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Immediate Maternal and Neonatal Effects of Forceps

and Vacuum-Assisted Deliveries


Jennifer H. Johnson, MD, Reinaldo Figueroa, MD, David Garry, DO, Andrew Elimian, MD, and
Dev Maulik, MD, PhD

OBJECTIVE: To estimate the differences in immediate ma- Data from the last 3 decades confirm that the rate of
ternal and neonatal effects of forceps and vacuum-assisted operative vaginal deliveries is decreasing in North Amer-
deliveries. ica.1– 4 The United States, Canada, Eastern Europe, and
METHODS: We conducted a medical record review of all South America prefer the use of forceps extractions. The
forceps and vacuum-assisted deliveries that occurred from vacuum is the instrument of choice in Western Europe,
January 1, 1998, to August 30, 1999, at Winthrop-Univer- Asia, Israel, and the Middle East.5
sity Hospital. Maternal demographics and delivery charac- It has been reported that 60% of residency programs in
teristics were recorded. Maternal outcomes, such as use of the United States perform less than 10% of their total
episiotomy and presence of lacerations, were studied. Neo- deliveries with the assistance of the vacuum or forceps.6 At
natal outcomes evaluated were Apgar scores, neonatal in- our institution, the use of vacuum has increased whereas
tensive care unit admissions, cephalohematomas, instru- forceps use has decreased during the past 10 years. Six
ment marks and bruising, and caput and molding. percent of the total deliveries are operative vaginal deliver-
RESULTS: Of 508 operative vaginal deliveries, 200 were ies. Review of the literature suggests differential maternal
forceps and 308 were vacuum assisted. Forceps were used and neonatal complications between forceps and vacuum
more often than vacuum for prolonged second stage of assisted deliveries.7–11 The purpose of this study was to
labor (P ⴝ .001). There was a higher rate of epidural (P ⴝ estimate the differences in immediate maternal and neona-
.02) and pudendal (P < .001) anesthesia, episiotomies (P ⴝ tal effects of forceps and vacuum-assisted deliveries in a
.01), maternal third- and fourth-degree perineal (P < .001) community-based teaching hospital with a residency pro-
and vaginal lacerations (P ⴝ .004) with the use of forceps, gram in obstetrics and gynecology.
whereas periurethral lacerations were more common in
vacuum-assisted (P ⴝ .026) deliveries. More instrument
marks and bruising (P < .001) were found in the neonates MATERIALS AND METHODS
delivered by forceps, whereas there was a greater incidence We performed a record review of all forceps and vacu-
of cephalohematomas (P ⴝ .03) and caput and molding um-assisted deliveries that occurred from January 1,
(P < .001) in the neonates delivered with vacuum. Multi- 1998, through August 30, 1999, at Winthrop-University
variable logistic regression analysis showed that forceps use Hospital. The study was approved by the institutional
was associated with an increase in major perineal and
review board. The deliveries were performed by a senior
vaginal tears (odds ratio [OR] 1.85; 95% confidence inter-
resident under the supervision of an attending physician.
val [CI] 1.27, 2.69; P ⴝ .001), an increase in instrument
marks and bruising (OR 4.63; 95% CI 2.90, 7.41; P < .001)
Maternal demographics recorded included age, parity,
and a decrease in cephalohematomas (OR 0.49; 95% CI and gestational age. Delivery characteristics recorded
0.29, 0.83; P ⴝ .007) compared with the vacuum. included indication for the use of an instrument, use of
oxytocin, fetal position and station, change in instru-
CONCLUSIONS: Maternal injuries are more common with
the use of forceps. Neonates delivered with forceps have
ment, delivery by cesarean, and type of anesthesia. Ma-
more facial injuries, whereas neonates delivered with vac- ternal outcomes of interest were the use of episiotomy,
uum have more cephalohematomas. (Obstet Gynecol lacerations sustained, and presence of vulvovaginal he-
2004;103:513– 8. © 2004 by The American College of matomas. The delivery information was entered in the
Obstetricians and Gynecologists.) medical record by the physician performing the delivery.
LEVEL OF EVIDENCE: II-3 Neonatal outcomes of interest were birth weight, Ap-
gar scores, neonatal intensive care unit (NICU) admis-
From the Department of Obstetrics and Gynecology, Winthrop-University Hospital, sions, cephalohematomas, instrument marks and bruis-
Mineola, New York, and the State University of New York at Stony Brook. ing, and caput and molding. The pediatricians who

