 year postpartum compared with the
third trimester. Rates of incontinence of flatus and liquids
also did not differ from the third trimester through 1 year
postpartum. Only anal incontinence of solids was reported
to be more prevalent at 6 weeks postpartum than before
delivery (5% versus 1%; P5.02), but this difference
resolved by 1 year postpartum (22). If no anal sphincter
laceration occurs with operative vaginal birth, anal incontinence
rates at 5–10 years after delivery are similar to
those in women who had a spontaneous vaginal birth
(23). After an anal sphincter tear, the recurrence rate of
sphincter tears is low (3.2%) but is significantly increased
if operative vaginal birth is used for subsequent births (24).
Forceps delivery appears to have a higher risk of anal
sphincter injury in comparison with vacuum delivery. In
a review of 13 randomized trials of forceps delivery versus
vacuum delivery, including 3,338 women, forceps use was
associated with a higher rate of third- and fourth-degree
tears (8). In one randomized trial of vacuum delivery versus
forceps delivery, altered fecal continence at 3 months
postpartum was reported more frequently after forceps
delivery (59% versus 33%; P5.006), although most occurrences
were occasional flatal incontinence, and median
continence scores were similar. The two groups did not
differ in anal manometry measurements or anal sphincter
ultrasonographic findings (25). As previously noted, a randomized
trial comparing forceps delivery with vacuum
delivery found no difference in either bowel or urinary
dysfunction 5 years postpartum (9).
Newborn Complications of Operative
Vaginal Birth
Although operative vaginal birth is not without risk, the
absolute rate of newborn injury with forceps and vacuum
deliveries is low. Estimates from large cohort studies
have indicated that intracranial hemorrhage occurs in one
of every 650–850 operative vaginal deliveries and neurologic
complications occur in one of every 220–385
infants delivered using forceps or vacuum extraction
(26, 27). Additionally, there is evidence that some injuries
(such as intracranial hemorrhage) attributed to operative
delivery actually are associated with the indication
for delivery rather than the procedure itself, and that the
alternative of cesarean birth does not lessen the risk.
Similarly, given that operative vaginal birth can be
accomplished more quickly than cesarean birth, it remains
uncertain (for example, in the setting of nonreassuring
fetal heart rate pattern) whether foregoing an
operative vaginal birth would lead to fewer neurologic
injuries overall.
Various neonatal injuries have been reported with
operative vaginal deliveries and, to some degree, the type
and frequency vary with the instrument used. With
vacuum extraction, traction is applied to the fetal scalp,
which can result in laceration, cephalohematoma formation,
and subgaleal or intracranial hemorrhage. Retinal
hemorrhages and increased rates of hyperbilirubinemia
also have been reported. With forceps deliveries, reported
injuries have included facial lacerations and facial nerve
palsy, corneal abrasions and external ocular trauma, skull
fracture, and intracranial hemorrhage. The risk of these
complications is low, but large database studies are
required to establish complication rates. One study
evaluated singleton births in California from 1992 to
1994 and found that the rate of neonatal death was
similar for infants delivered spontaneously, by cesarean
birth, and by forceps or vacuum extraction (26). Also, the
rates of intracranial hemorrhage were similar for forceps,
vacuum, and cesarean deliveries performed during labor.
Another study examined data on births to nulliparous
women in New York City from 1995 to 2003 (28). Relative
to infants delivered by cesarean birth, those delivered
with forceps had higher rates of fracture, facial nerve
palsy, and brachial plexus injury, but lower rates of neurologic
complications, including seizures, intraventricular
hemorrhage, and subdural hemorrhage.
