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Immediate Maternal and Neonatal Effects of Forceps

and Vacuum-Assisted Deliveries


Jennifer H. Johnson, MD, Reinaldo Figueroa, MD, David Garry, DO, Andrew Elimian, MD, and
Dev Maulik, MD, PhD
OBJECTIVE: To estimate the differences in immediate ma-
ternal and neonatal effects of forceps and vacuum-assisted
deliveries.
METHODS: We conducted a medical record review of all
forceps and vacuum-assisted deliveries that occurred from
January 1, 1998, to August 30, 1999, at Winthrop-Univer-
sity Hospital. Maternal demographics and delivery charac-
teristics were recorded. Maternal outcomes, such as use of
episiotomy and presence of lacerations, were studied. Neo-
natal outcomes evaluated were Apgar scores, neonatal in-
tensive care unit admissions, cephalohematomas, instru-
ment marks and bruising, and caput and molding.
RESULTS: Of 508 operative vaginal deliveries, 200 were
forceps and 308 were vacuum assisted. Forceps were used
more often than vacuum for prolonged second stage of
labor (P .001). There was a higher rate of epidural (P
.02) and pudendal (P <.001) anesthesia, episiotomies (P
.01), maternal third- and fourth-degree perineal (P <.001)
and vaginal lacerations (P .004) with the use of forceps,
whereas periurethral lacerations were more common in
vacuum-assisted (P .026) deliveries. More instrument
marks and bruising (P <.001) were found in the neonates
delivered by forceps, whereas there was a greater incidence
of cephalohematomas (P .03) and caput and molding
(P < .001) in the neonates delivered with vacuum. Multi-
variable logistic regression analysis showed that forceps use
was associated with an increase in major perineal and
vaginal tears (odds ratio [OR] 1.85; 95% condence inter-
val [CI] 1.27, 2.69; P .001), an increase in instrument
marks and bruising (OR 4.63; 95% CI 2.90, 7.41; P <.001)
and a decrease in cephalohematomas (OR 0.49; 95% CI
0.29, 0.83; P .007) compared with the vacuum.
CONCLUSIONS: Maternal injuries are more common with
the use of forceps. Neonates delivered with forceps have
more facial injuries, whereas neonates delivered with vac-
uum have more cephalohematomas. (Obstet Gynecol
2004;103:5138. 2004 by The American College of
Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: II-3
Data from the last 3 decades conrm that the rate of
operative vaginal deliveries is decreasing in North Amer-
ica.
14
The United States, Canada, Eastern Europe, and
South America prefer the use of forceps extractions. The
vacuum is the instrument of choice in Western Europe,
Asia, Israel, and the Middle East.
5
It has been reported that 60% of residency programs in
the United States perform less than 10% of their total
deliveries with the assistance of the vacuum or forceps.
6
At
our institution, the use of vacuum has increased whereas
forceps use has decreased during the past 10 years. Six
percent of the total deliveries are operative vaginal deliver-
ies. Review of the literature suggests differential maternal
and neonatal complications between forceps and vacuum
assisted deliveries.
711
The purpose of this study was to
estimate the differences in immediate maternal and neona-
tal effects of forceps and vacuum-assisted deliveries in a
community-based teaching hospital with a residency pro-
gram in obstetrics and gynecology.
MATERIALS AND METHODS
We performed a record review of all forceps and vacu-
um-assisted deliveries that occurred from January 1,
1998, through August 30, 1999, at Winthrop-University
Hospital. The study was approved by the institutional
reviewboard. The deliveries were performed by a senior
resident under the supervision of an attending physician.
Maternal demographics recorded included age, parity,
and gestational age. Delivery characteristics recorded
included indication for the use of an instrument, use of
oxytocin, fetal position and station, change in instru-
ment, delivery by cesarean, and type of anesthesia. Ma-
ternal outcomes of interest were the use of episiotomy,
lacerations sustained, and presence of vulvovaginal he-
matomas. The delivery information was entered in the
medical record by the physician performing the delivery.
Neonatal outcomes of interest were birth weight, Ap-
gar scores, neonatal intensive care unit (NICU) admis-
sions, cephalohematomas, instrument marks and bruis-
ing, and caput and molding. The pediatricians who
Fromthe Department of Obstetrics and Gynecology, Winthrop-University Hospital,
Mineola, New York, and the State University of New York at Stony Brook.
VOL. 103, NO. 3, MARCH 2004
513 2004 by The American College of Obstetricians and Gynecologists. 0029-7844/04/$30.00
Published by Lippincott Williams & Wilkins. doi:10.1097/01.AOG.0000114985.22844.6d
examined the newborns were aware of the delivery
history.