VOL. 103, NO. 3, MARCH 2004


© 2004 by The American College of Obstetricians and Gynecologists. 0029-7844/04/$30.00 513
Published by Lippincott Williams & Wilkins. doi:10.1097/01.AOG.0000114985.22844.6d
examined the newborns were aware of the delivery Table 1. Delivery Characteristics
history. Forceps Vacuum P
Statistical analysis included Student t test for continu- Number of women 200 308
ous variables and ␹2 test for categorical variables. The Indications
Fisher exact test was used when the expected cell fre- Maternal exhaustion 77 (38.5) 124 (40.3) .76
quencies were equal to or less than 5. Multivariable Fetal status 94 (47.0) 168 (54.5) .12
Prolonged 2nd stage 28 (14.0) 16 (5.2) .001
logistic regression was performed to examine the role of
Elective/Other 5 (2.5) 9 (2.9) ⬎ .95
vacuum or forceps use on selected outcomes: major Use of oxytocin 155 (77.5) 225 (73.1) .31
perineal/vaginal lacerations, periurethral tears, cephalo- Completed delivery 189 (94.5) 294 (95.5) .78
hematomas, and instrument marks and bruising control- Change of instruments 10 (5.0) 12 (3.9) .71
ling for confounding variables. P ⬍ .05 was considered Cesarean delivery 1 (0.5) 1 (0.3) ⬎ .95
Use of anesthesia
statistically significant. Statistical analyses were per- Epidural 181 (90.5) 255 (82.8) .02
formed by using True EPISTAT (Epistat Services, Local 83 (41.5) 130 (42.2) .95
Richardson, TX). Pudendal 26 (13.0) 6 (1.9) ⬍ .001
Intravenous narcotic 21 (10.5) 32 (10.4) .91
None 0 6 (1.9) .09
Position n ⫽ 196 n ⫽ 245 ⬍ .001
RESULTS Left occiput anterior 43 (21.5) 49 (15.9)
Of 8,241 deliveries during the study period, 1,989 were Right occiput anterior 27 (13.5) 39 (12.7)
cesarean deliveries for a rate of 24.1%. The primary Occiput anterior 94 (47.0) 100 (32.5)
Left occiput posterior 4 (2.0) 10 (3.2)
cesarean delivery rate was 14.9%. Of 508 operative Right occiput posterior 3 (1.5) 10 (3.2)
vaginal deliveries (6.2% of all deliveries), 200 (39.4%) Occiput posterior 25 (12.5) 15 (4.9)
were forceps and 308 (60.6%) were vacuum assisted. Left occiput transverse 0 12 (3.9)
There were no differences between the forceps and Right occiput transverse 0 10 (3.2)
Not documented 4 (2.0) 63 (20.5)
vacuum-assisted groups in maternal age (31.2 ⫾ 5.1 Station n ⫽ 165 n ⫽ 247 .06
years versus 31.6 ⫾ 5.0 years; P ⫽ .89), parity (75.5% Mid 2 (1.0) 13 (4.2)
versus 68.5% primiparous; P ⫽ .10), and gestational age Low 59 (29.5) 96 (31.2)
(39.3 ⫾ 1.8 weeks versus 39.6 ⫾ 1.5 weeks; P ⫽ .68). All Outlet 104 (52.0) 138 (44.8)
operative vaginal deliveries were of 34 weeks or more of Not documented 35 (17.5) 61 (19.8)
gestation. Data are presented as number (%).

