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OfficialreprintfromUpToDate
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Operativevaginaldelivery
Authors
ElisabethKWegner,MD
IraMBernstein,MD

SectionEditor
CharlesJLockwood,MD,
MHCM

DeputyEditor
VanessaABarss,MD,
FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Nov2015.|Thistopiclastupdated:Nov19,2015.
INTRODUCTIONOperativevaginaldeliveryreferstoadeliveryinwhichtheoperatorusesforcepsora
vacuumdevicetoextractthefetusfromthevagina,withorwithouttheassistanceofmaternalpushing.The
decisiontouseaninstrumenttodeliverthefetusbalancesthematernal,fetal,andneonatalimpactofthe
procedureagainstthealternativeoptionsofcesareanbirthorexpectantmanagement.
PREVALENCEIntheUnitedStates,3.3percentofalldeliveriesin2013wereaccomplishedviaan
operativevaginalapproach[1].Forcepsdeliveriesaccountedfor0.6percentofvaginalbirthsandvacuum
deliveriesaccountedfor2.7percentofvaginalbirths.However,thereisawiderangeinuseofoperative
vaginaldeliverybothacrossandwithingeographicregionsintheUnitedStates(1to23percent)which
suggeststhatevidencebasedguidelinesforoperativevaginaldeliveryareeitherinadequateorrandomly
appliedorfamiliarityandexpertisewiththetechniqueisdeclining[2].
INDICATIONSUseofforcepsorvacuumisreasonablewhenaninterventiontoterminatelaborisindicated
andoperativevaginaldeliverycanbesafelyandreadilyaccomplishedotherwise,cesareandeliveryisthe
betteroption.
WeagreewithanAmericanCollegeofObstetriciansandGynecologistspracticebulletinthatconsidered
protractedsecondstageoflabor,suspicionofimmediateorpotentialfetalcompromise,andshorteningthe
secondstageformaternalbenefitappropriateindicationsforoperativevaginaldelivery(forcepsorvacuum)[3].
However,noindicationisabsolute,andcesareandeliveryisalsoanoptionintheseclinicalsettings.
Althoughonecanneverbecertainofasuccessfuloutcome,weattemptanoperativevaginaldeliverywhenwe
believesuccessislikely,sincetherateofbirthtraumamaybehigherafterfailedattemptsatoperativedelivery
[4,5].Thedecisiontoproceedwithoperativevaginaldeliveryisongoinganddecidedmomentbymoment
basedonassessmentofthesuccessofthevariousstepsintheprocedure.
ProtractedsecondstageoflaborFornulliparouswomen,aprotractedsecondstagecanbedefinedasno
progress(descent,rotation)afteraboutfourhourswithepiduralanesthesiaandaboutthreehourswithout
epiduralanesthesia(table1)[6].Formultiparouswomen,aprotractedsecondstagecanbedefinedasno
progress(descent,rotation)afterabouttwohourswithepiduralanesthesiaandaboutonehourwithoutepidural
anesthesia.(See"Overviewofnormallaborandprotractionandarrestdisorders".)
Forpatientswithslowprogressapproachingtheselimits,anormalfetalhearttracing,andnootherindication
forexpeditingdelivery,weevaluatetherelativevalueofanoperativevaginaldeliveryversusexpectant
management.Wefavorexpectantmanagementwhenwebelievethepatientislikelytogoontohavea
spontaneousdeliverybecausefetaldescentisprogressing,albeitslowly,orbecausetherehasbeenarecent
favorablechangeintheclinicalsituation,suchasmoreeffectivepushing,rotationfromocciputposteriorto
occiputanterior,oroxytocinaugmentation.Wefavoroperativevaginaldeliverywhenthepatientisexhausted
andisjudgedtobeagoodcandidateforoperativedelivery.
Inthepast,shorteningthesecondstagewasanacceptableoption,independentofanyspecificmaternalor
fetalindications,becauseearlystudiesreportedthattheriskoffetalmorbiditywashigherwhenthesecond
stageexceededtwohours.Morerecentevidencedoesnotsupportthisconcept.Theabilityofelectronicfetal
heartratemonitoringtoidentifytheacidoticfetushasgenerallymadethearbitraryterminationoflaborbecause
ofanyelapsedperiodoftimeunwarranted[710].(See"Intrapartumfetalheartrateassessment".)
Aprotractedsecondstagehasbeenassociatedwithpelvicfloorinjuryandpostpartumhemorrhage,butthisis
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likelyrelatedtoinstrumentalinterventionratherthanthespecificlengthofthesecondstage[813].(See
'Maternalcomplications'below.)
FetalcompromiseUseofforcepsorvacuumisappropriatewhenexpeditiousdeliveryisindicatedbecause
offetalcompromiseorprobablyimminentfetalcompromise(eg,acuteabruption)andvaginaldeliverycanbe
safelyandreadilyaccomplishedotherwise,cesareandeliveryisthebetteroption.(See"Managementof
intrapartumcategoryI,II,andIIIfetalheartratetracings".)
MaternalmedicaldisorderForcepsorvacuumcanbeusedtoshortenthesecondstageoflaborifthe
Valsalvamaneuveriscontraindicatedorexertionshouldbeminimizedbecauseofmaternalmedicaldisorders
(typicallycardiacorneurologic,alsocysticlungdisease),orifpushingisineffectivebecauseofmaternal
neurologicormusculardisease.Operativeinterventionisperformedwhenuterinecontractionsdescendthe
fetustoastationwheretheclinicianbelievesforcepsorvacuumextractioncanbeperformedsafelyand
effectively.
CONTRAINDICATIONSInstrumentaldeliveryiscontraindicatediftheclinicianorpatientbelievesthatthe
risktomotherorfetusisunacceptable.Examplesinclude,butarenotlimitedto[3,14]:
Extremefetalprematurity.(See'Minimumandmaximumestimatedfetalweight'below.)
Fetaldemineralizingdisease(eg,osteogenesisimperfecta).Thesafetyofforcepsorvacuumdeliveryhas
notbeenestablishedindisordersthatresultindemineralizationoftheskull.Thereisatheoreticriskfor
intracranialbleeding,extracranialbleeding,andotherbraininjuriesduetocranialdeformationorfracture
fromtheseinstruments.
Fetalbleedingdiathesis(eg,fetalhemophilia[15]).
Unengagedhead.(Theheadisengagedwhenthewidestdiameter[thebiparietaldiameter]hasreachedor
passedthroughthepelvicinlet.Thistypicallyoccurswhentheleadingbonyparthasreachedorpassed
throughtheischialspines).
Unknownfetalposition.
Broworfacepresentation.
Suspectedfetalpelvicdisproportion.
Relativecontraindicationstouseofvacuumdevices,butnotforceps,includegestationalage<34weeksor
priorscalpsampling.(See"Procedureforvacuumassistedoperativevaginaldelivery",sectionon
'Contraindications'.)
CLASSIFICATIONAmericanCollegeofObstetriciansandGynecologists'classificationsystemforforceps
deliveriesisbasedonstationandamountofrotation,whichcorrelatewiththedegreeofdifficultyandriskof
theprocedure(eg,lowerfetalstationandsmallerdegreeofheadrotationareassociatedwithlessriskof
maternalandfetalinjury[16])[3]:
Outletforceps
Theleadingpointofthefetalskullhasreachedthepelvicfloor,andatorontheperineum,thescalp
isvisibleattheintroituswithoutseparatingthelabia.
Thesagittalsutureisinanteroposteriordiameterorarightorleftocciputanteriororposterior
position.
Rotationdoesnotexceed45degrees.
Lowforceps
