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.
I am an anecdotal sample of one and my forceps baby is almost 41 years old… born in the heyday of forceps deliveries. Do I want any and all measures used to save the life of a mother and her baby ~ absolutely. Do I think “operative vaginal delivery” should be used to reduce cesareans ~ hell no!
That said, my son’s mid-forceps delivery was performed by a perfectly competent obstetrician in a perfectly fine hospital. No one has been sued.
Before commenting I read the excellent New Yorker article “How Childbirth Went Industrial”… all of it. I am also a nurse.
I went into labor at 40 weeks gestation with a SROM (spontaneous rupture of membranes) and progressed normally for a first labor. That is until the second stage of labor (pushing). After three hours of trying very hard to push an occiput posterior baby out, a forceps delivery was recommended. A spinal anesthetic was administered and forceps applied.
My entire body moved down the table with the pulling and tugging applied to my son’s tiny head and body. With gratitude from all that is within me, he arrived healthy and whole and suffered no more than a bruise to his beautiful face. He had no lingering problems from his traumatic entry into the world.
However, forceps delivery is an incredibly invasive procedure and can and does result in trauma to babies and to their mothers’ bodies. This consequence appears to be grossly under reported or even recognized. The above New Yorker article cites the historical lack of use of evidence based practices in obstetrics. Perhaps that has changed, but no one has asked how I have fared since my forceps encounter.
My first experience was intense perineal pain. Sitting for a month plus was very difficult. On the plus side, I was able to have 3 more children with natural, vaginal deliveries. Would I have traded being able to have fewer children had I undergone a cesarean section the first time and having 4 with the pelvic difficulties I have had? That is a loaded question I can’t answer since I adore all of my children.
I had complete urinary incontinence immediately following my son’s forceps delivery. I was horribly embarrassed. This improved but persisted as a problem. By the time my youngest child was 4 (and the first one was10) I was experiencing pelvic prolapse. I underwent a hysterectomy and bladder suspension. 4 years after that I underwent an A & P repair. The damaged tissues between the vagina and the urinary tract and between the vagina and the end of the digestive system needed to be repaired to improve function of both systems and decrease urinary incontinence.
With the passage of time, aging and gravity, inherited quality of tissue, and the emerging thought that these procedures are not what should be done, I found myself needing a pelvic reconstruction at age 55. Seems old ~ so what? It’s not old when it is you this is happening to. Again, I was fortunate to work with an exceptional surgeon and had insurance to assist me obtain good care. But, there is no putting it back the way it was no matter what kind of deliveries you had. With my history, I had even less chance than that.
Still, the evidence seems to suggest that the kind of damage I have suffered is less common following cesarean section deliveries. Did anyone ask how it went for me? Did they ask anyone? Any real studies done that support using operative vaginal deliveries in lieu of cesarean section deliveries?
I am not writing about a few tugs on a vacuum, though this should be done with the utmost thought, skill and care. I am writing about a violent procedure and to say that there is no reason any woman should again endure a forceps delivery merely done to avoid a c-section. It may look cost effective and that it reduces pain and suffering. I am telling you that from my experience, it costs plenty of money, plenty of suffering and it costs women world wide their dignity.
So, try asking some women how forceps delivery worked out for them. And, women… fight to retain control of your bodies, your healthcare and your birth process!