Assisted Delivery

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Assisted delivery is a procedure in which obstetric forceps or a vacuum device are used to help deliver your baby, towards the end of labour.

Assisted delivery is a procedure in which obstetric forceps or a vacuum device are used to help deliver your baby, towards the end of the second stage of labour. It's different from assisted labour, (in which you are given treatment to start off your labour or to increase the power and frequency of contractions). Assisted delivery is also sometimes called instrumental vaginal delivery, or an operative vaginal delivery.

Assisted delivery happens in about 1 in 8 births in the UK. It is less common in women who have already had at least one vaginal birth. About half of assisted deliveries use vacuum extraction; the other half use forceps.

Assisted delivery is usually used when you need help pushing your baby out, at the end of the second stage of labour. This may be because:

  • You have been advised not to push (for example, because you have very high blood pressure).
  • You are tired and need help in the final stage to deliver your baby. This may also be because your contractions have become less strong at the last minute.
  • Your baby is lying with his or back against your back (sometimes called occiput posterior, or OP). Your baby's head will need to rotate out from this position so that he or she is looking sideways when coming down the birth canal. This rotation needs more 'push' than if he or she is already perfectly positioned, and you may need extra help pushing him or her out.
  • Your baby is getting tired and showing signs of distress, and your midwife or doctor feels your baby's delivery needs to be speeded up.
  • You are having a vaginal breech delivery, in which case forceps are used to protect the baby's head from your perineum.
  • You are having a vaginal delivery of a premature baby. Forceps may be used to protect the baby's soft head during delivery through your perineum.

Assisted delivery is less likely to be successful if you are overweight, if your baby is large (over 4 kg) and if rotation is needed because your baby is lying in a posterior position (as described above).

The two main kinds of assisted delivery are vacuum delivery and forceps delivery. Both have been around for a long time. You may soon also hear the Odón device discussed.

  • The ventouse extractor is a suction device that attaches to your baby's head and connects to a small machine that generates suction. Various models have been made over the years. Most models evolved from a design from the 1950s, although the first documented vacuum-assisted birth was in the mid 19th century.
  • The Kiwi® cup is a vacuum device similar in principle to the ventouse, although the various cups are smaller and they do not attach to a machine, but instead to a small hand-held pump called a palm pump.
  • There are various different kinds of obstetric forceps, described below. Forceps were first used regularly in the mid-19th century, although there is evidence for their use in the 16th century.
  • The Odón device is a variation on the ventouse, which is currently being evaluated by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP).

If you already have an epidural in place, this will usually be 'topped up' for either a vacuum or a forceps birth.

If you don't already have an epidural then other options are:

  • Spinal anaesthetic: this works more quickly than an epidural and is for short-term use (as it's a one-off injection, so it can't just be topped up when it wears off - it would have to be done again). An anaesthetist is needed to administer a spinal anaesthetic.
  • Pudendal block: this is a painkilling injection to the pudendal nerves, given by the doctor, to block pain in the pelvic floor and perineum. The pudendal nerves are behind the vaginal wall in your pelvis, so this type of block is given by an injection into the vagina. It takes 5-10 minutes to work fully.

If you are having low forceps or outlet forceps (see below) or a ventouse delivery then you may not need any of these options, as the upper part of your birth canal has been passed by the baby's head, and local anaesthetic low down in your perineal area is usually all that is needed.

If you are having a forceps delivery you will need to have an episiotomy to protect you from tearing and to allow enough space to deliver your baby and the forceps. When the forceps are around your baby's head, they make the size of the head and forceps both bigger and more rigid than your baby's head alone. Additionally, because your baby won't usually have been pushing at your perineum for as long before the birth, your perineum won't have had time to stretch naturally.

In the case of ventouse delivery, although your perineum may not have had the chance to stretch naturally, the combination of your baby's head and the ventouse is no wider than your baby's head alone, and your baby's head can still be gently moulded by your birth canal, so there is less chance of vaginal or perineal injury and you might not need an episiotomy. You are more likely to avoid an episiotomy if this is not your first baby, and your perineum has stretched before.

