Title of Guideline (must include the word “Guideline” (not protocol,
policy, procedure etc)
Author: Contact Name and Job Title
Guideline for Operative Vaginal
Delivery
Amita Mahendru, Post CCT Special
interest Fellow in Fetal and Maternal
medicine
Pallavi Dhange, Locum consultant
Obstetrician and Gynaecologist, NUH
Mausumi Das, Consultant Obstetrician
and Gynaecologist.
Directorate & Speciality
Obstetrics and Gynaecology
Date of submission
March 2016
Explicit definition of patient group to which it applies (e.g. inclusion
and exclusion criteria, diagnosis)
Women in second stage of labour
Version
Four
If this version supersedes another clinical guideline please be
explicit about which guideline it replaces including version number.
Statement of the evidence base of the guideline – has the
guideline been peer reviewed by colleagues?
Version three
Evidence base: (1-6)
1
NICE Guidance, Royal College Guideline, SIGN
(please state which source).
2a
meta analysis of randomised controlled trials
2b
at least one randomised controlled trial
3a
at least one well-designed controlled study without
randomisation
3b
at least one other type of well-designed quasiexperimental study
4
well –designed non-experimental descriptive
studies (ie comparative / correlation and case
studies)
5
expert committee reports or opinions and / or
clinical experiences of respected authorities
6
recommended best practise based on the clinical
experience of the guideline developer
Consultation Process
Ratified by:
Yes
1- RCOG Green-top Guideline No.
26 Operative Vaginal Delivery
(Jan 2011)
And
NICE Guideline-Intra-partum
care for healthy women and
babies CG190 (Dec 2014)
Obstetricians and midwives
Maternity guidelines group March
2016
Date:
Target audience
Obstetricians and midwives
Review Date: (to be applied by the Integrated Governance Team)
March 2021
A review date of 5 years will be applied by the Trust. Directorates
can choose to apply a shorter review date, however this must be
managed through Directorate Governance processes.
This guideline has been registered with the trust. However, clinical guidelines are guidelines only.
The interpretation and application of clinical guidelines will remain the responsibility of the
individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using
guidelines after the review date.
PRACTITIONER UNDERTAKING PROCEDURE
All practitioners undertaking operative vaginal deliveries should
have the knowledge, experience and skills necessary to assess
the woman, use the instruments and manage complications that
may arise.
Obstetric trainees should achieve appropriate training prior to
performing independent operative vaginal deliveries (supported by
log of experience, skills and drills and work-place based
assessments) or be supervised by an appropriately trained
practitioner.
Deliveries in theatre must be done by or supervised by senior
registrars or consultants.
INDICATIONS
 Presumed fetal compromise
 Delay in second stage of labour:
This is defined as lack of continuing progress (in terms of rotation
and/or descent of the presenting part) after 2 hours of active
second stage of labour in nulliparous women and 1 hour of active
second stage in parous women (NICE 2014)
 Maternal reasons:
To shorten and reduce second stage in case of maternal medical
indications to avoid Valsalva (forcible exhalation against a closed
airway) e.g. Cardiac disease (New York Heart Association
classification III or IV, hypertensive crises, cerebral vascular
disease, myasthenia gravis, spinal cord injury, proliferative
retinopathy)
Maternal request and exhaustion
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CONTRAINDICATIONS
Lack of engagement of fetal head (except in second twin)
Inability to define fetal position (an attempt to define position
should have been made by a senior obstetrician)
Brow presentation
Face presentation (with exception of mentoanterior position when
forceps can be applied by an experienced operator)
Known pelvic abnormality likely to cause fetopelvic disproportion
Forceps should be avoided in conditions where the fetus has
predisposition to fracture (e.g. osteogenesis imperfecta)
Ventouse should be avoided if risk of fetal bleeding in maternal
haematological conditions e.g. alloimmune thrombocytopenia, Von
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Willibrands disease and at gestation of less than 34 weeks
gestation (between 34 and 36 weeks relative contraindication)
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PRE-REQUISITES
Informed verbal consent should be obtained from women
undergoing operative vaginal delivery and this should be
documented in the intrapartum records along with the indication of
the procedure and the time of decision.
Abdominal palpation must be performed to determine no more
than 1/5th head is palpable abdominally.
Vaginal examination must be performed to establish full dilatation
of cervix.
The vertex must be at or below ischial spines on vaginal
assessment.
Assess for position of fetal head (must be clearly identified if
necessary by feeling for ears or ultrasound)
Also assess for caput and moulding.
Empty bladder (catheterise before attempting delivery).
Adequate analgesia (a pudendal block combined with local
anaesthetic to the perineum, or epidural/spinal anaesthesia).
Regional analgesia is necessary for Kielland forceps.
Check equipment- Ventouse, forceps, neonatal resuscitator, suture
pack.
Swab count – It is mandatory to count swab pre and post
procedure.
Appropriate members of team including personnel for neonatal
resuscitation.
