The document discusses the advantages and disadvantages of vacuum extraction versus forceps for assisted vaginal delivery. It summarizes that vacuum extraction is associated with less maternal trauma, less need for anesthesia, and lower failure rates compared to forceps. However, vacuum extraction may be associated with a higher risk of cephalhematoma, retinal hemorrhage, and intracranial hemorrhage in the baby. The choice of extraction method depends on the clinical situation and experience of the attending physician.

1. VACUUM VERSUS FORCEPS

2. Vacuum versus Forceps
*ACOG Practice Bulletin #17 (June 2000)
**Johnson RB. The Cochrane Library Issue 4, 1999
• “Selection of the appropriate instrument and decisions about
the maternal and fetal consequences should be based on
clinical findings at the time of delivery.”
• A meta-analysis comparing vacuum extraction to forceps
delivery showed that vacuum extraction was associated with
significantly:
– Less maternal trauma
– Less need for general and regional anesthesia

3. Effect of Delivery on Neonatal Injury
Towner D et al. Effect of Mode of Delivery in NulliparousWomen on Neonatal
Intracranial Injury. NEJM 1999;341:1709
DELIVERY DEATH ICH OTHER
NSVD 1/5,000 1/1,900 1/216
C/S IN LABOR 1/1,250 1/952 1/71
C/S P VAC OR FORCEPS N/R 1/333 1/38
C/S W/O LABOR 1/1,250 1/2,040 1/105
VACUUM 1/3,333 1/860 1/122
FORCEPS 1/2,000 1/664 1/76
VACUUM & FORCEPS 1/1,666 1/280 1/58

8. BLESSINGS

12. Sources of support:
Latin American Centre for Perinatology (CLAP). Pan American
Health Organization - W H O.
Acknowledgements:
Agustín Conde Agudelo for useful suggestions.
This document should be cited as:
Althabe F. Vacuum extraction versus forceps for
assisted vaginal delivery: RHL commentary (last
revised: 14 November 2002). The WHO
Reproductive Health Library; Geneva: World
Health Organization.

13. VACUUM EXTRACTION VERSUS FORCEPS FOR ASSISTED
VAGINAL DELIVERY
• USE OF THE VACUUM EXTRACTOR RATHER THAN FORCEPS
FOR ASSISTED DELIVERY APPEARS TO REDUCE MATERNAL
MORBIDITY.
• THE REDUCTION IN CEPHALHAEMATOMA AND RETINAL
HAEMORRHAGES SEEN WITH FORCEPS MAY BE A
COMPENSATORY BENEFIT.

14. VACUUM VERSUS FORCEPS
• Overview
• The decision to use a vacuum extractor instead of forceps in
assisted vaginal delivery is based on the clinical situation and
the experience and expertise of the doctor. For many
physicians, these two instruments are interchangeable, while
others feel more comfortable with one or the other. The use
of the vacuum extractor has recently increased while the
number of forceps deliveries has declined. Therefore, it is
possible that a physician may have more experience using the
vacuum extractor and this may be a key factor in the final
decision. The advantages and disadvantages of these two
methods are discussed next.

15. ADVANTAGES OF VACUUM DELIVERIES (VERSUS FORCEPS DELIVERIES)
LESS INJURY TO THE MOTHER'S SOFT TISSUES.
• Trauma to the vaginal walls /vaginal opening is decreased due
to easy placement of the instrument on top of baby's head.
• The vacuum extractor does not increase the width of the
presenting part of the fetus as can happen with forceps.
• The amount of vaginal trauma is directly related to the force
of the traction. In most cases, the amount of traction that can
be applied by vacuum is less than that produced by forceps.
• Therefore, the descent of the baby's head occurs in a more
controlled fashion when the vacuum is used. When the head
is delivered slowly, less tearing occurs.
• Significant maternal injuries were less likely when vacuum
extraction was used. As the overall reduction in maternal
injuries is the main benefit associated with vacuum
extraction, a better description of these maternal outcomes
would be desirable. The outcome "significant maternal injury"
is not defined.

