In a labor ward, the scene is familiar to many obstetricians—a fully dilated cervix, fetal head at the perineum, but no maternal expulsive effort. The fetal heart rate is borderline, the clock is ticking, and the team faces a crucial decision. While cesarean sections have become the default for many, there remains a time-tested, underutilized option: instrumental (operative vaginal) delivery.
In today’s cesarean-centric obstetric practice, the art and science of instrumental deliveries have nearly faded into academic obscurity. Yet, for women with certain medical risks where cesarean is contraindicated—or in resource-limited settings—the ability to safely perform a forceps or vacuum-assisted birth is not just valuable, it’s essential.
Why Consider Instrumental Deliveries?
Instrumental vaginal delivery becomes a lifesaving or labor-shortening necessity in several clinical situations:
Non-reassuring fetal heart patterns indicating possible hypoxia.
Prolonged second stage of labor where spontaneous delivery seems unlikely.
Maternal exhaustion or medical conditions (e.g., cardiac disease, severe preeclampsia, cerebrovascular disease) precluding active pushing.
Inaccessible cesarean facilities—especially in rural or low-resource settings.
When used judiciously by skilled hands, instrumental delivery can expedite birth more swiftly than arranging an emergency cesarean section, potentially minimizing neonatal complications.
Forceps and Vacuum: Tools with Purpose
Forceps
Dating back to the 16th century with the Chamberlen family, obstetric forceps have evolved through centuries:
- Outlet forceps – for when the fetal scalp is visible.
- Low forceps – head at or below +2 station.
- Mid cavity forceps – rarely used today due to increased trauma risks.
- Piper’s forceps – for after-coming head in breech delivery.
Despite their declining use, forceps offer precision and control. However, they are associated with higher maternal trauma (e.g., vaginal lacerations, anal sphincter injuries) if improperly used.
Vacuum (Ventouse) Extraction
First described by Malmström in 1953, the vacuum device uses a suction cup (soft or rigid) applied to the fetal scalp to assist descent during contractions. Its success hinges on:
- Correct cup placement over the flexion point.
- Adequate traction pressure (up to 0.8 kg/cm²).
- Delivery within 20–30 minutes, with no more than 3 pulls or 2–3 cup detachments (“pop-offs”).
Contraindications include:
- Gestation <34 weeks.
- Known fetal bleeding disorders.
- Unengaged vertex.
- Incomplete cervical dilation.
Vacuum extraction has a lower risk of maternal trauma compared to forceps, but carries a higher chance of neonatal cephalohematoma and scalp injuries.
New Innovations: The Odon Device
An unexpected innovation came from an Argentinian car mechanic, Jorge Odon, who invented a new tool to ease instrumental births. The Odon device uses an inflatable sleeve to gently encase and extract the fetal head—minimizing trauma and contamination risks (e.g., maternal-fetal HIV transmission). WHO praises it for its potential in rural settings, especially where C-sections aren’t feasible. Though promising, the device is still undergoing international trials and is not yet widely available.
Clinical Guidelines and Considerations
Professional bodies like RCOG, ACOG, and RANZCOG emphasize several crucial criteria for safe instrumental delivery:
- Clear indication documented in the maternal record.
- Informed consent and effective analgesia.
- Experienced operator—novices must be supervised.
- Immediate access to cesarean delivery if the attempt fails.
- Avoiding sequential use of instruments (e.g., vacuum then forceps).
The ACOG discourages routine episiotomy and prophylactic antibiotics in vacuum delivery, and insists on minimizing fetal trauma through careful case selection and technique.
The Way Forward: Training and Revival
Operative vaginal delivery is a highly skilled procedure with a steep learning curve and considerable medicolegal risk when poorly performed. Yet, as obstetricians, abandoning this skill altogether does a disservice to patients who might benefit from it. As Edmund Chapman once said:
“So far from hurting or destroying, [forceps] frequently save the mother’s life and that of the child.”
To bring balance to our surgical-heavy approach, we must reintegrate hands-on training in instrumental deliveries into obstetrics curricula. Simulation models, supervised practice, and re-emphasizing this skill during residency can help preserve this valuable art.
Conclusion
In the right hands, instrumental delivery is not a relic of the past, but a powerful ally in modern obstetrics. With adequate training and appropriate clinical judgment, we can ensure that more mothers and babies benefit from this safe, effective, and timely mode of delivery—especially where the luxury of an operating room is not always available.
Let us not allow instrumental deliveries to become a lost tradition. Instead, let’s ensure it remains a vital part of our obstetric toolkit.