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.
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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.

The rate of operative vaginal birth has decreased

Background over the past few decades, accounting for part of the
Operative vaginal birth is used to achieve or expedite increase in cesarean birth rates in the United States. As
safe vaginal birth for maternal or fetal indications. the rate of cesarean birth increased over the past two
Examples include maternal exhaustion and an inability decades, the rate of operative vaginal birth decreased
to push effectively; medical indications such as maternal from 9.01% of all deliveries in 1992 to 3.3% of all
cardiac disease and a need to avoid pushing in the second deliveries in 2013 (1). Nonetheless, operative vaginal
stage of labor; prolonged second stage of labor, arrest of birth remains an important part of modern obstetric care
descent, or rotation of the fetal head; and nonreassuring and in the appropriate circumstances can be used to
fetal heart rate patterns in the second stage of labor. safely avoid cesarean birth. Operative vaginal deliveries
Operative vaginal birth is beneficial for women because are accomplished by applying direct traction on the fetal
it avoids cesarean birth and its associated morbidities. skull with forceps or applying traction to the fetal scalp
The short-term risks of cesarean birth include hemor- by means of a vacuum extractor (3). Various types of
rhage, infection, prolonged healing time, and increased forceps and vacuum extractors have been developed for
cost. The long-term morbidities associated with cesarean this purpose, and readers should refer to textbooks for
birth include the high likelihood of repeat cesarean birth, review of these instruments (4–6). Whichever instrument
the complications that can occur with labor after cesarean is used, the indications for operative vaginal birth are the
birth, and the risks of placental abnormalities such as same (Box 1).
placenta accreta. For the fetus showing signs of possible Operative vaginal deliveries are classified by the
compromise, successful operative vaginal birth can station of the fetal head at application and the degree of
shorten the exposure to additional labor and reduce or rotation necessary for delivery (Box 2). In an evaluation
prevent the effect of intrapartum insults (2). Often, oper- of the American College of Obstetricians and Gynecolo-
ative vaginal birth can be safely accomplished more gists’ classification, investigators demonstrated that the
quickly than cesarean birth. lower the fetal head and the less rotation required, the

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 Box 1. Indications for Operative Vaginal Box 2. Criteria for Types of Forceps
Delivery Deliveries
c Prolonged second stage of labor Outlet forceps
c Suspicion of immediate or potential fetal
c Fetal scalp is visible at the introitus without sep-
compromise
arating the labia.
c Shortening of the second stage of labor for
c Fetal skull has reached the pelvic floor.
maternal benefit
c Fetal head is at or on perineum.
Data from Royal Australian and New Zealand College of c Sagittal suture is in an anteroposterior diameter
Obstetricians and Gynaecologists. Instrumental vaginal d- or right or left occiput anterior or posterior
elivery. College Statement C-Obs 16. East Melbourne, A-
ustralia: RANZCOG; 2012. Available at https://ranzcog.
position.
edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Wom- c Rotation does not exceed 45 degrees.
en%27s%20Health/Statement%20and%20guidelines/C-
linical-Obstetrics/Instrumental-Vaginal-Birth-(C-Obs-16)- Low forceps
Review-March-2016.pdf?ext5.pdf. Retrieved June 9, 2015.
c Leading point of the fetal skull is at station +2 cm
or more and not on the pelvic floor.
less the risk of injury to the woman and the fetus (7). c Without rotation: Rotation is 45 degrees or less
Before use of either forceps or vacuum extractor, an (right or left occiput anterior to occiput anterior, or
assessment by the operator of the factors that contribute right or left occiput posterior to occiput posterior).
to success and safety should be performed, including c With rotation: Rotation is greater than 45 degrees.
estimated fetal weight, the clinical adequacy of the mater-
Midforceps
nal pelvis, the fetal station and position, and the adequacy
of anesthesia. Operative vaginal birth is contraindicated c Station is above +2 cm but head is engaged.
if the fetal head is not engaged in the maternal pelvis or if Adapted from Royal Australian and New Zealand Col-
the position of the vertex cannot be determined. lege of Obstetricians and Gynaecologists. Instrumental
vaginal delivery. College Statement C-Obs 16. East Me-
Clinical Issues lbourne, Australia: RANZCOG; 2012. Available at http-
s://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-
MEDIA/Women%27s%20Health/Statement%20and%
Choice of Instruments 20guidelines/Clinical-Obstetrics/Instrumental-Vaginal-
Forceps and vacuum extractors have low risk of compli- Birth-(C-Obs-16)-Review-March-2016.pdf?ext5.pdf. Re-
trieved June 9, 2015.
cations 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 experi- with no difference in the occurrence of neonatal cepha-
ence and training. Both types of instruments can be lohematomas (RR, 0.64; 95% CI, 0.37–1.11) (8). In
effective in delivering the fetus and shortening the time another study that analyzed longer-term outcomes, no
to delivery. Vacuum extraction is believed to be easier to difference in urinary incontinence or anal sphincter dys-
learn and may be used when asynclitism prevents proper function was found after 5 years in women who had
forceps placement. Use of forceps provides a more secure deliveries by forceps versus vacuum extractor (9). Vac-
application and is appropriate for rotation of the fetal uum extraction has been discouraged for gestational age
head to occiput anterior or occiput posterior position. less than 34 weeks, although a safe lower limit for ges-
A vaginal birth is more likely to be achieved with tational age has not been established (10–12).
