Clinical Review

Preserving the option of vacuum extraction: 5 experts tell why and how

In properly selected cases, vacuum extraction or forceps delivery may be the best option for the patient, but declining usage rates threaten their availability.



  • Operative vaginal deliveries have been declining overall, and the ratio of vacuum to forceps deliveries has increased.
  • Avoid forceps rotations exceeding 45° and do not attempt to forcibly rotate the head with a vacuum device because of the potential for injury and litigation.
  • The best candidates for operative vaginal delivery have a prolonged second stage of labor or non-reassuring fetal status, the fetal head at the outlet or low in the pelvis, and a functioning epidural.
  • Avoid sequential use of vacuum and forceps.

Neal M. Lonky, MD, MPH, moderator of this discussion, is director of medical education and colposcopic services, department of obstetrics and gynecology, Kaiser Permanente, Orange County, Calif. He serves on the board of directors, Southern California Permanente Group, and is clinical professor of obstetrics and gynecology at the University of California, Irvine. He is an OBG Management contributing editor.

James A. Bofill, MD, is associate professor, division of maternal-fetal medicine, University of Mississippi Medical Center, Jackson, Miss.

Thomas Garite, MD, is E.J. Quilligan Professor and chair, obstetrics and gynecology, University of California, Irvine.

Robert Hayashi, MD, is J. Robert Willson Professor of obstetrics and director, division of maternal-fetal medicine, University of Michigan, Ann Arbor, Mich.

Victor L. Vines, MD, is in private practice, Medical City Dallas Hospital, Dallas, Tex. He serves on the physician advisory board for the Perinatal Safety Initiative of the Hospital Corporation of America and is clinical associate professor of obstetrics and gynecology at the University of Texas Southwestern Medical Center, Dallas.

Operative vaginal deliveries are on the wane, even though they may produce the best outcomes in some cases. The reasons? Fear of litigation, patient resistance, and diminishing numbers of experienced physicians. OBG Management convened a panel of experts from a variety of practice settings to address the challenge of offering vacuum and forceps appropriately when external forces discourage their use. Our panelists discuss patient selection, sequential use of vacuum and forceps, and the need to use universal documentation terminology consistently.

Why vacuum and forceps are losing favor

LONKY: Operative vaginal deliveries have declined over the past 2 decades as cesarean section rates have increased. What factors are responsible for the shift?

VINES: Some of our colleagues believe operative delivery should no longer be performed. Although this view is based more on fear of litigation than any scientific basis, we are seeing a downturn in forceps and vacuum deliveries in response, although the proportion of vacuum deliveries has increased notably.

A California study1 of more than half a million women found that about 13% of deliveries were operative. In a Washington study2 on sequential use of vacuum and forceps, the operative delivery rate was 14.4%. Both investigations gathered data from the late 1980s to late 1990s. Perhaps there has been a drop more recently, but Hospital Corporation of America (HCA) data suggest an operative delivery rate of 12% to 14%—mostly vacuum.

BOFILL: The best report on regional differences3 demonstrated that the rate of operative vaginal delivery and even cesarean is much higher in the Southeast than in the rest of the country.

Fear of litigation starts a vicious cycle. As for whether operative vaginal deliveries are declining overall, Yeomans and Hankins4 describe a vicious cycle in which fear of litigation leads to less teaching, which leads to less use of forceps and vacuum, which leads to more bad outcomes—because of meager training—which leads to more litigation.

In our hospital, operative vaginal delivery rates have dropped from about 16% to approximately 12%.

GARITE: The ratio of vacuum deliveries to forceps is changing most dramatically.

Vacuum injuries increase as vacuum displaces forceps

VINES: The number of vacuum-related injuries has increased because the frequency of vacuum and forceps deliveries has reversed. The incidence hasn’t necessarily gone up, but the absolute numbers have, and that has prompted critical review.

LONKY: At Kaiser Permanente on the West Coast, there has been a dramatic shift to the vacuum over the forceps. When I completed my training in 1986, I probably performed forceps and vacuum deliveries at equal rates. Now I may do 1 forceps delivery a year.

HAYASHI: Other factors are early descriptive studies that implicated operative deliveries as the cause of poor outcomes in infants. Although those studies were of poor quality, they influenced physician behavior.

A growing base of studies on the effects of operative delivery on pelvic floor function also has contributed.

The ease, safety, and acceptance of cesarean birth has also played a role in diminishing operative vaginal deliveries, as has the increasing number of women trainees, many of whom feel they lack adequate strength to pull forceps effectively to deliver the fetal head.


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