Relative to cesarean birth, vacuum delivery is
associated with higher rates of cephalohematoma or
scalp laceration, fracture, and brachial plexus injury,
but not central neurologic complications. Researchers
studied outcomes from a single obstetric unit from 2000
to 2009 and found that compared with neonates delivered
by cesarean birth in the second stage of labor, those
delivered with forceps or vacuum had similar rates of
neonatal death and neonatal encephalopathy. Operative
vaginal birth was associated with a rate of neonatal
encephalopathy of 4.2 per 1,000 term neonates (compared
with 3.9 per 1,000 delivered by cesarean birth), and
a rate of neonatal death from intracranial hemorrhage of
3–4 per 10,000 operative vaginal deliveries (27). In
a review of 13 randomized trials comparing forceps with
vacuum extraction, no significant differences were found
in umbilical pH, severe morbidity, or death (8).
In summary, some differences in rates of various
complications may exist between forceps and vacuum,
but the use of either instrument is associated with
relatively low rates of major morbidity and mortality,
and complications do not appear to be substantially
greater than with cesarean birth performed in labor. For
the fetus that manifests signs of compromise in the
second stage of labor, the timely and skilled use of
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instrumental vaginal birth has the potential to decrease the
exposure to intrauterine insults and could decrease the
contribution of intrapartum factors leading to neonatal
encephalopathy and hypoxic–ischemic encephalopathy
(2). Neonatal care providers should be made aware of the
mode of delivery in order to observe for potential complications
associated with operative vaginal birth.
Long-Term Infant Morbidity
There are few current data that assess the long-term
consequences of operative vaginal birth on the infant, but
the evidence indicates that long-term outcomes of
operative vaginal birth are equivalent to those of
spontaneous vaginal birth. One study analyzed the effect
of forceps delivery on cognitive development in a cohort
of 3,413 children at age 5 years (29). No significant
differences were seen in the 1,192 children delivered
with forceps compared with the 1,499 children delivered
spontaneously. In another study, evaluations were performed
at age 10 years in 295 children delivered by
vacuum extraction and 302 children in the control group
who delivered spontaneously at the same hospital in the
same year. No differences were seen between the two
groups in terms of scholastic performance, speech, or
neurologic abnormality (30).
Operative Vaginal Birth With
Fetal Macrosomia
To evaluate the risk of operative vaginal birth with fetal
macrosomia, one study compared 2,924 infants who had
birth weights greater than 4,000 g with those who had
birth weights between 3,000 g and 3,999 g. Infants with
birth weights greater than 4,000 g had an overall injury
rate of 1.6% compared with 0.4% in the lower birth weight
group. Forceps delivery in the group with birth weights
greater than 4,000 g produced a 7.3-fold increase in the
incidence of persistent injury at 6 months (95% CI, 6.5–
8.2) compared with the lower birth weight group. However,
the risk of persistent injury was not different from the
increased risk with spontaneous vaginal birth and birth
weights greater than 4,000 g (RR, 7.7; 95% CI, 7.4–
8.1). The authors calculated that as many as 258 elective
cesarean deliveries would have to be performed for macrosomia
to prevent a single case of persistent injury (31).
There are no studies that evaluate the risk of
complications with operative vaginal birth based on
estimated fetal weight. Regardless, judicious use of
operative vaginal birth for infants with suspected macrosomia
is not contraindicated. Recognizing the inherent
inaccuracy in estimating fetal weight, the additional
variables that should be considered include the adequacy
of the maternal pelvis and the progress of labor,
particularly during the second stage. Caution should be
used and preparations made for the increased possibility
of encountering a shoulder dystocia.
Clinical Considerations
and Recommendations
< What are contraindications to operative vaginal
birth?
Under certain circumstances, operative vaginal birth
should be avoided or, at the least, carefully considered
in terms of relative maternal and fetal risk. Operative
vaginal birth is contraindicated if the fetal head is
unengaged, the position of the fetal head is unknown, or
a live fetus is known or strongly suspected to have a bone
demineralization condition (eg, osteogenesis imperfecta)
or a bleeding disorder (eg, alloimmune thrombocytopenia,
hemophilia, or von Willebrand disease).
Operative vaginal birth should be performed only by
experienced obstetricians and obstetric care providers
with privileges for such procedures and the ability to
perform emergency cesarean birth in the event the
operative vaginal birth is unsuccessful. Indeterminate
fetal heart rate patterns are not a contraindication to
operative vaginal birth, and an expedited vaginal birth
can potentially benefit the deteriorating fetus if delivery
can be accomplished more expeditiously than a cesarean
birth can be performed.
