Doctors in the labor and delivery room will often utilize birth assistance tools such as forceps and vacuum extraction pumps to facilitate a difficult vaginal delivery. A delivery with the aid of birth assistance tools is referred to as an “operative vaginal delivery.” Although operative vaginal deliveries are often necessary, they present a much higher risk of birth injuries. This is particularly true with forceps which have a higher rate of injury compared to vacuum extractors.
What are Forceps?
Obstetrical forceps are a tool used by OB/GYNs to grip the head of a baby and help maneuver them through the birth canal. Forceps look like a pair of large pliers with curved cups on the ends. The cups are designed to grip the exposed head of the baby during childbirth so the doctor can then guide the baby through the birth canal by the head.
When Should Forceps be Used?
If everything goes well during labor and delivery, the doctors won’t even need to consider using obstetrical forceps. Forceps only get used when normal pushing isn’t working and a number of other criteria are present: membranes have already ruptured, the cervix is fully dilated; and the baby has entered into the birth canal head first. These are all basic preconditions to the use of forceps. Assuming all of these prerequisites are present, medical guidelines from the American College of Obstetricians and Gynecologists (ACOG) set forth specific circumstances for when the use of forceps or vacuum extraction pumps may be appropriate. The guidelines published by ACOG describe the following situations as appropriate indications for used of birth-assistance tools such as forceps:
- Prolonged Labor: prolonged labor is typically defined as when the pushing in the 2nd phase results in no progress after 3 hours.
- Fetal Distress: non-reassuring fetal heart rates and other signs of fetal duress may prompt doctors to use forceps, but this is only appropriate if forceps delivery will be faster than an emergency C-section.
- Maternal Fatigue: when a mother has become physically wiped out after prolonged pushing, doctors will sometimes use forceps to facilitate delivery.
All of the indicators for use of forceps described above are somewhat controversial because they could also be described as situations that call for an emergency C-section as the more appropriate response. In fact, there is quite a bit of research evidence to suggest that emergency C-sections are a much safer alternative to using obstetrical forceps. The results of a study published in the 2018 in the Canadian Medical Association Journal clearly indicate a higher rate of injury with forceps delivery compared to C-sections.
How do Forceps Cause Birth Injuries?
Obstetrical forceps can be an effective tool for facilitating a difficult vaginal delivery. The problem is that using forceps correctly requires a very high level of skill and experience on the part of the doctor. Once the forceps grip the baby’s head, the margin for potential error becomes extremely small. If the doctor grips the baby’s head in the wrong way or uses slightly too much pressure, forceps can easily cause extensive damage to the baby’s head. Unlike vacuum extractors, obstetrical forceps can be used to twist the baby into position. This is a very difficult maneuver and if not done perfectly it can result in devastating injuries to the spinal cord as well as head and brain injuries.
When forceps are used improperly or a mistake is made, injuries to both baby and mother can easily occur. Typical forceps related injuries range from mild bruises on the head to severe, permanent brain damage or spinal cord injury. Trauma to the head and brain are the primary point of concern with forceps because that it where the spoons grip the baby and apply pressure. The baby’s spine is also at risk of injury when forceps are used in a particular way which involves high force twisting. Some of the more significant and potentially dangerous types of birth injuries commonly associated with forceps include:
- Hematomas: a hematoma refers to an abnormal pooling or buildup of blood or fluid in or around the brain. There are 2 different types of hematoma injuries commonly associated with the use of obstetrical forceps: subgaleal hematomas; and cephalohematomas. A subgaleal hematoma occurs when emissary veins which cover the outside of the brain and head the skull and brain are damaged by external force (such as pressure from forceps). The external trauma is significant enough the emissary veins will actually break or rupture. Emissary vein ruptures will resulting in a dangerous pooling of blood up in the delicate space between the skull bone and the scalp. Blood pooling in this area typically triggers swelling and a buildup of internal pressure around the skull. Unless the mounting pressure from the pooling blood is alleviated it will eventually result in damage to brain cells. When a newborn baby is diagnosed with a subgaleal hematoma there is a very high likelihood that it is the result of birth assistance tools such as obstetrical forceps. Cephalohematomas are a similar but less serious type of hematoma. Cephalohematomas are also caused by a buildup of blood but the is occurs in a different part of the head/skull than a subgaleal hematoma. The particular location of cephalohematomas tends to restrict and limit the buildup and spread of pooling blood thereby reducing the likelihood of damaging the brain.
- Hydrocephalus: hydrocephalus is a somewhat different type of internal brain injury that is also characterized by fluid buildup. Instead of blood, however, hydrocep serious type of injury that occurs when external head trauma causes swelling which blocks the circulation of cerebrospinal fluid (CSF) out of the brain ventricles. The blockage causes CSF to accumulate within the brain causing dangerous internal swelling that often results in permanent damage to the brain.
- Intracranial Hemorrhage: neonatal intracranial hemorrhage (or brain bleeds) occurs when blood vessels around the head a ruptured causing internal cranial bleeding. Intracranial hemorrhages are similar to hematomas but they occur in somewhat different locations within the head and brain.
