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CHAPTER 169

FORCEPS- AND
VACUUM-ASSISTED DELIVERIES
Carol Osborn  •  Jennifer Bell  •  Dale A. Patterson

Knowledge and experience with instrument-assisted (forceps or With the classification change, the term high forceps has been
vacuum) delivery are important for all obstetrics providers managing eliminated. High forceps describes application of the forceps before
the second stage of labor, particularly if there is an emergency, such engagement of the vertex. This procedure has no place in modern
as severe fetal or maternal compromise. In unexpected situations the obstetrics because of unacceptably high morbidity rates. Mid-
knowledgeable use of an assisted delivery may be lifesaving and help instrumentation is reserved for providers who are experienced with
reduce morbidity. Assisted deliveries are also a safe alternative to an this application. If an obstetrics provider is uncomfortable with the
operative delivery, as long as criteria and indications are followed. evaluation or application of forceps, a cesarean section is likely a
The incidence of assisted delivery is decreasing (especially forceps safer route of delivery.
deliveries), in part because the incidence of cesarean delivery is Before any forceps or vacuum application proceeds, the position
increasing. Only 6% of all vaginal deliveries were assisted deliveries and station of the vertex presentation must be determined. First,
in the United States in 2002. The safe use of these procedures fetal engagement is verified. By definition, engagement indicates the
depends on understanding and clinically establishing the station and biparietal diameter has passed the plane of the inlet. Clinically the
position of the vertex. A Cochrane review comparing forceps with fetal skull is at or below the ischial spines (i.e., 0 station). Checking
vacuum found slightly more deliveries with vacuum, and fewer the amount of space between the fetal head and the symphysis gives
cesarean sections, less maternal trauma, and less general and regional an additional measurement of station (Fig. 169-1).
anesthesia use with vacuum. However, the vacuum extractor was Two things that complicate the clinician’s ability to ensure com-
associated with an increase in neonatal cephalhematoma and retinal plete engagement and assess descent are (1) molding, which leads
hemorrhages. Serious neonatal injury was uncommon with either to overestimation of descent or station, and (2) asynclitism or OP
form of assisted delivery or instrument. presentation, which also leads to overestimation of station. To avoid
this miscalculation, the clinician should always confirm that the
fetal head fills the sacral hollow. When the vertex fills the sacral
CLASSIFICATION hollow there should not be room to admit the fingers of the examin-
Because of difficulties in estimating engagement and in defining ing hand.
different stations, the American College of Obstetrics and Gynecol- Position can be difficult to determine, especially if the head has
ogy (ACOG) defined and reclassified instrumented deliveries. The marked caput. The following method helps determine position:
intention of this reclassification is to improve the safety of assisted
• Anterior fontanelle is shaped like a cross or plus (+) and is usually
deliveries and is discussed in the following sections.
larger than the posterior fontanelle.
• Posterior fontanelle is shaped like a Y.
Outlet Forceps or Vacuum • When in doubt, the clinician should find the fetal ears to deter-
mine position.
• Fetal skull has reached the pelvic floor.
• Fetal scalp is visible between contractions. If the position and descent meet criteria for an outlet or low
• Sagittal suture is in an anteroposterior diameter (i.e., occipitoan- instrumentation, then the provider needs to consider whether to use
terior [OA], right occipitoanterior [ROA], left occipitoanterior forceps or a vacuum to assist the delivery. The pros and cons of
[LOA], occipitoposterior [OP], right occipitoposterior [ROP], or forceps versus vacuum extraction are described in Box 169-1.
left occipitoposterior [LOP]) that is less than 45 degrees from the
midline.
INDICATIONS
Low Forceps or Vacuum Conditions Required for Instrumentation
• Leading edge of the vertex is at +2 or greater station. • Vertex presentation (As noted previously, instrumentation may
• Fetal head at this station fills the hollow of the sacrum. also be required to deliver the head in breech presentation.
• Head is not on the pelvic floor. However, vertex presentation is required for the usual suction and
• Rotations are less than 45 degrees. outlet or low forceps applications.)
• Complete cervical dilatation
• Ruptured membranes
Midforceps or Vacuum • No known severe cephalopelvic disproportion
• Head is engaged. • If unsuccessful, willingness to abandon procedure and proceed to
• Vertex is higher than +2 station. cesarean section
• Advisable only in emergency situations. • Adequate anesthesia is established