16. EASE OF PLACEMENT.
• Because of its design, the vacuum may be applied to the top
of the baby's head as it becomes visible in the birth canal.
Forceps, on the other hand, must encircle the baby's head
and therefore it is extremely important to know the exact
position of the baby's head.
• The newer, soft plastic cups are pliable and can be folded for
insertion and maneuverability.
• There is also significant risk of injury to the vaginal walls
during placement of the forceps. If the baby's head is tilted
slightly to one side (asynclitic presentation), application of the
forceps may be impossible.
• There are, however, contraindications to vacuum placement
when the baby's head is in certain positions, so it is a
requirement, nonetheless, to know the position of the baby's
head.

17. LESS ANESTHESIA IS REQUIRED.
• Because the vacuum extractor is easier to apply and is
associated with less trauma to the vagina, it requires less
anesthesia.
• Although epidural anesthesia is preferable, vacuum extraction
may be performed after injection of local anesthetic that
numbs the lower vagina.
• When regional anesthesia (epidural or spinal block) is not
possible because of time constraints or unavailability, vacuum
extraction may be performed safely and comfortably after
local injection of medication.
• The use of pudendal or general anaesthesia and pain during
delivery were also less common in the vacuum group.
• The outcome "Regional and general anaesthesia" is presented
in a subgroup analysis. Pudendal, epidural and general
anaesthesia, are first analysed independently and a subtotal
typical relative risk is calculated for each one.

18. FEWER BOWEL PROBLEMS.
• Less bowel incontinence compared to forceps delivery; most
likely, this is due to potential for more vaginal trauma with
forceps- more likely to result in vaginal tears that partially
involve or even completely transect the anal sphincter and
rectal lining.
• This type of injury is referred to as a fourth-degree laceration
and can be associated with long-term anal sphincter
dysfunction, resulting in occasional leakage of stool or gas.
LESS FORCE/ TRACTION IS APPLIED TO THE BABY'S HEAD.
• One study found that vacuum extraction exerted
approximately 40% less force to the baby's head than forceps
delivery.
• Although vacuum delivery may be associated with
development of a bruise on top of the baby's head, the
forceps may cause similar injuries and may result in more
serious nerve or skull injuries.

19. DISADVANTAGES OF VACUUM DELIVERIES (VERSUS FORCEPS
DELIVERIES)
THE VACUUM CUP MAY BECOME DISLODGED.
• When the second stage of labor has been prolonged, it is
common to find that the baby's head has a significant amount
of swelling at the presenting point., it may be difficult to
obtain an optimal application of the cup against the baby's
head and the cup may become detached.
• Improper placement of the vacuum cup may also result in
detachment.
VACUUM EXTRACTION SHOULD BE USED ONLY IN FULL-TERM
INFANTS.
• Because of an increased risk of bleeding in the brain in
premature infants, the vacuum extractor should be used only
in term infants.
• This limits the use of vacuum extraction to deliveries at 34
weeks of gestation or later. Forceps may be used safely to
deliver preterm babies.

20. DELIVERY MAY TAKE LONGER.
• Vacuum traction should be applied only during contractions;
therefore, vacuum-assisted vaginal delivery may be slower
than forceps delivery.
• Forceps delivery may be performed with very little maternal
effort, while vacuum-assisted delivery requires maternal
participation.
SUCCESS RATES ARE SLIGHTLY LOWER FOR VACUUM
DELIVERIES.
• Compared to vacuum extraction, the use of forceps resulted
in greater success in achieving an instrument-aided vaginal
delivery.
• However, the caesarean section rate was lower with vacuum
extraction. This was so because after vacuum extraction
failed, an attempt to deliver by forceps was more likely than
the use of vacuum extraction after failure to deliver with
forceps.

