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Operative vaginal delivery

Elisabeth K Wegner, MD
Ira M Bernstein, MD
Section Editor
Vincenzo Berghella, MD
Deputy Editor
Vanessa A Barss, MD, FACOG


Operative vaginal delivery refers to a delivery in which the operator uses forceps, a vacuum, or other devices to extract the fetus from the vagina, with or without the assistance of maternal pushing. The decision to use an instrument to deliver the fetus balances the maternal, fetal, and neonatal impact of the procedure against the alternative options of cesarean birth or expectant management.

This topic will discuss issues related to operative vaginal delivery. The technique for vacuum assisted operative delivery is reviewed separately. (See "Procedure for vacuum-assisted operative vaginal delivery".)


In the United States, 3.1 percent of all deliveries in 2015 were accomplished via an operative vaginal approach [1]. Forceps deliveries accounted for 0.56 percent of vaginal births and vacuum deliveries accounted for 2.58 percent of vaginal births. However, there is a wide range in the prevalence of operative vaginal delivery both across and within geographic regions in the United States (1 to 23 percent) which suggests that evidence-based guidelines for operative vaginal delivery are either inadequate or randomly applied, or familiarity and expertise with the technique is declining [2].

Prevalence rates vary worldwide depending on local practice patterns and availability of trained clinicians and other necessary resources [3]. A nonscientific survey from 111 countries showed that knowledge, training, and use of vacuum extraction range widely in different countries, and in certain regions, instrumental deliveries are not taught or performed [4].


Overview — Use of forceps or vacuum is reasonable when an operative intervention to terminate labor is indicated and operative vaginal delivery can be safely and readily accomplished; otherwise, cesarean delivery is the better option.