forceps than with vacuum extractors; however, forceps
are more likely to be associated with third- and fourth- Technique
degree perineal tears. In a review of randomized trials Few specific aspects of operative vaginal birth technique
comparing forceps deliveries with vacuum deliveries, the have been studied. Nonetheless, it is reasonable to
authors found that when all deliveries were considered, perform many parts of the procedure based on traditional
use of vacuum was more likely to fail as the instrument teaching and longstanding experience. A full list of
of delivery compared with forceps (relative risk [RR], prerequisites for an operative vaginal birth is presented
0.65; 95% confidence interval [CI], 0.45–0.94). Forceps in Box 3. In addition, the reason for the procedure, alter-
were more likely to be associated with third- and fourth- natives, and risks involved should be discussed with the
degree perineal tears (RR, 1.89; 95% CI, 1.51–2.37), patient and agreement obtained.

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 with regard to anal sphincter tears, neonatal trauma, or
Box 3. Prerequisites for Operative urinary or fecal incontinence.
Vaginal Birth There are no data to support the use of routine
episiotomy with operative vaginal birth. Routine episi-
c Cervix fully dilated and retracted otomy with operative vaginal birth is not recommended
c Membranes ruptured because poor healing and prolonged discomfort have
c Engagement of the fetal head been reported with mediolateral episiotomy (15) and
c Position of the fetal head has been determined because of the association of midline episiotomies with
c Fetal weight estimation performed increased risk of injury to the anal sphincter and exten-
c Pelvis thought to be adequate for vaginal birth sion into the rectum (16). Several retrospective studies
c Adequate anesthesia have found an association between midline episiotomy
c Maternal bladder has been emptied
and anal sphincter trauma with operative vaginal birth
(17) and a lower risk of anal sphincter injury when me-
c Patient has agreed after being informed of the
risks and benefits of the procedure diolateral episiotomy was used instead of midline episi-
c Willingness to abandon trial of operative vaginal otomy with delivery by forceps or vacuum extraction
birth and back-up plan in place in case of failure (18, 19). Thus, when episiotomy is indicated with forceps
to deliver or vacuum delivery, mediolateral episiotomy may have
Adapted from Royal Australian and New Zealand Col- a lower risk of anal sphincter injury than midline episi-
lege of Obstetricians and Gynaecologists. Instrumental otomy, but it is associated with an increased likelihood of
vaginal delivery. College Statement C-Obs 16. East Me- long-term perineal pain and dyspareunia (15).
lbourne, Australia: RANZCOG; 2012. Available at http-
s://www.ranzcog.edu.au/doc/instrumental-vaginal-
delivery.html. Retrieved June 9, 2015. Maternal Complications of Operative
Vaginal Birth
Research into the complications of operative vaginal
Before applying traction with either forceps or birth has been hampered by a number of confounders and
a vacuum extractor, it is important to confirm appropriate potential biases, including the level of experience of the
placement. For vacuum extraction, the cup should be operators, changes in practice and definitions over time,
placed 2 cm anterior to the posterior fontanelle and the small number of patients studied under similar
centered over the sagittal suture, ensuring that no circumstances, and the inability to achieve statistical
maternal tissue is included. For forceps, the application power to answer relevant questions. Outcomes of
should be checked to ensure that the sagittal suture is operative vaginal deliveries should not be compared
aligned with the shanks, that the posterior fontanelle is with those of spontaneous vaginal deliveries, but rather
one finger breadth above the shanks, and that the with second stage cesarean birth because cesarean birth is
lambdoid sutures are equidistant from the forceps blades. the clinical alternative.
A full description of operative vaginal birth techniques Operative vaginal birth has been recognized as a risk
are detailed elsewhere (4–6). factor for anal sphincter injury, but it is difficult to
separate its contribution to these injuries from other
Episiotomy clinical factors associated with its use. Other clinical
Episiotomy should not be performed routinely for all factors include prolonged second stage of labor, fetal
operative vaginal deliveries. Use of episiotomy has size, maternal age and obesity, shoulder dystocia, and
significantly decreased among all deliveries; decreasing episiotomy. In one study that controlled for these other
from 60.9% in 1979 to 24.5% in 2004, with a similar clinical factors, forceps use was still associated with
decrease in episiotomy rates with operative vaginal birth a sixfold increase in the risk of third- and fourth-degree
(13). In the past, routine mediolateral episiotomy was perineal tears, and vacuum extractor use was still
often recommended with operative vaginal birth to lessen associated with a twofold increase compared with
the chance of marked perineal stretching and damage to patients who had a spontaneous delivery (20). However,
the underlying pelvic muscles (5). More recently, a ran- in another study of 109 primiparous women with second
domized clinical trial compared routine episiotomy with stage arrest who completed symptom questionnaires at 1
selective episiotomy for operative vaginal birth (14). year postpartum, the 53 women with successful operative
Although the study was underpowered and no distinction vaginal birth did not differ in pelvic floor function or
was made between mediolateral and midline episiotomy, sexual function scores from those who had a cesarean
it found no significant differences between the groups birth (21). In addition, one study reported that many of

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the morbidities attributed to operative vaginal birth were operative vaginal birth would lead to fewer neurologic
present antenatally to a greater or similar degree. Specifi- injuries overall.
