Delay in Labour and Instrumental Delivery

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The rate of operative vaginal delivery has remained fairly constant at around 10-13%[1]. However, there are emerging trends - for example, an increased tendency to conduct the delivery in the operating theatre, increased rate of caesarean section at full dilatation, increasing failures of operative vaginal delivery (especially using the ventouse) and reduced attempts at instrumentation[2]. There has also been a significant increase in the use of vacuum extraction compared with forceps delivery, so that in 2011/12 it accounted for half of the instrumental deliveries[3].

Although it is now generally well established that there are significant risks associated with rotational and mid-cavity deliveries, there are low morbidity rates with most operative deliveries[4]. It should also be remembered that caesarean section in the second stage of labour is not without considerable morbidity[5].

The operator should use their skill and judgement to determine the best choice of instrument for the situation[6]. Vacuum extraction and forceps have different risks and benefits. Vacuum extraction can have a higher failure rate and increased risks of cephalohaematoma; it has, however, been shown to be associated with less maternal trauma (particularly pelvic floor injuries and subsequent faecal incontinence) than forceps[4, 7]. Forceps delivery may, however, have a lower rate of neurological problems in the neonate than vacuum extraction or caesarean section[8].

The following factors have been shown to be favourable in avoiding assisted delivery:

  • The presence of someone to support the woman during childbirth, especially if they are not a member of staff.
  • The mother labours in an upright or left lateral position.
  • Avoidance of use of epidural anaesthesia.

NB: there is no evidence that discontinuing an epidural in the second stage of labour or using a partogram to monitor progress will decrease the risk of assisted delivery[9].

The following factors can reduce the number of mid-cavity or rotational deliveries:

  • Using oxytocin in a nulliparous mother with an epidural.
  • Delaying active pushing in a nulliparous mother[10].
  • Fetal scalp visible with labia separated.
  • Fetal skull has reached the pelvic floor.
  • Sagittal suture is in anteroposterior (AP) diameter or right occiput anterior (ROA)/left occiput anterior (LOA) or occipito-posterior (OP) position.
  • Rotation required ≤45°.
  • Fetal head on perineum.
  • Leading point (not caput) is at +2 station.
  • Subdivided into:
    • Rotation ≥45° required.
    • Rotation ≤45° required.
  • Head 1/5 palpable per abdomen.
  • Leading point is above +2, but not above the ischial spines.
  • Subdivided into:
    • Rotation ≥45° required.
    • Rotation ≤45° required.
HighNot recommended.

They are used to shorten the second stage of labour.


  • Presumed, or diagnosed (by fetal blood sampling) compromise.
  • To protect the head during breech vaginal delivery[11].


  • To avoid Valsalva manoeuvre (eg, maternal cardiac disease - Class 3 or 4).
  • Hypertensive crises.
  • Cardiovascular disease, particularly uncorrected malformations.
  • Myasthenia gravis.
  • Spinal cord injury.

Inadequate progress[6]

Maternal morbidity increases significantly after three hours of the second stage and further increases after four hours. The most frequent adverse effects in the woman of a prolonged second stage are chorioamnionitis, third- and fourth-degree perineal tears and uterine atony[12].

  • Nulliparous women:
    • Delay diagnosed if active second stage ≥2 hours. Most nulliparous women will have delivered after 3 hours
  • Multiparous women:
    • Delay diagnosed if active second stage ≥1 hour. Most multiparous women will have delivered after 2 hours.
    • Maternal fatigue/exhaustion. 
  • Predisposition to fractures in the fetus.
  • Bleeding tendency or active bleeding in the fetus.
  • Face presentation and vacuum extractor.
  • Vacuum extractor should not be used for gestation of ≤34 weeks[1]. Use with caution at 34-36 weeks of gestation.

Full discussion and consent should take place with mother/parents.

(Acronym = FORCEPS):

  • Fully dilated cervix.
  • Occipito-anterior position preferably - OP delivery is possible with Kielland's forceps and vacuum.
  • Ruptured membranes.
  • Cephalic presentation.
  • Engaged presenting part, ie the greater diameter of the baby's head has passed the pelvic brim.
  • Pain relief is adequate:
    • Vacuum extraction or low forceps - minimum of perineal nerve block.
    • Mid-forceps - epidural or pudendal nerve block, or general anaesthetic.
  • Sphincter (bladder) empty.

A mediolateral episiotomy should be performed prior to an instrumental delivery to reduce the risk of third- and fourth-degree tears[6]. The evidence to support this, however, is not robust[1].

These are associated with:

  • Maternal body mass index >30.
  • Estimated fetal weight >4 kg.
  • OP position.
  • Mid-cavity deliveries.

These factors should prompt trial of delivery, with preparations to proceed to caesarean section immediately if unsuccessful.

  • The procedure should be abandoned if no descent is seen with three pulls.
  • An incident report should be completed.
  • Using differing instruments sequentially is not recommended[8, 13]. However, the operator should balance this decision against the risks of subsequent caesarean section[1].

