Clinical Review

2015 Update on operative vaginal delivery

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New questions in the old debate of forceps versus cesarean delivery

In this Article

  • Rate of suboptimal instrument placement
  • Are we educating ourselves in the most productive manner?
  • Keep the risks of second-stage cesarean in mind



There’s a cyclical lament in obstetrics, and it goes something like this: Forceps are waning and are going to fade away completely if something isn’t done about it. This lament resounds every few decades, as a look at the literature confirms:

  • 1963: “Midforceps delivery—a vanishing art?”1
  • 1992: “Kielland’s forceps delivery: Is it a dying art?”2
  • 2000: “Operative obstetrics: a lost art?”3
  • 2015: “Forceps: towards obsolescence or revival?”4

In this, our latest cycle of lament, 4 or 5 papers have suggested that forceps in general and Kielland forceps in particular ought not be abandoned because outcomes are better than those suggested by the older literature. With the cesarean delivery rate hovering at about 31% in the United States, perhaps it is time to revisit the issue.

This Update is not intended to be a comprehensive review of the literature. Rather, it offers a snapshot of articles published within the past year—articles that highlight some new features of a very old debate:

  • a nested observational study of 478 nulliparous women at term undergoing instrumental delivery, which found that instrument placement was “suboptimal” in a significant percentage of deliveries
  • a retrospective study of major teaching hospitals, minor teaching facilities, and nonteaching institutions in 9 states, which found forceps delivery volumes so low they may make it difficult for clinicians to maintain their skills and prevent many trainees from acquiring proficiency
  • a commentary calling for the discontinuation of forceps deliveries in light of an ultrasonographically identified injury to the pelvic floor—levator ani muscle ­avulsion—and a cadaveric study refuting this argument
  • a systematic review and meta-analysis of maternal and neonatal morbidity following cesarean delivery in the first stage versus the second stage of labor.

With the cesarean delivery rate hovering at about 31% in the United States, it may be time to revisit the use of forceps in general and Kielland forceps in particular.

Forceps and vacuum device placement is “suboptimal” in almost 30% of operative vaginal deliveries
Ramphul M, Kennelly MM, Burke G, Murphy DJ. Risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery: observational study nested within the Instrumental Delivery & Ultrasound randomised controlled trial ISRCTN 72230496. BJOG. 2015;122(4):558–563.

Rouse DJ. Instrument placement is sub-optimal in three of ten attempted operative vaginal deliveries. BJOG. 2015;122(4):564.

Over the years, many clinicians have argued that we don’t do enough forceps deliveries to maintain our own competence with the procedure, let alone teach residents how to perform it. This observational study nested in a randomized clinical trial is intriguing because Ramphul and colleagues looked for objective evidence of clinicians’ skill at the vacuum and forceps. Specifically, they looked for evidence that the forceps or vacuum was malpositioned during attempts at operative vaginal delivery. In the process, they nicely documented the absolute rate of malpositioning of the forceps and vacuum, finding that it is much higher than expected, even in an institution that performs a lot of operative vaginal deliveries.

Details of the trial
A cohort of 478 nulliparous women at term (≥37 weeks) underwent instrumental delivery at 2 university-affiliated maternity hospitals in Ireland. Ramphul and colleagues documented fetal head position prior to application of the instrument and at delivery. The midwife or neonatologist attending each delivery examined the neonate after birth and recorded the markings of the instrument on the infant’s head to determine whether instrument placement had been optimal.

Instrument placement was considered optimal when the vacuum cup included the flexion point (3 cm anterior to the posterior fontanelle) and the posterior fontanelle, with central placement. For forceps, instrument placement was considered optimal when the blades were positioned bilaterally and symmetrically over the malar bones. Two main types of forceps were used in this study—direct-traction Neville Barnes forceps (n = 138) and rotational Kielland forceps (n = 13)—and the rates of optimal and suboptimal placement were similar between them.

Each case was labeled as “optimal” or “suboptimal” by 2 investigators, with a third observer arbitrating when the 2 investigators differed in opinion.

Instrument placement was clearly documented in 478 deliveries, 138 of which (28.8%) involved suboptimal placement. There was a lower rate of induction of labor among deliveries with suboptimal placement (42.8% vs 53.2%; odds ratio [OR], 0.66; 95% confidence interval [CI], 0.44–0.98; P = .038). There were no differences between the optimal and suboptimal groups in terms of duration of labor, use of oxytocin, and analgesia. In addition, the seniority of obstetricians performing operative vaginal delivery was similar between groups.

Fetal malposition was more common in the suboptimal group (58.7% vs 37.4%; OR, 2.44; 95% CI, 1.62–3.66; P<.0001). Midcavity station also was more common in the suboptimal group (82.6% vs 73.8%; OR, 1.68; 95% CI, 1.02–2.78; P = .042).


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