cally, among 108 patients with operative vaginal birth, the Various neonatal injuries have been reported with
reported prevalence of urinary incontinence was not differ- operative vaginal deliveries and, to some degree, the type
ent at 6 weeks and 1 year postpartum compared with the and frequency vary with the instrument used. With
third trimester. Rates of incontinence of flatus and liquids vacuum extraction, traction is applied to the fetal scalp,
also did not differ from the third trimester through 1 year which can result in laceration, cephalohematoma forma-
postpartum. Only anal incontinence of solids was reported tion, and subgaleal or intracranial hemorrhage. Retinal
to be more prevalent at 6 weeks postpartum than before hemorrhages and increased rates of hyperbilirubinemia
delivery (5% versus 1%; P5.02), but this difference also have been reported. With forceps deliveries, reported
resolved by 1 year postpartum (22). If no anal sphincter injuries have included facial lacerations and facial nerve
laceration occurs with operative vaginal birth, anal incon- palsy, corneal abrasions and external ocular trauma, skull
tinence rates at 5–10 years after delivery are similar to fracture, and intracranial hemorrhage. The risk of these
those in women who had a spontaneous vaginal birth complications is low, but large database studies are
(23). After an anal sphincter tear, the recurrence rate of required to establish complication rates. One study
sphincter tears is low (3.2%) but is significantly increased evaluated singleton births in California from 1992 to
if operative vaginal birth is used for subsequent births (24). 1994 and found that the rate of neonatal death was
Forceps delivery appears to have a higher risk of anal similar for infants delivered spontaneously, by cesarean
sphincter injury in comparison with vacuum delivery. In birth, and by forceps or vacuum extraction (26). Also, the
a review of 13 randomized trials of forceps delivery versus rates of intracranial hemorrhage were similar for forceps,
vacuum delivery, including 3,338 women, forceps use was vacuum, and cesarean deliveries performed during labor.
associated with a higher rate of third- and fourth-degree Another study examined data on births to nulliparous
tears (8). In one randomized trial of vacuum delivery ver- women in New York City from 1995 to 2003 (28). Rel-
sus forceps delivery, altered fecal continence at 3 months ative to infants delivered by cesarean birth, those deliv-
postpartum was reported more frequently after forceps ered with forceps had higher rates of fracture, facial nerve
delivery (59% versus 33%; P5.006), although most oc- palsy, and brachial plexus injury, but lower rates of neu-
currences were occasional flatal incontinence, and median rologic complications, including seizures, intraventricu-
continence scores were similar. The two groups did not lar hemorrhage, and subdural hemorrhage.
differ in anal manometry measurements or anal sphincter Relative to cesarean birth, vacuum delivery is
ultrasonographic findings (25). As previously noted, a ran- associated with higher rates of cephalohematoma or
domized trial comparing forceps delivery with vacuum scalp laceration, fracture, and brachial plexus injury,
delivery found no difference in either bowel or urinary but not central neurologic complications. Researchers
dysfunction 5 years postpartum (9). 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
Newborn Complications of Operative delivered with forceps or vacuum had similar rates of
Vaginal Birth neonatal death and neonatal encephalopathy. Operative
Although operative vaginal birth is not without risk, the vaginal birth was associated with a rate of neonatal
absolute rate of newborn injury with forceps and vacuum encephalopathy of 4.2 per 1,000 term neonates (com-
deliveries is low. Estimates from large cohort studies pared with 3.9 per 1,000 delivered by cesarean birth), and
have indicated that intracranial hemorrhage occurs in one a rate of neonatal death from intracranial hemorrhage of
of every 650–850 operative vaginal deliveries and neu- 3–4 per 10,000 operative vaginal deliveries (27). In
rologic complications occur in one of every 220–385 a review of 13 randomized trials comparing forceps with
infants delivered using forceps or vacuum extraction vacuum extraction, no significant differences were found
(26, 27). Additionally, there is evidence that some inju- in umbilical pH, severe morbidity, or death (8).
ries (such as intracranial hemorrhage) attributed to oper- In summary, some differences in rates of various
ative delivery actually are associated with the indication complications may exist between forceps and vacuum,
for delivery rather than the procedure itself, and that the but the use of either instrument is associated with
alternative of cesarean birth does not lessen the risk. relatively low rates of major morbidity and mortality,
Similarly, given that operative vaginal birth can be and complications do not appear to be substantially
accomplished more quickly than cesarean birth, it re- greater than with cesarean birth performed in labor. For
mains uncertain (for example, in the setting of nonreas- the fetus that manifests signs of compromise in the
suring fetal heart rate pattern) whether foregoing an second stage of labor, the timely and skilled use of

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instrumental vaginal birth has the potential to decrease the used and preparations made for the increased possibility
exposure to intrauterine insults and could decrease the of encountering a shoulder dystocia.
contribution of intrapartum factors leading to neonatal
encephalopathy and hypoxic–ischemic encephalopathy
(2). Neonatal care providers should be made aware of the
Clinical Considerations
mode of delivery in order to observe for potential com- and Recommendations
plications associated with operative vaginal birth.
< What are contraindications to operative vaginal
Long-Term Infant Morbidity birth?