21. INTRACRANIAL HEMORRHAGE IS MORE COMMON.
• Due to the pressure of the suction cup applied to the baby's
head, a particular type of serious bleeding, though rare, is
more common with and unique to vacuum delivery

22. ASSOCIATED WITH A HIGHER INCIDENCE OF
CEPHALHAEMATOMA AND RETINAL HAEMORRHAGE
• The use of vacuum was associated with a higher incidence of
cephalhaematoma and retinal haemorrhage, although the
latter was evaluated in a small proportion of infants.
TENDENCY TOWARDS A HIGHER INCIDENCE OF LOW APGAR
SCORES AT FIVE MINUTES
• There was also a tendency towards a higher incidence of low
Apgar scores at five minutes with the use of vacuum
extraction. It is possible that the higher use of an alternative
instrument after extraction failed in the vacuum group,
contributed to the worse neonatal outcomes associated with
the use of vacuum.
• No conclusion can be drawn about the effect on perinatal
mortality ,no differences were observed.

23. BENEFITS OF FORCEPS (VERSUS VAGINAL DELIVERY)
• It is currently estimated that 10 to 15% of all babies born in
are delivered via operative vaginal delivery, of which about
two-thirds are forceps deliveries and the remainder are
vacuum deliveries.
• The great majority of these forceps deliveries are outlet or
low-forceps deliveries. These deliveries pose little or no risk
to mother or baby and are an advantage in some situations.
For example, a baby who is shown to have an abnormal heart
rate can be safely delivered by outlet or low forceps delivery
and promptly evaluated with resuscitation as needed.

24. • Likewise, a woman who has been in the second stage of labor
for several hours, who is unable to make further progress for
whatever reason, and whose baby is at a station and position
consistent with an outlet or low forceps delivery, will clearly
benefit from such an operative vaginal delivery, with
negligible risks to her baby.
• Finally, a woman who has a medical condition that prevents
her from pushing in the second stage of labor can benefit
from an assisted vaginal delivery. The most common examples
of this include women with significant heart disease,
respiratory compromise, or certain neurologic conditions.

25. • Forceps delivery places a woman at higher risk for blood
transfusion and infection than does spontaneous vaginal
delivery. However, compared to women who deliver by
cesarean section following the onset of labor, women who
deliver with forceps have significantly lower rates of these
complications.
• An additional benefit of forceps delivery is the avoidance of a
surgical scar in the uterus (compared to cesarean section).
This is particularly significant if she plans to have additional
pregnancies. Women with histories of cesarean section have
increased risks in subsequent pregnancies (whether they opt
to attempt labor first or plan for repeat cesarean) that may
have been prevented by successful vaginal birth (with the use
of forceps or not) in the previous pregnancy.

26. RISKS OF FORCEPS (VERSUS VAGINAL DELIVERY)
 Potential risks associated with forceps deliveries must be
balanced against the potential benefits. These risks may affect
the mother or the baby.
 The possibility of injury to the mother, in the form of vaginal
tears or perineum incisions extending to rectum, increases –
o with rotations of greater than 45 degrees and
o at higher stations of the fetus's head. However, the likelihood
of injury to the perineum is no greater for outlet forceps
deliveries than for vaginal deliveries.
 Rectal sphincter dysfunction occurs more frequently during
forceps deliveries than spontaneous vaginal deliveries. This is
due to muscle damage rather than nerve injury; the doctor
can minimize this damage by pulling slowly and steadily with
the forceps during contractions.
 The mother's bladder should always be emptied (usually by
catheterization) immediately prior to a planned forceps
delivery. This will minimize risk of inadvertent bladder injury.

