Assisted Delivery
Assisted delivery has changed in the last few decades, with more HCPs being trained – and specifically choosing to use – vacuum extraction over forceps. However, research indicates that overall, HCPs are choosing cesarean section over any attempt at assisted delivery during a prolonged pushing stage.
Cesarean section is considered to have higher risks to both mother and baby than assisted delivery, and the American Congress of Obstetricians and Gynecologists is encouraging HCPs to use assisted delivery to lower cesarean section rates.
An HCP must be properly trained and comfortable in using various assisted delivery techniques, as both are recommended for very specific purposes in the second stage of labor (pushing).
Women should also understand that the use of an epidural does not automatically increase the risk of assisted delivery, as several options are available prior to the use of either vacuum or forceps, as long as fetal heart rate/movement is reassuring.
Women planning on a vaginal delivery should talk to their HCP about the HCP's experience and opinion of the use of assisted delivery, and whether these methods or cesarean section should be used as first options if required during that specific woman’s delivery.
Background
When complications occur during the second stage of labor, HCPs have several options, which include expectant management ("wait and see"), oxytocin (Pitocin®), assisted delivery (forceps/vacuum), or cesarean section. Most often, HCPs will choose cesarean section.
The American College of Obstetrics and Gynecology (ACOG) has recommended training in forceps/vacuum use to reduce the rates of cesarean section, which is the main advantage of their use. Complications are considered to be much higher in cesarean sections than assisted delivery. However, HCPs need to be properly trained.
Currently, assisted delivery is done in about 3% to 5% of vaginal deliveries in the United States (U.S.) sand about 12% in the United Kingdom, and is considered safe and effective when done properly.
Indications
The focus of assisted delivery has changed, and the main purpose behind its use today is when deemed necessary by the HCP for the health of the baby, and not to speed up labor if all vital signs are normal.
An HCP may decide to use assisted delivery:
If there are concerns about the baby’s heart rate
The woman is tired, and the baby’s head has stopped moving through the birth canal (subjective – the woman should have time to rest if fetal assessment is reassuring)
A medical condition (such as heart disease) limits her ability to push
The baby’s position (head rotation only)
There are two instruments available for assisted delivery –forceps and vacuum (ventouse). While the overall rate of assisted delivery has been declining, the proportion of vacuum-assisted deliveries has been increasing and accounts for almost four times the rate of forceps-assisted births. It is currently not recommended that numerous attempts be completed using more than one type of instrument.
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Most complications during assisted delivery are a direct result of tearing in the vaginal and perineal area. This can also occur during a normal, unassisted vaginal delivery. Assisted delivery also increases the risk for potential postpartum urinary and anal complications, such as incontinence. This complication can affect about 4% of vacuum deliveries and up to 12% of women requiring forceps delivery.
Vacuum (Ventouse)
The vacuum device is a suction cup with a handle attached; the cup (plastic, polyethylene, or silicone) is placed in the vagina and applied to the top of the baby’s head via suction. During a contraction, and while the woman pushes, the HCP gently pulls to help deliver the baby.
The vacuum was invented prior to forceps but did not become more common until research began showing its benefits over forceps – to include the ability to limit the amount of traction used by vacuum.
Vacuum extraction is less likely to cause vaginal tearing and perineal trauma than forceps, as well as a reduced need for general or regional anesthesia and cesarean section, and less postpartum pain.
Correct cup placement on the fetal head and knowing when to abandon the procedure, appear to be key components to conducting a safe and successful vacuum delivery. Vacuum extraction is not used for pregnancies less than 34 weeks as the baby’s head is too premature.
Prior to vacuum use, the woman's bladder should be emptied (a catheter may be used to assist this part). A local anesthetic may also be given to numb the vagina and perineum if an epidural has not already been placed. An episiotomy to help vacuum placement (or forceps) is not recommended and is generally discouraged.
The HCP will carefully apply the suction cup to the baby’s head and will avoid placing it directly over the fontanelle. The HCP will then sweep around the cup to make sure no vaginal or cervical tissue is trapped under the cup. Suction is then applied, and the HCP will gently pull as the woman pushes with a contraction.