All of the brain / head injuries described above have the potential to cause long term neurologic injuries to brain cells which can potentially result in permanent disabilities such as cerebral palsy.
Some milder side effects include:
Recent Medical Literature on the Use of Forceps
Childbirth is unpredictable, and the best practices for how to handle all aspects of labor and delivery are difficult to perfect. However, medical researchers publish dozens of articles every day in attempt to make giving birth safer for mothers and children. One of the hottest debates in the medical community is the use of assisted labor techniques, such as forceps deliveries. Below are some recent articles exploring this topic.
- “Operative vaginal delivery and pelvic floor complications” by Richard P. Deane, Best Practice & Research Clinical Obstetrics & Gynaecology, 2019.
Operative vaginal delivery (OVD) is the use of forceps or vacuum extractors to deliver babies in emergency situations. OVD is commonly associated with injuries to the mother’s pelvic floor, the group of muscles in the underside of the pelvis that affect the urinary, genital, and gastrointestinal systems. Recently, there have been a significant changes in the practice of OVD in an effort to address these complications. Under investigation is the use of forceps and vacuum delivery, routine and selective episiotomies, and the recognition and management of obstetric anal sphincter injuries (OASIS). This review considers several key questions, such as: What effect does OVD have on the pelvic floor? How can we reduce these effects? At what point should an episiotomy be performed? How can we better manage OVD and OASIS in future pregnancies? By asking these questions, the hope is to better understand the potential risks of using forceps during delivery in order to prevent any mistakes or injuries in the future.
- “A comparison of maternal and neonatal outcomes with forceps delivery versus cesarean delivery” by Xiaohua Liu, et al., The Journal of Maternal-Fetal & Neonatal Medicine, 2018.
This is a study that compares the effects of a cesarean delivery versus one where triceps are used on both the mother and baby. Essentially, the study looked at a controlled group of mothers who delivered either by forceps vaginal delivery or cesarean delivery from a low station in the 2nd stage of labor. Results showed that use of forceps were associated with a lower frequency of maternal infection but a higher occurrence of mild postpartum hemorrhage (PPH). Deliveries performed due to worrisome fetal status were finished faster when forceps were used and showed a lower instance of death for the infant and hypoxic ischemic encephalopathy (HIE)—a brain injury caused by oxygen deprivation to the baby’s brain.
- “Rotational forceps versus manual rotation and direct forceps: A retrospective cohort study” by Stephen O’Brien, et al., European Journal of Obstetrics & Gynecology and Reproductive Biology, 2017.
Sometimes, the baby needs to be turned when forceps are used—the question is, what is the best method to accomplish this? There is a lot of debate over the safety and utility of rotational forceps versus manual rotation followed by direct forceps. These are both techniques that are used by doctors during a delivery where the baby’s head is not in the proper position. The results of the study showed that the rate of vaginal birth was significantly higher with rotational forceps than with manual rotation followed by direct forceps—in other words, a c-section was avoided. The rotational forceps method was also associated with a much higher rate of shoulder dystocia, a dangerous complication when one or both of the baby’s shoulders get stuck on the mother’s pelvic bone during labor, but not of neonatal injury. Other than this, there were no other significant differences between the two methods of delivery. What can we conclude from this study? The data supports that use of rotational forceps during delivery increases the chance of having a vaginal birth, although there is also a higher chance of shoulder dystocia occurring.
- “Forceps delivery: Contemporary tips for a classic obstetric tool” by Melissa S. Wong, M.D., Contemporary OB/GYN, 2019.
This article argues that deliveries with forceps are usually likely to be successful, but that this form of delivery should only be performed if it is likely to be successful. This is because, according to a study that the article cites, the risk of injury during a forceps delivery increased when other procedures were also needed. Sometimes, for example, if a forceps delivery is not successful, the baby must be delivered via c-section, increasing the length of the delivery and the risk of injury. Basically, the article says, we can improve the likelihood of a successful forceps delivery by choosing the appropriate candidates, utilizing the optimal techniques, and avoiding pitfalls that can contribute to failure.
- “Successful versus unsuccessful instrumental deliveries—Predictors and obstetric outcomes” by Abdullatif Elfituri et al., European Journal of Obstetrics & Gynecology and Reproductive Biology, January 2020.
This is a large retrospective study that included almost 8,000 mothers. The goal was to identify factors that influenced the success or failure of instrumental deliveries, e.g. the use of forceps. Failure was defined as needing to resort to a cesarean delivery. A data analysis revealed that mothers with a BMI greater than 30, macrosomia (high birth weight of baby), the use of forceps versus a vacuum, a prolonged second stage of labor, and a senior obstetrician performing the procedure. High maternal and fetal weight as well as prolonged labor were expected to contribute to failure based on previous studies. It is unclear taking other studies into account if vacuums or forceps are safer—the higher failure rate for forceps in this study may be due to the decline in their use, which makes doctors less familiar with using them. The data does not show that experience and seniority improve outcomes, though this may partially be because senior physicians are called on to perform more complicated procedures.
