Author's details
Reviewer's details
Instrumental deliveries
Operative vaginal delivery (OVD) is defined as the use of an instrument to aid delivery of the fetus. It is one of the key strategies advocated to reduce the rate of Cesarean deliveries which has been on the rise globally. All over the world, about 10–20% of all deliveries need some form of assistance or intervention at delivery and 6–12% of these interventions are by OVDs. The instruments used are the forceps and vacuum (ventouse) devices. The forceps tend to have a lower risk of fetal complications and a higher risk of maternal complications while the vacuum has been associated with a lower risk of maternal complications.
The forceps are a double-bladed metal instrument. There have been over 700 variations and modifications to this instrument that have been described over the years and can be broadly classified based on the purpose of its use, Classical forceps, rotational forceps, and specialized forceps used in breech delivery.
Common types include:
- Pipers – used for delivery of after coming head in breech delivery
- Wrigley’s – used as outlet forceps.
- Kielland’s – used for rotational deliveries.
Forceps are generally classified as outlet forceps, low cavity forceps, mid cavity forceps and high cavity forceps. The high cavity forceps delivery is no longer used in clinical practice due to the complications associated with it.
| Type of procedure | Criteria |
| Outlet forceps | 1. Scalp is visible at the introitus without separating labia |
| 2. Fetal skull has reached pelvic floor | |
| 3. Station is > +2 | |
| 4. Sagittal suture is in anteroposterior diameter or right or left occiput anterior or posterior position | |
| 5. Fetal head is at or on perineum | |
| 6. Rotation does not exceed 45° | |
| Low forceps | 1. Leading point of fetal skull is at station 2 cm |
| 2. Fetal skull has not reached the pelvic floor | |
| 3a. Rotation 45° (left or right occiput anterior to occiput anterior, or left or right occiput posterior to occiput posterior) | |
| 3b. Rotation >45° | |
| Mid forceps | Station above +2 cm but head engaged |
| High Forceps | Not included in the classification |
| (American College of Obstetricians and Gynecologists. Operative Vaginal Deliveries. Technical Bulletin No. 196, ACOG, Washington, DC 1994) |
Examples of Obstetrics Delivery forceps. Image courtesy film medical
Image courtesy Healthwise incorporated.
Indications for forceps use
Indications for the use of forceps for delivery include maternal exhaustion, prolonged second stage, sickle cell disease in pregnancy, cardiac disease in pregnancy, fetal distress in the second stage of labour, malposition, and delivery of after coming head in breech delivery.
Vacuum (ventouse) device
The ventouse is an instrument that is characterized by the application of a cup to the fetal head via a vacuum device with the aim of achieving vaginal delivery. The device can be manual or automated. The two major types of cups used for the vacuum device are rigid and soft cups. There are more success with the metallic rigid cups, and the automated vacuum when compared with the silastic and manual vacuum. The Kiwi OmniCup is a new single use affordable vacuum that can also be used
Indications for vacuum use
Indications for vacuum use include maternal exhaustion, malposition, fetal distress in the second stage and prolonged second stage.
Metal vacuum cups with its varying sizes: image courtesy IndiaMART
Image courtesy Gynocare Services
F- Fully dilated cervix
O- No obstruction
R- Ruptured membranes
C- Cephalic presentation
E- Empty Bladder/ Head Engaged/Episiotomy should be given
P- Position should be known
S- Skilled operator/Station known
Complications seen with forceps delivery include perineal injuries, uterine rupture, postpartum hemorrhage, puerperal sepsis, and vesicovaginal fistula. Fetal complications include birth asphyxia, intracranial haemorrhage, cephalhematoma, skull fracture, facial nerve injury, and spinal injury
Complications seen with vacuum delivery include perineal lacerations, hematomas, blood loss and anemia, urinary retention, and long-term problems with urinary and fecal incontinence. Fetal complications include caput succedaneum, cephalhematoma, subgaleal hemorrhage, and intracranial hemorrhage.