Theleadingpointofthefetalskullis2cmbeyondtheischialspines,butnotonthepelvicfloor(ie,
stationisatleast+2/5cm(figure1)).
Lowforcepshavetwosubdivisions:
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Rotation45degrees
Rotation>45degrees
Midforceps
Theheadisengaged(ie,atleast0station),buttheleadingpointoftheskullisnot2cmbeyond
theischialspines(ie,stationis0/5cmor+1/5cm(figure1)).
Vacuumdeliveriesdonothaveaseparateclassificationsystem.Theclinicianshoulddocumentthestationat
whichthevacuumwasapplied.Rotationalmaneuversshouldnotbeperformedwithvacuumbecauseofthe
riskofseverescalplacerations.(See"Procedureforvacuumassistedoperativevaginaldelivery".)
PREREQUISITES
OverviewTheoperatorshouldbeexperiencedinoperativevaginaldeliveryandresponsiblefordetermining
thatthefollowingprerequisitesaremetpriortoapplicationofinstruments:
Cervixisfullydilated.
Membranesareruptured.
Headisengagedandatleast+2/5cmstation.Forcepsshouldneverbeusedwhentheheadisnot
engaged.
Fetalpresentation,position,station,andanyasynclitismareknown,andextentofmoldingisestimated.
Thefetusmustbeinacephalicpresentation(unlessthepurposeistouseforcepstoassistindeliveryof
anaftercominghead).
Iffetalpresentationorpositionisuncertain,intrapartumsonographicvisualizationoffetalintracranial
structures,includingthecerebellum,orbits,andmidlinefalx,canbeusedtodeterminefetalheadposition
andismoreaccuratethandigitalexamination.Intwostudies,digitalexaminationincorrectlydefinedfetal
headpositioninover20percentofcasesabouttoundergooperativevaginaldelivery[17,18].
Largeinfants,extrememolding,extensionofthefetalhead,pelvicdeformities,andasynclitismmay
falselysuggestengagement.Inthesecases,theleadingbonypartisattheischialspines,althoughthe
biparietaldiameterhasnotpassedthroughthepelvicinlet.Nomorethanonefifthofthefetalheadshould
bepalpableabdominallyabovethesymphysispubisifthevertexisengaged[19].
Fetalsizeisneithertoolargenortoosmall.(See'Minimumandmaximumestimatedfetalweight'below.)
Clinicalpelvimetrysuggestsanadequatepelvis,withnoobstructionsorcontractures.
Thepatientconsentstotheprocedure.Themedicalrecordshoulddocumenttheindicationforthe
procedure,relevantclinicalassessmentofmotherandfetus,andasummaryoftheinformedconsent
discussion(specificrisks,benefits,alternatives)[20].
Theoptionofperforminganimmediatecesareandeliveryisavailableifcomplicationsarise.Personnelfor
neonatalresuscitationareavailable,ifneeded.
Thepatienthasadequateanesthesiafortheplannedprocedure.
MinimumandmaximumestimatedfetalweightTheminimumandmaximumestimatedfetalweightsfor
operativevaginaldeliverydependonthechoiceofinstrument(vacuumversusforceps),sizeofavailable
instruments,andpatientspecificfactors(eg,progressoflabor,previouspregnancyhistory).
UpperthresholdInstrumentaldeliveryofthemacrosomicinfantmaybeassociatedwithanincreased
riskofinjury.Asanexample,inastudyincludingalmost3000newborns4000grams,theriskof
persistentsignificantinjuryatsixmonthsofagewas1.5percent(4/261)afterforcepsdelivery,0.24
percent(4/1666)afterspontaneousdelivery,and0(0/862)aftercesareandeliveryorvacuumdelivery
(0/135)[21].Theauthorsestimatedthatapolicyofelectivecesareanbirthformacrosomiawould
necessitate148to258cesareandeliveriestopreventasinglepersistentinjuryavoidanceofoperative
vaginaldeliverywouldrequire50to99cesareanbirthsperinjuryprevented.However,theseestimates
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areimprecisebecauseofthesmallnumberofobservedinjuriesandthepoorperformanceofintrapartum
identificationofmacrosomicfetuses.(See"Fetalmacrosomia".)
TheAmericanCollegeofObstetriciansandGynecologistspracticebulletinonoperativedeliverysuggests
thatjudicioususeofforcepsorvacuumextractionisnotcontraindicatedformostfetusessuspectedtobe
macrosomic,ifthematernalpelvisandprogressoflaborareadequate[3].However,theobstetrician
shouldbeawareoftheriskofshoulderdystocia,especiallywhenthesecondstageoflaborisprolonged.
Webelieveestimatedfetalweightisoneofseveralfactorstoassesswhenconsideringoperativedelivery
ofasuspectedmacrosomicinfant.Multiplematernalfactors(eg,diabetes,bodymassindex[BMI],prior
infantsizeinsuccessfulvaginaldeliveries,clinicalpelvimetry,progressinthesecondstage)andfetal
factors(eg,headpositionandstation,caputandmolding,estimatedabdominalcircumferencecompared
withheadcircumference)caninfluencethedecisiontoattemptanoperativedelivery.Ingeneral,patients
withmorbidobesity,diabetes,slowprogressinthesecondstageoflaborwithsignificantcaput/molding,
andaninfantestimatedtobeover4000gprobablyshouldnotbeconsideredforoperativevaginal
delivery.Bycomparison,wewouldconsideroperativevaginaldeliveryforapatientwithfetalcompromise
at+3stationandestimatedfetalweight4800gwhohasanormalBMI,nodiabetesmellitus,anda
historyofaprior4600gspontaneousvaginaldelivery.(See"Shoulderdystocia:Riskfactorsandplanning
deliveryofatriskpregnancies".)
LowerthresholdUseofvacuumdevicesislimitedtodeliveries34weeksofgestationbecausethe
riskofintraventricularhemorrhageappearstobeincreasedabovebaselinewhenthesedevicesare
employedatearliergestationalages.
"Baby"Elliotand"baby"Simpsonforcepshavesmallerdimensionsthanstandardforcepsandhavebeen
usedtodeliverfetusesassmallas1000g[22].Wewereunabletoidentifyanystudiesormanufacturer
guidelinesregardingprerequisitesforestimatedfetalweightorgestationalageforuseofthese
instruments.Whenclinicallyindicated,wewouldgenerallyconsiderusingforcepsforfetusesestimated
toweighatleast2000g.Weapplystandardforcepsiftheheadsizeisnearoratthesizeofaterm
infant,andbabyforcepsforsmallerheads.(See"Deliveryofthepretermlowbirthweightsingletonfetus",
sectionon'Spontaneousvaginalversusassistedvaginal'and"Deliveryofthepretermlowbirthweight
singletonfetus",sectionon'Useofepisiotomy,vacuum,andforceps'.)
PATIENTPREPARATIONBeforebeginninganoperativevaginaldelivery,maternalanesthesiashouldbe
satisfactory.Neuraxialanesthesiaprovidesmoreeffectiveanalgesiathanpudendalblockforforcepsdelivery
[23].Pudendalblockmaybeadequateforvacuumextractionbecause,unlikeforcepsblades,thevacuumcup
doesnotsignificantlydisplacethewallsofthebirthcanalorincreasethecephalicdiameter.
Thematernalbladdershouldbeemptyasthismayprovidemoreroomfordescentofthefetusandpossibly
reduceinjurytothebladder.
Wedonotadministerantibioticprophylaxisasthereisnoconvincingevidencethatitreducesinfectioninthis
setting[24].
Wedonotroutinelyperformanepisiotomy.Observationalstudiessuggestthatepisiotomyincreases,rather
thandecreases,theriskofperinealtraumainoperativevaginaldeliveries[2529].Theonlyrandomizedtrial