Statistical analysis included Student t test for continu-
ous variables and
2
test for categorical variables. The
Fisher exact test was used when the expected cell fre-
quencies were equal to or less than 5. Multivariable
logistic regression was performed to examine the role of
vacuum or forceps use on selected outcomes: major
perineal/vaginal lacerations, periurethral tears, cephalo-
hematomas, and instrument marks and bruising control-
ling for confounding variables. P .05 was considered
statistically signicant. Statistical analyses were per-
formed by using True EPISTAT (Epistat Services,
Richardson, TX).
RESULTS
Of 8,241 deliveries during the study period, 1,989 were
cesarean deliveries for a rate of 24.1%. The primary
cesarean delivery rate was 14.9%. Of 508 operative
vaginal deliveries (6.2% of all deliveries), 200 (39.4%)
were forceps and 308 (60.6%) were vacuum assisted.
There were no differences between the forceps and
vacuum-assisted groups in maternal age (31.2 5.1
years versus 31.6 5.0 years; P .89), parity (75.5%
versus 68.5% primiparous; P .10), and gestational age
(39.3 1.8 weeks versus 39.6 1.5 weeks; P .68). All
operative vaginal deliveries were of 34 weeks or more of
gestation.
Forceps were used more often than the vacuum for
prolonged second stage of labor (14% versus 5.2%; P
.001). The differences in the use of oxytocin, success in
operative delivery, rate of instrument changes, and ce-
sarean delivery were not signicant between the 2
groups. There was a higher rate of epidural (90.5%
versus 82.8%; P .02) and pudendal (13% versus 1.9%;
P .001) anesthesia in the forceps group than in the
vacuum-assisted group. Frequently, women were given
another anesthetic after an epidural (Table 1). Ninety
ve percent of the instrumental deliveries were com-
pleted with 1 instrument. Twenty-two women (4.3%)
required a change of instrument to complete the delivery
whereas only 2 women required cesarean delivery. For-
ceps were applied more often when the fetal position was
occiput anterior or posterior whereas the vacuum was
used more frequently with occiput transverse positions.
There was a trend for a more frequent use of forceps
than vacuum at the outlet, whereas vacuum was applied
more frequently than forceps at midstation but the dif-
ferences were not statistically signicant (Table 1).
There were more episiotomies performed in the for-
ceps (90.5% versus 81.8%; P .01) than in the vacuum-
assisted group. There was a greater incidence of mater-
nal third- and fourth-degree perineal lacerations (44.4%
versus 27.9%; P .001), and vaginal lacerations (19%
versus 9.7%; P .004) with the use of forceps. However,
more periurethral lacerations were seen in the vacuum-
assisted group (4.2% versus 0.5%; P .026) than in the
forceps group. More women in the vacuum-assisted
group were free of injury to the perineum or vagina than
in the forceps group, although the difference was not
statistically signicant (38.3% versus 30%; P .07;
Table 2).
Birth weights, Apgar scores, and NICU admissions
were similar between the 2 groups. More instrument
marks and bruising (36.5%versus 10.7%; P .001) were
found in the neonates delivered by forceps. However,
there was a greater incidence of cephalohematomas (20.5%
versus 12.5%; P .03), and caput and molding (28.2%
versus 13.5%; P .002) in the neonates who were deliv-
ered by the assistance of the vacuum (Table 3).
Using multivariable logistic regression analysis and
vacuum as the reference group, forceps use (odds ratio
[OR] 1.85; 95% condence interval [CI] 1.27, 2.70; P
Table 1. Delivery Characteristics
Forceps Vacuum P
Number of women 200 308
Indications
Maternal exhaustion 77 (38.5) 124 (40.3) .76
Fetal status 94 (47.0) 168 (54.5) .12
Prolonged 2nd stage 28 (14.0) 16 (5.2) .001
Elective/Other 5 (2.5) 9 (2.9) .95
Use of oxytocin 155 (77.5) 225 (73.1) .31
Completed delivery 189 (94.5) 294 (95.5) .78
Change of instruments 10 (5.0) 12 (3.9) .71
Cesarean delivery 1 (0.5) 1 (0.3) .95
Use of anesthesia
Epidural 181 (90.5) 255 (82.8) .02
Local 83 (41.5) 130 (42.2) .95
Pudendal 26 (13.0) 6 (1.9) .001
Intravenous narcotic 21 (10.5) 32 (10.4) .91
None 0 6 (1.9) .09
Position n 196 n 245 .001
Left occiput anterior 43 (21.5) 49 (15.9)
Right occiput anterior 27 (13.5) 39 (12.7)
Occiput anterior 94 (47.0) 100 (32.5)
Left occiput posterior 4 (2.0) 10 (3.2)
Right occiput posterior 3 (1.5) 10 (3.2)
Occiput posterior 25 (12.5) 15 (4.9)
Left occiput transverse 0 12 (3.9)
Right occiput transverse 0 10 (3.2)
Not documented 4 (2.0) 63 (20.5)
Station n 165 n 247 .06
Mid 2 (1.0) 13 (4.2)
Low 59 (29.5) 96 (31.2)
Outlet 104 (52.0) 138 (44.8)
Not documented 35 (17.5) 61 (19.8)
Data are presented as number (%).