27.  Forceps deliveries are also associated with a greater risk for
blood transfusion than are spontaneous vaginal deliveries.
o Although elective (planned) cesarean births are associated
with decreased chances of transfusion in comparison to
forceps deliveries, emergency cesarean sections are
associated with increased chances for transfusion in
comparison to forceps deliveries.
 Forceps deliveries are associated with an increased risk of
injury to the newborn, particularly facial marks or injuries. On
the other hand, forceps deliveries are associated with less
bruising to the head (cephalohematoma) and retinal bleeding
than are vacuum deliveries.
 A prolonged second stage of labor should suggest an
increased risk of shoulder dystocia.
o Although the frequency of shoulder dystocia is increased in
forceps deliveries as compared to spontaneous deliveries, it
does occur in spontaneous deliveries and its association with
forceps deliveries has not been proven.

28. ALTERNATIVE TO CESAREAN SECTION
FORCEPS DELIVERY IN 21st CENTURY OBSTETRICS PRACTICE
• Obviously, there is a strong emphasis in this country on
pregnancies ending with a healthy mother and baby. There is
also clear evidence that the average age of women at their first
childbirth is increasing and that the average number of births
per woman is decreasing. All of these issues have contributed to
the increased frequency of operative deliveries (primarily
cesarean births) during the last quarter of twentieth century.
• There are now increasing numbers of health care providers,
health care consumers, and health insurance companies who
question the high cesarean birth rate and are searching for
alternative and safe methods to reduce this rate.
• In selected cases, it is clear that forceps delivery can, and
should, be used instead of cesarean section. When the criteria
for forceps delivery are met and when there are appropriate,
fetal and/or maternal indications for delivery, such assisted
vaginal deliveries are appropriate and safe.

29. • In view of the fact that there is a reduction in the rate of
maternal morbidity with vacuum extraction compared to the
use of forceps, in settings with good experience of the use of
vacuum extraction, this method should be promoted as the
first choice when an instrument aided delivery has to be
performed.
o In settings with little or no experience with the use of
vacuum, training programmes in vacuum extraction at
residency and senior level should be developed.
o The adoption of vacuum extraction as the first choice for
instrument-aided delivery should be promoted only after a
minimum standard of training has been reached.
o Participation of settings with low vaginal operative delivery
rates should be encouraged.

30. • The trial should compare two policies of instrumental
delivery: one in which vacuum extraction is the instrument of
first choice and the other in which forceps is the first choice.
• The type of vacuum extraction method in this trial should be
the one which is the best in terms of reducing failure rates
and neonatal morbidity. The main outcomes to be studied
should be neonatal outcomes and success in achieving vaginal
delivery.
• Long-term follow-up of infants should also be considered as
an important outcome to study.
• Such a follow-up study of the women and children
participating in the Johanson et al trial (Keele 93 in the
review) has been published .
• There were no significant differences between instruments in
terms of bowel or urinary dysfunction although urinary
incontinence was high overall (47%) at five years' follow-up.
There were also no differences with regard to development
and visual problems in children.

31. VACUUM VERSUS FORCEPS
 Decision to Delivery Interval 14mts 8mts
 Failed Delivery as 1stl line inst. 30% 20%
 LSCS Dec (rot+seq) Inc.
 Pain/Discomfort(A,D,24) Dec Inc
 Analg./Anesthesia Less (pudendal) More
MAT. INJ-
1. Serious(Tocophobia) 20%(anus+inconti) 80%
2. Less Serious (Cx,vag.,epi.,perineum) Less More
3. Non Serious (PPH,stay,BT) Less More
 Birth Asphyxia/APGAR -5 SAME
 Skull fracture/s.cord inj. Less More

32. NERVE INJ.
1. 8 th hearing,6th vision(cranial distort) More Less
2. 7th facial-mandible ramus, cr.plxs Less More
 Scalp- Stress-Cephalhematoma , More Less
o Scalp- Other inj.+Sub galeal Less More
 ICH Less More
 Face inj. Less More
 Eye- Retinal Hem. More Less
 Eye-S C Hem Less More
 Jaundice N.Hyperbil. More Less
 PNMR/Fetal Mortal. Less More
 NICU SAME
 F/U Adm. Less More