Forceps were used more often than the vacuum for


prolonged second stage of labor (14% versus 5.2%; P ⫽ assisted group. There was a greater incidence of mater-
.001). The differences in the use of oxytocin, success in nal third- and fourth-degree perineal lacerations (44.4%
operative delivery, rate of instrument changes, and ce- versus 27.9%; P ⬍ .001), and vaginal lacerations (19%
sarean delivery were not significant between the 2 versus 9.7%; P ⫽ .004) with the use of forceps. However,
groups. There was a higher rate of epidural (90.5% more periurethral lacerations were seen in the vacuum-
versus 82.8%; P ⫽ .02) and pudendal (13% versus 1.9%; assisted group (4.2% versus 0.5%; P ⫽ .026) than in the
P ⬍ .001) anesthesia in the forceps group than in the forceps group. More women in the vacuum-assisted
vacuum-assisted group. Frequently, women were given group were free of injury to the perineum or vagina than
another anesthetic after an epidural (Table 1). Ninety in the forceps group, although the difference was not
five percent of the instrumental deliveries were com- statistically significant (38.3% versus 30%; P ⫽ .07;
pleted with 1 instrument. Twenty-two women (4.3%) Table 2).
required a change of instrument to complete the delivery Birth weights, Apgar scores, and NICU admissions
whereas only 2 women required cesarean delivery. For- were similar between the 2 groups. More instrument
ceps were applied more often when the fetal position was marks and bruising (36.5% versus 10.7%; P ⬍ .001) were
occiput anterior or posterior whereas the vacuum was found in the neonates delivered by forceps. However,
used more frequently with occiput transverse positions. there was a greater incidence of cephalohematomas (20.5%
There was a trend for a more frequent use of forceps versus 12.5%; P ⫽ .03), and caput and molding (28.2%
than vacuum at the outlet, whereas vacuum was applied versus 13.5%; P ⬍ .002) in the neonates who were deliv-
more frequently than forceps at midstation but the dif- ered by the assistance of the vacuum (Table 3).
ferences were not statistically significant (Table 1). Using multivariable logistic regression analysis and
There were more episiotomies performed in the for- vacuum as the reference group, forceps use (odds ratio
ceps (90.5% versus 81.8%; P ⫽ .01) than in the vacuum- [OR] 1.85; 95% confidence interval [CI] 1.27, 2.70; P ⫽

514 Johnson et al Forceps and Vacuum Deliveries OBSTETRICS & GYNECOLOGY


Table 2. Maternal Outcomes
Odd ratio (95%
Forceps Vacuum confidence interval) P
Number of women 200 308
No injuries 60 (30.0) 118 (38.3) 0.69 (0.46, 1.03) .07
Episiotomy 181 (90.5) 252 (81.8) 2.12 (1.18, 3.83) .01
Lacerations
Perineal
First degree 5 (2.5) 17 (5.5)* .16
Second degree 30 (15.0) 61 (19.8) 0.71 (0.43, 1.18) .20
Third degree 66 (33.0) 73 (23.7) 1.59 (1.05, 2.40) .03
Fourth degree 23 (11.5) 13 (4.2) 2.95 (1.39, 6.33) .003
Third and fourth degree 89 (44.4) 86 (27.9) 2.07 (1.40, 3.06) ⬍ .001
Periurethral 1 (0.5) 13 (4.2)* .026
Labial 1 (0.5) 2 (0.6)* ⬎ .95
Vaginal 38 (19.0) 30 (9.7) 2.17 (1.26, 3.76) .004
Hematomas 0 1 (0.3)* ⬎ .95
Data are presented as number (%).
* Fisher exact test was used.

.001) was independently associated with an increase in were seen in the vacuum-assisted group (2.4% versus 0;
major perineal and vaginal tears. In addition, a birth P ⫽ .04) than in the forceps group. More instrument
weight of 4,000 g or more (OR 2.09; 95% CI 1.06, 4.10; marks and bruising (37.6% versus 10.3%; P ⬍ .001) were
P ⫽ .03) and use of episiotomy (OR 2.22; 95% CI 1.22, found in the neonates delivered by forceps. However,
4.05; P ⫽ .01) were independently associated with major there was a greater incidence of cephalohematomas
tears (Table 4). When neonatal outcomes were evalu- (21.4% versus 13.8%; P ⬍ .04) and caput and molding
ated, the use of forceps was associated with an increase in (33.7% versus 16%; P ⬍ .001) in the neonates who were
instrument marks and bruising (OR 4.63; 95% CI 2.90, delivered by the assistance of the vacuum.
7.41; P ⬍ .001; Table 5) and a decrease in cephalohema- There were 151 nulliparas in the forceps group and
tomas (OR 0.49; 95% CI 0.29, 0.83; P ⫽ .007; Table 6). 211 nulliparas in the vacuum group. Forceps were used
One hundred eighty-one women in the forceps group more often than vacuum for prolonged second stage of
and 252 women in the vacuum group had an episiotomy labor (15.9% versus 6.6%; P ⫽ .008). There was a higher
performed. This subgroup of women was analyzed for rate of epidural (95.4% versus 86.7%; P ⫽ .01) and
injuries. We found a greater incidence of fourth-degree pudendal (12.6% versus 1.4%; P ⬍ .001) anesthesia in
perineal lacerations (12.2% versus 4.8%; P ⫽ .005) and the forceps group than in the vacuum-assisted group.
vaginal lacerations (18.8% versus 9.5%; P ⫽ .005) with The difference in episiotomy use (92.7% versus 89.6%;
the use of forceps. There were no significant differences P ⫽ .31) and in the number of women without injury
in the incidence of third-degree perineal lacerations be- (42.5% versus 37.9%; P ⫽ .28) was not significant be-
tween the 2 groups (33.7% forceps versus 27.4% vac- tween the forceps and vacuum groups. We found a
uum; P ⫽ .16). However, more periurethral lacerations greater incidence of fourth-degree perineal lacerations

