From the Guidelines
Operative vaginal delivery (OVD) is indicated for expedited delivery in the second stage of labor with a fully dilated cervix, engaged fetal head, and no cephalopelvic disproportion, while cesarean section (CS) is recommended for cases with unacceptable risks, such as placenta previa, active genital herpes, or severe fetal distress. The choice between OVD and CS depends on the specific clinical situation, provider experience, and patient factors. Key considerations for OVD include:
- Prolonged second stage of labor
- Maternal exhaustion
- Certain fetal heart rate abnormalities
- Medical conditions requiring limited maternal pushing efforts, such as cardiac disease or neurologic conditions
- Adequate anesthesia
- Empty bladder
- Fully dilated cervix
- Ruptured membranes
- Engaged head
- Known fetal position In contrast, CS is indicated for cases with:
- Placenta previa
- Active genital herpes
- Previous classical uterine incision
- Certain malpresentations, such as transverse lie
- Cephalopelvic disproportion
- Failed operative vaginal delivery
- Severe fetal distress requiring immediate delivery According to the most recent and highest quality study, for pregnant women with active perianal disease, cesarean delivery is recommended over vaginal delivery to reduce the risk of perianal injury 1. Additionally, with an estimated fetal weight more than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery 1. It is essential to weigh the benefits and risks of each intervention and consider the individual patient's circumstances to make an informed decision. In cases where the evidence is equivocal, a decision should be made on the side of caution, prioritizing the well-being and safety of both the mother and the fetus. Ultimately, the choice between OVD and CS should be based on the most recent and highest quality evidence, taking into account the specific clinical situation and patient factors.
From the Research
Indications for Operative Vaginal Delivery (OVD)
- Non-reassuring fetal status 2
- No progress from 30 minutes of adequate active pushing 2
- Maternal exhaustion 2
- Medical indications to avoid Valsalva 2
Prerequisites for Operative Vaginal Delivery (OVD)
- The cervix must be fully dilated and the fetal head must be fully engaged before performing operative vaginal delivery 2
- Obstetricians must know the patient's medical record and the fetal head position before performing operative vaginal delivery 2
- Transvaginal examination can be used to determine fetal engagement and intrapartum fetal head position, but transabdominal ultrasound assessment is recommended in cases of doubt 2
Comparison with Cesarean Section (CS)
- Midpelvic operative vaginal delivery is not recommended and should be considered individually, depending on the skill of the obstetrician 2
- The presence of factors predictive of failed operative vaginal delivery should contraindicate midpelvic operative vaginal delivery and indicate a cesarean delivery 2
- Routine instrumental delivery in theatre and episiotomy for operative vaginal delivery are not recommended 2
Risks and Benefits
- Operative vaginal delivery is associated with more extensive damage to the pelvic floor and perineal structures, with forceps carrying a stronger risk compared to vacuum 3
- The purpose of operative vaginal birth is to provide a review of the current evidence regarding the benefits and risks of operative vaginal birth 4