1145

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1146 OBSTETRICS

Symphysis Symphysis

l
eta
i p ari ter tric
B m e ste )
dia the ( o b te
ter
ve let et ga
o
Ab lvic i
n Inl onju iame s
c l d lvi
pe ari
et a pe d)
P P Bip rue ge
S n t ga
ti hi d en
Occiput w ea
above (h
ischial Occiput at or below
spines ischial spines

A B
Figure 169-1  A, When the lowermost portion of the fetal head is above the ischial spines, the biparietal diameter of the head is not likely to have
passed through the pelvic inlet and therefore is not engaged. B, When the lowermost portion of the fetal head is at or below the ischial spines, it is usually
engaged. Exceptions occur when there is considerable molding, caput formation, or both. P, sacral promontory; S, ischial spine. (Modified from Cunningham FG,
MacDonald P, Gant N, et al [eds]: William’s Obstetrics, 19th ed. East Norwalk, Conn., Appleton & Lange, 1993.)

Maternal Indications for Instrument Delivery • Malpresentation (face or breech); use forceps only. For breech
deliveries, forceps are often needed for the aftercoming head once
• Maternal exhaustion. This is associated with prolonged second- the body has been delivered.
stage pushing. Maternal exhaustion is especially common in the • Hemorrhage.
nulliparous labor. The lack of a trained labor companion during • Intrapartum infection.
the second stage is associated with a longer labor and increased
use of instrumentation.
• Lack of maternal cooperation. Fetal Indications for Instrument Delivery
• Prolonged second stage or failure to progress. The average • Nonreassuring fetal heart tracing
second stage is 50 minutes for primiparous patients and 20 • Rapid deterioration of the tracing or any condition that makes it
minutes for multiparous patients. Regional anesthesia prolongs unsafe for the fetus
the second stage by inhibiting the maternal urge to push (Table • Premature placental separation
169-1).
• Medical conditions for which the strain of the second stage of labor
would be deleterious. Examples include cardiac valvular disease, CONTRAINDICATIONS
respiratory disease (e.g., active asthma), cerebrovascular disease,
toxemia, and chronic hypertension. Absolute
• Fetal head not engaged
• Position of the head not determined (forceps)
Maternal and Fetal Indications for Instrument
Delivery Relative
• Relative cephalopelvic disproportion. • History of a failed forceps or vacuum delivery with a macrosomic
• Malposition (OP or OT). fetus

Box 169-1.  Forceps versus Vacuum Extraction


Forceps Vacuum
Pros Pros
Higher rate of successful vaginal delivery Easy to apply
Usually a more rapid delivery (e.g., for fetal Teaches the clinician to follow the pelvic curve
distress) Allows autorotation from occipitoposterior and occipitotransverse positions
Useful in breech (for the aftercoming head) Less force applied to the head
and face presentations Requires less anesthesia
Useful for rotations if clinician is experienced Results in fewer cervical, vaginal, and perineal lacerations
with these Easier to learn
Cons Clinician can use if not completely sure of head position
Requires significant experience Cons
Increased risk of neonatal craniofacial injuries Difficult to maintain vacuum if head is molded or infant has full head of hair
Increased risk of intracranial hemorrhage Pull only with contractions, which increases time needed for successful delivery
Requires more maternal anesthesia Associated with intracranial hemorrhage at a greater rate than spontaneous
Associated with more cervical, vaginal, and deliveries
perineal lacerations Only useful in vertex presentations
Increased incidence of cephalhematomas and retinal hemorrhage

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169  ——  FORCEPS- AND VACUUM-ASSISTED DELIVERIES 1147

TABLE 169-1  Limits of the Duration of the Second


Stage of Labor before Intervention
Without Regional With Regional
Parity Anesthetic Anesthetic