There are few current data that assess the long-term
consequences of operative vaginal birth on the infant, but Under certain circumstances, operative vaginal birth
the evidence indicates that long-term outcomes of should be avoided or, at the least, carefully considered
operative vaginal birth are equivalent to those of in terms of relative maternal and fetal risk. Operative
spontaneous vaginal birth. One study analyzed the effect vaginal birth is contraindicated if the fetal head is
of forceps delivery on cognitive development in a cohort unengaged, the position of the fetal head is unknown, or
of 3,413 children at age 5 years (29). No significant a live fetus is known or strongly suspected to have a bone
differences were seen in the 1,192 children delivered demineralization condition (eg, osteogenesis imperfecta)
with forceps compared with the 1,499 children delivered or a bleeding disorder (eg, alloimmune thrombocytopenia,
spontaneously. In another study, evaluations were per- hemophilia, or von Willebrand disease).
formed at age 10 years in 295 children delivered by Operative vaginal birth should be performed only by
vacuum extraction and 302 children in the control group experienced obstetricians and obstetric care providers
who delivered spontaneously at the same hospital in the with privileges for such procedures and the ability to
same year. No differences were seen between the two perform emergency cesarean birth in the event the
groups in terms of scholastic performance, speech, or operative vaginal birth is unsuccessful. Indeterminate
neurologic abnormality (30). fetal heart rate patterns are not a contraindication to
operative vaginal birth, and an expedited vaginal birth
Operative Vaginal Birth With can potentially benefit the deteriorating fetus if delivery
Fetal Macrosomia can be accomplished more expeditiously than a cesarean
birth can be performed.
To evaluate the risk of operative vaginal birth with fetal
macrosomia, one study compared 2,924 infants who had < Is there a role for a trial of operative vaginal
birth weights greater than 4,000 g with those who had birth?
birth weights between 3,000 g and 3,999 g. Infants with
birth weights greater than 4,000 g had an overall injury A trial of operative vaginal birth is an attempt at
rate of 1.6% compared with 0.4% in the lower birth weight operative delivery with the intention to abandon the
group. Forceps delivery in the group with birth weights procedure if potentially dangerous resistance or difficulty
greater than 4,000 g produced a 7.3-fold increase in the is met (4). The rate of failed operative vaginal birth has
incidence of persistent injury at 6 months (95% CI, 6.5– been reported to be 2.9–6.5% (26, 32). In an analysis of
8.2) compared with the lower birth weight group. How- 3,798 operative vaginal deliveries, only increased birth
ever, the risk of persistent injury was not different from the weight and second stage labor duration were significantly
increased risk with spontaneous vaginal birth and birth associated with failure, after controlling for operator
weights greater than 4,000 g (RR, 7.7; 95% CI, 7.4– experience (32).
8.1). The authors calculated that as many as 258 elective The few studies that address maternal and neonatal
cesarean deliveries would have to be performed for macro- outcome after an unsuccessful attempt at operative
somia to prevent a single case of persistent injury (31). vaginal birth show conflicting results. Although the
There are no studies that evaluate the risk of analysis of California births from 1992 to 1994 found
complications with operative vaginal birth based on similar rates of neonatal death and intracranial hemor-
estimated fetal weight. Regardless, judicious use of rhage for forceps, vacuum, and cesarean deliveries
operative vaginal birth for infants with suspected macro- performed during labor, cesarean birth after a failed
somia is not contraindicated. Recognizing the inherent attempt at vacuum or forceps delivery was associated
inaccuracy in estimating fetal weight, the additional with increased rates of subdural or cerebral hemorrhage,
variables that should be considered include the adequacy mechanical ventilation, and seizures compared with
of the maternal pelvis and the progress of labor, either successful operative vaginal birth or cesarean
particularly during the second stage. Caution should be birth (26).

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 In contrast, a secondary analysis of the Eunice Ken- < What special considerations are involved with
nedy Shriver National Institute of Child Health and Human the use of a vacuum extractor?
Development cesarean birth registry data found that neo-
natal morbidity was more common with cesarean birth after Modern vacuum extractors differ substantially from the
forceps attempt compared with cesarean without forceps. original metal cup and vary by material, cup size and
However, this association was confined to the subgroup of shape, and the method of vacuum application to the fetal
patients with nonreassuring fetal heart rate pattern as an scalp. Randomized trials comparing soft vacuum cups
indication for cesarean birth, and there was no difference with the original metal cup indicate that the pliable cup is
between the groups when delivery was for other indications associated with decreased fetal scalp trauma but with
(33). In both reports, the rates of neonatal complications increased rates of detachment from the fetal head (36–
after forceps attempt were low. A trial of operative vaginal 39). However, there are no differences in Apgar scores,
birth is an appropriate option in a situation in which the cord pH, neurologic complications, retinal hemorrhage,
obstetrician or obstetric care provider feels the chances of maternal trauma, or blood loss when comparing rigid cup
success are high, but must be prepared to abandon the vacuum deliveries with soft cup vacuum deliveries (39).
attempt if appropriate descent does not occur. Although Cephalohematoma is more likely to occur as the
a number of authors have offered concrete limits for trial duration of vacuum application increases. One study
of operative vaginal birth, there are no adequate data to found that cephalohematoma was diagnosed clinically in
generate an evidence-based guideline for the number of 28% of neonates when the time from application to
forceps pulls or vacuum detachments that should be al- delivery exceeded 5 minutes (40). It does not appear that
lowed before abandoning the procedure. In general, descent reducing the vacuum pressure between contractions re-
should be expected with traction and if there is no descent duces the incidence of fetal scalp injury. One trial ran-
with the first several pulls, a reappraisal is necessary. domized 164 patients to continuous vacuum application
during and between contractions in an effort to prevent
< Is there a role for the use of alternative instru- fetal loss of station and randomized 158 patients to
ments after a failed attempt? reduction of vacuum pressure between contractions.