comparingroutineversusrestrictiveepisiotomyatoperativevaginaldeliveryfoundnosignificantdifferences
betweengroupsintherateofanalsphinctertear,postpartumhemorrhage,neonataltrauma,orpelvicfloor
symptomsuntil10dayspostpartumhowever,thiswasapilotstudywithonly200participants[30].If
episiotomyisperformed,amediolateralorlateralepisiotomyispreferableasitprotectsagainstanalsphincter
injury,althoughinitialpostpartumdiscomfortisgreaterthanwithamidlineincision[3134].(See"Approachto
episiotomy",sectionon'Mediolateral'.)
CHOICEOFINSTRUMENTBothforcepsandvacuumareacceptableinstrumentsforoperativevaginal
delivery[3].Ourapproachdependsonpatientspecificfactors,asdescribedbelow.
WhentochoosevacuumversusforcepsWechoosevacuumextractionwhenarelativelyeasyextraction
isanticipated(eg,occipitoanteriorpositionwithnosignsofrelativecephalopelvicdisproportion).Because
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successislikely,theprimaryconsiderationinthesecasesistominimizetheriskofmaternalandfetalinjury.If
adifficultextractionisanticipated,wechooseforcepsdespiteaslightlyhigherriskofmaternalinjurybecause
vacuumextractionislikelytofail[35].
Thechoiceofinstrumentisdeterminedbytheclinician'sexpertisewiththevariousforcepsandvacuum
devices,availabilityoftheinstrument,levelofmaternalanesthesia,andknowledgeoftherisksandbenefits
associatedwitheachinstrumentinvariousclinicalsettings.Vacuumdeliveryisgenerallylesstraumaticforthe
motherthanforcepsdelivery,whileforcepsdeliveryislesstraumaticforthefetusthanvacuumdelivery(see
'Complications'below).Vacuumdevicesareeasiertoapply,placelessforceonthefetalhead,requireless
maternalanesthesia,resultinlessmaternalsofttissuetrauma,anddonotcompressthediameterofthefetal
headcomparedwithforceps.Fetalheadrotationmayoccursecondarytofetalextraction.Theadvantagesof
forcepsarethattheyareunlikelytodetachfromtheheadduringadifficultextraction,canbeusedon
prematurefetusesortoactivelyrotatethefetalhead,resultinfewercasesofcephalohematomaandretinal
hemorrhage,anddonotaggravatebleedingfromscalplacerations.
ChoiceofvacuumcupAllvacuumextractiondevicesconsistofasoftorrigidplasticcup,avacuumpump
toprovidesuctionbetweenthecupandfetalscalp,andatractionsystem.Asoftvacuumcupisappropriatefor
mostdeliveries.Rigidcupsmaybepreferableforocciputposterior,occiputtransverse,anddifficultocciput
anteriordeliveriesbecausetheyarelesslikelytodetach.Amoredetaileddiscussionregardingthechoiceofan
extractorcupcanbefoundseparately.(See"Procedureforvacuumassistedoperativevaginaldelivery",
sectionon'Extractorcup'.)
ChoiceofforcepsThetypeofforcepsselectedforaparticularproceduredependsonseveralfactors,
including:
Thesizeandshapeofthefetalheadandmaternalpelvis,whichshouldmatchthesize,cephaliccurve,
andpelviccurveoftheforceps.Agoodheadapplicationisakeygoalinchoiceofforceps.
Simpsontypeforceps,whichhavelongtaperedblades,tendtobethebestfitforamoldedhead
(picture1).
Elliotttypeforceps(picture2)orTuckerMcLanetypeforceps(picture3)arebettersuitedtoaround,
unmoldedhead.
Fetalheadpositionandwhetherrotationisplanned.Choosingtherightforcepsforthedirectionoftraction
andtypeofrotationisanotherkeygoal.
Kiellandforcepsareusefulforrotationsbecauseoftheirminimalpelviccurveandslidinglock
(picture4).Aslidinglockishelpfulwhenthereisasynclitism.
Piperforcepsareusedtodelivertheaftercomingheadinvaginalbreechdeliveries(picture5).
Station.
Midpelvicdeliveriesarefacilitatedbyaninstrumentthatcanbeusedwithatractionhandle(eg,
Bill'saxistractionhandleorIrvingforceps).Tractionisappliedintheaxisofthepelvis,whichis
curvedinmostwomen.Ifthefetalheadisatastationthatrequiresanaxisoftractionthatisnot
feasiblewithastandardmanualmethodofaxistraction(thePajotSaxtorphmaneuver),thenan
instrumentwithaxistractionishelpful.
Operatorexperienceandpreference.
Applicationofforcepsismoredifficult,requiresmoremanipulationforagoodapplication,andismorelikelyto
resultinmaternalorfetaltraumawithhigherstations,headasynclitism,nonanteriorpositions,rotations
beyond45degrees,andunusualpelvictypestherefore,choiceofthecorrectinstrumentisparticularly
importantinthesesettings.Adetaileddiscussionofthehundredsoftypesofinstrumentsavailableforforceps
deliveryandtheirapplicationisbeyondthescopeofthisreview.TheclassicresourceisDennen'sForceps
Deliveries,butbooksonoperativeobstetricsarealsohelpful.
Noveldevices
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ThierryorTeissierspatulaTheThierryandTeissierspatulasconsistoftwoindependentand
symmetricbrancheswhichincludeashank,handle,andwidesolidblade[36].Theshanksdonotarticulate
thus,eachbranchactsasanindependentleverandtheheadisnotcompressedbetweentheblades.Outcome
dataarelimitedandprimarilypublishedinFrench,butneonatalcomplicationratesappeartobesimilarto,or
slightlylowerthan,rateswithotherinstruments[37,38].Inonelargestudy,therateofsevereperinealinjuries
wasequivalenttothatreportedwithotherextractioninstruments,butvaginaltearsweremorecommon[37].
OdondeviceTheOdondevicewasdevelopedbytheWorldHealthOrganizationforuseinareasthat
havelimitedornoaccesstocesareanbirth.Itisundergoingthefirstphaseoftestingforsafetyandfeasibility
inArgentinaandruralSouthAfrica[39].Itisalowcostdevicemadeoffilmlikepolyethylenematerialthat
createsasacfilledwithairthatsurroundstheentireheadandenablesextractionwhentractionisapplied.It
hasthepotentialtobesaferandeasiertoapplythanforcepsoravacuumextractor.Videosshowing
applicationofthedeviceandfetalextractionareavailableonline(www.odondevice.org).
PROCEDURE
Forceps
ApplicationAppropriatelyappliedforcepsgrasptheocciputanterior(OA)fetalheadsuchthat:
Thelongaxisofthebladescorrespondstotheoccipitomentaldiameter(figure2).
Thetipsofthebladeslieoverthecheeks(figure3).
Thebladesareequidistantfromthesagittalsuture,whichshouldbisectahorizontalplanethrough
theshanks.
Theposteriorfontanelleshouldbeonefingerbreadthanteriortothisplane.
Fenestratedbladesshouldadmitnomorethanonefingerbreadthbetweentheheelofthe
fenestrationandthefetalhead.
Nomaternaltissuehasbeengrasped.
MidforcepsMidforcepsdeliveriesaregenerallyavoidedbecausetheyhaveahigherpotentialfor
maternalandfetalmorbiditythanloworoutletforceps.Clinicianshighlyexperiencedwithforceps
deliveriesmaychoosetoattemptamidforcepsdeliveryinselectcircumstances,suchassuddensevere
fetalormaternalcompromise,iftheclinicianbelievesthathe/shecansafelyexpediteandaffectasafe
operativevaginaldelivery.Simultaneouspreparationforcesareandeliveryshouldbeunderway.