TRIAL OF INSTRUMENTAL DELIVERY
Operative vaginal births that have a higher chance of failure should
be considered a trial and conducted in a place where immediate
recourse to caesarean section can be undertaken.
This does not necessarily equate to such deliveries being done in
the operating theatre itself, so long as easy access to a theatre is
available. However, it is important to balance the risk of worse fetal
outcomes due to delays involved in transfer to theatre.
In case of suspected fetal compromise at the time of decision for
instrumental delivery, measures should be taken to expedite
delivery in a similar way as in cases of category 1 caesarean
section.
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Ventouse might not be appropriate in the situation of trial in theatre
as the ability of the woman to push might be affected by regional
anaesthesia.
Higher failure rates are associated with:
Raised maternal body mass index
Clinically big baby
Occipito-posterior position
Mid-cavity delivery or when 1/5 head palpable per abdomen
The senior registrar or consultant should assess the woman when
a trial of instrumental delivery is being considered, and decide on
the most appropriate place to undertake this. If a trial in theatre is
appropriate, the consultant should be informed. It is necessary to
obtain written consent for both instrumental delivery and
emergency caesarean section in case vaginal delivery is
unsuccessful. The senior registrar or consultant should be present
at the delivery. The anaesthetist and the scrub nurse should be
prepared to proceed with immediate caesarean section, should the
procedure be unsuccessful / need to be abandoned.
CHOICE OF INSTRUMENT
The operator should use the most appropriate instrument for the
clinical situation and appropriate to their skill and experience with
each instrument.
Forceps and ventouse are associated with different benefits and
risks, as outlined below.
Ventouse
Forceps
Is associated with less maternal Forceps is preferred in
perineal and vaginal trauma.
situations such as face
presentation (mento-anterior),
aftercoming head of the breech,
gestation of less than 34 weeks,
large amount of caput or mother
who is unwilling to push.
Is associated with a higher
More risk of maternal trauma
failure rate, more
cephalhaematoma, and a higher
risk of retinal haemorrhage
The risk of injury is significantly higher in those babies exposed to
attempts with both instruments.
The options for rotational deliveries include
 Kielland forceps
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 Manual rotation followed by direct traction forceps
 Rotational ventouse
VENTOUSE
1. Silicone rubber cup is appropriate for occipito-anterior (OA)
and possibly for occipito-transverse (OT) positions, but should
not be used for the occipito-posterior (OP) position or in the
presence of excessive caput. It does not form a chignon and is
less traumatic for the baby.
2. Kiwi cup can be used for OA, OT and OP positions. It has a
higher failure rate than conventional ventouse and should be
reserved for outlet deliveries when the fetal head is visible at
the perineum.
3. Anterior metal cup should be used for positions between OA
and OT, especially if there is moderate or severe caput, and
may also be suitable for the slightly deflexed head.
4. Posterior metal cup is for use in OP and OT positions where
deflexion of the head is also usually present.
Method
1. For silicone cups, lubricate cup, fold and gently insert into the
vagina. For metal and Kiwi cups, lubricate and insert sideways.
2. Apply to the flexion point (3cm anterior to the posterior
fontanelle on the saggital suture)
3. Ensure no maternal tissue is trapped under the cup.
4. Increase vacuum to 0.2 kg/cm2 and check again for entrapment
of maternal tissue. Increase vacuum to 0.8 kg/cm2.
5. Apply traction along the pelvic axis during contractions and
helped by maternal effort. With the posterior metal cup the first
pull should be in the direction required to flex the head followed
by traction along the pelvic axis.
6. Use the thumb of the non-pulling hand to apply counter traction
to the cup to avoid detachment, whilst assessing descent using
the index and middle finger of the same hand.
7. Mediolateral episiotomy may be necessary as the occiput
distends the vulva.
Indications for abandoning procedure
1. No evidence of progressive descent with each pull i.e. with each
contraction.
2. Delivery not imminent following three pulls of a correctly applied
instrument by an experienced operator.
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3. The cup should not be reapplied more than twice (three
detachments).
FORCEPS
1. Non-rotational (Neville-Barnes) forceps are most useful for
direct OA, LOA, and ROA positions but can sometimes be
useful for direct OP positions.
2. Kielland forceps are used for rotational deliveries from OT and
OP positions. The key difference between this instrument and
straight forceps lies in the sliding lock, which allows correction
of asynclitism and the parallel axis of the blades and handles,
which facilitates rotation in the pelvis. Suspected fetal
compromise is a relative contraindication, unless the clinician
expects an easy delivery.
3. Wrigley’s forceps are used for cases requiring assistance
during caesarean section.
Method: Non-rotational
1. Check the pair of forceps fit together and lock before
application.
2. Apply the blades of the forceps to the fetal head between
contractions. Apply the left blade first, using the other hand to
protect the maternal tissues during application. Check correct
application by:
 Ensuring sagittal suture is in midline of shanks
 No more than a finger tip can be placed through the
fenestration of the blade and the fetal head
3. Moderate traction should be applied along the correct axis using
Pajot’s manoeuvre. This requires outward traction with one
hand, using the other hand to push the shank downwards. The
angle of traction is changed as the occiput appears at the vulva.
