Forceps Delivery and Vacuum Extraction

Laetitia Poisson De Souzy MD

Aaron B. Caughey MD, PhD
Basics
Description
In an operative vaginal delivery, the deliverer uses forceps or vacuum to assist
the delivery of the fetal head.
Historically, the use of instruments to assist delivery of the newborn dates
back to at least 1500 BC, when it was described in Sanskrit writings:
o

Credit for design of modern forceps in 1600 is given to Peter

Chamberlen of England.

Vacuum extractors were 1st described in the early 1800s. In 1954,

Malmstrm patented the metal-cup extractor, and vacuum extraction
became more common.

Indications
The following indications for operative delivery apply only when the cervix is
fully dilated and the fetal head is engaged:
o Prolonged 2nd stage:

Nulliparous women: Failure to progress for 3 hours with

regional anesthesia or 2 hours without regional anesthesia.

Multiparous women: Failure to progress for 2 hours with

regional anesthesia or 1 hour without regional anesthesia.

Immediate fetal distress (e.g., prolonged fetal heart rate decelerations)

in the 2nd stage of labor, and high probability of successful expedient
operative vaginal delivery.

Shortening the 2nd stage for maternal indications (e.g., maternal

cardiac disease, maternal exhaustion)

Both absolute and relative contraindications exist for operative vaginal

delivery:
o

Absolute contraindications:

Position of the fetal head is unknown.

Fetal head is not engaged.

Fetal bone demineralization disorder (e.g., osteogenesis

imperfecta)

Fetal collagen disorder (e.g., Ehlers-Danlos)

Fetal coagulopathy (e.g., alloimmune thrombocytopenia)

Gestational age <34 weeks (for vacuum deliveries)

Relative contraindications:

Fetal scalp sampling or multiple fetal scalp electrode

placements

Suspected fetal macrosomia

Epidemiology
Operative vaginal delivery rates are declining in the US.
o 2004: 5.2% of all deliveries were performed via forceps or vacuum.
o

2000: 7%

1989: 9%

The majority of operative vaginal deliveries are now vacuum-assisted:

2004: Vacuum deliveries accounted for 4.1% of all births.

1989: 3.5% of all births

Forceps births continue to decline:

2004: 1.1% of all births

1989: 5.5% of all births

In contrast, cesarean rates are increasing in the US:

o

2005: Delivery by cesarean increased to an all-time high of 30.2% of

all births, as rates of primary cesarean increased and vaginal birth after
cesarean decreased.

Treatment
Procedure
Informed Consent
Before placing forceps or vacuum, the following conditions must be met:
o Fetus is in vertex presentation (unless used to aid in delivery of
aftercoming head in breech delivery).
o

Cervix is fully dilated.

Fetal membranes are ruptured.

Fetal head is engaged and exact position is known (i.e., direction of

occiput and asynclitism).

Maternal pelvis is adequate.

Maternal anesthesia is adequate.

Maternal bladder is empty.

Deliverer is experienced OR

Is immediately available for cesarean if operative vaginal delivery is

not successful.

Consent should include a thorough discussion and documentation of the

indications, risks, benefits, and alternatives of operative vaginal delivery. The
deliverer should also document fetal and maternal assessments.

Indications (as above)

Maternal/Fetal assessments:
o

Maternal: Clinical pelvimetry demonstrates adequate pelvis.

Fetal: GA, estimated fetal weight, position, presentation, lie,

engagement, asynclitism

Risks

There are potential risks to both mother and fetus of operative vaginal
delivery, although these risks may have more to do with abnormal labor (i.e.,
the indication for operative vaginal delivery) than the operative vaginal
delivery itself.
Maternal risks:
o

Lower genital tract lacerations, including risk of 3rd- and 4th-degree

lacerations

Hematomas

Urinary retention

Postpartum perineal pain

Postpartum hemorrhage

Delayed complications: urinary or fecal incontinence

Fetal risks:
o

Skin bruising, abrasions, lacerations

Ocular injury (e.g., retinal hemorrhage)