Overall, 93.5% had a delivery by the intended method,
The California study raised significant concerns regarding and the cephalohematoma rate was 11.5%. Time to deliv-
the sequential use of forceps and vacuum. Compared with ery, method failure, maternal lacerations, episiotomy
vacuum extraction alone, the combination of forceps and extension, incidence of cephalohematoma, and neonatal
vacuum was associated with significantly higher rates of outcome were similar between the two groups (41). As
subdural or cerebral hemorrhage, subarachnoid hemor- such, release of vacuum pressure between contractions
rhage, facial nerve injury, and brachial plexus injury (26). does not appear to be associated with improved
An increased incidence of intracranial hemorrhage with outcomes.
sequential instrument use compared with either forceps Traditional teaching has held that the direction of
or vacuum alone also was seen in a study of a Washington traction with vacuum delivery should follow the pelvic
State multiyear database, as was an increase in the rate of curvature, and that rocking motions and application of
severe perineal lacerations (34). However, in both studies, torque to affect rotation should be avoided (4). Only
the rates of complications with sequential use of instru- gentle augmentation of the natural rotation that occurs
ments were compared with spontaneous vaginal birth and with maternal pushing and fetal descent is recommended.
not with the rates for cesarean birth during labor after Because of the risk of cephalohematoma and other com-
a failed operative vaginal birth attempt. plications, clinicians caring for the neonate should be
In a more recent report of 1,360 nulliparous women notified of the vacuum delivery so that the newborn
undergoing operative vaginal birth, use of sequential can be appropriately monitored for the signs and symp-
instruments was associated with increased anal sphincter toms of instrument-related injuries.
tears and low umbilical artery pH compared with patients
undergoing single instrument vaginal birth (35). Sequen- < Is there a role for midforceps and rotational
tial use of vacuum extractor and forceps has been asso- forceps deliveries in current practice?
ciated with increased rates of neonatal complications and
should not routinely be performed. Thus, even though the Midforceps and rotational forceps deliveries are appro-
reported rates of neonatal complications were relatively priate options in select clinical circumstances. Recent
low, the weight of available evidence appears to be studies comparing midforceps deliveries with cesarean
against routine use of sequential instruments at operative deliveries confirmed older data that showed no difference
vaginal birth. in neonatal outcome. One study of 144 cases in which

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Kielland forceps were used for rotation, 90% resulted in operative vaginal birth with episiotomy, particularly
vaginal birth, and there were no instances of forceps- mediolateral episiotomy as was performed in the
related neonatal trauma or hypoxic–ischemic encepha- ANODE trial, use of routine prophylactic antibiotics
lopathy (42). Another study compared outcomes of before delivery would not be recommended. Because
deliveries with rotational forceps with nonrotational wound infections and complications are more common in
forceps, vacuum, spontaneous vaginal, and emergency the setting of a third- or fourth-degree laceration, it may
cesarean deliveries at any dilation. No difference in the be more judicious to consider antibiotics if a third- or
rate of neonatal encephalopathy was found between the fourth-degree laceration occurs (48).
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 for- Recommendations
ceps delivery to emergency cesarean birth in the second
stage of labor and saw no difference in rates of neonatal
and Conclusions
intensive care unit admission or other measures of neo- The following recommendations and conclusions are
natal morbidity (44). based on good and consistent scientific evidence (Level A):
With regard to occiput posterior position with arrest
of descent in the second stage of labor, there may be < Forceps and vacuum extractors have low risk of com-
a benefit from an attempt at rotation to occiput anterior. plications and are acceptable for operative vaginal birth.
In a retrospective study of patients with forceps deliver- < vaginal birth is more likely to be achieved with
A
ies, 99 patients with manual (n564) or forceps (n535) forceps than with vacuum extractors; however, for-
rotation were compared with 57 patients delivered from ceps are more likely to be associated with third- and
the occiput posterior position without an attempt at rota- fourth-degree perineal tears.
tion. No difference in neonatal outcomes was seen, but < Routine episiotomy with operative vaginal birth is not
forceps delivery without attempt at rotation was associ- recommended because poor healing and prolonged
ated with a significantly higher rate of severe perineal discomfort have been reported with mediolateral
laceration (odds ratio, 3.67; 95% CI, 1.42–9.47) (45). episiotomy and because of the association of midline
Thus, it seems reasonable to attempt forceps delivery episiotomies with increased risk of injury to the anal
with manual or forceps rotation of occiput posterior posi- sphincter and extension into the rectum.
tion in certain circumstances. The following recommendations and conclusions are
based on limited or inconsistent scientific evidence
< Should prophylactic antibiotics be adminis- (Level B):
tered at the time of operative vaginal birth?
