The Facts About Operative Vaginal Delivery The VBAC Link

Attempting a vaginal delivery, particularly after a previous C-section, is something many expectant parents hope to do. Finding evidence-backed VBAC facts can be tough.

Doulas can help families prepare by learning about what to expect if an operative vaginal delivery becomes necessary during labor.

Whether or not your client has previously had a Cesarean birth, sometimes a C-section can’t be avoided. But there are also times when a vaginal birth may still be an option, with some assistance, allowing you to reap the benefits of a natural birth.

Stick with us as we dive into what it means to have an operative vaginal delivery, and what you may want to know so you can help educate your clients along the way.

Originally written July 4, 2018, this post was updated and republished on January 19, 2022.

What is an operative vaginal delivery?

Operative delivery is when a provider uses a device such as forceps or a vacuum to assist the birthing person in avoiding a cesarean and having a vaginal birth. The decision on what method to use is based on the skill and comfort level of the provider.

Some couples would rather have a cesarean than do an operative vaginal delivery. There are pros and cons to both methods. It is important to encourage your clients to have this discussion with their providers before going into labor.

With some time to learn about the options and research risks and benefits, families can decide what they are most comfortable with.

Forceps delivery

Forceps look like two large spoons that go around the baby’s head and allow a provider to help assist the birthing parent from the outside.

Forceps would be placed on the baby’s head in-between contractions. A provider will then gently use force by pulling as the birthing parent pushes. A provider may only need to pull once to move the baby along, although they may need to pull again. Each provider also may have a different preference or protocol on how many assists they are comfortable with before moving to a Cesarean Section.

A forceps delivery may be suggested by a provider when a baby is very close to delivery but having a hard time making that final push under the pubic bone. Other times, the baby may be having decelerations in the heart rate, but the provider feels confident a forceps delivery will be successful. The provider will often have to assess the full situation before making a decision if a forceps delivery is the best option at that moment.

There are risks to using forceps in delivery. However, when a skilled provider uses them correctly, there are low risks overall. Some risks for mom and baby may include:

Risks of forceps delivery to the birthing parent

Tearing to the perineum and inside the vagina that may not have occurred otherwise
Bladder or rectal pain
Pelvic floor may become weaker and need pelvic floor work
A harder time using the bathroom
The operative vaginal delivery may not be successful, and a Cesarean Section may still be required.

Risks of forceps delivery to the baby

Bruising to the baby’s head, that can last for days or weeks
VERY rare, but the baby may experience temporary nerve damage to the face
Temporary swelling (hematoma) to the baby’s head, making the baby look more like a “cone head”
Also rare, but possible lacerations on the face or head
Skull fracture
Cephalohematoma: A hematoma that occurs under the baby’s skull bone. It doesn’t appear that it poses any known risk to the brain cells, but may cause a pooling of blood between the baby’s head and the skin.

Vacuum-assisted delivery

Like forceps, vacuum-assisted delivery is a method used to help assist a birthing parent in the final pushing stage of labor. Some examples of when a provider may suggest using vacuum assistance are:

If the baby is not quite making it around the pubic bone or not descending the way the provider feels the baby should be
The baby is showing signs of needing assistance due to drops in the heart rate.
The parent is tired and not able to push effectively but is very close to delivery.

A vacuum is a strong “suction cup” that attaches to the baby’s head. It has a handle attached to it with a lever that will allow the provider to adjust the amount of suction applied.

As with forceps, the vacuum is placed in between contractions. Then as pushing begins, the provider will pull to help assist in bringing the baby down.

The idea of vacuum extraction was first introduced in 1705 by Dr. James Yonge, an English surgeon. This was several decades before the forceps were invented. It wasn’t until the 1980s that vacuum assistance became a more popular choice. By the year 1992, most assisted deliveries were using vacuum rather than forceps.

A provider may run through the same scenarios as above before choosing to do a vacuum.

Because there are very specific circumstances where operative vaginal delivery is indicated, vs. proceeding to a Cesarean, it is important to always discuss the risks with the provider. We have listed a few of them here.

Risks of vacuum-assisted delivery to the birthing parent

Weakened pelvic floor
Possible larger tears in the perineum and vagina
The chance of being unsuccessful and needing to go to the OR for a Cesarean

Risks of vacuum-assisted delivery to the baby

There is a chance the suction will not be very strong and may pop off and need to be replaced, or it being placed incorrectly
Wrong size cup being placed for baby’s head
Hydrocephalus: A type of brain injury that occurs when an infant experiences internal trauma to the brain. Hydrocephalus is a medical condition that occurs when cerebrospinal fluid (CSF) becomes blocked and starts to build up within the brain, eventually flooding into the ventricle cavities.
Cephalohematoma: Although more common in forcep delivery, this is still a risk.
Subgaleal Hematoma: A rare but possibly life-threatening injury, when there is an effect on the emissary veins, which are connections between the dural sinuses and the scalp veins.