Table 3. Neonatal Outcomes


Odds ratio (95%
Forceps Vacuum confidence interval) P
Number of women 200 308
Birth weight (g) 3,317 ⫾ 524 3,398 ⫾ 505 .09
1-minute Apgar score ⬍3 1 (0.5) 3 (1.0) ⬎ .95
5-minute Apgar score ⬍7 0 1 (0.3) ⬎ .95
Neonatal intensive care unit admissions 19 (7.8) 24 (9.5) 1.24 (0.63, 2.43) .61
Instrument bruises 73 (36.5) 33 (10.7) 4.79 (2.95, 7.81) ⬍ .001
Cephalohematomas 25 (12.5) 63 (20.5) 0.56 (0.33, 0.94) .03
Caput and molding 27 (13.5) 87 (28.2) 0.40 (0.24, 0.65) ⬍ .001
Data are presented as mean ⫾ standard deviation or number (%).
Fisher exact test was used for Apgar scores.

VOL. 103, NO. 3, MARCH 2004 Johnson et al Forceps and Vacuum Deliveries 515
Table 4. The Effect of Forceps Use on Major Perineal and Table 6. The Effect of Forceps Use on Neonatal Cephalo-
Vaginal Lacerations After Adjusting for Other Vari- hematomas After Adjusting for Other Variables on
ables on Multivariable Logistic Regression Analysis Multivariable Logistic Regression Analysis
Odds 95% confidence Odds 95% confidence
ratio interval P ratio interval P
Parity 0.80 0.52, 1.24 .32 Parity 0.59 0.33, 1.06 .08
Birth weight ⱖ 4,000 g 2.09 1.06, 4.10 .03 Birth weight ⱖ 4,000 g 1.26 0.55, 2.89 .58
Episiotomy 2.22 1.22, 4.05 .01 Episiotomy 1.53 0.71, 3.30 .28
Forceps 1.85 1.27, 2.70 .001 Forceps 0.49 0.29, 0.83 .007
Prolonged 2nd stage 1.80 0.94, 3.47 .08 Prolonged 2nd stage 1.44 0.67, 3.13 .35
Epidural 1.69 0.95, 3.01 .08 Epidural 0.89 0.45, 1.74 .73