Traction is stopped when the woman stops pushing. The pressure within the cup can be either lessened or maintained between contractions. Once the baby’s head begins crowning, the suction is released, and the cup is removed; the rest of the delivery proceeds in a normal fashion.
The maximum number of pulls (contractions) in which the vacuum should be used and then abandoned is not known. The suction cup can also pop off during attempted delivery. Most deliveries are usually completed within 1 to 3 pulls. It is recommended that no more than 3 sets of pulls are used and a maximum of 2 to 3 cup detachments be allowed, with a total time limited to 20 to 30 minutes.
The most common complications include a chignon and cephalohematoma; both are temporary soft tissue injuries.
The chignon is seen upon immediate removal of the cup and looks and feels like a firm swelling that starts to resolve within an hour of delivery. Complete resolution usually occurs within 18 hours; a chignon presents no long-term concerns for an infant’s health.
Other times, a bruise can be left on the baby’s head after delivery, known as a cephalohematoma. This is considered harmless and usually goes away with a few days to a few weeks. Cephalohematoma occurs in about 1 and 12 in 100 deliveries that used vacuum extraction. This type of bruising does not pose any long-term concerns.
Long-term complications from vacuum-associated injuries such as intracranial hemorrhage and neuromuscular injury are not common (about 5%). However, subgaleal hemorrhage (SGH) is the most serious complication of assisted delivery, and while rare, is life-threatening.
SGH can also occur following normal birth, forceps delivery, or cesarean section, but most frequently occurs after vacuum-assisted delivery. Therefore, newborns delivered by vacuum should have a vitamin K injection immediately after birth (aids in blood clotting/prevents bleeding).
It appears SGH is most often caused by incorrect positioning of the cup, prolonged extraction time (greater than 30 minutes), more than three pulls, or greater than two cup detachments.
It is also recommended that if a newborn was delivered by vacuum, that hats/bonnets should not be used so visual inspection of the baby’s head can occur often.
Forceps
Forceps are instruments similar to two very large curved spoons that are placed into the vagina and around the baby’s head during delivery. Forceps are specifically designed to assist in the rotation of the baby’s head, not necessarily to pull the baby out.
Although vacuum extraction is used significantly more often than forceps, forceps are used in premature infants which are safer than vacuum due to the underdevelopment of the top of the preterm head. Additionally, forceps may be used when a fast delivery is required, as forceps tend to lead to delivery quicker than vacuum (through rotation).
Forceps deliveries are also associated with a lower risk of scalp injury and cephalohematoma than vacuum.
Forceps use also tends be more effective than vacuum use in the following scenarios:
Breech delivery
Controlled delivery of head at caesarean section
Face presentation (cannot be done by vacuum)
Suspected coagulopathy or thrombocytopenia in fetus (blood-clotting concerns)
General anesthesia was used (mother cannot push; pushing is required for vacuum use)
Cord prolapse
The most common complication of forceps use is small marks or bruises on the baby’s face (10%) that usually disappear within 24 to 48 hours. However, forceps can result in severe consequences when not used properly, or for the correct indications.
Forceps are not advised if:
The cervix is not fully dilated
Membranes are still intact
The head is not engaged
Unconfirmed fetal position
Cephalopelvic disproportion is possible (baby cannot fit through mother's pelvis)
Complications of forceps use to the mother can include perineal and/or vaginal tearing, bruising, anal sphincter injury, and possible pelvic organ prolapse. For the baby, complications can include facial lacerations and nerve injury, eye trauma, skull fracture, intracranial hemorrhage, SGH, hyperbilirubinemia, and rarely, death.
Action
Women should ask their HCP all questions they have regarding their HCP's experience and opinion of vacuum and forceps use during delivery, as well as what circumstances the HCP may use either method during labor.
For women who had an assisted delivery, or tore from an unassisted vaginal delivery, management tips for postpartum healing can be read here.
Resources
Assisted Vaginal Delivery (American College of Obstetricians and Gynecologists)
Forceps of Vacuum Delivery (U.K. National Health Service)
Assisted vaginal birth (ventouse or forceps) (Royal College of Obstetricians and Gynecologists)