The doctor may be able to delay doing an episiotomy, only doing it if it becomes clear to them that you are otherwise at risk of a serious tear.

Obstetric forceps are metal instruments that look like a pair of large salad servers or tongs, which fit together. They are used to help your baby's birth by applying added pull (traction) to bring him or her gradually down the birth canal and/or to help lift and guide him or her out through your perineum. There are various types of forceps, described below. They have the dual purpose of both adding some extra pull to your contractions and pushing, and forming a protective cage around your baby's head as he or she is born.

If you need help with your second stage of labour then a forceps delivery may be suggested, but this will only be done with your agreement, once you understand why this is being suggested (and what other options there may be). Sometimes an ultrasound is done in labour to check the position of the baby accurately before your doctor advises you on the options.

Forceps deliveries are done by doctors and only in the second stage of labour (when you are fully dilated). If you are having a forceps delivery then you are likely to have your feet in stirrups, with your bottom at the end of the bed. There will be a cushion under your right lower back to tilt you slightly, so that your womb (uterus) and baby don't rest hard against the large vessels at the back of your tummy (abdomen), which can make you feel faint. The doctor will examine you to check the position of your baby's head - both how far down through your pelvis the baby has already come, and which way your baby is facing.

The doctor will be wearing theatre scrubs. Unless you have just emptied your bladder the doctor is likely to pass a catheter to make sure that your bladder is completely empty, to avoid it being damaged during the delivery. The catheter will not usually be left in place.

Forceps in head-first (cephalic) delivery

Most forceps deliveries are for babies who are coming down the birth canal head-first. Once your pain relief is in place, the forceps are inserted into your vagina, one at a time, and placed gently, one on each side of your baby's head, over his or her ears. The two arms of the forceps will then be put together. The forceps are now in place.

The doctor will normally wait for a contraction before applying gentle pulling (traction) on the forceps. You may be asked to push at the same time. With each contraction the doctor will apply added force, to draw your baby in the right direction down the birth canal. The forceps will stay on your baby's head until the head has been delivered through your birth canal. This usually involves several pulls, typically 3-4 in total, but the doctor will only continue if it is clear that the baby is moving down with each pull.

Because the forceps 'cage' around your baby's head enlarges what has to come through your perineum, an episiotomy is usually done before the forceps are put in, in order to widen the opening and avoid a tear. You may have a spinal block or epidural beforehand. If not then you will normally be given an injection of local anaesthetic into your perineum. If your baby is close to being born, your perineum may already be quite stretched and numb, so this will not be as bad as it may sound. Most women say that they didn't really notice the anaesthetic injection.

Once your baby's head is delivered. The forceps are then taken off your baby's head for delivery of the rest of your baby's body, and your baby can then be placed on your tummy. Your birth partner will usually still be able to cut the cord if they want to. Your third stage of labour will be the same as if forceps had not been used.

The doctor will then examine you carefully to make sure that the forceps have not caused any injuries to your tissues. This may include a back passage (rectal) examination with a finger to make sure that you don't have a tear there. If you have needed an episiotomy, or you have a tear that needs stitches, this will be done straightaway, whilst your pain relief is still working.

Rotational deliveries

Rotational assisted deliveries are considered if your baby isn't facing quite the right way and you haven't been able to push him or her into the ideal position. This means that his or her head needs to turn on the way down the birth canal. Sometimes the doctor may be able to turn your baby's head manually with their fingers or hand during vaginal examination, either during or between contractions. Manual rotation is a skilled procedure performed by experienced doctors. If it is successful then a regular forceps delivery (as above) can then follow, or you may even be able to push your baby out.

If the doctor is unable to perform manual rotation then rotational (Kielland's) forceps may be used. These are special forceps designed to rotate your baby as well as helping him or her down the birth canal. You will be given an epidural, spinal or painkilling block for this type of forceps delivery, which will be done in theatre (see below).