< Operative vaginal birth is contraindicated if the fetal
During the past two decades, the routine adoption of head is unengaged, the position of the fetal head is
prophylactic antibiotics given 30 minutes before skin unknown, or a live fetus is known or strongly sus-
incision for cesarean birth to reduce wound complica- pected to have a bone demineralization condition (eg,
tions has become standard practice (46). The evidence osteogenesis imperfecta) or a bleeding disorder (eg,
for the routine use of prophylactic antibiotics in the set- alloimmune thrombocytopenia, hemophilia, or von
ting of an operative vaginal birth has less supporting Willebrand disease).
evidence. In a recent prospective trial (known as the
ANODE trial), investigators randomized women to pro-
< A trial of operative vaginal birth is an appropriate
option in a situation in which the obstetrician or
phylactic antibiotics versus placebo before operative
obstetric care provider feels the chances of success
vaginal birth (47). Although fewer women had a confirmed
are high, but must be prepared to abandon the attempt
or suspected perineal wound infection that received a sin-
if appropriate descent does not occur.
gle intravenous dose of antibiotic (Risk Ratio 0.58; 95%
CI, 0.49–0.69), there are some potential issues that may < Sequential use of vacuum extractor and forceps has
not make the findings generalizable to a population in the been associated with increased rates of neonatal
United States. In the study, 89% of women received an complications and should not routinely be performed.
episiotomy; the majority of these episiotomies were < Cephalohematoma is more likely to occur as the
mediolateral, which is routine in the United Kingdom duration of vacuum application increases.
where the trial was conducted. Thus, although pro- < Midforceps and rotational forceps deliveries are
phylactic antibiotics may be reasonable at the time of appropriate options in select clinical circumstances.

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Unauthorized reproduction of this article is prohibited.
The following recommendations and conclusions are of 1,500–2,499 grams. J Reprod Med 1995;40:127–30.
based on limited or inconsistent scientific evidence (Level II-2) [PubMed]
(Level C): 11. Aberg K, Norman M, Ekeus C. Preterm birth by vacuum
extraction and neonatal outcome: a population-based
< Vacuum extraction has been discouraged for gesta- cohort study. BMC Pregnancy Childbirth 2014;14:42,
tional age less than 34 weeks, although a safe lower 2393-14–42. (Level II-2) [PubMed] [Full Text]
limit for gestational age has not been established. 12. Cargill YM, MacKinnon CJ, Arsenault MY, Bartellas E,
Daniels S, Gleason T, et al. Guidelines for operative vaginal
< For the fetus that manifests signs of compromise in
birth. Clinical Practice Obstetrics Committee. J Obstet
the second stage of labor, the timely and skilled use Gynaecol Can 2004;26:747–61. (Level III) [PubMed]
of instrumental vaginal birth has the potential to 13. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiot-
decrease the exposure to intrauterine insults and omy in the United States: has anything changed? Am J
could decrease the contribution of intrapartum factors Obstet Gynecol 2009;200:573.e1–7. (Level II-3) [PubMed]
leading to neonatal encephalopathy and hypoxic– [Full Text]
ischemic encephalopathy. 14. Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L,
< Neonatal care providers should be made aware of the Strachan B. A randomised controlled trial of routine versus
restrictive use of episiotomy at operative vaginal delivery:
mode of delivery in order to observe for potential a multicentre pilot study. BJOG 2008;115:1695–702; dis-
complications associated with operative vaginal birth. cussion 1702–3. (Level I) [PubMed] [Full Text]
15. Sartore A, De Seta F, Maso G, Pregazzi R, Grimaldi E,
Guaschino S. The effects of mediolateral episiotomy on
References pelvic floor function after vaginal delivery. Obstet Gynecol
1. Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Mat- 2004;103:669–73. (Level II-2) [PubMed] [Obstetrics &
thews TJ. Births: final data for 2013. Natl Vital Stat Rep Gynecology]
2015;64:1–65. (Level II-3) [PubMed] 16. Fitzgerald MP, Weber AM, Howden N, Cundiff GW,
2. American Academy of Pediatrics, American College of Brown MB. Risk factors for anal sphincter tear during
Obstetricians and Gynecologists. Neonatal encephalopathy vaginal delivery. Pelvic Floor Disorders Network. Obstet
and neurologic outcome. 2nd ed. Elk Grove Village (IL): Gynecol 2007;109:29–34. (Level II-3) [PubMed] [Obstet-
Washington, DC: AAP; American College of Obstetricians rics & Gynecology]
and Gynecologists; 2014. (Level III) 17. Kudish B, Blackwell S, Mcneeley SG, Bujold E, Kruger
3. American Academy of Pediatrics, American College of Obste- M, Hendrix SL, et al. Operative vaginal delivery and mid-
tricians and Gynecologists. Guidelines for perinatal care. 7th line episiotomy: a bad combination for the perineum. Am J
ed. Elk Grove Village (IL): AAP; Washington, DC: American Obstet Gynecol 2006;195:749–54. (Level II-3) [PubMed]
College of Obstetricians and Gynecologists; 2012. (Level III) [Full Text]
4. Hale RW, editor. Dennen’s forceps deliveries. 4th ed. 18. de Leeuw JW, de Wit C, Kuijken JP, Bruinse HW. Medio-
Washington, DC: American College of Obstetricians and lateral episiotomy reduces the risk for anal sphincter injury
Gynecologists; 2001. (Level III) during operative vaginal delivery. BJOG 2008;115:104–8.
(Level II-3) [PubMed] [Full Text]
5. Laufe LE. Obstetric forceps. New York (NY): Harper &
Row; 1968. (Level III) 19. de Vogel J, van der Leeuw-van Beek A, Gietelink D, Vuj-
kovic M, de Leeuw JW, van Bavel J, et al. The effect of
6. Laufe LE, Berkus MD. Assisted vaginal delivery: obstetric a mediolateral episiotomy during operative vaginal delivery
forceps and vacuum extraction techniques. New York on the risk of developing obstetrical anal sphincter injuries.
