Can a forceps (obstetric forceps) delivery cause an intrauterine stroke in a fetus, particularly in high-risk pregnancies with conditions such as placental abnormalities or fetal growth restriction?

Can Forceps Delivery Cause Intrauterine Stroke?

Forceps delivery does not cause intrauterine (in utero) stroke, but it can increase the risk of intracranial hemorrhage during labor and delivery in fetuses on maternal anticoagulation, particularly warfarin. The term "intrauterine stroke" is misleading in this context—strokes associated with forceps occur perinatally (during delivery), not while the fetus is still in utero.

Key Distinction: Timing of Stroke Risk

• True intrauterine strokes occur before labor begins and are unrelated to the mode of delivery 1
• Perinatal strokes associated with forceps delivery occur during the actual delivery process, not while the fetus remains in utero 1
• The critical risk factor is maternal warfarin use during labor, which can cause fetal cerebral hemorrhage that is exacerbated by forceps evacuation 1

Warfarin and Forceps: The Specific Risk

The ACC/AHA guidelines explicitly state that warfarin can cause bleeding in the fetus, and fetal cerebral hemorrhage can complicate labor and delivery, especially if forceps evacuation is necessary 1. This represents the only guideline-level evidence directly linking forceps to stroke risk.

Mechanism of Injury:

• Warfarin crosses the placenta and anticoagulates the fetus 1
• The mechanical forces of forceps application can precipitate intracranial bleeding in an anticoagulated fetus 1
• This risk is present throughout pregnancy but becomes clinically relevant during instrumental delivery 1

General Forceps-Related Intracranial Injury

Beyond the warfarin-specific risk, forceps delivery carries inherent risks of head trauma:

• Intracranial hemorrhage is a recognized complication of instrumental delivery, though the exact incidence varies 2
• Forceps are associated with subperiosteal hematoma (14.8% in one series) and other head injuries 3
• Facial nerve paralysis can occur from improper forceps application, though this is a peripheral nerve injury, not a stroke 4

Important Context:

• These complications occur during delivery, not in utero 5, 6, 2
• Modern studies show relatively low rates of serious neurological sequelae when forceps are used appropriately 6
• Long-term adverse neurological outcomes at 7 years were only 6.4% in one cohort, including mild disorders like delayed milestones 6

High-Risk Pregnancy Considerations

For pregnancies with placental abnormalities or fetal growth restriction:

• No specific evidence links forceps delivery to increased stroke risk in FGR fetuses 1
• The Society for Maternal-Fetal Medicine recommends cesarean delivery be considered (not mandated) for FGR with absent/reversed end-diastolic velocity based on the entire clinical scenario 1
• This recommendation is based on overall fetal compromise, not stroke risk specifically 1

Clinical Decision-Making Algorithm

When Forceps Are Indicated:

1. Screen for maternal anticoagulation status before any operative vaginal delivery 1
2. If mother is on warfarin during labor, avoid forceps and consider cesarean delivery 1
3. If no anticoagulation, forceps remain safer than second-stage cesarean for maternal outcomes 7, 8

Prevention Strategies:

• Discontinue warfarin several weeks before delivery and switch to heparin compounds 1
• Ensure proper forceps training to minimize mechanical trauma 4
• Avoid using a single forceps blade as a lever, which increases injury risk 7, 8, 4

Critical Pitfalls to Avoid

• Do not confuse intrauterine stroke with perinatal intracranial hemorrhage—these are distinct entities with different timing and mechanisms 1
• Never perform forceps delivery on a fetus whose mother is actively anticoagulated with warfarin 1
• Do not assume all head trauma from forceps represents stroke—most injuries are extracerebral (scalp hematomas, facial nerve injury) 3, 2
• Recognize that cesarean section at full dilation carries its own substantial risks and is not automatically safer than forceps 7, 8