Forceps delivery for a breech baby

if your baby is coming bottom-first (or breech) then the problem that your baby faces is that his or her bottom is smaller than his or her head, and will not stretch your vaginal opening quite as much as the head would do. It's very important, therefore, that his or her head doesn't come out too quickly, which could cause harm to the baby. Forceps may then be used to protect what is called the 'aftercoming head'. The doctor will first deliver your baby's bottom and then pull down your baby's legs. After this, gentle manipulation of your baby as your contractions come will deliver your baby's shoulders, one at a time. Your doctor will then ask you not to push whilst the forceps are placed gently around your baby's head. Once they are in place then, usually with the next contraction, your baby's head will be gently lifted out through your perineum.

As for a cephalic baby, you will usually have an episiotomy. This is to widen the opening for the baby and the forceps, to protect both you and the baby from damage.

Forceps delivery in the operating theatre

If there is felt to be a risk that the forceps delivery will not succeed then the procedure will performed in an operating theatre (under epidural or spinal anaesthetic), so that a caesarean section can be carried out quickly if needed.

If this happens then, once everything has been explained to you, you will be asked to sign a written consent to the forceps delivery, which includes a consent to caesarean section if the forceps delivery is not successful. This is important as, particularly if your baby is distressed, it reduces the 'decision time' - between the forceps delivery failing and your baby being delivered - to a minimum, whilst also giving you the chance to prepare yourself mentally for both options before the procedures begin.

Forceps are divided into rotational, straight and low forceps. The curved 'blades' on the forceps that encase your baby's head are similar on all the models. The types you are mostly likely to see used in the UK are Kielland's forceps, Neville-Barnes forceps and Wrigley's forceps. However, there are many others and if you are giving birth elsewhere in the world then other names will predominate. However, the principles are the same:

  • Kielland's forceps (rotational forceps) are used for turning babies who are only midway down the birth canal and who need to be rotated as well as helped down the birth canal. If these are to be used then you will usually have an epidural and the procedure will be carried out in obstetric theatre, so that a caesarean can be done if you and the doctor cannot rotate your baby between you.
  • Neville-Barnes forceps ('straight' forceps) are used if your baby is normally positioned (already facing sideways) and is well down in your birth canal, but some pulling is needed to help him or her down to be delivered.
  • Wrigley's forceps (low forceps) were designed to be used by GPs in the days of home delivery. They are sometimes called 'lift-out' forceps and are used to protect your baby's ahead when very little pulling is needed because your baby is almost out. They are also sometimes used during a caesarean section to protect your baby's head whilst they are being delivered through the cut (incision) in your womb (uterus).

You may sometimes hear these terms used. 'High, mid, low and outlet' refer to the position ot the baby's head in relation to his or her route out through your birth canal. The lower your baby is when the forceps are used, the more likely the forceps are to deliver your baby.

  • Outlet forceps delivery: the forceps are applied when your baby's head has reached your perineum so that the top of his or her head can be seen and felt between contractions, and his or her head is perfectly positioned for delivery.
  • Low and mid forceps deliveries: your baby is higher than this - but your baby's head is still engaged in your pelvis (meaning that the widest part of his or her head is down in your pelvis already).
  • High forceps delivery: used to be a forceps-assisted vaginal delivery performed when a baby's head was not yet engaged. However, this type of forceps delivery is no longer performed.

Forceps deliveries are very safe - in particular, they are safer for you and your baby than caesarean section (even though caesarean section is also very safe). However, there are risks and these should be discussed with you before the doctor goes ahead. The risks must be weighed against the complications of alternatives of caesarean section, or of continuing to allow vaginal birth to proceed without medical intervention.