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Literature review current through: Nov 2017. | This topic last updated: Nov 21, 2017.
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  1. Martin JA, Hamilton BE, Osterman MJ, et al. Births: Final Data for 2015. Natl Vital Stat Rep 2017; 66:1.
  2. Clark SL, Belfort MA, Hankins GD, et al. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol 2007; 196:526.e1.
  3. Ameh CA, Weeks AD. The role of instrumental vaginal delivery in low resource settings. BJOG 2009; 116 Suppl 1:22.
  4. Fauveau V. Is vacuum extraction still known, taught and practiced? A worldwide KAP survey. Int J Gynaecol Obstet 2006; 94:185.
  5. Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 154 Summary: Operative Vaginal Delivery. Obstet Gynecol 2015; 126:1118.
  6. Murphy DJ, Liebling RE, Verity L, et al. Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study. Lancet 2001; 358:1203.
  7. Baskett TF, Allen VM, O'Connell CM, Allen AC. Fetal trauma in term pregnancy. Am J Obstet Gynecol 2007; 197:499.e1.
  8. Palatnik A, Grobman WA, Hellendag MG, et al. Predictors of Failed Operative Vaginal Delivery in a Contemporary Obstetric Cohort. Obstet Gynecol 2016; 127:501.
  9. American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol 2014; 123:693.
  10. Gei AF, Belfort MA. Forceps-assisted vaginal delivery. Obstet Gynecol Clin North Am 1999; 26:345.
  11. Richards M, Lavigne Lissalde G, Combescure C, et al. Neonatal bleeding in haemophilia: a European cohort study. Br J Haematol 2012; 156:374.
  12. Hagadorn-Freathy AS, Yeomans ER, Hankins GD. Validation of the 1988 ACOG forceps classification system. Obstet Gynecol 1991; 77:356.
  13. Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Pract Res Clin Obstet Gynaecol 2007; 21:639.
  14. Dennen PC. Dermen's Forceps Deliveries, 3rd ed, FA Davis Co, Philadelphia 1989.
  15. Kolderup LB, Laros RK Jr, Musci TJ. Incidence of persistent birth injury in macrosomic infants: association with mode of delivery. Am J Obstet Gynecol 1997; 177:37.
  16. Schwartz DB, Miodovnik M, Lavin JP Jr. Neonatal outcome among low birth weight infants delivered spontaneously or by low forceps. Obstet Gynecol 1983; 62:283.
  17. Nikpoor P, Bain E. Analgesia for forceps delivery. Cochrane Database Syst Rev 2013; 9:CD008878.
  18. Akmal S, Kametas N, Tsoi E, et al. Comparison of transvaginal digital examination with intrapartum sonography to determine fetal head position before instrumental delivery. Ultrasound Obstet Gynecol 2003; 21:437.
  19. Ramphul M, Ooi PV, Burke G, et al. Instrumental delivery and ultrasound : a multicentre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery. BJOG 2014; 121:1029.
  20. Sherer DM, Miodovnik M, Bradley KS, Langer O. Intrapartum fetal head position I: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the active stage of labor. Ultrasound Obstet Gynecol 2002; 19:258.
  21. Kasbaoui S, Séverac F, Aïssi G, et al. Predicting the difficulty of operative vaginal delivery by ultrasound measurement of fetal head station. Am J Obstet Gynecol 2017; 216:507.e1.
  22. Popowski T, Porcher R, Fort J, et al. Influence of ultrasound determination of fetal head position on mode of delivery: a pragmatic randomized trial. Ultrasound Obstet Gynecol 2015; 46:520.
  23. Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev 2017; 8:CD004455.
  24. Robinson JN, Norwitz ER, Cohen AP, et al. Episiotomy, operative vaginal delivery, and significant perinatal trauma in nulliparous women. Am J Obstet Gynecol 1999; 181:1180.
  25. Kudish B, Blackwell S, Mcneeley SG, et al. Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol 2006; 195:749.
  26. Youssef R, Ramalingam U, Macleod M, Murphy DJ. Cohort study of maternal and neonatal morbidity in relation to use of episiotomy at instrumental vaginal delivery. BJOG 2005; 112:941.
  27. Hudelist G, Gelle'n J, Singer C, et al. Factors predicting severe perineal trauma during childbirth: role of forceps delivery routinely combined with mediolateral episiotomy. Am J Obstet Gynecol 2005; 192:875.
  28. de Tayrac R, Panel L, Masson G, Mares P. [Episiotomy and prevention of perineal and pelvic floor injuries]. J Gynecol Obstet Biol Reprod (Paris) 2006; 35:1S24.
  29. Murphy DJ, Macleod M, Bahl R, et al. A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG 2008; 115:1695.
  30. Lund NS, Persson LK, Jangö H, et al. Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2016; 207:193.
  31. de Leeuw JW, de Wit C, Kuijken JP, Bruinse HW. Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG 2008; 115:104.
  32. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 1980; 87:408.
  33. Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol 2014; 210:59.e1.
  34. Räisänen SH, Vehviläinen-Julkunen K, Gissler M, Heinonen S. Lateral episiotomy protects primiparous but not multiparous women from obstetric anal sphincter rupture. Acta Obstet Gynecol Scand 2009; 88:1365.
  35. O'Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev 2010; :CD005455.
