Delay in Second Stage of Labour and Use of Forceps

The rate of operative vaginal delivery has remained fairly constant at 10-15%.¹
Although it is now generally well established that there are significant risks associated with rotational and mid-cavity deliveries,² there are low morbidity rates with most operative deliveries.³ It should also be remembered that Caesarean section in the second stage of labour is not without considerable morbidity.^4,5

The operator should use their skill and judgement to determine the best choice of instrument for the situation.⁶ The RCOG currently advises that the vacuum extractor should be the first choice.¹ Although this can have a higher failure rate and increased risks of cephalohaematoma, it has been shown to be associated with less maternal trauma.^7,8,9

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

• Use of a partogram to monitor progress in labour
• Mother labours in an upright or left lateral position⁹
• Avoidance of use of epidural anaesthesia

NB: There is no evidence that discontinuing an epidural in the second stage of labour will decrease the risk of assisted delivery.¹⁰

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 mother¹¹

They are used to shorten the second stage of labour:

Fetal:

• Presumed, or diagnosed (by fetal blood sampling) compromise
• To protect the head during breech vaginal delivery¹²

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

• Nulliparous women:
  • Lack of progress for 3 hours (active and passive stage combined), with regional anaesthesia
  • Lack of progress for 2 hours if no regional anaesthesia
• Multiparous women:
  • Lack of progress for 2 hours if regional anaesthesia in place
  • Lack of progress for 1 hour if no regional anaesthesia in place
  • Maternal fatigue/exhaustion

• Predisposition to fractures in the fetus
• Bleeding tendency or active bleeding in fetus
• Face presentation and vacuum extractor
• Gestation ≤ 34 weeks¹

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

(Acronym=FORCEPS)

• [F]ully dilated cervix
• [O]ccipito-anterior position preferably - occipito-posterior position (OP) delivery is possible with Keillands forceps and vacuum.
• [R]uptured membranes
• [C]ephalic presentation
• [E]engaged presenting part i.e. the greater diameter of baby's head has passed pelvic brim
• [P]ain relief is adequate
  • Vacuum extraction or low forceps - minimum of perineal nerve block
  • Mid forceps - epidural or pudendal nerve block, or general anaesthetic
• [S]phincter (bladder) empty

These are associated with:

• Maternal BMI ≥ 30
• Estimated fetal weight ≥ 4kg
• 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 3 pulls.
• An incident report should be completed.
• Using differing instruments sequentially is not recommended.¹³

Analgesia

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

Antibiotics

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

Thromboprophylaxis

Each woman should be individually assessed for risk e.g. immobility.

Bladder care

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

• Vacuum-assisted delivery has a lower rate of successful delivery, but is less likely to lead to Caesarean section than the use of forceps.
• Vacuum-assisted delivery is also associated with less use of anaesthesia and fewer severe maternal injuries.
• However, use of forceps following failed vacuum extraction can lead to high level of damage to mother. Adverse symptoms such as urinary and faecal incontinence are common in mothers with both forms of assisted delivery.^8,9
• Cephalhaematomas and retinal haemorrhages are well recognised sequelae of vacuum extraction, but usually have no long term adverse effects.^7,15

Suitable subjects may include:

• Rate of use
• Rate of failures
• Incidence of maternal tears
• Neonatal trauma
• Standard of documentation