Whenattemptingamidforcepsdelivery,theleadingpointoftheskullshouldbeatorjustbeyondthe
ischialspinestoensuretheheadisengaged.Itwouldberaretohaveanengagedheadwhentheleading
pointisat1/5cmstationandextraordinarilyunlikelyat4or5station.
RotationArotationaldeliveryisanappropriateoptioninselectclinicalcircumstances[3],asneonatal
morbidityisnotincreasedcomparedwithappropriatecontrolswheninterventionisindicatedandwhen
performedbyexperiencedclinicians[4043].Rotation,whenneeded,isperformedbetweencontractions.
Rotationfollowedbyextractionismoredifficultandassociatedwithahigherriskofmaternalandfetal
complicationsthansimpletractionappliedtothenonorminimallyrotatedhead.Forcepsapplicationand
rotationwhenthefetalheadisnotdirectlyOAisbeyondthescopeofthistopicreview.
TractionTractionshouldbesteady(notrocking)andinthelineofthebirthcanal.Itshouldbeexerted
witheachcontractionandinconjunctionwithmaternalexpulsiveefforts.Inmostcases,progressisnoted
withthefirstorsecondpullanddeliveryoccursbythethirdorfourthpull[44].Theprocedureshouldbe
abandonedifdescentdoesnotoccurwithappropriateapplicationandtraction.
Forcepscanberelaxedbetweencontractionstoreducefetalcranialcompression.
RemovalToreducetheriskoflaceration,forcepsaredisarticulatedandremovedwhenexpulsionis
certain,butbeforethewidestdiameterofthefetalheadpassesthroughtheintroitus.Theheadcanthen
bedeliveredwithnoorminimalmaternalassistance.
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VacuumTheprocedureforvacuumextractionisreviewedseparately.(See"Procedureforvacuumassisted
operativevaginaldelivery".)
WHENTOABANDONTHEPROCEDUREOperativevaginaldeliveryshouldbeabandonedifitisdifficult
toapplytheinstrument,descentdoesnoteasilyproceedwithtraction,orthefetushasnotbeendelivered
withinareasonabletime[19].Someexpertssuggestabandoningtheprocedureifdeliveryhasnotoccurred
within15to20minutesorafterthreepulls.Acohortstudyfoundthat82percentofcompletedoperative
deliveriesoccurredwithonetothreepulls,andthatpullingmorethanthreetimeswasassociatedwithinfant
traumain45percentofsuchdeliveries[45].Basedonthesedata,webelieveitisprudenttoabandonthe
procedureifgoodinstrumentplacementisfollowedbynoprogressindescentoverthreeattempts.Ifdescent
hasoccurredanddeliveryisclearlyimminent,thenproceedingwithinstrumentaldeliveryafterthreepullsmay
beappropriateandlessmorbidthanacesareandeliveryofaninfantwithitsheadontheperineum.
Theoperatorshouldnotbefixatedonachievingavaginaldelivery.Itisessentialthattheoperatorbewillingto
abandonaplannedorattemptedoperativedeliveryandhavetheabilitytoperformacesareanbirthifevaluation
orreevaluationoftheclinicalstatusshowsthataninstrumentaldeliveryiscontraindicated(eg,thefetalheadis
notengaged,thepositionisuncertain,theprocedureisnotsucceeding).
Themostcommonclinicalfactorsassociatedwithfailedoperativevaginaldeliveryareocciputposterior
positionandmacrosomia[4,4652](see"Occiputposteriorposition",sectionon'Management'and"Shoulder
dystocia:Riskfactorsandplanningdeliveryofatriskpregnancies",sectionon'Planningdeliveryinatrisk
pregnancies').Othercharacteristicsthathavebeenassociatedwithfailureincludenulliparity,higherstation,
excessivemoldingofthefetalhead,protractedlabor,andmaternalobesity[4].
Higherratesofneonatalmorbidityhavebeenobservedwhencesareandeliverywasperformedafterafailed
operativevaginaldeliverythanwhenperformedduringlaborwithoutsuchattempts(table2)[53,54]thereare
manylimitationstotheseobservationaldata,includingconfoundingbyindicationforinterventionandlackof
appropriatecontrols.
SECONDATTEMPTWITHADIFFERENTINSTRUMENTWebelievemakingasecondattemptat
operativedeliverywithforcepsafterafailedvacuumisappropriateinrare,carefullyselectedcases,aslongas
noindicationsforabandoninganoperativevaginalapproachexist(see'Whentoabandontheprocedure'
above).Forexample,onemayperformatrialofforcepsafterafailedvacuumif,afterreassessingthepatient,
theclinicianbelievessheisagoodcandidateforaforcepsvaginaldeliveryandtheinitialchoiceofvacuum
wasnotthebestchoice,perhapsbecauseofpoormaternaleffortinhelpingwithvacuumextractionorbecause
ofanocciputposteriorheadposition.
Foraproceduretobeconsideredsequential,tractionshouldbeappliedsequentiallybytwodifferent
instruments.Situationswhereproperplacementofforcepscannotbeachievedoravacuumdevicefailsto
achievesuctionandnotractionhasbeenappliedfollowedbyapplicationandtractionusingasecond
instrumentshouldnotbeconsideredasequentialattempt.
AmericanCollegeofObstetriciansandGynecologistssuggestsavoidingsequentialattemptsatoperative
vaginaldeliveryusingdifferentinstrumentsduetothegreaterpotentialformaternaland/orfetalinjury[3].
Populationbaseddatahavereportedincreasedmaternalandneonatalmorbidityfromsequentialapplicationof
vacuumandforceps[53,55,56].Althoughafewstudieshavenotdemonstratedadverseeffectsfromsequential
useofvacuumandforceps,evenwhenvaginaldeliverywasnotachieved,atypeIIerrormayhaveresulted
fromthesmallnumberofparticipantsandeventsinthesestudies[57,58].
Forthemother,sequentialuseofvacuumandforcepshasbeenassociatedwithincreasedratesofthird/fourth
degreelacerationsandpostpartumhemorrhage[56].Fortheneonate,sequentialuseoftheseinstrumentshas
beenassociatedwithincreasedratesofsubduralhematomasandintracranialhemorrhage.Inonelargestudy,
theincidenceofsubduralorcerebralhemorrhageininfantsdeliveredbyvacuumandforceps,vacuumalone,or
forcepsalonewasapproximately21,10,and8per10,000births,respectively[53].Thesefindingswere
corroboratedbyanotheranalysisbaseduponstatewidebirthcertificatedata[55]andasmallstudyof
asymptomaticterminfantswhounderwentroutinemagneticresonanceimagingwithin48hoursofbirth[59].In
thelatter,9of111asymptomaticinfantshadasubduralhematoma,andthehighestproportionwasinthe
groupexposedtofailedvacuumfollowedbysuccessfulforcepsdelivery(fivesubduralhematomasamong18
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infants[28percent])[59].Bycomparison,threesubduralhematomasoccurredin49infantsspontaneously
deliveredfromvertexpresentation(6percent),onesubduralhemorrhageoccurredamong13successful
vacuumdeliveries(8percent),andnosubduralsoccurredamongfoursuccessfulforcepsdeliveries.All
hematomashadresolvedwithoutclinicalsequelaewhenreevaluatedfourweekslater.
SUCCESSRATEBirthcertificatedataincludingovertwomilliondeliveriessuggestthatoperativevaginal
deliveryisusuallysuccessful:Attemptedoperativevaginaldeliveryusingforcepsorvacuumextractionfailed
in0.4and0.8percentofcases,respectively[60].Thislikelyreflectsappropriatechoiceofcandidatesforthis
