Operative Vaginal
Delivery
District 1 ACOG Medical
Student Teaching Module 2011
Indications
Maternal Benefit – Shorten the 2nd stage of
labor, decrease the amount of pushing
Ie: maternal cardiac conditions (Eisenmenger’s,
pulmonary HTN) or history of aneurysm/stroke
Concern for immediate/potential fetal
compromise
Ie: Prolonged terminal bradycardia
Prolonged 2nd stage
Nulliparous = No progress for 3 hrs w/epidural or 2
hours w/o epidural
Multiparous = No progress for 2 hrs w/epidural or 1 hr
w/o epidural
Operative Vaginal Delivery
Incidence: 4.5% of vaginal deliveries
Forceps deliveries = 0.8%
Vacuum deliveries = 3.7%
Success Rate = 99%
Reflects appropriate choice of candidates
What Do I Need To Know Before
Attempting an Operative Delivery?
Presentation
(Cephalic/Breech)
Position (i.e. occiput
posterior, sacrum anterior)
Lie (longitudinal, oblique,
transverse)
Station
Presence of asyncliticism
Clinical pelvimetry
Anesthesia?
Contraindications
GA < 34 weeks (contraindication for
vacuum due to risk of fetal IVH)
Known bone demineralization condition
(e.g. osteogenesis imperfecta) or bleeding
disorder, ie: VWD)
Fetal head unengaged
Position of fetal head unknown
Vacuum-Assisted Vaginal Delivery
Do not apply rocking
motion or torque, only
steady traction in the
line of the birth canal
Stop after: three “pop-
offs” of vacuum, > 20
minutes elapsed, three
pulls with no progress
After determining position of the head, (A) insert the cup into the
vaginal vault, ensuring that no maternal tissues are trapped by the
cup. (B) Apply the cup to the flexion point 3 cm in front of the
posterior fontanel, centering the sagittal suture. (C) Pull during a
contraction with a steady motion, keeping the device at right angles
to the plane of the cup. In occipitoposterior deliveries, maintain the
right angle if the fetal head rotates. (D) Remove the cup when the
fetal jaw is reachable
Fetal Risks: VAVD
Designed to detach if traction is excessive (but
can produce traction up to 50 lbs)
* 5% incidence serious complications
Scalp lacerations: if torsion excessive
Cephalohematoma: limited to suture
line
Subgleal hematoma: crosses suture
line
Intracranial/retinal hemorrhage
Hyperbilirubinemia/jaundice
Higher incidence of
cephalohematoma/retinal
hemorrhage/jaundice compared to
forceps
Type of Forceps Delivery
Outlet forceps
Scalp visible at introitus w/o separating labia
Fetal skull reached pelvic floor & head at/on perineum
Sagittal suture in AP diameter or LOA, ROA, or posterior position
rotation does not exceed 45º
Low forceps
Leading point of fetal skull at >= +2, not on pelvic floor
Rotation 45º or less (LOA/ROA to OA, or LOP/ROP to OP); or rotation
greater than 45º.
Midforceps
Above +2 cm but head engaged
High forceps
Head not engaged; not included in ACOG classification
Not recommended
Forceps-Assisted Vaginal Delivery
Identify & apply
blades
Place instrument in
front of pelvis with tip
pointing up & pelvic
curve forward
Apply left blade,
guided by right hand,
then right blade with
left hand
Lock blades
Should articulate with
ease
FAVD
Check for correct application
Sagittal suture in midline of shanks
Cannot place more than one fingertip
between blade and fetal head
Apply traction
Steady and intermittent
Downward and then upward
Remove blades as fetus crowns
Risks: Forceps
Maternal Risks
Perineal Injury (extension of episiotomy)
Vaginal and Cervical lacerations
Postpartum hemorrhage
Fetal Risks
Intracranial hemorrhage
Cephalic hematoma
Facial / Brachial palsy
Injury to the soft tissues of face & forehead
Skull fracture
Using both forceps and vacuum
Highest risk for injury is for combined
forceps/vacuum extraction or cesarean
delivery after failed operative delivery
The weight of available evidence is
against multiple efforts with different
instruments