4. Halt in between contractions.
5. Perform episiotomy as the occiput distends the vulva.
6. Remove forceps as the jaw visible and remove the blades- right
blade followed by left.
Method: Rotational
1. Check the pair of forceps fit together before application
2. Align the knobs on the handle towards the occiput.
3. Apply the blades in between contractions.
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4. In OP positions, apply the blades as for non-rotational deliveries
i.e. the lower blade or posterior blade is applied followed by the
anterior blade and the knobs are facing downwards. Check that
the forceps lock with ease and that the suture lines are parallel
with the long axis of the blades.
5. In OT positions either blade can be applied first, but many
obstetricians prefer to apply the anterior blade first. This blade
is initially applied like non-rotational forceps using one of the
two methods:
 Wandering method: The blade is then guided over the fetal
face into position under the symphysis.
 Direct method: Slide anterior blade between the head and
the symphysis pubis.
6. Gently slide the posterior forceps blade into the posterior
vagina, guiding the heel of the blade into position where
posterior blade is directly along the concavity of the sacrum with
your thumb. The handle should follow in a downwards arc.
7. Engage handles and correct asynclitism
8. Disengage head and rotate head by shortest arc after
depressing the handles.
9. Effect rotation between contractions, using only light pressure
10. Check rotation of the fetal head has occurred by feeling for the
sagittal suture
11. Apply moderate traction with contractions initially downwards
and outwards, moving in an arc to finish with the handles
positioned over the symphysis pubis.
12. Perform mediolateral episiotomy as the head descends with
traction.
Indications for abandoning procedure
1. Forceps cannot be applied easily or do not lock.
2. Failure to rotate the head (Kielland)
3. No evidence of progressive descent with each pull.
4. Delivery not imminent following three pulls (i.e. with three
contractions) of a correctly applied instrument by an
experienced operator.
Use of sequential instruments
 After an unsuccessful attempt with the ventouse, any attempt
with a second instrument should only be done by a senior
registrar or consultant.
 The use of sequential instruments is associated with an
increased risk of trauma to the infant however, the operator
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must balance the risks of a caesarean section with the risks
of forceps delivery.
CARE STANDARDS FOLLOWING INSTRUMENTAL DELIVERY
Immediate care
1. Actively manage the third stage. Consider the use of
Syntometrine and / or 40 units Syntocinon infusion in 500mls of
normal saline (NUH Guideline for Management of third stage,
retained placenta and acute uterine inversion).
2. Obtain paired cord blood gas samples.
3. Carefully inspect the perineum and lateral walls of the vagina
for tears, and undertake a rectal examination prior to suturing.
Change gloves before commencing suturing.
4. Use adequate analgesia for repair. An epidural top up can be
prescribed for this purpose, or further local anaesthesia used.
5. Undertake vaginal and rectal examination at the end of the
procedure.
6. Prescribe regular paracetemol and diclofenac in the absence of
contraindications.
7. An indwelling catheter should be in place in cases of deliveries
in theatre under regional anaesthesia or in women with epidural
top up (refer to NUH, postpartum bladder care guideline)
8. The obstetrician conducting the delivery must clearly document
the time of decision to delivery, the time of birth and the details
of the procedure in the operative notes.
Subsequent care
The volume and time of first void following delivery or removal of
catheter must be recorded (Refer to Postpartum bladder care
guideline, NUH).
Women should be seen by an Obstetrician prior to hospital
discharge.
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References:
Groom K, Jones B, Miller N, Paterson-Brown S. A prospective
randomised controlled trial of the Kiwi Omnicup versus
conventional ventouse cups for vacuum-assisted vaginal delivery.
BJOG 2006; 113:183-189.
Guideline for postpartum bladder care NUH Clinical care
guidelines 2013
Guideline for management of third stage of labour, retained
placenta, and acute uterine inversion. NUH Clinical Guidelines
2013
Johanson RB, Menon V. Vacuum extraction versus forceps for
assisted vaginal delivery. Cochrane Database of Systematic
Reviews 1999, Issue 2.
Johanson RB, Menon V. Soft versus rigid vacuum extractor cups
for assisted vaginal delivery. Cochrane Database of Systematic
Reviews 2000, Issue 2
RCOG Clinical ‘Green-Top’ Guideline No 26. Operative vaginal
delivery. 2011 RCOG, London.
RCOG Consent Advice No. 11. Operative vaginal delivery. 2010.
RCOG, London
NICE Clinical Guideline CG190. Intrapartum care: management
and delivery of care to women in labour. 2014
Sullivan C, Hayman R. Instrumental vaginal delivery. Obstet
Gynaecol Reprod Med 2008;18:99-105
Suwannachat B, Lumbiganon P, Laopaiboon M. Rapid versus
stepwise negative pressure application for vacuum extraction
assisted vaginal delivery. Cochrane Database of Systematic
Reviews 2008, Issue 3.
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