The Royal Australian

and New Zealand

College of
Obstetricians and
Gynaecologists

College Statement
C-Obs 16
1st Endorsed: July 2002
Current: November 2012
Review: November 2015

C-Obs 16

Instrumental Vaginal Delivery

Instrumental Vaginal Delivery remains an important facet of modern obstetric practice. Vacuum
and forceps assisted vaginal delivery account for a fairly constant rate of 11% of deliveries in
Australia (1990-2009)1 and 10% of deliveries in New Zealand.2 Rates have been reported to vary
from 7.4-16% of all deliveries across a spectrum of Australian and New Zealand hospitals.3 A
number of reviews and guidelines have been published.4,5,6,7
Indications for Instrumental Delivery
There are few absolute indications or contraindications to instrumental delivery. Each case should
be judged on its merits taking into account the relative benefits and adverse effects of the possible
courses of action. Instrumental delivery is employed to accelerate delivery in the presence of:

Fetal compromise suspected or anticipated

The few hours immediately prior to birth is the time of greatest risk to the well-being of most
people in their entire life. The risk is even greater in the second stage of labour where fetal
descent may precipitate cord compression or a combination of intense uterine activity and
expulsive efforts by the mother may reduce placental blood flow to the extent that the fetus
is seriously compromised. It is fortuitous that, at the time of greatest fetal risk, instrumental
delivery can often be rapidly and safely accomplished.

Delay in the second stage of labour

There is no clear demarcation as to an appropriate length of time to wait before embarking
on instrumental delivery for failure to progress. Traditionally two hours in a primigravid and
one hour in a multigravid have been proposed as a cut off for prolonged second stage but
there is paucity of scientific data on which to base this practice, and the duration of second
stage may be altered by the presence of neuraxial anaesthesia. The upper time limit for
second stage should be a matter for the senior clinician supervising the labour and patient
given the particular circumstance. The following should be noted in making the decision.
a. Increased fetal compromise occurs with prolonged pushing in second stage or when the
presenting part is low on the perineum for an extended length of time. These concerns
arise largely from publications prior to the widespread use of electronic fetal monitoring.
Where electronic fetal monitoring is being utilised and shows no abnormality, the fetal
risks of a prolonged second stage are likely to be low.
b. Pelvic floor injury including anal sphincter dysfunction is more common both with
prolonged second stages and with instrumental delivery.8

Maternal effort contraindicated

Maternal valsalva may sometimes be contraindicated with maternal conditions such as
cerebral aneurysm, risk of aortic dissection, proliferative retinopathy, severe hypertension
or cardiac failure. Such women may benefit from epidural analgesia and elective
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RANZCOG College Statement: C-Obs 16

instrumental delivery.
Complications of instrumental delivery
The adverse effects of instrumental delivery must be weighed against the consequences of
awaiting vaginal delivery or alternatively performing a caesarean section with the head deep in the
pelvis. The more serious complications are very uncommon but include:

Fetal complications
a. Shoulder dystocia and consequences
The need to perform an instrumental delivery for lack of progress in the presence of
anticipated macrosomia should alert the clinician to the increased likelihood of shoulder
dystocia.9
b. Subaponeurotic/subgaleal haemorrhage
A potentially life threatening complication, occurring in approximately 1 in 300 cases of
vacuum delivery.10,11
c. Facial nerve palsy, corneal abrasion, retinal haemorrhage
Facial nerve palsy and corneal abrasion are more common with forceps and retinal
haemorrhage with vacuum delivery.6
d. Skull fracture and/or intracranial haemorrhage
e. Cervical spine injury
A consequence of rotational forceps delivery may be minimised by ensuring uterine
relaxation prior to performing the rotation.

Maternal complications
The Cochrane review indicates a lower incidence of serious maternal injury (vaginal trauma
and anal sphincter damage) with vacuum assisted delivery when compared to forceps.6

Choosing between Vacuum and Forceps delivery

Each instrument has a different profile of complications.6 Delivery is more likely to be achieved with
forceps than vacuum and will occur over a shorter time interval.12 The clinician should select the
instrument based on his or her clinical experience and the clinical circumstances.
Failed Instrumental Delivery
Failed instrumental delivery may be associated with adverse outcome.13 The following comments
are pertinent to this situation.

Each case should be assessed as to whether alternate instrumental delivery (e.g. forceps
after failed vacuum) should be attempted or a caesarean section performed without further
attempt at instrumental delivery.

On occasions, reports of poor outcome may reflect the indication for which instrumental
delivery was being attempted (e.g. extremely severe fetal compromise) rather than an effect
of attempts at instrumental delivery.

The threshold for abandoning an instrumental delivery and resorting to an alternate mode of
delivery is likely to differ between clinicians and the clinical circumstances.
Guidelines for Instrumental Delivery
Safe operative vaginal delivery requires careful assessment of the clinical situation, clear
communication with the mother and healthcare personnel and expertise in the chosen procedure.
Appropriate analgesia should be used.

RANZCOG College Statement: C-Obs 16

Obstetric pre-requisites for Instrumental Vaginal Delivery:

Full dilatation of the Cervix and membranes ruptured.

Engagement of the Fetal Head

The presenting part must be engaged before beginning an instrumental vaginal delivery.
Engagement is defined as the maximum diameter of the presenting part having entered the
pelvic inlet. This is determined clinically by both abdominal palpation and vaginal
examination.

Favourable presentation
Instrumental delivery may occur with a vertex, deflexed vertex or face (mento-anterior)
presentation. The latter is a contraindication to vacuum delivery.

The exact position of the fetal head has been determined so proper placement of the
instrument can be achieved (ultrasound may assist this assessment).