Cephalohematoma

Subgaleal hemorrhage

Intracranial hemorrhage

Facial nerve palsies

Shoulder dystocia

Brachial plexus injuries

Hyperbilirubinemia

Risk profile of forceps vs. vacuum:

Forceps:

Higher risk of perineal 3rd- or 4th-degree lacerations

Vacuum:

Higher risk of shoulder dystocia

Higher risk of cephalohematoma

Higher risk of postpartum hemorrhage

FDA public health advisory in 1998 regarding the risk of neonatal intracranial
injury with vacuum extraction:
o

The evidence suggests that there is no significant difference between

forceps, vacuum, or cesarean following labor in the risk of subdural or
cerebral hemorrhage.

This suggests that abnormal labor is the biggest risk factor for serious
neonatal intracranial injury.

Benefits
Potential benefits to mother and fetus of operative vaginal delivery are mostly
related to shortening of the 2nd stage and avoiding the need for cesarean.
A prolonged 2nd stage is associated with increased risk of:
o

Cesarean delivery itself is associated with increased risk of:

o

Cesarean, operative vaginal delivery, 3rd- and 4th-degree tears, and

chorioamnionitis

Endomyometritis, wound complications, hemorrhage, postpartum

maternal death, need for future cesarean, IUFD in future pregnancies,
and placenta previa, and accrete

Maternal benefits:
o

Quicker recovery

Lower risk of chorioamnionitis and endomyometritis

Decreased risk of hemorrhage

Mother-infant bonding

Shorter hospital stay

Fetal benefits:
o

Mother-infant bonding

Alternatives
The alternatives depend on the indication for operative vaginal delivery.
Cesarean

Spontaneous vaginal delivery (if indication is not emergent).

The data does NOT support the use of sequential methods of operative vaginal
delivery (e.g., going from forceps to vacuum) since this is associated with a
higher risk of neonatal intracranial hemorrhage and maternal 3rd- and 4thdegree perineal lacerations.

Surgical
Classification of forceps and vacuum deliveries is based on fetal station and
angle of rotation used.
Outlet:
o

Scalp is visible at introitus, without separating the labia.

Fetal skull is at pelvic floor.

P.389

o
o

Sagittal suture is in AP diameter, ROA/LOA or posterior position.

Fetal head is at or on perineum.

Rotation is 45 degrees or less.

Low:
o

Leading point of fetal skull is at +2 station or beyond, but not on the

pelvic floor.

Rotation is 45 or less (from LOA/ROA to OA, or LOP/ROP to OP).

Rotation is >45.

Mid:
o

Leading point of fetal skull is above +2 station but head is engaged.

High: Not included in classification, as no longer advisable to perform.

Choice of Instrument
Use of forceps vs. vacuum depends on:
o Clinician's skill's and comfort level
o

Maternal preference, based on informed consent discussion.

Type of forceps depends on deliverer's experience, indication, and fetal

anatomy (head molding and estimated fetal weight):
o

Tucker-McLane: Used for unmolded fetal head. Rotation possible, if

fetal head is flexed.

Simpson: Used when fetal head is molded. Rotation possible, if fetal

head is flexed.

Luikart-Simpson: Similar to Simpson, but blade is semifenestrated.

Eliotts: Similar to Simpson, with a lock to avoid head compression.

Kielland: Mid-pelvic rotation possible. Can correct asynclitism.

Piper: Aid in delivery of aftercoming head in breech delivery.

Type of vacuum extractor used is mostly regional. In the US, the metal cup is
nearly obsolete, and most providers use soft-cup vacuum extractors.
o

Metal cups: Higher success rate, but higher rate of neonatal scalp
injuries

Soft cups (CMI Tender Touch, Mityvac, Silastic): Lower success rate,
but lower rate of neonatal scalp injuries.

Kiwi: Vacuum tube inserts into side of vacuum disc, allowing

appropriate placement on fetal head even with severe asynclitism.