(12.6% versus 4.7%; P ⫽ .007) and vaginal lacerations


(17.2% versus 10.4%; P ⫽ .06) with the use of forceps. assisted deliveries in a community hospital with a resi-
There were no significant differences in the incidence of dency program in obstetrics and gynecology. Although
third-degree perineal lacerations (33.8% forceps versus there was a greater use of episiotomies in the forceps
27.5% vacuum; P ⫽ .2). However, more periurethral group, women in this group sustained more third- and
lacerations were seen in the vacuum-assisted group fourth-degree perineal and vaginal lacerations than
(4.3% versus 0; P ⫽ .01) than in the forceps group. More women in the vacuum-assisted group. This is in agree-
instrument marks and bruising (39.1% versus 10.9%; ment with the work of Bofill et al8 reporting that vacu-
P ⬍ .001) were found in the neonates delivered by um-assisted deliveries were associated with a lower rate
forceps. However, there was a greater incidence of of episiotomy, third-and fourth-degree perineal lacera-
cephalohematomas (22.7% versus 14.6%; P ⬍ .07) and tions, and vaginal lacerations. Other studies, although
caput and molding (31.3% versus 13.9%; P ⬍ .002) in the not commenting on the use of episiotomies, also showed
neonates who were delivered by the assistance of the that maternal soft tissue injuries in the form of vaginal
vacuum. lacerations or third- or fourth-degree lacerations were
Twenty-two (4.3%) vaginal deliveries were completed more common in the women delivered with the use of
after there was a change of instrument. Seventeen forceps.7,9 –11 Ecker et al12 reviewed the use of episiot-
(77.3%) women were nulliparas. All 22 women had an omy for operative vaginal delivery at their institution
episiotomy performed. Ten (45.5%) women had a third- between 1984 and 1994. Interestingly, the use of episiot-
or fourth-degree perineal laceration, 4 (18.2%) had vag- omy fell significantly whereas there was an increase in
inal lacerations, and 1 (4.5%) woman sustained a peri- the rate of vaginal lacerations and no significant change
urethral tear. Five (22.7%) neonates had cephalohema- in the rate of third-degree lacerations with the use of
tomas, 6 (27.3%) had instrument marks and bruising, forceps or vacuum. In addition, there was a significant
and 8 (36.4%) had caput and molding. One neonate decrease in the rate of fourth-degree lacerations with
required admission to the NICU. forceps use but not with vacuum.12
Of interest is our finding of more periurethral tears in
the vacuum-assisted group than in the women delivered
DISCUSSION with the assistance of forceps. More periurethral tears
This study was designed to estimate the immediate were seen in the vacuum-assisted group even with the
maternal and neonatal effects of forceps and vacuum- performance of an episiotomy, suggesting the perfor-
mance of the episiotomy was not protective. Bofill et al8
Table 5. The Effect of Forceps Use on Instrument Marks found more periurethral tears in the women delivered by
and Bruising After Adjusting for Other Variables vacuum, although the difference was not statistically
on Multivariable Logistic Regression Analysis significant (P ⫽ .08).
Odds 95% confidence Epidural anesthesia was used very frequently in both
ratio interval P groups but more so in the forceps group. It is possible
that in our institution physicians are more likely to use
Parity 0.72 0.41, 1.25 .25
Birth weight ⱖ 4,000 g 2.08 0.99, 4.34 .052 forceps in women who have received an epidural. Gen-
Episiotomy 0.96 0.47, 1.93 .90 erally, epidural anesthesia has been associated with
Forceps 4.63 2.90, 7.41 ⬍ .001 longer first and second stages of labor.13 The effect of
Prolonged 2nd stage 0.57 0.25, 1.28 .17 different epidural techniques on the second stage of labor
Epidural 1.41 0.66, 3.03 .37
needs to be studied more carefully. Perhaps, a stricter

516 Johnson et al Forceps and Vacuum Deliveries OBSTETRICS & GYNECOLOGY


definition of prolonged second stage for nulliparas and associated with the vacuum extractor. Instruments used
multiparas with or without epidural anesthesia should be to accomplish vaginal delivery must be used with caution
used and studied prospectively. and the delivery supervised by trained personnel. Our
At our institution, 95% of the instrumental deliveries findings should assist obstetricians in selecting an instru-
were completed with 1 instrument. In the study by Bofill ment for an operative vaginal delivery and in counseling
et al,8 93% of the women were delivered with the in- the patient regarding the risks and benefits of alternative
tended instrument. In the study by Johanson et al,11 85% approaches.
of the women in the vacuum group and 90% in the The limitations of our study were related to its retro-
forceps group were delivered by the assigned instru- spective nature and the lack of randomization. Delivery
ment. It is possible that the high rate of success with 1 documentation was incomplete. Newborn examinations
instrument was the result of the appropriate selection of were performed by physicians who knew the delivery
the instrument. There are significant concerns related to
information therefore the exams may have been “selec-
maternal and neonatal injury when more than 1 instru-
tive” rather than “objective.” More information related
ment is used. In these situations, we found the rates of
to the use of regional anesthesia would have been bene-
maternal and neonatal injury to be similar to the rates of
ficial in understanding its relation to the second stage of
the instrument causing the highest injury when only 1
instrument is used. We did not encounter serious injury labor. Despite their limitations, our findings are in agree-
but, in a retrospective review, Gardella et al14 found that ment with other prospective studies.
the sequential use of vacuum and forceps was associated
with increased rates of intracranial hemorrhage, brachial
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518 Johnson et al Forceps and Vacuum Deliveries OBSTETRICS & GYNECOLOGY

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