Perineal examination

All women should have a thorough examination of the perineum with careful rectal examination to ensure no third-degree tear is missed[3].


Routine paracetamol and diclofenac should be prescribed, if there are no contra-indications[1]


There is no evidence that these should be routinely prescribed[14].


Each woman should be individually assessed for risk - eg, immobility.

Bladder care

The woman should have a fluid volume chart for the first 24 hours, to assess for retention and function. Referral to physiotherapy may be appropriate.

Future deliveries

The woman should be reassured that there is a high chance that any future delivery will be vaginal. Some women are very traumatised by an operative vaginal delivery and have a fear of subsequent childbirth. If this is severe they may have a form of post-traumatic stress disorder named tocophobia. There is no evidence on how to prevent psychological problems following instrumental delivery. However, it is recommended that the woman be reviewed by the obstetrician who conducted the delivery, to discuss the reasons for it and any concerns she may have[1].

  • Vacuum-assisted delivery has a lower rate of successful delivery[15].
  • Vacuum-assisted delivery is associated with less use of anaesthesia and fewer severe maternal injuries[16].
  • However, use of forceps following failed vacuum extraction can lead to a high level of damage to the mother. Adverse symptoms such as urinary and faecal incontinence are common in mothers with both forms of assisted delivery[7, 17].
  • Third- and fourth-degree tears are more common with operative delivery, due to the reduced time for stretching of the perineum[3].
  • The risk of pelvic organ prolapse following operative delivery is still unclear: it is associated with pregnancy; it is less likely following caesarean delivery than a vaginal delivery; it may be more common after forceps delivery[18, 19].
  • Cephalohaematomas and retinal haemorrhages are well recognised sequelae of vacuum extraction but usually have no long-term adverse effects[4].

Suitable subjects may include:

  • Rate of use.
  • Ratio of vacuum extraction to forceps delivery.
  • Rate of failures.
  • Incidence of maternal tears.
  • Neonatal trauma.
  • Standard of documentation.

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Further reading and references

  1. Operative Vaginal Delivery; Royal College of Obstetricians and Gynaecologists (February 2011)

  2. Loudon JA, Groom KM, Hinkson L, et al; Changing trends in operative delivery performed at full dilatation over a 10-year J Obstet Gynaecol. 2010 May30(4):370-5.

  3. Patterns of Maternity Care in English NHS Hospitals 2011/12; Royal College of Obstetricians and Gynaecologists

  4. O'Mahony F, Hofmeyr GJ, Menon V; Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev. 2010 Nov 10(11):CD005455. doi: 10.1002/14651858.CD005455.pub2.

  5. Villar J, Carroli G, Zavaleta N, et al; Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ. 2007 Nov 17335(7628):1025. Epub 2007 Oct 30.

  6. Intrapartum care: care of healthy women and their babies during childbirth; NICE Clinical Guideline (Dec 2014 last updated February 2017).

  7. Fitzpatrick M, Behan M, O'Connell PR, et al; Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery. BJOG. 2003 Apr110(4):424-9.

  8. Werner EF, Janevic TM, Illuzzi J, et al; Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol. 2011 Dec118(6):1239-46. doi: 10.1097/AOG.0b013e31823835d3.

  9. Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH. Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD004457. DOI: 10.1002/14651858.CD004457.pub2

  10. Brancato RM, Church S, Stone PW; A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor. J Obstet Gynecol Neonatal Nurs. 2008 Jan-Feb37(1):4-12. doi: 10.1111/j.1552-6909.2007.00205.x.

  11. The management of breech presentation; Royal College of Obstetricians and Gynaecologists (2006)

  12. Rouse DJ, Weiner SJ, Bloom SL, et al; Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes. Am J Obstet Gynecol. 2009 Oct201(4):357.e1-7. doi: 10.1016/j.ajog.2009.08.003.

  13. Towner D, Castro MA, Eby-Wilkens E, et al; Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med. 1999 Dec 2341(23):1709-14.

  14. Liabsuetrakul T, Choobun T, Peeyananjarassri K, et al; Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev. 2014 Oct 1310:CD004455. doi: 10.1002/14651858.CD004455.pub3.

  15. Yeomans ER; Operative vaginal delivery. Obstet Gynecol. 2010 Mar115(3):645-53.

  16. Boucoiran I, Valerio L, Bafghi A, et al; Spatula-assisted deliveries: a large cohort of 1065 cases. Eur J Obstet Gynecol Reprod Biol. 2010 Jul151(1):46-51.

  17. Johanson RB, Heycock E, Carter J, et al; Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse. Br J Obstet Gynaecol. 1999 Jun106(6):544-9.

  18. Handa VL, Blomquist JL, McDermott KC, et al; Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol. 2012 Feb119(2 Pt 1):233-9. doi: 10.1097/AOG.0b013e318240df4f.

  19. Quiroz LH, Munoz A, Shippey SH, et al; Vaginal parity and pelvic organ prolapse. J Reprod Med. 2010 Mar-Apr55(3-4):93-8.