The use of instrumental delivery is declining in obstetrics due to the risk of complications and fear of medicolegal problems. However, with proper training and careful patient selection, instrumental delivery can be a useful and effective means of reducing the rising rate of Cesarean deliveries globally.
A 28-year-old woman in her second pregnancy, at 39 weeks gestation, was admitted in labor at a rural district hospital. Despite strong contractions, the fetal head failed to descend, and an ultrasound confirmed a cephalic presentation without fetal distress. To avoid complications from prolonged labor, a vacuum-assisted vaginal delivery was performed. After three pulls, the baby was successfully delivered with good Apgar scores. The mother sustained a minor perineal tear, which was repaired. Both mother and baby were discharged in good condition after 48 hours, highlighting the effective use of operative vaginal delivery in a low-resource setting.
- Charles, A, Glob. libr. women’s med.,(ISSN: 1756-2228) 2011; DOI 10.3843/GLOWM.10131
- Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011 Jul;118(1):29-38.
- Shimalis C, Hasen T, Regasa MT, Desalegn Z, Mulisa D, Upashe SP. Complications of instrumental vaginal deliveries and associated factors in hospitals of Western Oromia, Ethiopia. SAGE open medicine. 2022 Jul;10:20503121221113091.
- Foglia LM, Nielsen PE, Deering SH, Galan HL. Operative Vaginal Delivery. Obstetrics: Normal and Problem Pregnancies E-Book. 2024 Aug 31:290.
Author's details
Reviewer's details
Instrumental deliveries
Operative vaginal delivery (OVD) is defined as the use of an instrument to aid delivery of the fetus. It is one of the key strategies advocated to reduce the rate of Cesarean deliveries which has been on the rise globally. All over the world, about 10–20% of all deliveries need some form of assistance or intervention at delivery and 6–12% of these interventions are by OVDs. The instruments used are the forceps and vacuum (ventouse) devices. The forceps tend to have a lower risk of fetal complications and a higher risk of maternal complications while the vacuum has been associated with a lower risk of maternal complications.
- Charles, A, Glob. libr. women’s med.,(ISSN: 1756-2228) 2011; DOI 10.3843/GLOWM.10131
- Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011 Jul;118(1):29-38.
- Shimalis C, Hasen T, Regasa MT, Desalegn Z, Mulisa D, Upashe SP. Complications of instrumental vaginal deliveries and associated factors in hospitals of Western Oromia, Ethiopia. SAGE open medicine. 2022 Jul;10:20503121221113091.
- Foglia LM, Nielsen PE, Deering SH, Galan HL. Operative Vaginal Delivery. Obstetrics: Normal and Problem Pregnancies E-Book. 2024 Aug 31:290.
Content
Author's details
Reviewer's details
Instrumental deliveries
Background
Operative vaginal delivery (OVD) is defined as the use of an instrument to aid delivery of the fetus. It is one of the key strategies advocated to reduce the rate of Cesarean deliveries which has been on the rise globally. All over the world, about 10–20% of all deliveries need some form of assistance or intervention at delivery and 6–12% of these interventions are by OVDs. The instruments used are the forceps and vacuum (ventouse) devices. The forceps tend to have a lower risk of fetal complications and a higher risk of maternal complications while the vacuum has been associated with a lower risk of maternal complications.
Further readings
- Charles, A, Glob. libr. women’s med.,(ISSN: 1756-2228) 2011; DOI 10.3843/GLOWM.10131
- Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011 Jul;118(1):29-38.
- Shimalis C, Hasen T, Regasa MT, Desalegn Z, Mulisa D, Upashe SP. Complications of instrumental vaginal deliveries and associated factors in hospitals of Western Oromia, Ethiopia. SAGE open medicine. 2022 Jul;10:20503121221113091.
- Foglia LM, Nielsen PE, Deering SH, Galan HL. Operative Vaginal Delivery. Obstetrics: Normal and Problem Pregnancies E-Book. 2024 Aug 31:290.
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