Operative Vaginal Delivery Strategies May Curb Risk


SAN FRANCISCO — Use of forceps or vacuum extractor during a vaginal delivery seldom is the sole cause of litigation, but you can reduce that risk even more, several speakers said at a conference on ob.gyn., perinatal medicine, neonatology, and the law.

Operative vaginal delivery can invite litigation when one of the following happens, according to Larry C. Gilstrap III, M.D., professor and chair of ob.gyn. and reproductive services at the University of Texas at Houston:

Forceps or vacuum are used for an inappropriate indication, and the baby is damaged. Indications include a prolonged second stage of labor, fetal compromise, or a need to shorten the second stage for maternal health reasons. A prolonged second stage for nulliparous women is defined as 2 hours of labor, or 3 hours with regional anesthesia. In multiparous women, a prolonged second stage is 1 hour of labor, or 2 hours with regional anesthesia.

Forceps or vacuum are used for convenience. Labor and delivery are going well, but the physician grabs the forceps or vacuum to speed things along to get to a party or a tee time. “That sounds kind of ridiculous, but I've been asked to look at [such] cases. You can't defend that case,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

The mother doesn't know what to expect. Inform her of the indications, the procedure, and what to expect, Dr. Gilstrap said. “The residents and nurses are amazed sometimes at how much time I take when I go up to the head of the table and I explain to the patient why I'm going to use forceps, for example.”

He shows the mother the instrument and describes how it is going to fit on the baby's cheek, not the top of the head. He explains that the forceps will make an indentation on the cheeks that may be coded as trauma by the pediatrician and emphasizes that it is not trauma and will go away.

“I explain to them that several of my daughters and several grandchildren were delivered by forceps,” he added.

“I think this is a problem of public perception,” agreed Dennis J. Sinclitico, J.D., in a commentary on Dr. Gilstrap's presentation. Many childbirth classes don't mention operative vaginal deliveries. Trying to educate the woman and obtain informed consent in the midst of a delivery is not an ideal situation. It is better to give the patient information about the potential for operative vaginal delivery before labor starts, said Mr. Sinclitico, who is a defense attorney in Long Beach, Calif.

An inexperienced operator wields the forceps or vacuum. It is okay to have a resident perform the operative vaginal delivery as long as an experienced teacher is present, Dr. Gilstrap said.

With trends toward increased numbers of cesarean sections and fewer forceps deliveries over the last 2 decades, skill levels with forceps are dropping, Mr. Sinclitico added.

Forceps or the vacuum are applied incorrectly. Forceps should be placed halfway between the eyes and ears and down on the face, not the skull, Dr. Gilstrap said. Position the center of a vacuum cup 3 cm from the posterior fontanel, which puts the leading part of the cup about 3 cm from the anterior fontanel.

Precautions are inadequate. If the fetus has “considerable evidence of nonreassuring heart tones,” it may be appropriate to attempt forceps or vacuum delivery, but start setting up for a C-section at the same time, James S. Bostwick, J.D., advised in a separate commentary. Or move the patient to the operating room before trying the forceps or vacuum, said Mr. Bostwick, a plaintiff's attorney in San Francisco, Calif.

There is inadequate documentation. A lack of a written description of what happened, and when, leads to reliance on potentially conflicting oral accounts by physicians, nurses, and the baby's parents.

Be sure to document why you acted as you did, Mr. Sinclitico stressed. “These cases are easier to defend when my client has done something and has exercised his or her clinical judgment” rather than standing by or waiting for something to happen, he said.

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