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Delivery by Forceps or Vacuum – Birth Injury

The use of either forceps or a vacuum device to assist the obstetrician in delivering a baby is also known as operative vaginal delivery, or mechanical delivery. This method is used in cases where it is necessary to expedite a baby’s delivery. Indications for an operative delivery include fetal compromise, a prolonged second stage of labor, inadequate progress, or maternal fatigue/exhaustion. Choice of instrument and examination for any potential contraindications are important aspects of preventing maternal or fetal injury and morbidity. Operative vaginal delivery occurs in an estimated 5% of births in the United States, although the rate varies dramatically depending on the geographic location of the birth and experience of the physician. The lowest rates tend to be in the northeast part of the country, while the highest rates of operative delivery tend to be in the south.

A second stage of labor (the time period between complete dilation of the cervix and the delivery of the baby) exceeding 3 hours has been associated with increased maternal and fetal injury. The purpose of a vacuum or forceps delivery is to shorten the second stage. In order for a physician to perform a forceps or vacuum delivery, he or she must first ensure several criteria: the baby has descended to a +2 station, the baby is vertex in presentation (where the head of the baby enters the cervix first), the cervix is completely dilated and membranes are ruptured, the maternal pelvis is adequate for delivery, and there is not excessive molding of the fetal head.

There are over 700 different types of forceps, but most resemble salad tongs. The shapes of forceps differ, and using the correct type for the presentation of the baby and size of the maternal pelvis, among other factors, is an important choice for the operator. Vacuum extractors resemble a suction cup attached to a tube or hand pump. There are different types of vacuum extractors, and most are equipped with a soft cup on the end.

Forceps may be useful in cases where the infant needs to be turned slightly into a true vertex presentation.  However, special care must be taken when a baby is in the occiput-posterior position, as the baby’s position can appear to be lower than it truly is. Inexperienced operators may attempt using a vacuum or forceps in these situations and doing so is extremely dangerous.  Misapplication is associated with intracranial hemorrhaging, fetal skull fractures, brachial plexus injury, uterine rupture, and poor outcome.

Vacuum extraction has its own unique dangers. If a vacuum delivery is not achieved within 2 pulls, or the vacuum “pops off” the fetal head, injuries to the fetal skull and hemorrhage may occur, including cephalohematoma, intracranial hemorrhage, and subgaleal hematoma.

The most common cause of fetal injury during these procedures is the physician continuing with the procedure when it is clear operative vaginal delivery will fail.  Physicians must be ready to perform an immediate caesarean section following a protracted attempt at operative deliveries.  Delays may have devastating results for the infant. Use of both forceps and vacuum in the same delivery is always contraindicated and is also associated with a high risk of fetal injury.

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