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Operative vaginal delivery

Elisabeth K Wegner, MD
Ira M Bernstein, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG


Operative vaginal delivery refers to a delivery in which the operator uses forceps or a vacuum device to assist the mother in transitioning the fetus to extrauterine life. The instrument is applied to the fetal head and then the operator uses traction to extract the fetus, typically during a contraction while the mother is pushing.

The first instrumental deliveries were performed to extract fetuses from parturients who were at high risk of maternal mortality due to prolonged and/or obstructed labor. In these cases, saving the mother's life took precedence over possible harm to the fetus. The focus of these procedures has changed as a result of modern obstetrical practices that have drastically reduced the risk of intrapartum maternal mortality and major morbidity. Decisions regarding use of instrumental delivery are now based primarily upon the fetal/neonatal impact of these procedures and are weighed against the alternative options of cesarean birth, expectant management (prolonging the second stage), and augmentation of contractions with oxytocin.


In the United States, 3.5 percent of all deliveries are accomplished via an operative vaginal approach [1]. The overall rate of operative vaginal delivery has been diminishing, but the proportion of operative vaginal deliveries conducted by vacuum assisted births has been increasing and is more than four times the rate of forceps assisted births. Forceps deliveries account for 1 percent of vaginal births and vacuum deliveries account for about 4 percent of vaginal births.

In recent years, the success rate for operative vaginal deliveries has been quite high (99 percent) [2]. This likely reflects appropriate choice of candidates for this intervention. However, the wide range of operative vaginal delivery rates (1 to 23 percent), both across and within geographic regions in the United States, suggests that evidence based guidelines for operative vaginal delivery are either inadequate or randomly applied [3].


An American College of Obstetricians and Gynecologists (ACOG) practice bulletin outlined the following indications for operative vaginal delivery (forceps or vacuum), recognizing that no indication is absolute; cesarean delivery is also an option in these clinical settings [4]:


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Literature review current through: Jul 2015. | This topic last updated: Jun 26, 2015.
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  1. Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data for 2011. Natl Vital Stat Rep 2013; 62:1.
  2. Menacker F, Martin JA. Expanded health data from the new birth certificate, 2005. Natl Vital Stat Rep 2008; 56:1.
  3. 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.
  4. American College of Obstetricians and Gynecologists. Operative vaginal delivery. ACOG Practice Bulletin number 17. American College of Obstetricians and Gynecologists; Washington, DC 2012.
  5. Spong CY, Berghella V, Wenstrom KD, et al. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol 2012; 120:1181.
  6. Cohen WR. Influence of the duration of second stage labor on perinatal outcome and puerperal morbidity. Obstet Gynecol 1977; 49:266.
  7. Myles TD, Santolaya J. Maternal and neonatal outcomes in patients with a prolonged second stage of labor. Obstet Gynecol 2003; 102:52.
  8. Gerber S, Vial Y, Hohlfeld P. [Maternal and neonatal prognosis after a prolonged second stage of labor]. J Gynecol Obstet Biol Reprod (Paris) 1999; 28:145.
  9. Cheng YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes? Am J Obstet Gynecol 2004; 191:933.
  10. Yancey MK, Herpolsheimer A, Jordan GD, et al. Maternal and neonatal effects of outlet forceps delivery compared with spontaneous vaginal delivery in term pregnancies. Obstet Gynecol 1991; 78:646.
  11. Cheng YW, Hopkins LM, Laros RK Jr, Caughey AB. Duration of the second stage of labor in multiparous women: maternal and neonatal outcomes. Am J Obstet Gynecol 2007; 196:585.e1.
  12. Allen VM, Baskett TF, O'Connell CM, et al. Maternal and perinatal outcomes with increasing duration of the second stage of labor. Obstet Gynecol 2009; 113:1248.
  13. Society of Obstetricians and Gynaecologists of Canada. Guidelines for operative vaginal birth. Number 148, May 2004. Int J Gynaecol Obstet 2005; 88:229.
  14. 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.
  15. 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.
  16. Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Pract Res Clin Obstet Gynaecol 2007; 21:639.
  17. Nikpoor P, Bain E. Analgesia for forceps delivery. Cochrane Database Syst Rev 2013; 9:CD008878.
  18. Dennen PC. Dermen's Forceps Deliveries, 3rd, FA Davis Co, Philadelphia 1989.
  19. Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev 2014; 10:CD004455.
  20. Gei AF, Belfort MA. Forceps-assisted vaginal delivery. Obstet Gynecol Clin North Am 1999; 26:345.
  21. Lucas MJ. The role of vacuum extraction in modern obstetrics. Clin Obstet Gynecol 1994; 37:794.
  22. Thiery M. Fetal hemorrhage following blood samplings and use of vacuum extractor. Am J Obstet Gynecol 1979; 134:231.
  23. Roberts IF, Stone M. Fetal hemorrhage: complication of vacuum extractor after fetal blood sampling. Am J Obstet Gynecol 1978; 132:109.
  24. 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.
  25. Zhang J, Bowes WA Jr. Birth-weight-for-gestational-age patterns by race, sex, and parity in the United States population. Obstet Gynecol 1995; 86:200.
  26. 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.
  27. Bishop EH, Israel SL, Briscoe CC. Obstetric influences on the premature infant's first year of development. A report from the collaborative study of cerebral palsy. Obstet Gynecol 1965; 26:628.
  28. Shaver DC, Bada HS, Korones SB, et al. Early and late intraventricular hemorrhage: the role of obstetric factors. Obstet Gynecol 1992; 80:831.
  29. Haesslein HC, Goodlin RC. Delivery of the tiny newborn. Am J Obstet Gynecol 1979; 134:192.
  30. O'Driscoll K, Meagher D, MacDonald D, Geoghegan F. Traumatic intracranial haemorrhage in firstborn infants and delivery with obstetric forceps. Br J Obstet Gynaecol 1981; 88:577.
  31. Beverley DW, Chance GW, Coates CF. Intraventricular haemorrhage--timing of occurrence and relationship to perinatal events. Br J Obstet Gynaecol 1984; 91:1007.
  32. 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.
  33. Baskett TF, Allen VM, O'Connell CM, Allen AC. Fetal trauma in term pregnancy. Am J Obstet Gynecol 2007; 197:499.e1.
  34. 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.
  35. 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.
  36. Gopalani S, Bennett K, Critchlow C. Factors predictive of failed operative vaginal delivery. Am J Obstet Gynecol 2004; 191:896.
  37. 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.
  38. Saropala N, Chaturachinda K. Failed instrumental delivery: Ramathibodi Hospital, 1980-1988. Int J Gynaecol Obstet 1991; 36:203.
  39. 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.
  40. Olagundoye V, MacKenzie IZ. The impact of a trial of instrumental delivery in theatre on neonatal outcome. BJOG 2007; 114:603.
  41. 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.
  42. Aiken CE, Aiken AR, Brockelsby JC, Scott JG. Factors influencing the likelihood of instrumental delivery success. Obstet Gynecol 2014; 123:796.
  43. Hagadorn-Freathy AS, Yeomans ER, Hankins GD. Validation of the 1988 ACOG forceps classification system. Obstet Gynecol 1991; 77:356.
  44. O'Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev 2010; :CD005455.
  45. Groom KM, Jones BA, Miller N, Paterson-Brown S. A prospective randomised controlled trial of the Kiwi Omnicup versus conventional ventouse cups for vacuum-assisted vaginal delivery. BJOG 2006; 113:183.
  46. Attilakos G, Sibanda T, Winter C, et al. A randomised controlled trial of a new handheld vacuum extraction device. BJOG 2005; 112:1510.