Complications of forceps delivery for the mother

These include:

  • Failed forceps delivery so that you have already had an episiotomy but now need to have a caesarean section. Having a failed forceps delivery and then a caesarean section is more traumatic for your baby than just having a forceps delivery or just having a caesarean section.
  • Episiotomy (this is usual).
  • Injury to your cervix, pelvic floor, vaginal wall or perineum.
  • A more severe tear. Many women get a tear during childbirth. Most occur in the perineum, the area between the vaginal opening and the anus. Tears can be:
    • First-degree tears, which affect only the skin and usually heal naturally.
    • Second-degree tears, which are deeper and involve the muscle, and usually need stitching.
    • Third-degree and fourth-degree tears, which affect only around 3 in 100 women. Third-degree tears extend downwards to the anal sphincter, the muscle that controls the anus. A fourth-degree tear goes further, right to the anus or rectum. These types of tears are repaired by a surgeon (obstetrician), usually in theatre.
  • Shoulder dystocia, when your baby's shoulders are large and delivery is difficult. This is more likely if your baby is particularly large (more than 4 kg).
  • Increased bleeding after delivery.

Complications of forceps delivery for the baby

These include:

  • Small marks, bruising or scratching from the forceps, which is quite common. These usually heal or disappear within a day or two.

Ventouse devices consist of a cup, made of plastic or metal, that sits closely against your baby's head and which is attached to a vacuum pump via a tube. When the cup is applied to your baby's head and the vacuum is turned on, the cup holds your baby's head via suction. When the doctor pulls on the cup he or she is therefore pulling on your baby.

A variation of the ventouse device is the Kiwi® device, in which the suction is created by the doctor using the device, via a small, hand-held pump.

Ventouse delivery

You will only be offered a ventouse delivery if you are fully dilated and your baby is midway down through your pelvis, or lower. You'll be given painkillers, just as for a forceps delivery, and a catheter will be passed to make sure that your bladder is completely empty and won't get damaged, or get in the way of delivery. The doctor will then examine you to check the position of your baby's head one more time and will then place the cap of the ventouse machine against it.

The suction machine is then turned on. Many devices make an odd, rhythmic sound, like a very quiet drummer. Typically, during a ventouse delivery, the doctor will then wait for a contraction and will pull firmly but evenly with your contractions to help your baby down the birth canal. You may be asked to push at the same time, and delivering your baby will typically take about 3-4 pulls. Once your baby's head is delivered, the vacuum is released and the cup is taken off your baby's head, so that the rest of the delivery goes ahead as normal.

Because the ventouse device does not go around your baby's head, but sits on the top like a cap, it does not increase the space needed for your baby to come out. It is possible, therefore, that you won't need an episiotomy, particularly if this is not your first baby. Ventouse extractors are less likely than forceps to cause bruising or tears to the vagina and perineum. However, they are also less likely to be successful, as sometimes the baby needs more pull than can be delivered without the suction device coming off your baby's head. If ventouse delivery does not succeed then you will normally be offered a caesarean section.

Ventouse delivery risks

Ventouse delivery is a safe procedure for you and your baby. You don't need to have an epidural, spinal or pudendal anaesthetic to have a ventouse delivery. The possible complications are:

  • Episiotomy (although this is less likely than with forceps delivery).
  • Injury to your birth canal and perineum (less likely than after forceps delivery).
  • Your baby can be left with a temporary lump or bulge on his or her head, called a 'chignon'. This is a patch of swelling caused by the suction on the skin of your baby's scalp. Sometimes there is bleeding in the swelling, so your baby will have a swollen bruise (haematoma). Simple swelling will settle in the first few days but if there is a haematoma it can take many weeks or months to completely reabsorb and disappear.
  • Ventouse delivery is slightly less likely to succeed than forceps delivery and so has a slightly greater chance of you needing to go on to caesarean section.

Ventouse and forceps both have strengths and weaknesses. If both options are available to you then your doctor should explain which option they suggest is best, and why. This will be affected by things like the position your baby is in, whether he or she is in the best possible position, how far down your birth canal he or she has already come, and whether he or she is distressed.

Forceps deliveries

  • Are slightly more likely to succeed, which may be very important if time is of the essence.
  • Offer better protection for your baby's head.
  • Usually need an episiotomy.
  • May need epidural, spinal or pudendal anaesthetic, particularly if rotation of your baby is needed.
  • Are more likely than ventouse to injure your birth canal or perineum. If injury does occur, it is usually bruising and grazing; however, (rarely) more serious injury, affecting your pelvic floor muscles, can occur.

