Operative Vaginal Delivery

Operative vaginal delivery is used to achieve or expedite safe vaginal delivery for maternal or fetal indications. Examples include maternal exhaustion and an inability to push effectively; medical indications such as maternal cardiac disease and a need to avoid pushing in the second stage of labor; prolonged second stage of labor, arrest of descent, or rotation of the fetal head; and nonreassuring fetal heart rate patterns in the second stage of labor. Operative vaginal delivery is beneficial for women because it avoids cesarean delivery and its associated morbidities. The short-term risks of cesarean delivery include hemorrhage, infection, prolonged healing time, and increased cost. The long-term morbidities associated with cesarean delivery include the high likelihood of repeat cesarean delivery, the complications that can occur with trial of labor after cesarean delivery, and the risks of placental abnormalities such as placenta accreta. For the fetus showing signs of possible compromise, successful operative vaginal delivery can shorten the exposure to additional labor and reduce or prevent the effect of intrapartum insults (2). Often, operative vaginal delivery can be safely accomplished more quickly than cesarean delivery. The rate of operative vaginal delivery has decreased over the past few decades, accounting for part of the increase in cesarean birth rates in the United States. As the rate of cesarean delivery increased over the past two decades, the rate of operative vaginal delivery decreased from 9.01% of all deliveries in 1992 to 3.30% of all deliveries in 2013. (1) Nonetheless, operative vaginal delivery remains an important part of modern obstetric care and in the appropriate circumstances can be used to safely avoid cesarean delivery. Operative vaginal deliveries are accomplished by applying direct traction on the fetal skull with forceps or applying traction to the fetal scalp by means of a vacuum extractor (3). Various types of forceps and vacuum extractors have been developed for this purpose, and readers should refer to textbooks for review of these instruments (4–6). Whichever instrument is used, the indications for operative vaginal delivery are the same (Box 1). Operative vaginal deliveries are classified by the station of the fetal head at application and the degree of rotation necessary for delivery (Box 2). In an evaluation of the American College of Obstetricians and Gynecologists’ classification, investigators demonstrated that the lower the fetal head and the less rotation required, Operative Vaginal Delivery