intervention.Whenunsuccessful,60percentofwomenwentontohaveavaginaldeliveryand40percenthad
acesareandelivery.
Failedforcepsismorelikelytoleadtocesareandeliverythanfailedvacuum.Failedvacuumextractionmaybe
followedbyasuccessfultrialofforceps,buttheconverserarelyoccurs.Midforcepsdeliveryismorelikelyto
failthanlowforcepsdeliveryfailurerateswere8.9and0.3percent,respectively,inonelargeprospective
study[61].
COMPLICATIONSMaternalandfetal/neonatalcomplicationratesvarywidelyanddependonanumberof
factors,whicharenotindependent.Thesefactorsincludetypeofinstrument,headpositionatapplication,
station,indicationforintervention,andoperatorexperience.Rotation,higherstation,longeractivesecondstage
oflabor,andoperatorinexperiencevariablyincreasetheriskofcomplications.Virtuallyallcomplications
associatedwithoperativevaginaldeliverycanalsooccurinthecourseofaspontaneousvaginaldelivery,but
theincidenceislowerinthelatter.
Neonatalcomplications
OverviewofbirthtraumaBirthtraumaisthemajorcomplicationofinstrumentassisteddelivery.
Traumamaybecausedbyheadcompressionandtractiononthefetalintracranialstructures,face,andscalp,
orbysuboptimalinstrumentplacement[62].
Themostserioussequelaeoftraumaisintracranialhemorrhage.Othercomplicationsincludebruises,
abrasionsandlacerations,facialnervepalsy,cephalohematoma,retinalhemorrhage,subgalealhemorrhage,
skullfracture,andenablingshoulderdystocia[19,63].
ApopulationbasedanalysisofsingletonbirthsintheUnitedStatesprovidedcrudemorbidity/mortalitydatafor
over11millionunassisted(spontaneous),forcepsassisted,andvacuumassistedbirths(table3)[64].Vacuum
assisteddeliverieswereassociatedwithsignificantlylowerratesofbirthinjury,seizures,andassisted
ventilationthanforcepsassisteddeliveries,afteradjustmentforconfoundersneonataldeathrateswere
equivalent.StatebaseddataforCaliforniaandNewJerseyprovideamoredetaileddescriptionofthespecific
typesofinjuriesassociatedwithdifferentinstruments(table4andtable5)[53,64].
Birthinjuryratesaccordingtomethodofdelivery(eg,intracranialhemorrhage(table6))shouldbeinterpreted
withcautionandwithrespecttoappropriatecontrolgroupsandreasonablealternativeprocedures.For
example,secondstagecesareandeliveryisanalternativetooperativevaginaldelivery,butprelaborcesarean
deliveryandspontaneousvaginaldeliveryarenotrealisticalternativesinthesettingofsecondstagelabor
complications.Biasinpatientselectionisalsoanimportantfactorthevacuumapproachisoftenfavoredover
forcepsinpatientsmostlikelytodeliverwithminimalassistance.
OverviewofneurodevelopmentaloutcomeIntworandomizedtrials,developmentaloutcomewas
similarforbothforcepsandvacuumassistedbirths[65,66].Bothofthesetrialslackedacomparisonwith
infantsdeliveredspontaneouslyorbycesareandelivery.Athirdtrialcomparedneurodevelopmentaloutcomeat
agefiveforchildrenbornbysuccessfulinstrumentalvaginaldelivery,failedinstrumentaldelivery,andcesarean
deliveryinthesecondstageoflabor[67].Neurodevelopmentalmorbiditywaslowwithnosignificant
differencesamongthethreegroups,butthestudywasunderpowered.
Oneofthefewfollowupevaluationscomparingoutcomeatschoolageafteroperativeorspontaneousdelivery
inover3000fiveyearoldsfoundnodifferencesincognitivetesting[68].Thisseriesincluded1192forceps
deliveries,ofwhich114weremidforceps.Anotherstudycomparedtheneurologicoutcomeof29510yearold
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childrendeliveredbyvacuumextractionwiththatof302childrendeliveredspontaneouslyinthesamehospital
bythesamedoctorsandmatchedformaternalage,gestationalage,andbirthweight[69].Bothgroupshad
similarresultsfortestsoffineandgrossmotorcontrol,perceptualintegration,behavioralmaturity,scholastic
performance,speechability,andselfcare.Inaddition,anationalcohortstudyof126,03216yearoldsbornas
nonanomalousvertexsingletons34weeksofgestationtoSwedishbornparentsnotedthatthosedelivered
byvacuumextractionhadslightlylowermeanmathematicstestscoresthanchildrenbornvaginallywithout
instrumentsafteradjustmentformajorconfounders,butsimilarscorestothosebornbyintrapartumcesarean
delivery[70].
NeonatalcomplicationswithvacuumassisteddeliveriesTorsionandtractionofthevacuumcupcan
belifethreateningcomplicationsfollowinguseofvacuumassisteddevices,includingsubgalealhematoma(ie,
collectionofbloodbetweentheaponeurosiscoveringthescalpandtheperiosteumbloodcanextendacross
suturelinesandbeneaththescalpandintotheneck)andintracranialhemorrhage(subdural,subarachnoid,
intraventricular,and/orintraparenchymalhemorrhage)(figure4)[71].
Othercomplicationsincludefetalscalpabrasionsandlacerations,cephalohematoma,skullfracture,andretinal
hemorrhage[53,7274].Theincidenceofretinalhemorrhageishigherforvacuumassistedthanforspontaneous
vaginalorcesareandeliveries(75,33,and7percent,respectively)[75].Thesehemorrhagestypicallyresolve
withoutsequelaewithinfourweeksofbirth.Cephalohematomaisalsomorecommonaftervacuumassisted
extractionthanforcepsdelivery(table5)[64,76,77].Lastly,shoulderdystociaismorecommonwithvacuum
assistedthanforcepsdeliveries[64,78].Thisislikelythereasonthatvacuumassisteddeliveriesareathigher
riskofbrachialplexusinjurythanforcepsassisteddeliveriesorcesareandelivery[79].
NeonatalcomplicationswithforcepsassisteddeliveriesForcepsdeliverycancauseskinmarkings
andlacerations,externaloculartrauma,intracranialhemorrhage,subgalealhematomas,retinalhemorrhage,
lipoidnecrosis,nerveinjury,skullfractures,anddeath[14,53,80,81].Facialpalsies(table5)[79,81]and
depressedskullfractures[81]aremorecommonwithuseofforcepsthanvacuumdevices.
MaternalcomplicationsMaternalcomplicationsassociatedwithinstrumentaldeliveryincludelowergenital
tractlacerations(suchasadeeplacerationofthevaginalsulcus),vulvarorvaginalhematomas,urinarytract
injury/voidingdysfunction(urinaryretentionorincontinence),analsphincterinjury,pain,hemorrhage,local
infection,andrehospitalization[77,8289].
Allofthesecomplicationscanalsooccurwithspontaneousvaginaldelivery,buttheriskappearstobehigher
withoperativevaginaldelivery.Forexample,studieshavereportedthefollowingratesofthird/fourthdegree
lacerationbydeliverytype:spontaneousdelivery(2percent),vacuumextraction(10to11percent),forceps
delivery(17to20percent)[88,90].
Rotationalandmidforcepsoperations[16,91]arethemajorriskfactorsformaternaltraumaduringoperative
delivery.Directbladderinjury,ureterallacerations/transections,anduterinerupturehavebeenreportedinsuch
cases[92].Occiputposterior(OP)positionisanotherriskfactorformaternaltraumaduringforcepsorvacuum