Ventouse deliveries

  • Do not usually have the need for epidural, spinal or pudendal anaesthetic, although you will still need an anaesthetic injection in your perineum.
  • Are slightly less likely than forceps to succeed.
  • Are less traumatic for your tissues.
  • Can also be used to rotate your baby.
  • Protect your baby's head less well than forceps.
  • Can cause a bump or swollen bruise on your baby's head.
  • Are less traumatic to your birth canal compared with forceps.
  • May not need an episiotomy.

The Odón device is a possible alternative to ventouse and forceps deliveries. It was invented in 2013 by Jorge Odón, a car mechanic from Argentina who had seen a video describing a method to extract a loose cork from inside an empty wine bottle by inserting a plastic bag until it enveloped the cork, inflating it and then pulling out the bag, which brought the cork with it.

The Odón device places a lubricated sleeve around the baby's head. This is inflated, both gripping the baby's head rather than just pulling on it by suction, and at the same time protecting it from the vaginal walls. Pulling (traction) can be applied as for a ventouse or forceps delivery. The device can be made very cheaply. The World Health Organization (WHO) says the device is: 'the first simple new tool for assisted delivery since forceps and vacuum extractors were introduced centuries ago.' The device is still undergoing testing, and the manufacturers are expected to launch production in 2019, when clinical trials are to be carried out in Europe.

Being pregnant increases the risk of blood clots forming in the veins in your legs and pelvis (this is called deep vein thrombosis). The risk is a little higher after an assisted birth. You can reduce the risk by being mobile as soon as possible after delivery, but you may be given special stockings to wear, or be given injections of blood thinners, or both.

This is a tear to the wall of the vagina, which involves the muscle or wall of the anus or rectum. This kind of tear affects 1 in 100 women having a normal vaginal birth, 1 in 25 having a ventouse delivery and about 1 in 10 having a forceps delivery. It will need to be carefully repaired by a doctor, usually under anaesthetic.

Urinary incontinence is leaking of urine. It isn't unusual after childbirth - it affects 1 in every 3 to 4 women, probably due to bruising around the neck of the bladder during labour. It's more common after a ventouse or forceps delivery. After an assisted delivery you should be offered advice on pelvic floor exercises, but problems with passing urine normally settle as your bruising goes down.

Anal incontinence is leaking wind or poo. It can happen after a third- or fourth-degree tear has occurred, but this is much less common.

Not all births go to plan and whilst nobody would want to have an assisted delivery, if things don't go as hoped this may be the best option for you and your baby.

Assisted delivery is more common in first deliveries. We know that the chances of assisted delivery are reduced if you have someone with you in labour who is not a staff member, who can support and encourage you and if you spend as much time upright in labour as you can (allowing gravity to assist you).

Having an epidural may slightly increase your chance of assisted delivery. However, in first-time mums, having an epidural with oxytocin (to strengthen contractions) actually reduces the chance of needing assisted delivery with rotational forceps. First-time mums are also advised not to start pushing too soon in the second stage of labour, in case they become too tired.

You are likely to be more bruised after an assisted delivery. This is partly because of the delivery and episiotomy (if you needed one), but partly because of the reasons the assisted delivery was needed: if you had already been pushing for a long time, or your baby was particularly large, you will be a little more swollen and bruised.

You may also feel very upset that things didn't go as you planned or that you feel you were not in control of the situation. Nobody puts having a forceps delivery into their birth plan, so this was probably not what you hoped would happen. Before you go home from hospital, you should be able to discuss with the doctor and/or midwife why you needed an assisted delivery. It's very important that you understand the decisions that were made and why you were given the information that you were.

After any birth, including an assisted vaginal birth, you may feel bruised and sore underneath. Stitches and swelling may make it extremely painful when you pass urine. Pain relief will help, and some women find pouring warm water over themselves as they urinate or passing urine in the bath helps reduce the stinging.

Assisted birth is most often needed in your first pregnancy. Most women who have an assisted vaginal birth do not need one the next time.

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