Updated: Jun 7, 2019
What is a operative vaginal delivery? It is when a device, such as forceps or vacuum, is used to assist the mom during delivery to achieve a vaginal birth. Approximately 5% of deliveries in the US are operative vaginal deliveries. The overall rate of operative vaginal deliveries are going down however, we are seeing an increase in vacuum-assisted deliveries which now accounts for almost 4 times the rate of forceps assisted vaginal births.
Back in the day deliveries performed with instruments bought possible harm to the fetus. The idea of vacuum extraction was first introduced in 1705 by Dr. James Yonge, an English surgeon. This was several decades before the forceps were invented. The vacuum did not actually start being used until the 1950’s when a study showed its success rates and it nearly replaced forceps assisted deliveries. By the year 1992 most assisted deliveries were using vacuum rather than forceps.
When would a vacuum delivery or forceps delivery need to take place?
In 2000 ACOG published guidelines on when an operative vaginal delivery should only be performed if there is an appropriate indication. These may be:
Prolonged pushing with lack of progress for 3 hours with regional anesthesia (generally an epidural) or 2 hours for women without.
Suspicion that the fetus may be compromised such as the heart rate is not recovering or has a non reassuring pattern.
The vacuum may be used electively to shorten the second stage of labor because of maternal cardiovascular or neurologic disease, and is not well defined with maternal exhaustion.
Although there are the indications as to why an operative vaginal delivery would be needed there are also contractions.
If the baby has some underlying fetal disorders such as a bleeding disorder or a demineralizing disease an operative vaginal delivery may not be appropriate.
If the Cervix has not dilated completely, membranes are still in tact or the babies head has not engaged well into the pelvis.
If the baby has a malpresentation such as breech, transverse or facial presentation it may also be contradiction as to why an assisted birth may not qualify.
“Changes in maternal positioning, a reduction in neuraxial anesthesia, increased emotional support to the patient, and “laboring down” (delayed pushing) in the second stage have all been shown to increase the likelihood of a successful vaginal delivery” (Unzila, 2019)
When a provider feels an operative vaginal delivery is appropriate a consent either written or verbal must take place prior to performing a vacuum or forceps delivery. Along with this consent it is suggested that alternative management options be discussed as well such as Pitocin augmentation or Cesarean. Studies show that a prolonged second stage of labor will typically deliver vaginally and that second stage exceeding 2 hours does not adversely affect neonatal outcome if continued management is reasonable. If the mother does not meet the criteria for operative vaginal delivery a Cesarean delivery would then be discussed.
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