  36. Mazouni C, Bretelle F, Collette E, et al. Maternal and neonatal morbidity after first vaginal delivery using Thierry's spatulas. Aust N Z J Obstet Gynaecol 2005; 45:405.
  37. Boucoiran I, Valerio L, Bafghi A, et al. Spatula-assisted deliveries: a large cohort of 1065 cases. Eur J Obstet Gynecol Reprod Biol 2010; 151:46.
  38. Parant O, Simon-Toulza C, Capdet J, et al. [Immediate fetal-maternal morbidity of first instrumental vaginal delivery using Thierry's spatulas. A prospective continuous study of 195 fetal extractions]. Gynecol Obstet Fertil 2009; 37:780.
  39. World Health Organization, Odon device. www.odondevice.org/ (Accessed on June 23, 2015).
  40. Burke N, Field K, Mujahid F, Morrison JJ. Use and safety of Kielland's forceps in current obstetric practice. Obstet Gynecol 2012; 120:766.
  41. Stock SJ, Josephs K, Farquharson S, et al. Maternal and neonatal outcomes of successful Kielland's rotational forceps delivery. Obstet Gynecol 2013; 121:1032.
  42. Tempest N, Hart A, Walkinshaw S, Hapangama DK. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour. BJOG 2013; 120:1277.
  43. Bradley MS, Kaminski RJ, Streitman DC, et al. Effect of rotation on perineal lacerations in forceps-assisted vaginal deliveries. Obstet Gynecol 2013; 122:132.
  44. Sjöstedt JE. The vacuum extractor and forceps in obstetrics. A clinical study. Acta Obstet Gynecol Scand 1967; 46 Suppl 10:Suppl 10:1.
  45. Murphy DJ, Liebling RE, Patel R, et al. Cohort study of operative delivery in the second stage of labour and standard of obstetric care. BJOG 2003; 110:610.
  46. Gopalani S, Bennett K, Critchlow C. Factors predictive of failed operative vaginal delivery. Am J Obstet Gynecol 2004; 191:896.
  47. Al-Kadri H, Sabr Y, Al-Saif S, et al. Failed individual and sequential instrumental vaginal delivery: contributing risk factors and maternal-neonatal complications. Acta Obstet Gynecol Scand 2003; 82:642.
  48. Saropala N, Chaturachinda K. Failed instrumental delivery: Ramathibodi Hospital, 1980-1988. Int J Gynaecol Obstet 1991; 36:203.
  49. Ben-Haroush A, Melamed N, Kaplan B, Yogev Y. Predictors of failed operative vaginal delivery: a single-center experience. Am J Obstet Gynecol 2007; 197:308.e1.
  50. Olagundoye V, MacKenzie IZ. The impact of a trial of instrumental delivery in theatre on neonatal outcome. BJOG 2007; 114:603.
  51. Bhide A, Guven M, Prefumo F, et al. Maternal and neonatal outcome after failed ventouse delivery: comparison of forceps versus cesarean section. J Matern Fetal Neonatal Med 2007; 20:541.
  52. Aiken CE, Aiken AR, Brockelsby JC, Scott JG. Factors influencing the likelihood of instrumental delivery success. Obstet Gynecol 2014; 123:796.
  53. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999; 341:1709.
  54. Alexander JM, Leveno KJ, Hauth JC, et al. Failed operative vaginal delivery. Obstet Gynecol 2009; 114:1017.
  55. Gardella C, Taylor M, Benedetti T, et al. The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes. Am J Obstet Gynecol 2001; 185:896.
  56. Fong A, Wu E, Pan D, et al. Temporal trends and morbidities of vacuum, forceps, and combined use of both. J Matern Fetal Neonatal Med 2014; 27:1886.
  57. Revah A, Ezra Y, Farine D, Ritchie K. Failed trial of vacuum or forceps--maternal and fetal outcome. Am J Obstet Gynecol 1997; 176:200.
  58. Ezenagu LC, Kakaria R, Bofill JA. Sequential use of instruments at operative vaginal delivery: is it safe? Am J Obstet Gynecol 1999; 180:1446.
  59. Whitby EH, Griffiths PD, Rutter S, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 2004; 363:846.
  60. Osterman MJ, Martin JA, Menacker F. Expanded health data from the new birth certificate, 2006. Natl Vital Stat Rep 2009; 58:1.
  61. Ducarme G, Hamel JF, Bouet PE, et al. Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery According to Fetal Head Station. Obstet Gynecol 2015; 126:521.
  62. Demissie K, Rhoads GG, Smulian JC, et al. Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis. BMJ 2004; 329:24.
  63. Pergialiotis V, Vlachos DG, Rodolakis A, et al. First versus second stage C/S maternal and neonatal morbidity: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2014; 175:15.
  64. Center for Devices and Radiological Health. FDA Public Health Advisory: Need for caution when using vacuum assisted delivery devices. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm062295.htm (Accessed on March 26, 2008).
  65. Baskett TF, Fanning CA, Young DC. A prospective observational study of 1000 vacuum assisted deliveries with the OmniCup device. J Obstet Gynaecol Can 2008; 30:573.
  66. Wen SW, Liu S, Kramer MS, et al. Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries. Am J Epidemiol 2001; 153:103.
  67. Simonson C, Barlow P, Dehennin N, et al. Neonatal complications of vacuum-assisted delivery. Obstet Gynecol 2007; 109:626.
  68. Werner EF, Janevic TM, Illuzzi J, et al. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol 2011; 118:1239.
