Operative vaginal delivery remains an important skill for obstetricians to provide the full spectrum of care for pregnant patients. It can reduce the need for cesarean deliveries, an important goal of both our specialty nationwide and of individual providers and patients. Notably, 2017 was the first year the cesarean delivery rate increased since 2009, suggesting an even greater urgency in focusing on tools to reduce it.1 The top two reasons for cesarean delivery – labor dystocia and abnormal or indeterminate fetal heart rate tracings – can both potentially be resolved by operative vaginal delivery.2 Despite this, the overall trend for operative deliveries has shown a dramatic decline. While approximately 10% of deliveries were performed via operative delivery in the 1990s, the most recent National Vital Statistics Survey shows a 2.58% rate for vacuum deliveries and 0.56% for forceps deliveries. It is these latter deliveries – forceps-assisted vaginal deliveries – which will be the focus of this article.
The history of the obstetric forceps is one of the more theatrical tales in medical literature. Invented by the two Chamberlen brothers (Peter the Elder and Peter the Younger) in the 1600s, the timing was particularly fortuitous because malnourishment, rickets and thus pelvic dystocia were on the rise. The two male midwives were so maligned, however, and so obsessed with the secrecy of their invention that before employing the forceps they would make all attendees leave the room and blindfold the laboring woman before applying them. The secret method ultimately remained with the family for another century and the instruments unseen until their discovery under the floorboards of Peter’s son’s house in 1813. And though some modifications were made in the following years, the two most commonly used forceps designs of today – Simpson and Elliot-type forceps – were each invented about a century and a half ago.3
Indications and contraindications for forceps deliveries
Indications and prerequisites for proceeding with a forceps delivery mirror those for a vacuum delivery and include prolonged second stage of labor, suspicion of fetal compromise, and shortening of the second stage for maternal benefit. Prerequisites include the cervix being fully dilated, membranes ruptured, and the head being fully engaged. An estimation of fetal weight, fetal position, and pelvic adequacy should also have been previously performed. Regarding the patient, adequate anesthesia should be in place, the bladder empty, and consent obtained. At a system level, there should be a willingness and ability to have a back-up plan in place in case of failure to deliver. A helpful mnemonic for recalling these may be to remember A-B-Cs and is described in Table 1.
Contraindications for both forceps and vacuum include a strong suspicion for a fetal bone demineralizing or bleeding disorder. But while vacuum delivery has been discouraged for the fetus less than 34 weeks, there is no lower limit for gestational age for forceps delivery.4
The author reports no potential conflicts of interest with regard to this article.
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