Technique
Forceps:
o Empty maternal bladder

Choose appropriate forceps (as above). Biparietal diameter of fetal

head should be equal to greatest distance between blades of forceps.

Forceps placement: Place blades directly along the sides of the fetal
head in the occipitomental diameter.

Traction: Pull in line with pelvic axis; steady intermittent traction

coordinated with maternal push.

Stop if no progress occurs after 2 pulls along with uterine contractions

or there is no progressive descent.

Vacuum:
o

Empty maternal bladder.

Cup placement: Place center of cup over the sagittal suture and 3 cm in
front of the posterior fontanelle towards the face. Make sure cup is free
of maternal soft tissue.

Traction: Pull in line with pelvic axis, steady intermittent traction

coordinated with maternal push.

Stop if 3 pop-offs occur, there is no progressive descent, or fetal scalp

trauma occurs.

Postoperative Care

Thorough examination of the mother and newborn.

Maternal postoperative care:
o

Examine maternal tissues (vaginal, cervical, perineal, and rectal) for

injury.

Ice and stool softeners for comfort

Pelvic and rectal examination prior discharge

Newborn postoperative care:

o

Examine newborn for lacerations, hematomas, retinal hemorrhage,

brachial plexus injuries, and fractures.

Notify pediatricians of the mode of delivery, so they can monitor for

possible delayed complications.

Followup
Unless complications occur, maternal follow-up care is routine, with a postpartum
examination within 46 weeks.
Complications
Potential for early and delayed maternal and fetal complications.
For routine operative vaginal deliveries, there is a low risk of delayed
complications.

Delayed maternal complications are mostly related to injury to pelvic support

structures:
o

Urinary incontinence

Fecal incontinence

Anal sphincter injury

Pelvic organ prolapse

Bibliography
ACOG Practice Bulletin. Operative Vaginal Delivery. Washington DC: ACOG; 2007
Compendium of Selected Publications 2007, 543550.
Bofill JA, et al. A randomized prospective trial of the obstetric forces versus the Mcup vacuum extractor. Am J Obstet Gynecol. 1996;175:13251330.
Caughey AB, et al. Forceps compared with vacuum: Rates of neonatal and maternal
morbidity. Obstet Gynecol. 2006;107(2 Pt 1);426427.
Center for Devices and Radiological Health. FDA Public Health Advisory: Need for
caution when using vacuum assisted delivery devices. 1998 May 21.
Cheng YW, et al. How long is too long: Does a prolonged 2nd stage in labor in
nulliparous women affect maternal and neonatal outcomes? Am J Obstet Gynecol.
2004;191(3):933938.
Demissie K, et al. Operative vaginal delivery & neonatal and infant adverse
outcomes: Population based retrospective analysis. Br Med J. 2004;329(7465):547.
Kuit JA, et al. A randomized comparison of vacuum extraction delivery with a rigid
and pliable cup. Obstet Gynecol. 1993;82:280284.

Martin JA, et al. Births: Final data for 2004. Natl Vital Stat Rep. 2006;55(1):1101.
Silver R, et al. Maternal morbidity associated with repeat cesarean deliveries. Obstet
Gynecol. 2006;107(6):12261232.
Smith GC, et al. Cesarean section and risk of unexplained stillbirth in subsequent
pregnancies. Lancet. 2003;362(9398):17791784.
Towner D, et al. Effect of mode of delivery in nulliparous women on neonatal
intracranial injury. N Engl J Med. 1999;341(23):17091714.
Miscellaneous
Abbreviations
GAGestational age
IUFDIntrauterine fetal demise
Codes
ICD9-CM
72 Forceps, vacuum, and breech delivery:
72.0 Low/Outlet forceps operation
72.1 Low/Outlet forceps operation with episiotomy
72.2 Mid forceps operation
72.3 High forceps operation
72.4 Forceps rotation of the fetal head
72.7 Vacuum extraction
Patient Teaching
Patient discharge instructions:
Activity:
Pelvic rest for 6 weeks postpartum
Keep area clean and dry.
Use stool softeners (in case of 3rd- or 4th-degree laceration).