The pelvis is assessed clinically to be adequate for safe delivery.

Maternal bladder has been recently emptied.

Clear explanation given and consent obtained.

o Verbal consent, preferably witnessed by a health care professional and later
documented in the medical record, is reasonable in the labour ward setting.
Consideration should be given to written consent if a forceps delivery is to be
attempted in theatre.

Personnel present who are trained in neonatal resuscitation.

Back-up plan exists in case of failure to deliver.

o Consideration given to performance in theatre with a view to proceeding to caesarean
section if there is concern in this regard.

Anticipation of complications which may arise (e.g. shoulder dystocia, post-partum

haemorrhage).

Appropriately skilled personnel available for neonatal resuscitation.

Fetal contraindications to Instrumental Delivery
A fetal bleeding disorder (e.g. alloimmune thrombocytopenia) or predisposition to fracture (e.g.
osteogenesis imperfecta) are relative contraindications to instrumental delivery but will also be
associated with considerable fetal and maternal risk if the baby is to be delivered abdominally with
the head deep in the pelvis.
A vacuum extraction should not be used on a face presentation or at a gestational age of less than
34 weeks. Between 34 and 36 weeks, there is no clear safety data to guide clinical practice.
References
1. Australias Mothers & Babies Report (1999-2009). Perinatal Statistics Reports. AIHW
National Perinatal Epidemiology & Statistics Unit. Available
at: http://www.preru.unsw.edu.au/PRERUWeb.nsf/page/Perinatal+Statistics
2. Reports on maternity (1999-2002, 2004) New Zealand Minister of Health Publications.
Available at: http://www.health.govt.nz/publications/births
3. Womens Hospitals Australasia. Clinical Forum on Caesarean Sections Briefing Kit
2001, pp. 4-5, 47.
4. ACOG Committee on Practice Bulletins - Obstetrics. ACOG Practice Bulletin, 2000: 17
(reaffirmed 2012).
5. Royal College of Obstetricians and Gynaecologists Guidelines and Audit Committee.
RCOG Clinical Green Top Guidelines. Instrumental Vaginal Delivery No.26. (2011)
Available at: www.rcog.org.uk/files/rcog-corp/GTG26.pdf
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RANZCOG College Statement: C-Obs 16

6. OMahony F, Hofmeyr G J, Menon V. Choice of Instruments for Assisted Vaginal

Delivery (Review) IN: The Cochrane Library 2010, Issue 11. DOI:
10.1002/14651858.CDOO5455.pub2. Available
at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005455.pub2/pdf
7. Guidelines for Operative Vaginal Birth. SOGC Clinical Practice Guidelines 2004.
Available at: http://www.sogc.org/guidelines/public/148E-CPG-august2004.pdf
8. Zetterstrom JP, Lopez A, Anzen B, Dolk A, Norman M, Mellgren A. Anal incontinence
after vaginal delivery: a prospective study in primiparous women. Br J Obstet Gynaecol
1999; 106: 324-330.
9. Kolderup LB, Laros LK, Musci TJ. Incidence of persistent birth injury in macrosomic
infants: association with mode of delivery. Am J Obstet Gynecol 1997; 177: 37-41.
10. Fortune PM, Thomas RM. Sub-aponeurotic haemorrhage: a rare but life-threatening
neonatal complication associated with ventouse delivery. Br J Obstet Gynaecol 1999;
106: 868-870.
11. Ng PC, Siu YK, Lewindon PJ. Subaponeurotic haemorrhage in the 1990s: a 3 year
surveillance. Acta Paediatr 1995; 84: 1065-1069.
12. Okunwobi-Smith Y, Cooke I, MacKenzie IZ. Decision to delivery intervals for assisted
vaginal vertex delivery. Br J Obstet Gynaecol 2000; 107: 467-471.
13. Edozien LC. Failed instrumental delivery: How safe is the use of a second instrument?
J Obstet Gynaecol 1999; 19: 460-2.
Links to other related College Statements
(C-Obs 11) Breech deliveries at term
http://www.ranzcog.edu.au/component/docman/doc_download/945-c-obs-11-management-of-term-breechpresentation-.html

(C-Obs 13) Rotational forceps

http://www.ranzcog.edu.au/component/docman/doc_download/947-c-obs-13-rotational-forceps-.html

(C-Obs 28) Prevention detection and management of Subgaleal Haemorrhage in the

newborn http://www.ranzcog.edu.au/component/docman/doc_download/960-c-obs-28-prevention-detectionand-management-of-subgaleal-haemorrhage-in-the-newborn-.html

(C-Gen 15) Evidence-based Medicine, Obstetrics and Gynaecology

http://www.ranzcog.edu.au/component/docman/doc_download/894-c-gen-15-evidence-based-medicineobstetrics-and-gynaecology.html?Itemid=341

Disclaimer
This College Statement is intended to provide general advice to Practitioners. The statement should never be relied on as a
substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient.
The statement has been prepared having regard to general circumstances. It is the responsibility of each Practitioner to have regard
to the particular circumstances of each case, and the application of this statement in each case. In particular, clinical management
must always be responsive to the needs of the individual patient and the particular circumstances of each case.
This College statement has been prepared having regard to the information available at the time of its preparation, and each
Practitioner must have regard to relevant information, research or material which may have been published or become available
subsequently.

RANZCOG College Statement: C-Obs 16

Whilst the College endeavours to ensure that College statements are accurate and current at the time of their preparation, it takes no
responsibility for matters arising from changed circumstances or information or material that may have become available after the date
of the statements.

RANZCOG College Statement: C-Obs 16