Operative Vaginal Birth

Operative vaginal birth or operative vaginal delivery – refers to the use of forceps, vacuum, or more than one instrument to extract the fetus from the vagina, with or without the assistance of maternal pushing. Operative vaginal births account for 10–15% of all deliveries in the United Kingdom, with an incidence of up to 30% in first time mothers.

In the USA in 1990 – 9% of livebirths resulted from either forceps delivery or vacuum extraction, by 2014 only 3.21% of livebirths resulted from operative vaginal delivery; in 2017 3.1 percent of all deliveries were accomplished via an operative vaginal approach. Forceps deliveries accounted for 0.5 percent of vaginal births, and vacuum deliveries accounted for 2.6 percent of vaginal births.

One of the reasons for the great reduction in operative procedures is the lack of experience and hence reduced confidence of the operator, who instead will do a Caesarean Section. As a Resident/Registrar, I did hundreds of forceps deliveries. These days Obstetricians in training, in some regions, see very few.

Operative vaginal birth should be performed by, an operator who has the knowledge, skills and experience necessary to assess the woman, complete the procedure and manage any complications that arise. The majority of operative vaginal births, when performed correctly by appropriately trained personnel, result in a safe outcome for the woman and baby. Women who achieve an assisted vaginal birth rather than have a caesarean birth with their first child are far more likely to have an uncomplicated vaginal birth in subsequent pregnancies.

Operative vaginal delivery is indicated for both maternal and fetal reasons.

Indications for assisted vaginal birth

Fetal – Suspected fetal compromise (cardiotocography showing abnormal fetal heart rate (FHR) tracings; abnormal fetal blood sampling result; thick meconium). The need to rotate the fetal head to effect vaginal delivery.

Maternal – Maternal exhaustion or distress and ineffectual pushing in the second stage of labor.  Prolonged second stage of labor, arrest of descent. Various medical factors requiring an expedited second stage, such as preexisting cardiovascular disease or deteriorating medical conditions

No indication is absolute and each case should be considered individually. 

Safety of Operative Vaginal Birth

When considering adverse neurologic outcome, forceps deliveries are associated with a reduced risk of such outcomes compared with both vacuum extraction and cesarean delivery.

Forceps rotations to effect delivery are not linked to excess neonatal neurological morbidity. Furthermore, because forceps rotation of a fetus in a persistent occiput posterior position to an occiput anterior position may reduce maternal perineal laceration, it seems reasonable to attempt rotation in such circumstances.

Vacuum extraction is discouraged at gestational age of less than 34 weeks.

Although the routine use of episiotomy with operative vaginal delivery has been questioned.  A large observational study from the Netherlands of 28,732 assisted vaginal births concluded that mediolateral episiotomy is protective against Obstetric Anal Sphincter Injury (OASI) in both vacuum extraction and forceps birth. 

The balance between the art and science of medicine has been shifting for years, unfortunately operative vaginal delivery is an increasingly lost art.


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