delivery[9395].AlogisticregressionmodeladjustingforanumberoffactorsshowedthatOPwasfourtimes
morelikelythanocciputanterior(OA)tobeassociatedwithanalsphincterinjuryatvacuumextractionthe
unadjustedratesofanalsphincterinjuryfortheOPandOApositionswere42and22percent,respectively
[94].
Althoughspontaneousvaginaldeliveryislesstraumaticforthemotherthanoperativevaginaldelivery,
operativevaginaldeliveriesareassociatedwithlessshorttermmaternalmorbiditythancesareandelivery,
particularlylowerratesofpostpartumfeverandvenousthromboembolism[96].Datafromlongitudinalcohort
studiessuggestthatoperativevaginaldeliveryisassociatedwithahigherlongtermriskofurinary
incontinence,analincontinence,andprolapsesymptomsthancesareandeliveryafterfulldilation,butthese
differenceswerenotconsistentlystatisticallysignificant[97,98].Whenconsideringthemorbidityofoperative
vaginalversuscesareandelivery,itshouldbenotedthatsecondstagecesareandeliveryisassociatedwith
greatermaternalmorbiditythanfirststagecesareandelivery[99].
Thechoiceofinstrumentdoesnotappeartobeariskfactorforlongtermcomplications,suchasurinaryand
analdysfunctionandpelvicorganprolapse.Atrialthatrandomlyassigned75womentoforcepsorvacuum
deliveryandsurveyedthemfiveyearspostpartumreported47percenthadsomedegreeofurinaryincontinence
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and20percenthadlossofbowelcontrol"sometimes"or"frequently"[65].However,longtermmorbidityrates
weresimilarregardlessoftheinstrumentusedtoassistdelivery.Thisstudywaslimitedbythelackofa
controlgroupofwomenwhounderwentcesareandeliveryfollowingadysfunctionallabor.(See"Effectof
pregnancyandchildbirthonanalsphincterfunctionandfecalincontinence"and"Urinaryincontinenceand
pelvicorganprolapseassociatedwithpregnancyandchildbirth".)
POSTPARTUMISSUESThelowergenitaltract,peritoneum,andanus/rectumshouldbeexaminedafter
deliveryforlacerations.Itisimportanttoremembertoperformthisexaminationinwomenwhoundergo
cesareandeliveryafterafailedattemptatoperativedelivery.
Theneonatalcareprovidershouldbeinformedthatvacuumorforcepswereusedtoassistdelivery.Since
mostseriouscomplications,suchasasubgalealhematoma,occurwithinhoursofdelivery[100],itisimportant
toinforminfantcareprovidersbyeitherareliablechartingmethod,directnotification,orboth.
RATEOFRECURRENTOPERATIVEVAGINALDELIVERYAbout5percentofwomenwhohavean
operativevaginaldeliverywillhaveasecondoperativevaginaldelivery[101,102].
USEOFVACUUMORFORCEPSATCESAREANDELIVERY(See"Managementofdeeplyengaged
andfloatingfetalpresentationsatcesareandelivery".)
SUMMARYANDRECOMMENDATIONS
Therisksandbenefitsofoperativevaginaldeliveryforeachpatientneedtobebalancedagainstthosefor
cesareandeliveryandlessinvasiveinterventions.Useofforcepsorvacuumisreasonablewhenan
interventiontoterminatelaborisindicatedandoperativevaginaldeliverycanbesafelyandreadily
accomplishedotherwise,cesareandeliveryisthebetteroption.Situationswhereoperativevaginal
deliverymaybepreferabletocesareandeliveryorlessinvasiveinterventionsincludeprolongedsecond
stageoflabordespiteinterventionwithlessinvasivemeasures,fetalcompromisewhereexpeditious
deliveryisdesirable,andmaternalmedicaldisorderswherepushing(Valsalva)needstobeavoidedor
minimized.Nonmedicallyindicatedshorteningofthesecondstageisnotanindicationforoperative
vaginaldelivery.(See'Indications'above.)
Beforeresortingtoanoperativevaginaldelivery,theclinicianshouldensurethatprerequisitesaremet
(eg,headisengaged,membranesruptured,presentationandpositionknown,anesthesiaissatisfactory,
thefetusisofappropriategestationalageandsize,maternalbladderisempty)andthereareno
contraindications.(See'Prerequisites'aboveand'Contraindications'above.)
Forcepsdeliveriesareclassifiedasoutlet,low,ormid,dependingonthefetalstationanddegreeofhead
rotation.(See'Classification'above.)
Ingeneral,vacuumdevicesareeasiertoapply,placelessforceonthefetalhead,requirelessmaternal
anesthesia,anddonotcompressthediameterofthefetalheadcomparedwithforceps.Theadvantages
offorcepsarethattheyareunlikelytodetachfromthehead,canbesizedtoaprematurecranium,may
beusedforarotation,anddonotaggravatebleedingfromscalplacerations.(See'Whentochoose
vacuumversusforceps'above.)
Forwomenwhoaretoundergoanoperativevaginaldeliveryat>34weeksandhaveahighlikelihoodof
success(eg,outletprocedure),wesuggestuseofvacuumoverforceps(Grade2C).Maternalmorbidity
islowerwithvacuumthanforcepsandneonatalmorbidityislikelytobelowinthissettingwitheither
approach.Whensuccessisuncertain,primaryuseofforcepsmayreducethemorbidityassociatedwith
combinedsequentialinstrumentaldelivery.(See'Choiceofinstrument'aboveand'Secondattemptwitha
differentinstrument'above.)
Thedecisiontoproceedwithoperativevaginaldeliveryisongoinganddecidedmomentbymomentbased
onassessmentofthesuccessofthevariousstepsintheprocedure.Operativevaginaldeliveryshouldbe
abandonedifitisdifficulttoapplytheinstrument,descentdoesnoteasilyproceedwithtraction,orthe
babyhasnotbeendeliveredwithinareasonabletime(eg,15to20minutes)orafterthreepullswithno
progress.(See'Whentoabandontheprocedure'above.)
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Maternalandfetal/neonatalcomplicationratesvarywidelyanddependonanumberoffactors,whichare
notindependent.Virtuallyallcomplicationsassociatedwithoperativevaginaldeliverycanalsooccurin
thecourseofaspontaneousvaginaldelivery,buttheincidenceislowerinthelatter.(See'Overviewof
birthtrauma'aboveand'Complications'above.)
Vacuumassisteddeliveriesareassociatedwithanincreasedriskofneonatalcephalohematomataand
retinalhemorrhagecomparedwithforcepsorspontaneousdeliveries.Thesecomplicationsgenerally
resolvewithoutsequelae.Forcepsassisteddeliveriescausemoreacutematernalinjuryandfetalfacial
nerveinjurythanvacuumassistedoperativedeliveriesorspontaneousdeliveries.(See'Neonatal
complicationswithvacuumassisteddeliveries'aboveand'Neonatalcomplicationswithforcepsassisted
deliveries'above.)
Althoughshorttermneonatalmorbidityvariesbetweenprocedures,developmentaloutcomeappearstobe
equivalentforbothforcepsandvacuumassistedbirths.(See'Overviewofneurodevelopmentaloutcome'
above.)
Thematernalbladderisemptiedbeforeoperativedelivery.Werecommendnotperforminganepisiotomy
routinely(Grade1B).(See'Patientpreparation'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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hemorrhageinnewborns.Ophthalmology2001108:36.
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Topic4474Version37.0