(NY): McGraw-Hill; 1992. (Level III) Am J Obstet Gynecol 2012;206:404.e1–5. (Level II-3)
7. Hagadorn-Freathy AS, Yeomans ER, Hankins GD. Valida- [PubMed] [Full Text]
tion of the 1988 ACOG forceps classification system. Ob- 20. Gurol-Urganci I, Cromwell DA, Edozien LC, Mahmood
stet Gynecol 1991;77:356–60. (Level II-3). [PubMed] TA, Adams EJ, Richmond DH, et al. Third- and fourth-
[Obstetrics & Gynecology] degree perineal tears among primiparous women in England
8. O’Mahony F, Hofmeyr GJ, Menon V. Choice of instru- between 2000 and 2012: time trends and risk factors. BJOG
ments for assisted vaginal delivery. Cochrane Database of 2013;120:1516–25. (Level II-3) [PubMed] [Full Text]
Systematic Reviews 2010, Issue 11. Art. No.: CD005455. 21. Crane AK, Geller EJ, Bane H, Ju R, Myers E, Matthews
DOI: 10.1002/14651858.CD005455.pub2. (Meta-analysis) CA. Evaluation of pelvic floor symptoms and sexual func-
[PubMed] [Full Text] tion in primiparous women who underwent operative vag-
9. Johanson RB, Heycock E, Carter J, Sultan AH, Walklate inal delivery versus cesarean delivery for second-stage
K, Jones PW. Maternal and child health after assisted vag- arrest. Female Pelvic Med Reconstr Surg 2013;19:13–6.
inal delivery: five-year follow up of a randomised con- (Level II-3) [PubMed] [Full Text]
trolled study comparing forceps and ventouse. Br J 22. Macleod M, Goyder K, Howarth L, Bahl R, Strachan B,
Obstet Gynaecol 1999;106:544–9. (Level I) [PubMed] Murphy DJ. Morbidity experienced by women before and
10. Morales R, Adair CD, Sanchez-Ramos L, Gaudier FL. after operative vaginal delivery: prospective cohort study
Vacuum extraction of preterm infants with birth weights nested within a two-centre randomised controlled trial of

e156 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.
 restrictive versus routine use of episiotomy. BJOG 2013; extractor cups. Br J Obstet Gynaecol 1992;99:360–3.
120:1020–6. (Level I) [PubMed] [Full Text] (Level I) [PubMed]
23. Evers EC, Blomquist JL, McDermott KC, Handa VL. 37. Cohn M, Barclay C, Fraser R, Zaklama M, Johanson R,
Obstetrical anal sphincter laceration and anal incontinence Anderson D, et al. A multicentre randomized trial compar-
5–10 years after childbirth. Am J Obstet Gynecol 2012; ing delivery with a silicone rubber cup and rigid metal
207:425.e1–6. (Level II-3) [PubMed] [Full Text] vacuum extractor cups. Br J Obstet Gynaecol 1989;96:
545–51. (Level I) [PubMed]
24. Basham E, Stock L, Lewicky-Gaupp C, Mitchell C, Gos-
sett DR. Subsequent pregnancy outcomes after obstetric 38. Hofmeyr GJ, Gobetz L, Sonnendecker EW, Turner MJ.
anal sphincter injuries (OASIS). Female Pelvic Med Re- New design rigid and soft vacuum extractor cups: a prelim-
constr Surg 2013;19:328–32. (Level II-3) [PubMed] inary comparison of traction forces. Br J Obstet Gynaecol
1990;97:681–5. (Level I) [PubMed]
25. Fitzpatrick M, Behan M, O’Connell PR, O’Herlihy C.
Randomised clinical trial to assess anal sphincter function 39. Kuit JA, Eppinga HG, Wallenburg HC, Huikeshoven FJ. A
following forceps or vacuum assisted vaginal delivery. randomized comparison of vacuum extraction delivery
BJOG 2003;110:424–9. (Level I) [PubMed] [Full Text] with a rigid and a pliable cup. Obstet Gynecol 1993;82:
280–4. (Level I) [PubMed] [Obstetrics & Gynecology]
26. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM.