< Is there a role for a trial of operative vaginal
birth?
A trial of operative vaginal birth is an attempt at
operative delivery with the intention to abandon the
procedure if potentially dangerous resistance or difficulty
is met (4). The rate of failed operative vaginal birth has
been reported to be 2.9–6.5% (26, 32). In an analysis of
3,798 operative vaginal deliveries, only increased birth
weight and second stage labor duration were significantly
associated with failure, after controlling for operator
experience (32).
The few studies that address maternal and neonatal
outcome after an unsuccessful attempt at operative
vaginal birth show conflicting results. Although the
analysis of California births from 1992 to 1994 found
similar rates of neonatal death and intracranial hemorrhage
for forceps, vacuum, and cesarean deliveries
performed during labor, cesarean birth after a failed
attempt at vacuum or forceps delivery was associated
with increased rates of subdural or cerebral hemorrhage,
mechanical ventilation, and seizures compared with
either successful operative vaginal birth or cesarean
birth (26).
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In contrast, a secondary analysis of the Eunice Kennedy
Shriver National Institute of Child Health and Human
Development cesarean birth registry data found that neonatal
morbidity was more common with cesarean birth after
forceps attempt compared with cesarean without forceps.
However, this association was confined to the subgroup of
patients with nonreassuring fetal heart rate pattern as an
indication for cesarean birth, and there was no difference
between the groups when delivery was for other indications
(33). In both reports, the rates of neonatal complications
after forceps attempt were low. A trial of operative vaginal
birth is an appropriate option in a situation in which the
obstetrician or obstetric care provider feels the chances of
success are high, but must be prepared to abandon the
attempt if appropriate descent does not occur. Although
a number of authors have offered concrete limits for trial
of operative vaginal birth, there are no adequate data to
generate an evidence-based guideline for the number of
forceps pulls or vacuum detachments that should be allowed
before abandoning the procedure. In general, descent
should be expected with traction and if there is no descent
with the first several pulls, a reappraisal is necessary.
< Is there a role for the use of alternative instruments
after a failed attempt?
The California study raised significant concerns regarding
the sequential use of forceps and vacuum. Compared with
vacuum extraction alone, the combination of forceps and
vacuum was associated with significantly higher rates of
subdural or cerebral hemorrhage, subarachnoid hemorrhage,
facial nerve injury, and brachial plexus injury (26).
An increased incidence of intracranial hemorrhage with
sequential instrument use compared with either forceps
or vacuum alone also was seen in a study of a Washington
State multiyear database, as was an increase in the rate of
severe perineal lacerations (34). However, in both studies,
the rates of complications with sequential use of instruments
were compared with spontaneous vaginal birth and
not with the rates for cesarean birth during labor after
a failed operative vaginal birth attempt.
In a more recent report of 1,360 nulliparous women
undergoing operative vaginal birth, use of sequential
instruments was associated with increased anal sphincter
tears and low umbilical artery pH compared with patients
undergoing single instrument vaginal birth (35). Sequential
use of vacuum extractor and forceps has been associated
with increased rates of neonatal complications and
should not routinely be performed. Thus, even though the
reported rates of neonatal complications were relatively
low, the weight of available evidence appears to be
against routine use of sequential instruments at operative
vaginal birth.
< What special considerations are involved with
the use of a vacuum extractor?
Modern vacuum extractors differ substantially from the
original metal cup and vary by material, cup size and
shape, and the method of vacuum application to the fetal
scalp. Randomized trials comparing soft vacuum cups
with the original metal cup indicate that the pliable cup is
associated with decreased fetal scalp trauma but with
increased rates of detachment from the fetal head (36–
39). However, there are no differences in Apgar scores,
cord pH, neurologic complications, retinal hemorrhage,
maternal trauma, or blood loss when comparing rigid cup
vacuum deliveries with soft cup vacuum deliveries (39).