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GRAPHICS
Contemporaryestimatesofmedianand95thpercentileinhours
byparity
Parity0

Parity1

Mediannumberof
hours
th
(95 percentile)

Mediannumberof
hours
th
(95 percentile)

From4cmto5cm

1.3(6.4)

1.4(7.3)

From5cmto6cm

0.8(3.2)

0.8(3.4)

From6cmto7cm

0.6(2.2)

0.5(1.9)

From7cmto8cm

0.5(1.6)

0.4(1.3)

From8cmto9cm

0.5(1.4)

0.3(1.0)

From9cmto10cm

0.5(1.8)

0.3(0.9)

Secondstagewithepidural
analgesia

1.1(3.6)

0.4(2.0)

Secondstagewithoutepidural
analgesia

0.6(2.8)

0.2(1.3)

Changeincervix

Durationofsecondstage

Notethe95 thpercentilefordurationoftimetodilatefrom4to6cmisalmost10hoursin
nulliparouswomen.
Datafrom:ZhangJ,LandyHJ,BranchDW,etal.Contemporarypatternsofspontaneouslaborwith
normalneonataloutcomes.ObstetGynecol2010116:1281.
Graphic69170Version14.0

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Assessingdescentofthefetalheadbyvaginal
examination

Thefetusisat2stationsignifyingthattheleadingbonyedgeofthe
presentingpartistwocentimetersabovetheischialspines.Theheadis
engagedat0station.
Sp:ischialspine.
Graphic67068Version4.0

