Assisted Vaginal Delivery

Indications (after fetal engagement)

• Prolonged 2nd stage of labor
• Fetal compromise
• Medical maternal disorder that prevent the use of Valsalva maneuver
(cardiac, neural, pulmonary disease)
Contraindications
• Fetal prematurity (for vacuum only)
• A fetus with osteogenesis emperfecta
• Fetal bleeding diathesis
• Unengaged head
• Unknown fetal position
• Brow or face presentation
• Suspected fetal-pelvic disproportion
PREREQUISITES
• Cervix is fully dilated.
• Membranes are ruptured.
• Head is engaged (at least 0/5 cm station). Forceps should never be
used when the head is not engaged.
• Fetal presentation, position, station, and any asynclitism are known,
and extent of molding is estimated. The fetus must be in a cephalic
presentation (unless the purpose is to use Piper forceps to assist in
delivery of an after-coming head in a breech presentation).
• Fetal size is neither too large nor too small
• Clinical pelvimetry suggests an adequate pelvis relative to estimated fetal size.
• The patient consents to the procedure. The medical record should document the
indication for the procedure, relevant clinical assessment of mother and fetus,
and a summary of the informed consent discussion (specific risks, benefits,
alternatives).
• The option of performing an immediate cesarean delivery is available if
complications arise. Personnel for neonatal resuscitation are available, if needed.
• The patient has adequate anesthesia for the planned procedure.
• The maternal bladder is empty, as this may provide more room for fetal descent
and possibly reduce injury to the bladder.
Vacuum vs Forceps
• Forceps for difficult vaginal deliveries, but has a higher rate of
maternal and fetal injuries. Can be used in prematures.
• Vacuum is easier to apply but can’t be used in prematures and can
easily detach from the fetal head. They also have lower risk of
maternal and fetal injuries.
Choice of vacuum cup
• Rigid: less likely to detach, has higher rate of success, more risk of
maternal and fetal injuries.

• Soft: More likely to detach, has a lower rate of success, less risk of
maternal or fetal injuries.
Forceps choices
• Simpson forceps: for molded head
• Elliott type forceps or Tucker-McLane type forceps: for unmolded
head.
• Kielland forceps: for fetuses with asynclitism (because they have a
sliding lock).
• Piper forceps: for delivery of after coming head in breach
presentation.
Sampson forceps
Kielland forceps
Elliott type forceps
Tucker-McLane forceps
Piper forceps
When to abandon?
• After 15-20 min of pulling, or after 3 failed attempts of pulling.
Complications - Vacuum
• Intracranial hemorrhage
• Intraventricular hemorrhage
• Subgaleal hematoma
• More risk of dystocia than when forceps used (ie, higher rates of
brachial plexus injuries)
Complications - Forceps
• Skin markings
• Intracranial hemorrhage
• Facial nerve palsy
• Skull fracture