Nullipara 2 hr 3 hr


Multipara 1 hr 2 hr

• Suspected fetal coagulation defect


• Incomplete cervical dilatation (only exceptions are the urgent
delivery of a second twin and a severely abnormal tracing without
immediately available cesarean section) Figure 169-3  Tucker-McLean forceps.
• Delivery requiring excessive traction
• Prematurity (vacuum not recommended before 34 weeks’ gesta- PREPROCEDURE PATIENT EDUCATION
tion because of increased risk of intracranial hemorrhage)
• Malpresentation (e.g., breech, face, brow, transverse lie) Assisted delivery is a procedure that most women would choose to
• Prior scalp sampling (vacuum) avoid during their labor. It is optimal to discuss the possibility of the
• Position of fetal head not precisely determined in vertex presen- need for vacuum or forceps delivery before a patient is in labor, but
tation (vacuum) this is not always possible. Nonetheless, the risks and benefits of the
procedure must be explained to the patient in as much detail as
possible prior to attempting an assisted vaginal delivery. Consent
EQUIPMENT for the procedure should be obtained.
Include all equipment listed for normal vaginal delivery (see Chapter
177, Vaginal Delivery). Modern vacuum extractors are available TECHNIQUE
from numerous suppliers. Both rigid and soft cups are available; each
has advantages over the other. Rigid cups more often result in a Forceps Delivery
successful assisted delivery, but they are also more likely to be asso- The forceps have interlocking parts with a right and a left side that
ciated with complications. The operator should be familiar with the correspond to the side of the maternal pelvis in which they lie when
models available at the institution and should be trained in their applied. Each side has a handle, shank, and blade. The Simpson
proper use. Any associated tubing or pumps must also be available. forceps is most commonly used for low and outlet deliveries.
The Mityvac is one example of a vacuum apparatus (Fig. 169-2). Initially developed by Dr. J. Bachman, the acronym ABCDEF-
Tucker-McLean (Fig. 169-3) and Simpson (Fig. 169-4) forceps are GHIJ has become part of the Advance Life Support in Obstetrics
commonly used forceps with vertex presentation of term infants. (ALSO) curriculum; it is useful when training for forceps- and
Again, local availability and user training should determine the type vacuum-assisted deliveries. Except for F, G, and H, the acronym is
of forceps employed. Both forceps and vacuum equipment should be essentially the same for both procedures:
readily available on all labor floors.
A: Is the anesthesia adequate? Consider a local or pudendal block
or both. Ask for help.
PRECAUTIONS B: Is the bladder empty? Straight catheterize if needed.
The Food and Drug Administration (FDA) published a public advi- C: Is the cervix completely dilated?
sory in 1998 concerning complications resulting from vacuum deliv- D: Determine the position of the fetal head. Consider shoulder dys-
eries. The FDA found a fivefold increase in death and serious injury tocia (i.e., why is there a delay?).
after vacuum deliveries. Although part of this increase may be due • Anterior fontanelle is larger and forms a cross.
to the increased use of this procedure, the blame may also lie in • Posterior fontanelle is smaller and forms a Y.
failing to follow established protocols. The most concerning com- • Find the ear, feeling which way it bends.
plication is a life-threatening subgaleal hematoma. The length of • The descent should be to a +2 station, with the vertex filling
application of the vacuum may also be an important factor in the the sacrum.
development of complications. It is not recommended to apply a
vacuum for more than 20 minutes.

Figure 169-2  Mityvac extractor. Figure 169-4  Simpson forceps.