For both forceps and vacuum delivery, true informed consent would be where a provider runs through these scenarios (sometimes quickly) with the birthing parent, so they can make a decision together.

How common are operative vaginal deliveries?

Approximately 5% of deliveries in the US are operative vaginal deliveries, and the overall rate is decreasing. However, we are seeing an increase in vacuum-assisted deliveries, which now account for almost 4 times the rate of forceps assisted vaginal births.

According to NCBI In the United States, 3.1 percent of all deliveries in 2017 were accomplished via an operative vaginal approach. Forceps deliveries accounted for 0.5 percent of vaginal births, and vacuum deliveries accounted for 2.6 percent of vaginal births.

In comparison, Cesarean rates in May of 2019 were 31.9% — and 25% of those were considered low-risk deliveries.

When is an operative vaginal delivery used?

Deciding whether or not an operative vaginal delivery is appropriate may be done on a case by case basis. A birthing parent may discuss these options with their provider leading up to the birth to provide more education if this event ever comes up.

A provider may run through the following scenarios in making a decision:

Is the baby low enough? Typically the baby’s head will need to be +2/+3 station. This means that the baby has moved past the ischial spines and is close to crowning.
Is the baby’s head in a good position?
Is the birthing parent making good progress, but the baby needs to be born quickly due to signs of distress such as decelerating heart rate?
Is the birthing parent running out of steam?
Does the birthing parent want help?

Indications: ACOG guidelines for operative vaginal delivery

In 2020, The American College of Obstetricians and Gynecologists published guidelines on when an operative vaginal delivery should be performed, and when there is an appropriate indication. These may be:

Prolonged pushing with lack of progress for 3 hours with regional anesthesia (generally an epidural) or 2 hours for women without general anesthesia.
Suspicion that the fetus may be compromised, such as the heart rate is not recovering or has a non-reassuring pattern.
The vacuum may be used electively to shorten the second stage of labor because of maternal cardiovascular or neurological disease, and is not well defined with maternal exhaustion.

Although there are indications as to why an operative vaginal delivery would be needed, there are also contraindications.

Contraindications: When operative vaginal delivery may not be appropriate

According to the ACOG guidelines, operative vaginal delivery is not recommended in the following scenarios:

If the baby has some underlying fetal disorders such as a bleeding disorder or a demineralizing disease, an operative vaginal delivery may not be appropriate.
If the cervix has not dilated completely, membranes are still intact, or the baby’s head has not engaged well into the pelvis.
If the baby has a malpresentation such as breech, transverse, or facial presentation it may also be a contradiction as to why an assisted birth may not qualify. (See our posts on how to turn a transverse baby and how to turn a breech baby for advice on avoiding this.)

Changes in maternal positioning, a reduction in neuraxial anesthesia, increased emotional support to the patient, and “laboring down” (delayed pushing) in the second stage have all been shown to increase the likelihood of a successful vaginal delivery.
Unzila, 2019

Along with this consent, it is suggested that alternative management options be discussed as well, such as Pitocin augmentation or Cesarean.

Weighing the benefits and risks of operative vaginal delivery

Studies show that a prolonged second stage of labor will typically deliver vaginally, and that second stage exceeding 2 hours does not adversely affect neonatal outcomes or risk of maternal psychological birth trauma if continued management is reasonable.

If the parent does not meet the criteria for operative vaginal delivery, a Cesarean delivery would then be discussed.

Sometimes a provider may suggest an operative vaginal delivery and the parent will decline. In this event, it is important to look at the entire situation and assess if it is safe and suggested to continue pushing or not.

To learn more about this decision-making process, you can read our article on what failure to progress in labor looks like, and what options the ACOG suggests.

Supporting birth parents

All in all, it is important for every parent to feel that they are a part of the decision-making process. It is important for providers to offer or suggest what they are thinking, rather than telling a parent what they need to do.

Offering your clients ideas on how to bring this up, leading up to delivery, can be very beneficial.

Here is a list of questions that you may want to provide to parents, to help them ask their providers about operative vaginal delivery.

How comfortable are you with performing operative vaginal delivery?
Which method are you trained and skilled in, forceps or vacuum?
Why do you choose that method?
How often do you find yourself doing an operative delivery?
What circumstances would lead you to offer an operative vaginal delivery?
Would you suggest an operative vaginal delivery vs going straight to a Cesarean Section?

As birth professionals, we understand how exciting it is when we see a TOLAC or even a parent that is not a TOLAC, getting close to delivery. Seeing that squishy head means they are super close — but there can still be some work to be done.

Encouraging your clients and patients during this last push before delivery can truly be empowering for them. Don’t be scared to ask questions or offer suggestions such as changing positions or maybe resting and descending for a little bit.

Keep in mind this is a very emotional time for your client, and your role as a doula is to trust them and support their decisions.

If you would like to listen to a birth story that ended with a vacuum-assisted delivery, check out Episode 09 of our VBAC podcast.

Interested in becoming a doula yourself? Our Advanced Doula Certification Course gives you everything you need to start practicing.