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DeleeSimpsontypeforceps

Simpsontypeforcepshaveparallelseparatedshankswithbladesthat
havealongandtaperedcephaliccurve.
Reproducedwithpermissionfrom:AronSchuftan,MD.CopyrightAron
Schuftan,MD.
Graphic79792Version6.0

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Elliotttypeforceps

Elliottypeforcepshaveoverlappingshankswithbladesthatareshort
andhavearoundishcephaliccurve.
Reproducedwithpermissionfrom:AronSchuftan,MD.CopyrightAron
Schuftan,MD.
Graphic73043Version3.0

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TuckerMcLaneforceps

TheTuckerMcLaneforcepsareElliotttypewithbladesthataresmooth
andsolid.
Reproducedwithpermissionfrom:AronSchuftan,MD.CopyrightAron
Schuftan,MD.
Graphic58167Version4.0

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Kiellandforceps

Kiellandforcepshaveaslidinglocktocorrectforasynclitism.
Reproducedwithpermissionfrom:AronSchuftan,MD.CopyrightAron
Schuftan,MD.
Graphic80795Version3.0

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Piperforceps

Piperforcepshavelongshanksthatareseparatedandslightlycurved
beyondthelockinordertomanagedeliveryoftheaftercomingheadin
breechpresentation.
Reproducedwithpermissionfrom:AronSchuftan,MD.CopyrightAron
Schuftan,MD.
Graphic56439Version4.0

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Diametersofthefetalheadatterm

Measurementsfrom:CunnighamFG,LevenoKJ,BloomSL,etal(Eds).Williams
Obstetrics,23rdEdition.NewYork:McGrawHill,2010.
Graphic62883Version5.0

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Correctplacementoftheforcepsbladesonthe
fetalhead

Reproducedwithpermissionfrom:JamesR.Scott,RonaldS.Gibbs,Danforth's
ObstetricsandGynecology,NinthEdition.Philadelphia:LippincottWilliams&
Wilkins,2003.Copyright2003LippincottWilliams&Wilkins.
Graphic72994Version1.0

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Neonatalmorbidityafterintrapartumcesareandelivery,withor
withoutatrialofoperativevaginaldelivery
Cesareandelivery
afterattemptsat
operativevaginal
birth*

Morbidity

Cesarean
deliverywithno
attemptsat
operativevaginal
birth*

Subduralorcerebral
hemorrhage

25.7

6.8

Facialnerveinjury

12.8

2.8

Convulsions

68.8

19.9

CNSdepression

17.1

9.4

Mechanicalventilation

156.1

101.7

CNS:centralnervoussystem.
*Numberofcasesper10,000infants.
Datafrom:TownerD,CastroMA,EbyWilkensE,etal.Effectofmodeofdeliveryinnulliparous
womenonneonatalintracranialinjury.NEnglJMed1999341:1709.
Graphic69438Version5.0

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Neonatalmorbidityandmortalitydatabydeliverytypeforthe
UnitedStates,1995to1998(ratesareper10,000deliveries)
Outcome

Forceps
delivery

Spontaneous

Vacuum
delivery

Neonataldeath

3.7

5.0

4.7

Birthinjury

21.4

109.1

76.1

Neonatalseizures

5.0

8.7

6.5

Assistedventilation<30
minutes

147

293

250

Datafrom:DemissieK,RhoadsGG,SmulianJC,etal.Operativevaginaldeliveryandneonataland
infantadverseoutcomes:populationbasedretrospectiveanalysis.BMJ2004329:24.
Graphic70509Version4.0

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Frequencyofbirthtraumarelatedtomodeofdeliverycasesper
10,000births
Spontaneous
birth

Vacuum
assisted

Forceps
assisted

Cesarean
nolabor

Cesarean
with
labor

Subduralor
cerebral
hemorrhage

2.9

8.0

9.8

4.1

7.4

Intraventricular
hemorrhage

1.1

1.5

2.6

0.8

2.5

Subarachnoid
hemorrhage

1.3

2.2

3.3

0.0

1.2

Facialnerve
injury

3.3

4.6

45.4

4.9

3.1

Brachialplexus
injury

7.7

17.6

25.0

4.1

1.8

Convulsions

6.4

11.7

9.8

8.6

21.3

CNSdepression

3.1

9.2

5.2

6.7

9.6

Feeding
difficulty

68.5

72.1

74.6

106.3

117.2

Mechanical
ventilation

25.8

39.1

45.4

71.3

103.2

Trauma

CNS:centralnervoussystem.
Datafrom:TownerD,CastroMA,EbyWilkensE,etal.Effectofmodeofdeliveryinnulliparous
womenonneonatalintracranialinjury.NEnglJMed1999341:1709.
Graphic63989Version4.0

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Neonatalmorbidityandmortalitydatabydeliverytype,New
Jersey1989to1993,rateper10,000deliveries
Unassisted
(spontaneous)delivery

Forceps
delivery

Vacuum
delivery

Vacuum
plus
forceps

Cephalohematoma

167

635

1117

1361

Facialnerveinjury

2.4

37.0

5.2

52.9

Intracranial
hemorrhage

3.7

17.0

16.2

26.5

Mechanical
ventilation

23.5

31.3

40.3

74.1

Retinal
hemorrhage

18.2

19.3

15.7

31.8

Outcome

Datafrom:DemissieK,RhoadsGG,SmulianJC,etal.Operativevaginaldeliveryandneonataland
infantadverseoutcomes:populationbasedretrospectiveanalysis.BMJ2004329:24.
Graphic50159Version4.0

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Incidenceofintracranialhemorrhagebymodeofdelivery
Deliverytype

Incidence

Vacuumextraction

1in860

Forceps

1in664

Forcepsandvacuum

1in280

Cesareandeliverywithlabor

1in907

Cesareandeliverywithoutlabor

1in2750

Spontaneousvaginalbirth

1in1900

Datafrom:TownerD,CastroMA,EbyWilkensE,GilbertWM.Effectofmodeofdeliveryinnulliparous
womenonneonatalintracranialinjury.NEnglJMed1999341:1709.
Graphic50481Version5.0

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Neonatalextracranialandintracranialbirthinjuries

Modifiedfrom:VolpeJJ.NeurologyoftheNewborn,4thed,WBSaunders,Philadelphia2001.
Graphic53176Version9.0

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Disclosures
Disclosures:ElisabethKWegner,MDNothingtodisclose.IraMBernstein,MDNothingto
disclose.CharlesJLockwood,MD,MHCMConsultant/AdvisoryBoards:Celula[Aneuploidy
screening(PrenatalandcancerDNAscreeningtestsindevelopment)].VanessaABarss,MD,
FACOGNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,these
areaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsfor
referencestobeprovidedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofall
authorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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