Cephalohematoma is more likely to occur as the
duration of vacuum application increases. One study
found that cephalohematoma was diagnosed clinically in
28% of neonates when the time from application to
delivery exceeded 5 minutes (40). It does not appear that
reducing the vacuum pressure between contractions reduces
the incidence of fetal scalp injury. One trial randomized
164 patients to continuous vacuum application
during and between contractions in an effort to prevent
fetal loss of station and randomized 158 patients to
reduction of vacuum pressure between contractions.
Overall, 93.5% had a delivery by the intended method,
and the cephalohematoma rate was 11.5%. Time to delivery,
method failure, maternal lacerations, episiotomy
extension, incidence of cephalohematoma, and neonatal
outcome were similar between the two groups (41). As
such, release of vacuum pressure between contractions
does not appear to be associated with improved
outcomes.
Traditional teaching has held that the direction of
traction with vacuum delivery should follow the pelvic
curvature, and that rocking motions and application of
torque to affect rotation should be avoided (4). Only
gentle augmentation of the natural rotation that occurs
with maternal pushing and fetal descent is recommended.
Because of the risk of cephalohematoma and other complications,
clinicians caring for the neonate should be
notified of the vacuum delivery so that the newborn
can be appropriately monitored for the signs and symptoms
of instrument-related injuries.
< Is there a role for midforceps and rotational
forceps deliveries in current practice?
Midforceps and rotational forceps deliveries are appropriate
options in select clinical circumstances. Recent
studies comparing midforceps deliveries with cesarean
deliveries confirmed older data that showed no difference
in neonatal outcome. One study of 144 cases in which
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Kielland forceps were used for rotation, 90% resulted in
vaginal birth, and there were no instances of forcepsrelated
neonatal trauma or hypoxic–ischemic encephalopathy
(42). Another study compared outcomes of
deliveries with rotational forceps with nonrotational
forceps, vacuum, spontaneous vaginal, and emergency
cesarean deliveries at any dilation. No difference in the
rate of neonatal encephalopathy was found between the
groups, and the rate of neonatal intensive care unit
admission was highest with emergency cesarean birth
(43). The contemporary report with the largest number of
rotational deliveries (n51,038) compared Kielland forceps
delivery to emergency cesarean birth in the second
stage of labor and saw no difference in rates of neonatal
intensive care unit admission or other measures of neonatal
morbidity (44).
With regard to occiput posterior position with arrest
of descent in the second stage of labor, there may be
a benefit from an attempt at rotation to occiput anterior.
In a retrospective study of patients with forceps deliveries,
99 patients with manual (n564) or forceps (n535)
rotation were compared with 57 patients delivered from
the occiput posterior position without an attempt at rotation.
No difference in neonatal outcomes was seen, but
forceps delivery without attempt at rotation was associated
with a significantly higher rate of severe perineal
laceration (odds ratio, 3.67; 95% CI, 1.42–9.47) (45).
Thus, it seems reasonable to attempt forceps delivery
with manual or forceps rotation of occiput posterior position
in certain circumstances.
< Should prophylactic antibiotics be administered
at the time of operative vaginal birth?
During the past two decades, the routine adoption of
prophylactic antibiotics given 30 minutes before skin
incision for cesarean birth to reduce wound complications
has become standard practice (46). The evidence
for the routine use of prophylactic antibiotics in the setting
of an operative vaginal birth has less supporting
evidence. In a recent prospective trial (known as the
ANODE trial), investigators randomized women to prophylactic
antibiotics versus placebo before operative
vaginal birth (47). Although fewer women had a confirmed
or suspected perineal wound infection that received a single
intravenous dose of antibiotic (Risk Ratio 0.58; 95%
CI, 0.49–0.69), there are some potential issues that may
not make the findings generalizable to a population in the
United States. In the study, 89% of women received an
episiotomy; the majority of these episiotomies were
mediolateral, which is routine in the United Kingdom
where the trial was conducted. Thus, although prophylactic
antibiotics may be reasonable at the time of
operative vaginal birth with episiotomy, particularly
mediolateral episiotomy as was performed in the
ANODE trial, use of routine prophylactic antibiotics
before delivery would not be recommended. Because
wound infections and complications are more common in
the setting of a third- or fourth-degree laceration, it may
be more judicious to consider antibiotics if a third- or
fourth-degree laceration occurs (48).
