ACOG Urges More Frequent Use of Operative Vaginal Delivery

Troy Brown, RN

October 23, 2015

An updated practice bulletin from the American College of Obstetrics and Gynecology (ACOG) affirms the use of operative vaginal delivery as a way to avoid cesarean delivery and improve outcomes for mothers and babies.

ACOG's Obstetrics Practice Bulletins Committee published the updated practice bulletin in the November issue of Obstetrics & Gynecology. It replaces Practice Bulletin 17, released in June 2000.

Use of operative vaginal delivery has decreased significantly during the last 30 years. This decrease is partly responsible for the rise in cesarean delivery rates.

"High cesarean rates are a major concern in obstetric care. The updated ACOG Practice Bulletin reinforces the potential benefits of an appropriate operative vaginal delivery, with counseling of the patient regarding those benefits, the risks, and alternatives," Marc Jackson, MD, MBA, chair of ACOG's Obstetrics Practice Bulletins Committee, said in an ACOG news release. "Many cesareans may be avoided if operative vaginal delivery is considered an option in the delivery room."

"Operative vaginal delivery is used to achieve or expedite safe vaginal delivery for maternal or fetal indications," the authors write. "Examples include maternal exhaustion and an inability to push effectively; medical indications such as maternal cardiac disease and a need to avoid pushing in the second stage of labor; prolonged second stage of labor, arrest of descent, or rotation of the fetal head; and nonreassuring fetal heart rate patterns in the second stage of labor."

Successful operative vaginal delivery can shorten fetal exposure to additional labor and decrease or prevent the effect of intrapartum insults on a fetus that is showing signs of possible compromise. It can often be accomplished faster than cesarean delivery.

In operative vaginal delivery, the clinician applies direct traction on the fetal skull with forceps or applies traction to the fetal scalp with a vacuum extractor.

Each method has benefits and drawbacks, the authors write. Vacuum extraction is thought to be easier to learn and may be useful when the fetal head presents first but is tipped to the shoulder (asynclitism), preventing proper forceps placement.

Forceps allow a more secure application and are appropriate for rotating the fetal head to occiput anterior or occiput posterior position.

ACOG's recommendations include the following:

  • The risk for complications with forceps and vacuum extractors is low and they are acceptable for use in operative vaginal delivery. (Level A recommendation)

  • Forceps are more likely than vacuum extractors to achieve vaginal birth, but they are also more likely to be connected to third- and fourth-degree perineal tears. (Level A)

  • ACOG does not recommend routine episiotomy with operative vaginal delivery, because poor healing and prolonged discomfort have been reported with mediolateral episiotomy and midline episiotomy has been associated with increased risk for anal sphincter injury and extension into the rectum. (Level A)

  • Operative vaginal delivery is contraindicated when the fetal head is not engaged, the position of the fetal head is not known, or the clinician knows or strongly suspects that a live fetus has a bone demineralization condition (eg, osteogenesis imperfecta) or a bleeding disorder (eg, alloimmune thrombocytopenia, haemophilia, or von Willebrand disease). (Level B)

  • A trial of operative vaginal delivery is appropriate in situations in which the clinician feels success is likely, but the clinician must be prepared to stop the attempt if appropriate descent fails to occur. (Level B)

  • Clinicians should not routinely perform sequential use of vacuum extractor and forceps because this practice has been associated with higher rates of neonatal complications. (Level B)

  • The risk for cephalohematoma increases as the duration of vacuum application increases. (Level B)

  • Midforceps and rotational forceps delivery are appropriate in specific clinical situations. (Level B)

  • Vacuum extraction is discouraged for gestational age less than 34 weeks, but no safe lower limit for gestational age has been established. (Level C)

  • For the fetus with signs of compromise in the second stage of labor, the timely and skilled use of operative vaginal delivery can decrease fetal exposure to intrauterine insults and may decrease the effect of intrapartum factors leading to neonatal encephalopathy and hypoxic-ischemic encephalopathy. (Level C)

  • Neonatal care providers should be informed of the mode of delivery so they can watch for potential complications associated with operative vaginal delivery. (Level C)

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2015;126:1118-1119. Abstract

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