The American College of Obstetrics and Gynecology (ACOG) issued an updated practice bulletin to their members supporting the use of operative vaginal delivery, which is birth using forceps or vacuum extraction, to reduce cesareans and improve outcomes.

The full practice bulletin was published in the November issue of the journal, Obstetrics and Gynecology, and is available to ACOG members and the media via their website.

Reducing the cesarean rate appears to be a major driver of this updated bulletin. In encouraging physicians to consider the use of forceps or vacuum extraction over a cesarean, the bulletin notes that operative vaginal delivery can often be accomplished faster than a cesarean and avoids the short and long term risks associated with surgical birth including hemorrhage, infection, prolonged healing time and increased costs. (1)

In the last 30 years, the rates of operative vaginal delivery have declined while cesarean rates have increased. Just 3.3% of all US births were operative vaginal deliveries in 2013, declining from 9.01% in 1992 “accounting for part of the increase in cesarean birth rates in the United States” according to the bulletin.

This updated practice bulletin states that only experienced care providers should utilize forceps and vacuum extraction and those care providers should have the ability to perform a cesarean should the operative vaginal delivery be unsuccessful.

ACOG has outlined the following prerequisites for operative vaginal delivery including:
• Cervix is fully dilated and retracted
• Membranes ruptured
• Head is engaged
• Head position has been determined
• Baby’s weight has been estimated
• The mother’s pelvis is considered adequate
• Adequate anesthesia has been provided
• The mother’s bladder has been emptied
• The mother has agreed to the procedure after being informed of the risks and benefits
• The doctor is willing to perform a trial of operative delivery, abandon the trial if unsuccessful and has a back-up plan in place

The bulletin provides additional recommendations related to operative vaginal delivery including:

• Routine episiotomy is NOT recommended with operative vaginal delivery. The document states, “There are no data to support the use of routine episiotomy with operative vaginal delivery.” The bulletin also cites poor healing, prolonged discomfort and risks of anal sphincter injury as reasons that routine episiotomy not be performed with the use of forceps or vacuum extraction.
• Use of forceps is more successful than use of vacuum extraction, but there is an increased risk of third- and fourth-degree perineal tears with the use of forceps.
• Specific situations are outlined in which each method of operative delivery may be more useful (forceps to rotate baby from occiput anterior to occiput posterior position).

ACOG notes that the outcomes of operative vaginal birth for both mother and child should be compared to cesarean birth since that is the clinical alternative.

Like many aspects of birth, the use of forceps or vacuum extraction cannot be planned for in advance. As we doulas support families during or after a birth where these interventions took place, it is important to keep in mind ACOG’s comparison to a cesarean in terms of recovery. While our client will have had a vaginal birth, her experience and physical and emotional healing are likely to be more similar to those who have birthed via a cesarean than a low intervention vaginal birth.


1. Operative vaginal delivery. Practice Bulletin No. 154. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e56–65.