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1148 OBSTETRICS

E: Is the equipment ready (e.g., infant suction bulb, cord clamp, 2. Initially, one hand pulls the forceps handles in the same
instrument table)? direction that the handles extend (an approximately horizon-
F: Are the forceps ready for application? tal vector, outward and away from the mother).
1. Articulate the forceps to ensure a proper fit. 3. The other hand is placed on the shaft close to the perineum
2. Disarticulate the handles and take the left handle in your left and pushes in a downward vector.
hand (holding it like a pencil with concave cephalic curve 4. The summation of these two vectors creates an outward-and-
toward the vulva and the shank directed upward, perpen- downward force.
dicular to the floor). 5. As the crown of the head moves from under the symphysis,
3. Begin to ease the forceps along the left side of the fetal head the traction should begin upward. (For OP deliveries, the
(OA); use your right hand to protect the maternal sidewalls horizontal traction continues until the base of the infant’s
and guide the blade into position. (The right thumb is placed nose passes under the symphysis.)
on the heel of the blade and gently inserted.) H: The handle is elevated to follow the J-shaped pelvic curve (see
4. Right forceps handle is then held in your right hand. Fig. 169-5B).
5. Insertion is along the right side of the fetal head, with the I: Evaluate for the need for an episiotomy incision. The amount of
left hand protecting the maternal right pelvis and guiding the distention of the perineum will dictate the need. (For OP deliv-
blade into place. eries, there will be greater distention of the vulva, and a large
6. If correctly applied, the handles should fit together easily and episiotomy may be needed.)
lock easily. J: The forceps are removed when the jaw of the infant is reachable.
7. Check the application position for safety (posterior fonta-
nelle, fenestration, sagittal suture).
• Posterior fontanelle should be midway between the shanks
Vacuum Delivery
and 1 cm above the plane of the shanks. A: Is the anesthesia adequate? Ask for help.
• Fenestrations of the forceps should admit no more than B: Is the bladder empty?
one fingertip. C: Is the cervix completely dilated?
• Sagittal suture should be midline and midway between the D: Determine the position of the fetal head. Consider shoulder dys-
shanks. (For OP deliveries, the blades should be equidis- tocia (i.e., why is there a delay?).
tant from the midline of the face and brow.) • Anterior fontanelle is larger and forms a cross.
G: Use gentle traction (i.e., Pajot’s maneuver) (Fig. 169-5). • Posterior fontanelle is smaller and forms a Y.
1. The pelvic curve from the inlet through the outlet is described • Find the ear, feeling which way it bends.
as a J-shaped curve. • Descent should be to a +2 station, with the vertex filling the
sacrum.
E: Equipment and extractor ready (infant suction bulb, cord clamp,
instrument table, etc.)?
F: Insert and apply the cup over the posterior fontanelle.
• Wipe vertex clean of blood and fluid.
• Spread the labia.
• Compress and insert the cup.
• Place the cup over the posterior fontanelle (or over the sagit-
tal suture up to 3  cm in front of the posterior fontanelle,
toward the face).
• Sweep the finger around the cup to check for trapped mater-
nal tissue.
• Calibrate the vacuum dials, noting that yellow (10 mm Hg)
is the resting suction and that red (50 mm Hg) is the suction
pressure required for traction during contractions.
G: Use gentle traction (Fig. 169-6).
1. Apply traction at right angles to the plane of the applied
surface of the cup.
A

B
Figure 169-5  Occiput anterior delivery by outlet forceps (Simpson).
The direction of gentle traction for delivery of the head is indicated. Ini- Figure 169-6  Correct position of the vacuum cup and the correct direc-
tially, the forceps are horizontal (A) and they are gradually rotated forward tion of traction before the vertex clears the symphysis pubis. (Modified from
(B). Forces are as noted. Epperly T, Breitinger R: Vacuum extraction. Am Fam Physician 38:205, 1988.)

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169  ——  FORCEPS- AND VACUUM-ASSISTED DELIVERIES 1149

Figure 169-7  Occipitoposterior application (A), rotation (B), and


delivery (C) using vacuum extractor. (Modified from Lowdermilk DL, Perry
SE, Bobak IM: Maternity and Women’s Health Care, 7th ed. St. Louis, Mosby,
2000.)

A B C

2. Do not rock or torque the cup or handle. Only use gentle, COMMON ERRORS
steady traction.
3. As the fetal head moves around the symphysis and extends, • Starting the procedure too soon: Be sure that head is engaged and
the vacuum handle will rise from a horizontal to a nearly position is clear prior to attempting assisted vaginal delivery.
vertical position. (The angles and traction are more difficult • Incorrectly positioning the instrument: Ensure proper placement
for OP deliveries, with the handle often pointing toward the of vacuum or forceps prior to pulling.
floor.) • Including vaginal tissue in the vacuum application: Circle finger
4. If the cup detaches, consider the following problems: inade- around cup to ensure no tissue has been trapped between the cup
quate vacuum suction, trapped maternal tissue, a fetal scalp and the head.
electrode in the way, incorrect application of the extractor • Continuing with assisted vaginal delivery when success is
(not over the flexion point), or bending or rotation of the unlikely: Be prepared to stop and proceed to a cesarean section
shaft. if unable to deliver within 20 minutes or if vacuum “pops off”
H: Halt traction when the contraction is over. three times.
1. Reduce the vacuum to 10 mm Hg between contractions.
2. Repeat the gentle-traction cycle with the next contraction. COMPLICATIONS
3. Halt the procedure if the cup disengages more than three
times, if no progress is noted after three consecutive pulls, or • Cervical, vaginal, or perineal lacerations
if a delivery does not occur after 20 minutes of intermittent • Postpartum hemorrhage from the lacerations
traction. • Fetal birth trauma (e.g., fractured clavicle, cephalhematoma, lac-
4. Use caution when attempting a forceps delivery after a failed erations, abrasions, facial nerve palsy, intracranial and retinal
vacuum extraction (only if the vertex is right on the hemorrhage)
perineum). A cesarean section may be a better choice (intra- • Subgaleal hematoma
cranial hemorrhage is more common after a failed vacuum • Shoulder dystocia
extraction followed by a forceps delivery). • Neonatal scalp emphysema
I: Make an incision for episiotomy, if necessary. A midline episi- • Cephalhematoma
otomy may be associated with increased risk of third- and fourth- • Hyperbilirubinemia
degree perineal lacerations. • Fetal cervical trauma
J: Remove the vacuum cup when jaw of the infant can be reached • Maternal discomfort at delivery
or is delivered. • Maternal urinary retention

