Instrumental vaginal birth: ventouse and forceps

It is 23:40. She has been pushing for ninety minutes, the epidural is dense, the trace has developed decelerations, and the midwife has just said the sentence that starts every one of these stories: "Can you come and have a look?" What happens in the next ten minutes is decided almost entirely before you touch an instrument — by how carefully you examine, and by whether you are honest with yourself about what you find.^[1][4]

Overview and definition

Assisted vaginal birth means using a vacuum cup or obstetric forceps to shorten the second stage when continuing to push is no longer the safest option. It accounts for roughly 5 to 20 per cent of births across high-income settings, and it is a core RANZCOG Basic Obstetric Skills competency — ventouse and outlet forceps are named workshop stations, so the College has told you it is examinable.^[1][16]

The three indications are worth saying as a list, because examiners want the maternal one: ^[1][2]

• Delay in the second stage — inadequate progress despite active pushing, with the usual thresholds of two hours in a nullipara (three with regional analgesia) and one hour in a multipara (two with regional analgesia).^[1]
• Suspected fetal compromise — a pathological trace at a station where birth can be achieved quickly and safely.^[1][2]
• Maternal indication to shorten active pushing — significant cardiac disease, severe hypertension, myasthenia gravis, a spinal cord lesion, or maternal exhaustion.^[2]

References19ShowHide

1. [1]Murphy DJ, Strachan BK, Bahl R, et al. Assisted Vaginal Birth: Green-top Guideline No. 26 BJOG, 2020.PMID 32346983
2. [2]American College of Obstetricians and Gynecologists Operative Vaginal Birth: ACOG Practice Bulletin, Number 219 Obstet Gynecol, 2020.PMID 32217976
3. [3]Verma GL, Spalding JJ, Wilkinson MD, et al. Instruments for assisted vaginal birth Cochrane Database Syst Rev, 2021.PMID 34559884
4. [4]Murphy DJ, Liebling RE, Verity L, et al. Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study Lancet, 2001.PMID 11675055
5. [5]Bahl R, Van de Venne M, Macleod M, et al. Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study BJOG, 2013.PMID 23924292
6. [6]Knight M, Chiocchia V, Partlett C, et al. Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial Lancet, 2019.PMID 31097213
7. [7]Ramphul M, Ooi PV, Burke G, et al. Instrumental delivery and ultrasound : a multicentre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery BJOG, 2014.PMID 24720273
8. [8]Towner D, Castro MA, Eby-Wilkens E, et al. Effect of mode of delivery in nulliparous women on neonatal intracranial injury N Engl J Med, 1999.PMID 10580069
9. [9]Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors BJOG, 2013.PMID 23834484
10. [10]de Leeuw JW, de Wit C, Kuijken JP, et al. Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery BJOG, 2008.PMID 17999693
11. [11]Muraca GM, Sabr Y, Lisonkova S, et al. Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station CMAJ, 2017.PMID 28584040
12. [12]Muraca GM, Sabr Y, Lisonkova S, et al. Morbidity and Mortality Associated With Forceps and Vacuum Delivery at Outlet, Low, and Midpelvic Station J Obstet Gynaecol Can, 2019.PMID 30366887
13. [13]Johanson RB, Menon BK Vacuum extraction versus forceps for assisted vaginal delivery Cochrane Database Syst Rev, 2000.PMID 10796182
14. [14]Doumouchtsis SK, Arulkumaran S Head trauma after instrumental births Clin Perinatol, 2008.PMID 18280876
15. [15]Gardella C, Taylor M, Benedetti T, et al. The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes Am J Obstet Gynecol, 2001.PMID 11641674
16. [16]Majoko F, Gardener G Trial of instrumental delivery in theatre versus immediate caesarean section for anticipated difficult assisted births Cochrane Database Syst Rev, 2012.PMID 23076915
17. [17]de Vogel J, van der Leeuw-van Beek A, Gietelink D, et al. The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries Am J Obstet Gynecol, 2012.PMID 22425401
18. [18]Graham K, Phipps H, Hyett JA, et al. Persistent occiput posterior: OUTcomes following digital rotation: a pilot randomised controlled trial Aust N Z J Obstet Gynaecol, 2014.PMID 24627988
19. [19]Werner EF, Janevic TM, Illuzzi J, et al. Mode of delivery in nulliparous women and neonatal intracranial injury Obstet Gynecol, 2011.PMID 22105252