  47. 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.
  48. 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.
  49. 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.
  50. World Health Organization, Odon Device. www.odondevice.org/ (Accessed on June 23, 2015).
  51. Sjöstedt JE. The vacuum extractor and forceps in obstetrics. A clinical study. Acta Obstet Gynecol Scand 1967; 46 Suppl 10:Suppl 10:1.
  52. 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.
  53. Vacca A. Vacuum-assisted delivery: an analysis of traction force and maternal and neonatal outcomes. Aust N Z J Obstet Gynaecol 2006; 46:124.
  54. 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.
  55. 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.
  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. Ezenagu LC, Kakaria R, Bofill JA. Sequential use of instruments at operative vaginal delivery: is it safe? Am J Obstet Gynecol 1999; 180:1446.
  58. 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.
  59. Alexander JM, Leveno KJ, Hauth JC, et al. Failed operative vaginal delivery. Obstet Gynecol 2009; 114:1017.
  60. Johanson RB, Menon BK. Vacuum extraction versus forceps for assisted vaginal delivery. Cochrane Database Syst Rev 2000; :CD000224.
  61. 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.
  62. Liu S, Heaman M, Joseph KS, et al. Risk of maternal postpartum readmission associated with mode of delivery. Obstet Gynecol 2005; 105:836.
  63. 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.
  64. 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.
  65. 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.
  66. 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.
  67. 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.
  68. Dell DL, Sightler SE, Plauché WC. Soft cup vacuum extraction: a comparison of outlet delivery. Obstet Gynecol 1985; 66:624.
  69. Hankins GD, Rowe TF. Operative vaginal delivery--year 2000. Am J Obstet Gynecol 1996; 175:275.
  70. Rajasekar D, Hall M. Urinary tract injuries during obstetric intervention. Br J Obstet Gynaecol 1997; 104:731.
  71. 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.
  72. Landy HJ, Laughon SK, Bailit JL, et al. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011; 117:627.
  73. 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.
  74. 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.
  75. 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.
  76. 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.
  77. 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.
  78. 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.
  79. 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.
  80. 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.
  81. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything changed? Am J Obstet Gynecol 2009; 200:573.e1.
  82. Kudish B, Sokol RJ, Kruger M. Trends in major modifiable risk factors for severe perineal trauma, 1996-2006. Int J Gynaecol Obstet 2008; 102:165.
  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. Bashore RA, Phillips WH Jr, Brinkman CR 3rd. A comparison of the morbidity of midforceps and cesarean delivery. Am J Obstet Gynecol 1990; 162:1428.
  87. 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.
  88. 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.
  89. Handa VL, Blomquist JL, Knoepp LR, et al. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol 2011; 118:777.
  90. 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.
  91. 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.
  92. Smit-Wu MN, Moonen-Delarue DM, Benders MJ, et al. Onset of vacuum-related complaints in neonates. Eur J Pediatr 2006; 165:374.
  93. Ramphul M, Kennelly MM, Burke G, Murphy DJ. Risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery: observational study nested within the Instrumental Delivery & Ultrasound randomised controlled trial ISRCTN 72230496. BJOG 2015; 122:558.
  94. Werner EF, Janevic TM, Illuzzi J, et al. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol 2011; 118:1239.
  95. Doumouchtsis SK, Arulkumaran S. Head trauma after instrumental births. Clin Perinatol 2008; 35:69.
  96. 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.
  97. 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.
  98. Emerson MV, Pieramici DJ, Stoessel KM, et al. Incidence and rate of disappearance of retinal hemorrhage in newborns. Ophthalmology 2001; 108:36.
  99. Simonson C, Barlow P, Dehennin N, et al. Neonatal complications of vacuum-assisted delivery. Obstet Gynecol 2007; 109:626.
  100. 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).
  101. Caughey AB, Sandberg PL, Zlatnik MG, et al. Forceps compared with vacuum: rates of neonatal and maternal morbidity. Obstet Gynecol 2005; 106:908.
  102. 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.
  103. Schot MJ, Halbertsma FJ, Katgert T, Bok LA. Development of children with symptomatic intracranial hemorrhage born after vacuum extraction. J Child Neurol 2013; 28:520.
  104. 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.
  105. 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.
  106. Wesley BD, van den Berg BJ, Reece EA. The effect of forceps delivery on cognitive development. Am J Obstet Gynecol 1993; 169:1091.
  107. 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.
  108. 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.
  109. Murphy DJ, Libby G, Chien P, et al. Cohort study of forceps delivery and the risk of epilepsy in adulthood. Am J Obstet Gynecol 2004; 191:392.