Recommendations
and Conclusions
The following recommendations and conclusions are
based on good and consistent scientific evidence (Level A):
< Forceps and vacuum extractors have low risk of complications
and are acceptable for operative vaginal birth.
< A vaginal birth is more likely to be achieved with
forceps than with vacuum extractors; however, forceps
are more likely to be associated with third- and
fourth-degree perineal tears.
< Routine episiotomy with operative vaginal birth is not
recommended because poor healing and prolonged
discomfort have been reported with mediolateral
episiotomy and because of the association of midline
episiotomies with increased risk of injury to the anal
sphincter and extension into the rectum.
The following recommendations and conclusions are
based on limited or inconsistent scientific evidence
(Level B):
< Operative vaginal birth is contraindicated if the fetal
head is unengaged, the position of the fetal head is
unknown, or a live fetus is known or strongly suspected
to have a bone demineralization condition (eg,
osteogenesis imperfecta) or a bleeding disorder (eg,
alloimmune thrombocytopenia, hemophilia, or von
Willebrand disease).
< A trial of operative vaginal birth is an appropriate
option in a situation in which the obstetrician or
obstetric care provider feels the chances of success
are high, but must be prepared to abandon the attempt
if appropriate descent does not occur.
< Sequential use of vacuum extractor and forceps has
been associated with increased rates of neonatal
complications and should not routinely be performed.
< Cephalohematoma is more likely to occur as the
duration of vacuum application increases.
< Midforceps and rotational forceps deliveries are
appropriate options in select clinical circumstances.
VOL. 135, NO. 4, APRIL 2020 Practice Bulletin Operative Vaginal Birth e155
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The following recommendations and conclusions are
based on limited or inconsistent scientific evidence
(Level C):
< Vacuum extraction has been discouraged for gestational
age less than 34 weeks, although a safe lower
limit for gestational age has not been established.
< For the fetus that manifests signs of compromise in
the second stage of labor, the timely and skilled use
of instrumental vaginal birth has the potential to
decrease the exposure to intrauterine insults and
could decrease the contribution of intrapartum factors
leading to neonatal encephalopathy and hypoxic–
ischemic encephalopathy.
< Neonatal care providers should be made aware of the
mode of delivery in order to observe for potential
complications associated with operative vaginal birth.
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The MEDLINE database, the Cochrane Library, and the
American College of Obstetricians and Gynecologists’
own internal resources and documents were used to
conduct a literature search to locate relevant articles
published between January 2000 – November 2013.
The search was restricted to articles published in the
English language. Priority was given to articles
reporting results of original research, although review
articles and commentaries also were consulted.
Abstracts of research presented at symposia and
scientific conferences were not considered adequate for
inclusion in this document. Guidelines published by
organizations or institutions such as the National
Institutes of Health and the American College of
Obstetricians and Gynecologists were reviewed, and
additional studies were located by reviewing
bibliographies of identified articles. When reliable
research was not available, expert opinions from
obstetrician–gynecologists were used.
Studies were reviewed and evaluated for quality
according to the method outlined by the U.S.
Preventive Services Task Force:
I Evidence obtained from at least one properly designed
randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
case–control analytic studies, preferably from
more than one center or research group.
II-3 Evidence obtained from multiple time series with
or without the intervention. Dramatic results in
uncontrolled experiments also could be regarded
as this type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to
the following categories:
Level A—Recommendations are based on good and
consistent scientific evidence.
Level B—Recommendations are based on limited or
inconsistent scientific evidence.
Level C—Recommendations are based primarily on
consensus and expert opinion.
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This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use
of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of
care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
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