What are the indications for instrumental delivery, such as forceps (obstetric forceps) or vacuum extraction?

From the Guidelines

Instrumental delivery is indicated in specific situations where there is a need to expedite vaginal birth due to maternal or fetal concerns, and the prerequisites for a successful instrumental delivery are met. The primary indications for instrumental delivery include prolonged second stage of labor, maternal exhaustion, or certain medical conditions requiring limited maternal pushing efforts, as well as fetal indications such as non-reassuring fetal heart rate patterns suggesting distress 1. For successful instrumental delivery, several prerequisites must be met, including full cervical dilation, ruptured membranes, engaged fetal head, known fetal position, empty bladder, adequate anesthesia, and an experienced operator. The choice between forceps and vacuum extraction depends on operator experience, specific clinical situation, and contraindications such as prematurity (<34 weeks) for vacuum extraction or face presentation for both methods 1. Some key points to consider when deciding on instrumental delivery include:

• Prolonged second stage of labor (typically >2 hours in nulliparous women or >1 hour in multiparous women)
• Maternal exhaustion
• Certain medical conditions requiring limited maternal pushing efforts, such as cardiac disease, severe hypertension, or cerebrovascular conditions
• Fetal indications, including non-reassuring fetal heart rate patterns suggesting distress, while the fetal head is engaged and at an appropriate station (typically +2 or lower)
• Proper patient counseling about risks, including potential perineal trauma, neonatal cephalohematoma, or retinal hemorrhages, is essential before proceeding with instrumental delivery. In the context of skeletal dysplasia, cesarean delivery is often recommended due to the potential for a difficult vaginal delivery, and instrumental delivery may not be suitable in these cases 1. However, the decision to proceed with instrumental delivery should be made on a case-by-case basis, taking into account the specific clinical situation and the potential risks and benefits. It is also important to note that the evidence base for instrumental delivery is limited, and more research is needed to fully understand the effectiveness and safety of different techniques 1.

From the Research

Indications for Instrumental Delivery

The indications for instrumental delivery include:

• Prolonged second stage of labor 2, 3, 4, 5
• Dystocia 3
• Fetal distress 3
• Cephalopelvic disproportion 4

Maternal and Neonatal Outcomes

Instrumental delivery is associated with:

• Higher rates of maternal complications, such as perineal tears and post-partum hemorrhage 2, 3
• Higher rates of neonatal complications, such as caput succedaneum and cephalohematoma 2, 3
• Lower rates of maternal morbidity and mortality compared to Caesarean delivery in some cases 3

Comparison with Caesarean Delivery

Instrumental delivery is compared to Caesarean delivery in terms of:

• Maternal and neonatal outcomes 6, 3, 4
• Rates of complications, such as uterine rupture and fetal acidemia 5
• Instrumental delivery rates are higher when the second stage of labor is extended 5

Factors Influencing Delivery

Factors that influence the decision to perform instrumental delivery include:

• Pelvic station 3
• Fetal presentation 4
• Maternal characteristics, such as ethnicity 4
• Time of day, with higher rates of Caesarean delivery outside office hours 4