Operative Vaginal Delivery – Forceps & Vacuum Extractor Injuries
Operative vaginal delivery occurs when the delivering physician uses forceps or a vacuum extractor to aid in the delivery of the child. Approximately 3.6 percent of deliveries in the United States are accomplished using an operative vaginal approach. iVacuum assists are used about four times as often as forceps. ii
The use of these devices is not without controversy. In May 1998, the U.S. Food and Drug Administration issued a public health advisory titled “Need for CAUTION When Using Vacuum Assisted Delivery Devices.” iiiThe FDA addressed the advisory to Obstetricians, Birthing Centers, Nurse Mid-Wives, Pediatricians, Ultrasonographers, ObGyn Nurses, Family Practitioners, Radiologists, Hospital Risk Managers, and Hospital ObGyn Departments. The FDA advised these practitioners that the purpose in issuing the advisory was as follows:
This is to advise you that vacuum assisted delivery devices may cause serious or fatal complications, and to provide guidance to minimize the risk. While no instrumented delivery is risk free, we are concerned that some health care professionals who use vacuum assisted delivery devices, or those who care for these infants following delivery, may not be aware that the device may produce life-threatening complications . . . . We are also concerned that if health care professionals responsible for the care of neonates are not alerted when a vacuum assisted delivery device has been used on a particular infant, they may not adequately monitor for the signs and symptoms of device-related injuries.
The specific type of injuries the advisory highlighted were subgaleal hematomas and intracranial hemorrhage (subdural, subarachnoid, intraventricular, and/or intraparenchymal hemorrhage).
Two years later, in June 2000, the American College of Obstetricians and Gynecologists (ACOG) published ACOG Practice Bulletin No. 17, titled “Operative Vaginal Delivery.” ACOG noted that “recent reports have highlighted the potential for maternal and neonatal complications associated with operative vaginal delivery, although the risks associated with alternative procedures also must be considered.” ACOG set forth the “indications” for operative vaginal delivery as follows.
No indication for operative vaginal delivery is absolute. The following indications apply when the fetal head is engaged and the cervix is fully dilated.
- Prolonged second stage:
– Nulliparous women: lack of continued progress for three hours with regional anesthesia, or two hours without regional anesthesia.
– Multiparous women: lack of continuing progress for two hours with regional anesthesia, or one hour without regional anesthesia.
- Suspicion of immediate or potential fetal compromise
- Shortening of the second stage for maternal benefit iv
In issuing these indications, ACOG specifically noted that “most authorities consider vacuum extraction inappropriate in pregnancies before 34 weeks of gestation because of the risk of fetal intraventricular hemorrhage.”
Physicians continue to study the safety of these procedures. One study, published in 2011, compared the risk of adverse neonatal neurologic outcomes following vacuum-assisted delivery, cesarean delivery and forceps-assisted delivery. This study concluded that a forceps-assisted delivery was associated with a reduced risk of adverse neurologic outcomes when compared to a vacuum-assisted delivery or cesarean delivery. See Werner EF, Janevic TM, Illuzzi J, Funai EF, Daviz DA, and Lipkind HS, Mode of Delivery in Nulliparous Women and Neonatal Intracranial Injury, Obstetrics & Genecology, Vol. 118, No. 6, p. 1239.
If you or your child is injured as a result of a vacuum-assisted delivery or a forceps-assisted delivery, you may wish to have the medical records for you and your child reviewed by an experienced medical malpractice law firm.
iSee Wegner EK and Bernstein IM, Operative Vaginal Delivery, UpToDate, as of Feb. 14, 2013
iii Maternal cardiac or neurological disease