Effect of mode of delivery in nulliparous women on neo- 40. Bofill JA, Rust OA, Devidas M, Roberts WE, Morrison JC,
natal intracranial injury. N Engl J Med 1999;341:1709–14. Martin JN Jr. Neonatal cephalohematoma from vacuum
(Level II-3) [PubMed] [Full Text] extraction. J Reprod Med 1997;42:565–9. (Level I)
[PubMed]
27. Walsh CA, Robson M, McAuliffe FM. Mode of delivery at
term and adverse neonatal outcomes. Obstet Gynecol 2013; 41. Bofill JA, Rust OA, Schorr SJ, Brown RC, Roberts WE,
121:122–8. (Level II-3) [PubMed] [Obstetrics & Gynecology] Morrison JC. A randomized trial of two vacuum extraction
techniques. Obstet Gynecol 1997;89:758–62. (Level I)
28. Werner EF, Janevic TM, Illuzzi J, Funai EF, Savitz DA, [PubMed] [Obstetrics & Gynecology]
Lipkind HS. Mode of delivery in nulliparous women and
42. Burke N, Field K, Mujahid F, Morrison JJ. Use and safety
neonatal intracranial injury. Obstet Gynecol 2011;118:1239–
of Kielland’s forceps in current obstetric practice. Obstet
46. (Level II-3) [PubMed] [Obstetrics & Gynecology]
Gynecol 2012;120:766–70. (Level III) [PubMed] [Obstet-
29. Wesley BD, van den Berg BJ, Reece EA. The effect of rics & Gynecology]
forceps delivery on cognitive development. Am J Obstet 43. Stock SJ, Josephs K, Farquharson S, Love C, Cooper SE,
Gynecol 1993;169:1091–5. (Level II-2) [PubMed] Kissack C, et al. Maternal and neonatal outcomes of suc-
30. Ngan HY, Miu P, Ko L, Ma HK. Long-term neurological cessful Kielland’s rotational forceps delivery. Obstet Gy-
sequelae following vacuum extractor delivery. Aust N Z J necol 2013;121:1032–9. (Level II-3) [PubMed] [Obstetrics
Obstet Gynaecol 1990;30:111–4. (Level II-2) [PubMed] & Gynecology]
31. Kolderup LB, Laros RK Jr, Musci TJ. Incidence of per- 44. Tempest N, Hart A, Walkinshaw S, Hapangama DK. A re-
sistent birth injury in macrosomic infants: association with evaluation of the role of rotational forceps: retrospective
mode of delivery. Am J Obstet Gynecol 1997;177:37–41. comparison of maternal and perinatal outcomes following
(Level II-3) [PubMed] [Full Text] different methods of birth for malposition in the second
stage of labour. BJOG 2013;120:1277–84. (Level II-3)
32. Aiken CE, Aiken AR, Brockelsby JC, Scott JG. Factors [PubMed] [Full Text]
influencing the likelihood of instrumental delivery success.
Obstet Gynecol 2014;123:796–803. (Level II-3) [PubMed] 45. Bradley MS, Kaminski RJ, Streitman DC, Dunn SL, Krans
[Obstetrics & Gynecology] EE. Effect of rotation on perineal lacerations in forceps-
assisted vaginal deliveries. Obstet Gynecol 2013;122:132–
33. Alexander JM, Leveno KJ, Hauth JC, Landon MB, Gilbert 7. (Level II-3) [PubMed] [Obstetrics & Gynecology]
S, Spong CY, et al. Failed operative vaginal delivery. Eu-
nice Kennedy Shriver National Institute of Child Health 46. Caughey AB, Wood SL, Macones GA, Wrench IJ, Huang
and Human Development Maternal-Fetal Medicine Units J, Norman M, et al. Guidelines for intraoperative care in
Network. Obstet Gynecol 2009;114:1017–22. (Level II-3 cesarean delivery: Enhanced Recovery After Surgery Soci-
[PubMed] [Obstetrics & Gynecology] ety recommendations (Part 2). Am J Obstet Gynecol 2018;
219:533–44. (Level III)
34. Gardella C, Taylor M, Benedetti T, Hitti J, Critchlow C.
The effect of sequential use of vacuum and forceps for 47. Knight M, Chiocchia V, Partlett C, Rivero-Arias O, Hua
assisted vaginal delivery on neonatal and maternal out- X, Hinshaw K, et al. Prophylactic antibiotics in the pre-
comes. Am J Obstet Gynecol 2001;185:896–902. (Level vention of infection after operative vaginal delivery
II-3) [PubMed] [Full Text] (ANODE): a multicentre randomised controlled trial.
ANODE collaborative group [published erratum appears
35. Murphy DJ, Macleod M, Bahl R, Strachan B. A cohort in Lancet 2019;393:2394]. Lancet 2019;393:2395–403.
study of maternal and neonatal morbidity in relation to (Level I)
use of sequential instruments at operative vaginal delivery.
48. Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB,
Eur J Obstet Gynecol Reprod Biol 2011;156:41–5. (Level El-Sayed YY. Antibiotic prophylaxis for prevention of
II-2) [PubMed] [Full Text] postpartum perineal wound complications: a randomized
36. Chenoy R, Johanson R. A randomized prospective study controlled trial. Obstet Gynecol 2008;111:1268–73.
comparing delivery with metal and silicone rubber vacuum (Level I)

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 The MEDLINE database, the Cochrane Library, and the Published online on March 26, 2020.
American College of Obstetricians and Gynecologists’
own internal resources and documents were used to Copyright 2020 by the American College of Obstetricians and
conduct a literature search to locate relevant articles Gynecologists. All rights reserved. No part of this publication
published between January 2000 – November 2013. may be reproduced, stored in a retrieval system, posted on the
The search was restricted to articles published in the internet, or transmitted, in any form or by any means, elec-
English language. Priority was given to articles tronic, mechanical, photocopying, recording, or otherwise,
reporting results of original research, although review without prior written permission from the publisher.
articles and commentaries also were consulted.
American College of Obstetricians and Gynecologists
Abstracts of research presented at symposia and
409 12th Street SW, Washington, DC 20024-2188
scientific conferences were not considered adequate for
inclusion in this document. Guidelines published by Operative vaginal birth. ACOG Practice Bulletin No. 219.
organizations or institutions such as the National American College of Obstetricians and Gynecologists. Obstet
Institutes of Health and the American College of Gynecol 2020;135:e149–59.
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 de-
signed 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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