514 Johnson et al Forceps and Vacuum Deliveries OBSTETRICS & GYNECOLOGY
.001) was independently associated with an increase in
major perineal and vaginal tears. In addition, a birth
weight of 4,000 g or more (OR 2.09; 95% CI 1.06, 4.10;
P .03) and use of episiotomy (OR 2.22; 95% CI 1.22,
4.05; P .01) were independently associated with major
tears (Table 4). When neonatal outcomes were evalu-
ated, the use of forceps was associated with an increase in
instrument marks and bruising (OR 4.63; 95% CI 2.90,
7.41; P .001; Table 5) and a decrease in cephalohema-
tomas (OR 0.49; 95% CI 0.29, 0.83; P .007; Table 6).
One hundred eighty-one women in the forceps group
and 252 women in the vacuum group had an episiotomy
performed. This subgroup of women was analyzed for
injuries. We found a greater incidence of fourth-degree
perineal lacerations (12.2% versus 4.8%; P .005) and
vaginal lacerations (18.8% versus 9.5%; P .005) with
the use of forceps. There were no signicant differences
in the incidence of third-degree perineal lacerations be-
tween the 2 groups (33.7% forceps versus 27.4% vac-
uum; P .16). However, more periurethral lacerations
were seen in the vacuum-assisted group (2.4% versus 0;
P .04) than in the forceps group. More instrument
marks and bruising (37.6%versus 10.3%; P .001) were
found in the neonates delivered by forceps. However,
there was a greater incidence of cephalohematomas
(21.4% versus 13.8%; P .04) and caput and molding
(33.7% versus 16%; P .001) in the neonates who were
delivered by the assistance of the vacuum.
There were 151 nulliparas in the forceps group and
211 nulliparas in the vacuum group. Forceps were used
more often than vacuum for prolonged second stage of
labor (15.9% versus 6.6%; P .008). There was a higher
rate of epidural (95.4% versus 86.7%; P .01) and
pudendal (12.6% versus 1.4%; P .001) anesthesia in
the forceps group than in the vacuum-assisted group.
The difference in episiotomy use (92.7% versus 89.6%;
P .31) and in the number of women without injury
(42.5% versus 37.9%; P .28) was not signicant be-
tween the forceps and vacuum groups. We found a
greater incidence of fourth-degree perineal lacerations
Table 2. Maternal Outcomes
Forceps Vacuum
Odd ratio (95%
condence interval) P
Number of women 200 308
No injuries 60 (30.0) 118 (38.3) 0.69 (0.46, 1.03) .07
Episiotomy 181 (90.5) 252 (81.8) 2.12 (1.18, 3.83) .01
Lacerations
Perineal
First degree 5 (2.5) 17 (5.5)* .16
Second degree 30 (15.0) 61 (19.8) 0.71 (0.43, 1.18) .20
Third degree 66 (33.0) 73 (23.7) 1.59 (1.05, 2.40) .03
Fourth degree 23 (11.5) 13 (4.2) 2.95 (1.39, 6.33) .003
Third and fourth degree 89 (44.4) 86 (27.9) 2.07 (1.40, 3.06) .001
Periurethral 1 (0.5) 13 (4.2)* .026
Labial 1 (0.5) 2 (0.6)* .95
Vaginal 38 (19.0) 30 (9.7) 2.17 (1.26, 3.76) .004
Hematomas 0 1 (0.3)* .95
Data are presented as number (%).
* Fisher exact test was used.
Table 3. Neonatal Outcomes
Forceps Vacuum
Odds ratio (95%
condence interval) P
Number of women 200 308
Birth weight (g) 3,317 524 3,398 505 .09
1-minute Apgar score 3 1 (0.5) 3 (1.0) .95
5-minute Apgar score 7 0 1 (0.3) .95
Neonatal intensive care unit admissions 19 (7.8) 24 (9.5) 1.24 (0.63, 2.43) .61
Instrument bruises 73 (36.5) 33 (10.7) 4.79 (2.95, 7.81) .001
Cephalohematomas 25 (12.5) 63 (20.5) 0.56 (0.33, 0.94) .03
Caput and molding 27 (13.5) 87 (28.2) 0.40 (0.24, 0.65) .001
Data are presented as mean standard deviation or number (%).