A suction application can also be used to rotate the head from


an OP to an OA position before delivery (Fig. 169-7). POSTPROCEDURE PATIENT EDUCATION
Instrument-assisted deliveries increase the level of maternal concern
for the infant. The provider should discuss the need for the instru-
SAMPLE OPERATIVE REPORT ment delivery and maternal perceptions regarding the delivery on
The operative report from an assisted vaginal delivery should be the first postpartum day. After the procedure, the patient should be
included in the delivery note. The actual note will vary greatly advised to monitor the following and report any changes to the
depending on the individual labor and local custom. Following is an practitioner:
outline of suggested topics to include in this note: • Bleeding
• Fever
• Preoperative diagnosis (note indication for the assistance, such • Dysuria and urinary retention
as maternal exhaustion) • Pelvic pain (could indicate hematoma)
• Postoperative diagnosis (note preoperative diagnosis and result of
the procedure [e.g., vaginal delivery, term infant, weight, Apgar
score, cord pH]) CPT/BILLING CODES
• Operation (note outlet forceps or vacuum extraction) 59400 Global vaginal delivery (antepartum, vaginal delivery with
• Instrument (e.g., Simpson forceps) or without episiotomy and/or forceps or vacuum) and
• First stage (note length, interventions, any complication) postpartum care
• Second stage (same information as in first stage, including type 59409 Vaginal delivery only (with or without episiotomy and/or
of fetal monitoring) forceps or vacuum)
• Third stage (type of placenta delivery, description of placenta) 59410 Vaginal delivery only (with or without episiotomy and/or
• Repairs forceps or vacuum) including postpartum care
• Bladder 59610 VBAC (global)
• Estimated blood loss 59899 Unlisted procedure, maternity care and delivery
• Anesthesia (induction)

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1150 OBSTETRICS

ICD-9-CM DIAGNOSTIC CODE Hook CD, Damos RJ: Vacuum-assisted vaginal delivery. Am Fam Physician
78:953–960, 2008.
669.51 Forceps or vacuum delivery, without mention of indication Johanson RB, Menon BK: Vacuum extraction versus forceps for assisted
vaginal delivery. Cochrane Database Syst Rev 2:CD000224, 2000.
Putta LV, Spencer JP: Assisted vaginal delivery using the vacuum extractor.
BIBLIOGRAPHY Am Fam Physician 62:1316–1320, 2000.
American College of Obstetricians and Gynecologists: Operative vaginal Ratcliffe S, Byrd J, Sakornbut E: Pregnancy and Perinatal Care in Family
delivery. Practice Bulletin No. 17. Washington, DC, American College Practice. Philadelphia, Hanley & Belfus, 1996.
of Obstetricians and Gynecologists, June 2000. Society of Obstetricians and Gynaecologists of Canada: Guidelines for oper-
Bachman J: Forceps delivery (letter). J Fam Pract 29:360, 1989. ative vaginal birth. Int J Gynaecol Obstet 88:229–236, 2005.
Damos J: ALSO Curriculum. Leawood, KS, American Academy of Family Tuggy M, Garcia J: Procedures consult. Available at www.proceduresconsult.
Physicians, 2000. com, and as an application at www.apple.com/iTunes.
Forceps delivery and vacuum extraction. In Cunningham FG, Hauth JC,
Leveno KJ, et al (eds): William’s Obstetrics, 22nd ed. New York, McGraw-
Hill, 2005.

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