From the Guidelines
Cesarean delivery is indicated when vaginal delivery poses significant risks to the mother or baby, whereas operative vaginal delivery is considered when the conditions for a safe vaginal delivery are met, such as prolonged second stage of labor or maternal exhaustion, with no contraindications like cephalopelvic disproportion 1.
Indications for Operative Vaginal Delivery
- Prolonged second stage of labor
- Maternal exhaustion
- Certain fetal heart rate abnormalities
- Fully dilated cervix
- Engaged fetal head
- No contraindications like cephalopelvic disproportion
Indications for Cesarean Delivery
- Placenta previa
- Active genital herpes
- Previous classical cesarean incision
- Certain malpresentations
- Failed operative vaginal delivery
- Repeat cesarean delivery after previous cesarean section, considering the risks of abnormal placentation, hysterectomy, and surgical complications 1
Factors Influencing the Choice Between Operative Vaginal Delivery and Cesarean Delivery
- Stage of labor
- Fetal position and station
- Maternal and fetal condition
- Provider experience
- Patient's previous obstetric history, including previous cesarean deliveries or vaginal births after cesarean (VBAC) 1
Risks Associated with Each Procedure
- Operative vaginal delivery: perineal trauma, neonatal injury
- Cesarean delivery: surgical complications, implications for future pregnancies, increased risk of abnormal placentation, hysterectomy, and complications from surgery compared to VBAC 1
From the Research
Indications for Operative Vaginal Delivery
- Non-reassuring fetal status 2
- No progress from 30 minutes of adequate active pushing 2
- Maternal exhaustion or medical indications to avoid Valsalva 2
- To shorten the second stage of labor and improve maternal and fetal outcomes associated with delayed second stage 3
Indications for Cesarean Delivery
- When spontaneous vaginal delivery in the second stage of labor is not a possibility, and operative vaginal delivery is not feasible 4
- Suspected fetal distress, although the decision to perform a cesarean delivery should be made after careful consideration of the potential benefits and risks 5
- Presence of factors predictive of failed operative vaginal delivery 2
- Midpelvic operative vaginal delivery is not recommended, and cesarean delivery may be indicated in such cases 2
Considerations for Operative Vaginal Delivery versus Cesarean Delivery
- Operative vaginal delivery may be a safe and acceptable alternative to cesarean delivery when spontaneous vaginal delivery is not possible 4
- The decision to perform an operative vaginal delivery or cesarean delivery should be made after careful consideration of the potential benefits and risks, including maternal and fetal morbidity 5
- The availability of skilled healthcare workers and equipment is crucial for the safe performance of operative vaginal deliveries 3
- Routine instrumental delivery in theatre and episiotomy for operative vaginal delivery are not recommended 2