Fisher exact test was used for Apgar scores.
515 VOL. 103, NO. 3, MARCH 2004 Johnson et al Forceps and Vacuum Deliveries
(12.6% versus 4.7%; P .007) and vaginal lacerations
(17.2% versus 10.4%; P .06) with the use of forceps.
There were no signicant differences in the incidence of
third-degree perineal lacerations (33.8% forceps versus
27.5% vacuum; P .2). However, more periurethral
lacerations were seen in the vacuum-assisted group
(4.3% versus 0; P .01) than in the forceps group. More
instrument marks and bruising (39.1% versus 10.9%;
P .001) were found in the neonates delivered by
forceps. However, there was a greater incidence of
cephalohematomas (22.7% versus 14.6%; P .07) and
caput and molding (31.3%versus 13.9%; P .002) in the
neonates who were delivered by the assistance of the
vacuum.
Twenty-two (4.3%) vaginal deliveries were completed
after there was a change of instrument. Seventeen
(77.3%) women were nulliparas. All 22 women had an
episiotomy performed. Ten (45.5%) women had a third-
or fourth-degree perineal laceration, 4 (18.2%) had vag-
inal lacerations, and 1 (4.5%) woman sustained a peri-
urethral tear. Five (22.7%) neonates had cephalohema-
tomas, 6 (27.3%) had instrument marks and bruising,
and 8 (36.4%) had caput and molding. One neonate
required admission to the NICU.
DISCUSSION
This study was designed to estimate the immediate
maternal and neonatal effects of forceps and vacuum-
assisted deliveries in a community hospital with a resi-
dency program in obstetrics and gynecology. Although
there was a greater use of episiotomies in the forceps
group, women in this group sustained more third- and
fourth-degree perineal and vaginal lacerations than
women in the vacuum-assisted group. This is in agree-
ment with the work of Boll et al
8
reporting that vacu-
um-assisted deliveries were associated with a lower rate
of episiotomy, third-and fourth-degree perineal lacera-
tions, and vaginal lacerations. Other studies, although
not commenting on the use of episiotomies, also showed
that maternal soft tissue injuries in the form of vaginal
lacerations or third- or fourth-degree lacerations were
more common in the women delivered with the use of
forceps.
7,911
Ecker et al
12
reviewed the use of episiot-
omy for operative vaginal delivery at their institution
between 1984 and 1994. Interestingly, the use of episiot-
omy fell signicantly whereas there was an increase in
the rate of vaginal lacerations and no signicant change
in the rate of third-degree lacerations with the use of
forceps or vacuum. In addition, there was a signicant
decrease in the rate of fourth-degree lacerations with
forceps use but not with vacuum.
12
Of interest is our nding of more periurethral tears in
the vacuum-assisted group than in the women delivered
with the assistance of forceps. More periurethral tears
were seen in the vacuum-assisted group even with the
performance of an episiotomy, suggesting the perfor-
mance of the episiotomy was not protective. Boll et al
8
found more periurethral tears in the women delivered by
vacuum, although the difference was not statistically
signicant (P .08).
Epidural anesthesia was used very frequently in both
groups but more so in the forceps group. It is possible
that in our institution physicians are more likely to use
forceps in women who have received an epidural. Gen-
erally, epidural anesthesia has been associated with
longer rst and second stages of labor.