  69. Emerson MV, Pieramici DJ, Stoessel KM, et al. Incidence and rate of disappearance of retinal hemorrhage in newborns. Ophthalmology 2001; 108:36.
  70. Caughey AB, Sandberg PL, Zlatnik MG, et al. Forceps compared with vacuum: rates of neonatal and maternal morbidity. Obstet Gynecol 2005; 106:908.
  71. Robertson PA, Laros RK Jr, Zhao RL. Neonatal and maternal outcome in low-pelvic and midpelvic operative deliveries. Am J Obstet Gynecol 1990; 162:1436.
  72. Dupuis O, Silveira R, Dupont C, et al. Comparison of "instrument-associated" and "spontaneous" obstetric depressed skull fractures in a cohort of 68 neonates. Am J Obstet Gynecol 2005; 192:165.
  73. Dell DL, Sightler SE, Plauché WC. Soft cup vacuum extraction: a comparison of outlet delivery. Obstet Gynecol 1985; 66:624.
  74. Liu S, Heaman M, Joseph KS, et al. Risk of maternal postpartum readmission associated with mode of delivery. Obstet Gynecol 2005; 105:836.
  75. Meyer S, Schreyer A, De Grandi P, Hohlfeld P. The effects of birth on urinary continence mechanisms and other pelvic-floor characteristics. Obstet Gynecol 1998; 92:613.
  76. Meyer S, Hohlfeld P, Achtari C, et al. Birth trauma: short and long term effects of forceps delivery compared with spontaneous delivery on various pelvic floor parameters. BJOG 2000; 107:1360.
  77. Fitzpatrick M, Behan M, O'Connell PR, O'Herlihy C. Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery. BJOG 2003; 110:424.
  78. Pretlove SJ, Thompson PJ, Toozs-Hobson PM, et al. Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review. BJOG 2008; 115:421.
  79. Friedman AM, Ananth CV, Prendergast E, et al. Evaluation of third-degree and fourth-degree laceration rates as quality indicators. Obstet Gynecol 2015; 125:927.
  80. Landy HJ, Laughon SK, Bailit JL, et al. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011; 117:627.
  81. Macleod M, Strachan B, Bahl R, et al. A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery. BJOG 2008; 115:1688.
  82. Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013; 120:1516.
  83. Damron DP, Capeless EL. Operative vaginal delivery: a comparison of forceps and vacuum for success rate and risk of rectal sphincter injury. Am J Obstet Gynecol 2004; 191:907.
  84. Wu JM, Williams KS, Hundley AF, et al. Occiput posterior fetal head position increases the risk of anal sphincter injury in vacuum-assisted deliveries. Am J Obstet Gynecol 2005; 193:525.
  85. Benavides L, Wu JM, Hundley AF, et al. The impact of occiput posterior fetal head position on the risk of anal sphincter injury in forceps-assisted vaginal deliveries. Am J Obstet Gynecol 2005; 192:1702.
  86. Angioli R, Gómez-Marín O, Cantuaria G, O'sullivan MJ. Severe perineal lacerations during vaginal delivery: the University of Miami experience. Am J Obstet Gynecol 2000; 182:1083.
  87. Bahl R, Strachan B, Murphy DJ. Pelvic floor morbidity at 3 years after instrumental delivery and cesarean delivery in the second stage of labor and the impact of a subsequent delivery. Am J Obstet Gynecol 2005; 192:789.
  88. Handa VL, Blomquist JL, Knoepp LR, et al. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol 2011; 118:777.
  89. Johanson RB, Heycock E, Carter J, et al. Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse. Br J Obstet Gynaecol 1999; 106:544.
  90. Rajasekar D, Hall M. Urinary tract injuries during obstetric intervention. Br J Obstet Gynaecol 1997; 104:731.
  91. Al Wattar BH, Al Wattar B, Gallos I, Pirie AM. Rotational vaginal delivery with Kielland's forceps: a systematic review and meta-analysis of effectiveness and safety outcomes. Curr Opin Obstet Gynecol 2015; 27:438.
  92. Muraca GM, Sabr Y, Lisonkova S, et al. Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station. CMAJ 2017; 189:E764.
  93. Carmody F, Grant A, Mutch L, et al. Follow up of babies delivered in a randomized controlled comparison of vacuum extraction and forceps delivery. Acta Obstet Gynecol Scand 1986; 65:763.
  94. Bahl R, Patel RR, Swingler R, et al. Neurodevelopmental outcome at 5 years after operative delivery in the second stage of labor: a cohort study. Am J Obstet Gynecol 2007; 197:147.e1.
  95. Wesley BD, van den Berg BJ, Reece EA. The effect of forceps delivery on cognitive development. Am J Obstet Gynecol 1993; 169:1091.
  96. Ngan HY, Miu P, Ko L, Ma HK. Long-term neurological sequelae following vacuum extractor delivery. Aust N Z J Obstet Gynaecol 1990; 30:111.
  97. Ahlberg M, Ekéus C, Hjern A. Birth by vacuum extraction delivery and school performance at 16 years of age. Am J Obstet Gynecol 2014; 210:361.e1.
  98. Smit-Wu MN, Moonen-Delarue DM, Benders MJ, et al. Onset of vacuum-related complaints in neonates. Eur J Pediatr 2006; 165:374.
  99. Bahl R, Strachan B, Murphy DJ. Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study. BMJ 2004; 328:311.
  100. Melamed N, Ben-Haroush A, Chen R, et al. Pregnancy outcome and mode of delivery after a previous operative vaginal delivery. Obstet Gynecol 2009; 114:757.
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