In my opinion, operative vaginal delivery for maternal exhaustion should probably be reserved for someone who has progressed at a normal rate to crowning and who simply does not have the energy to push out a normal-sized baby.
Judicious use is key
Operative vaginal delivery can be used judiciously to remedy situations that have the potential to escalate. For example, a persistent transverse fetal head position in a primigravida with a platypelloid pelvis who has pushed for 1 hour with increasing caput and molding is highly unlikely to resolve. If the fetus is an appropriate candidate for rotational forceps, and the physician has the requisite training and experience, a rotational delivery after only 1 hour is entirely appropriate to avoid potential maternal and fetal injury that could follow 3 hours of pushing.
Persistent variable decelerations are another indication of potential fetal compromise and justify judicious use of operative vaginal delivery in appropriate candidates.
7. Do not use instruments sequentially
The use of sequential operative vaginal delivery methods to complete a vaginal delivery is no longer acceptable. Significantly increased neonatal and maternal risks have been demonstrated in at least 3 well-designed studies. Data indicate that a failed operative vaginal delivery attempt,2,9,10 more than 3 hours of maternal pushing,10 and more than 3 traction episodes (regardless of ultimate success with the instrument)10 are associated with an increased risk of neonatal intracranial hemorrhage.
Because we lack a standard of care for the optimal number of traction efforts or “pop-offs” for operative vaginal delivery, I suggest that any practitioners be familiar with, and adhere to, the manufacturer’s suggested guidelines. These guidelines will usually be designed to fall on the conservative side of safety issues.
I have heard of physicians who sometimes use the vacuum extractor to bring the head down to a place where they feel more comfortable applying forceps. This practice is unacceptable. By the same token, proceeding with vacuum extraction after concluding there is too much molding or caput for forceps is untenable.
8. Have a clear endpoint and exit strategy
Resist the temptation to persist with operative vaginal delivery in the face of inadequate descent or progress. It may sometimes seem as though “just one more pull” will effect delivery, but exceeding the recommended number of attempts can lead to excessive traction and maternal or fetal damage. It can be easy to become fixated on achieving vaginal delivery, and rational thought can become clouded.
I recommend that each department establish clear and agreed-upon limits for their practitioners. To this end, there should be an appropriately cooperative atmosphere in each delivery unit that encourages the provider team to work together to prevent adverse outcomes from operative vaginal delivery. Protocols or checklists that help the nursing staff keep the physician informed of the number of traction efforts and/or pop-offs that occur will help prevent inadvertent exceeding of the limits established for that unit.
Prior to attempting an operative vaginal delivery, the obstetrician should have a clear exit strategy, and this strategy should be outlined to the patient and the nursing/ancillary staff. When the predetermined criteria are met, operative vaginal delivery should be abandoned without delay, and cesarean section should be performed expeditiously. Obviously, this requires that preparations for emergent cesarean section be made prior to use of the forceps or vacuum extractor.
The necessary anesthesia and neonatal and operating room personnel should be ready and in position at the time the operative vaginal delivery is attempted.
Never resume maternal pushing after failed forceps or vacuum
There is no place for “rest and descend” protocols or further attempts at spontaneous vaginal delivery after a failed operative vaginal delivery. Once an easy operative vaginal delivery becomes impossible, immediate cesarean section is the best option.
Recommended prerequisites for operative vaginal delivery
- A valid indication documented preoperatively
- Unambiguous knowledge of the fetal head position
- Complete dilatation of the cervix
- Confirmed engagement of the fetal head
- Station at or below +2, unless the operator is experienced and there is a justifiable reason for a midpelvic delivery
- Rule of 3’s satisfied
- A documented estimate of appropriate fetal weight and adequate maternal pelvic anatomy
- Adequate anesthesia
- Preparations in place for immediate cesarean section and resuscitation of the neonate, if needed
- An informed, willing, and cooperative patient who understands that cesarean section may be an appropriate alternative mode of delivery (depending on the circumstances)
In addition, the person intending to perform the delivery should personally examine the patient before the attempt to confirm that the prerequisites have been met. I would go so far as to state that, unless there is a high expectation of an easy operative vaginal delivery, it should not be attempted.