13
The effect of
different epidural techniques on the second stage of labor
needs to be studied more carefully. Perhaps, a stricter
Table 5. The Effect of Forceps Use on Instrument Marks
and Bruising After Adjusting for Other Variables
on Multivariable Logistic Regression Analysis
Odds
ratio
95% condence
interval P
Parity 0.72 0.41, 1.25 .25
Birth weight 4,000 g 2.08 0.99, 4.34 .052
Episiotomy 0.96 0.47, 1.93 .90
Forceps 4.63 2.90, 7.41 .001
Prolonged 2nd stage 0.57 0.25, 1.28 .17
Epidural 1.41 0.66, 3.03 .37
Table 6. The Effect of Forceps Use on Neonatal Cephalo-
hematomas After Adjusting for Other Variables on
Multivariable Logistic Regression Analysis
Odds
ratio
95% condence
interval P
Parity 0.59 0.33, 1.06 .08
Birth weight 4,000 g 1.26 0.55, 2.89 .58
Episiotomy 1.53 0.71, 3.30 .28
Forceps 0.49 0.29, 0.83 .007
Prolonged 2nd stage 1.44 0.67, 3.13 .35
Epidural 0.89 0.45, 1.74 .73
Table 4. The Effect of Forceps Use on Major Perineal and
Vaginal Lacerations After Adjusting for Other Vari-
ables on Multivariable Logistic Regression Analysis
Odds
ratio
95% condence
interval P
Parity 0.80 0.52, 1.24 .32
Birth weight 4,000 g 2.09 1.06, 4.10 .03
Episiotomy 2.22 1.22, 4.05 .01
Forceps 1.85 1.27, 2.70 .001
Prolonged 2nd stage 1.80 0.94, 3.47 .08
Epidural 1.69 0.95, 3.01 .08
516 Johnson et al Forceps and Vacuum Deliveries OBSTETRICS & GYNECOLOGY
denition of prolonged second stage for nulliparas and
multiparas with or without epidural anesthesia should be
used and studied prospectively.
At our institution, 95% of the instrumental deliveries
were completed with 1 instrument. In the study by Boll
et al,
8
93% of the women were delivered with the in-
tended instrument. In the study by Johanson et al,
11
85%
of the women in the vacuum group and 90% in the
forceps group were delivered by the assigned instru-
ment. It is possible that the high rate of success with 1
instrument was the result of the appropriate selection of
the instrument. There are signicant concerns related to
maternal and neonatal injury when more than 1 instru-
ment is used. In these situations, we found the rates of
maternal and neonatal injury to be similar to the rates of
the instrument causing the highest injury when only 1
instrument is used. We did not encounter serious injury
but, in a retrospective review, Gardella et al
14
found that
the sequential use of vacuum and forceps was associated
with increased rates of intracranial hemorrhage, brachial
plexus, facial nerve injury, seizure, depressed 5-minute Ap-
gar score, assisted ventilation, fourth-degree and other lac-
erations, hematoma, and postpartum hemorrhage.
Neonates in the forceps group had a greater incidence
of instrument marks and bruising, whereas neonates in
the vacuum-assisted group had more cephalohemato-
mas. These ndings are consistent with the studies of
Johanson et al,
8
Boll et al,
9
and Wen et al.
11
At our institution, the use of vacuum has increased
whereas forceps use has decreased during the past 10
years. Our institutions 6% rate of operative vaginal
deliveries is comparable with 36% of the North Ameri-
can residency programs.
6
Fifty-nine percent of our oper-
ative vaginal deliveries were accomplished with the as-
sistance of the vacuum. Twenty-one percent of the
residency programs use vacuum in 51% to 75% of their
operative vaginal deliveries, whereas 68% of the resi-
dency programs prefer forceps and use vacuumless than
50% of the time.
6
In many parts of the country, vacuum
use has surpassed forceps delivery.
15
We anticipate the
rate of operative vaginal deliveries to continue to de-
crease because there is less training of residents as the
result of a shortage of skilled obstetricians, the cesarean
delivery rate increases, and the medical malpractice en-
vironment worsens.
Residents are assigned to the deliveries while being
supervised by attending physicians with different de-
grees of expertise. Although vacuum extraction clearly
causes less signicant maternal trauma, the incidence of
cephalohematomas is increased. Even although cephalo-
hematomas are not considered serious and the majority
resolve without much consequence, subgaleal and sub-
arachnoid hemorrhages are rare but signicant injuries
associated with the vacuum extractor. Instruments used
to accomplish vaginal delivery must be used with caution
and the delivery supervised by trained personnel. Our
ndings should assist obstetricians in selecting an instru-
ment for an operative vaginal delivery and in counseling
the patient regarding the risks and benets of alternative
approaches.
The limitations of our study were related to its retro-
spective nature and the lack of randomization. Delivery
documentation was incomplete. Newborn examinations
were performed by physicians who knew the delivery
information therefore the exams may have been selec-
tive rather than objective. More information related
to the use of regional anesthesia would have been bene-
cial in understanding its relation to the second stage of
labor. Despite their limitations, our ndings are in agree-
ment with other prospective studies.
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Address reprint requests to: Dr. Reinaldo Figueroa, Depart-
ment of Obstetrics and Gynecology, Winthrop-University
Hospital, 259 First Street, Mineola, NY 11501; e-mail:
rgueroa@winthrop.org.
Received November 24, 2003. Received in revised form November 25,
2003. Accepted December 4, 2003.
518 Johnson et al Forceps and Vacuum Deliveries OBSTETRICS & GYNECOLOGY

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