Forceps and Vacuum Extractors

Occasionally, during the pushing stage of labor (second stage), a baby will be close to being born, but “not quite there yet”. This is often the most stressful time for a mother or baby. A mother may be exhausted or nearly so, and a baby may show signs of head and cord compression (which usually do not permanently affect the baby [but may]). A doctor may decide to use forceps or a vacuum extractor to help with delivery in these situations.

Prior to modern times, the option of cesarean section was a death sentence for most mothers. Successful abdominal surgery relies on effective surgical technique, good anesthesia, intensive care, and fluid replacement (sometimes including blood transfusion)……factors which did not reach a level of adequate sophistication until the last 50-100 years. When obstetrical forceps were invented (in the 1500s), many mothers and babies who would have otherwised died, were saved. Similarly, the invention of the vacuum extractor (in the 1950s), provided another tool which might be used to facilitate difficult delivery.

Forceps have been overused in recent times. It may have been the recommendation of one famous doctor in the 1920s to deliver all babies employing forceps and episiotomy that helped establish a philosophy of over-medicalization of the birth process. Because of this overuse, the “iatrogenic” complications were unacceptably high. Delivery by forceps when the baby was still relatively high in the pelvis (“mid-” and “high-forceps”) was too often associated with damage to the mother and/or the baby. Also, in recent times, cesarean section became an increasingly safer option of delivery. Thus, during the 1970s and 1980s, many obstetrical physicians did not have an opportunity to learn to use forceps.

Both forceps and vacuum extractors facilitate birth “by traction” as opposed to “expulsion”. When used according to modern standards by an experienced accoucheur, forceps and vacuum extractors can be an invaluable tool. And although the use of “assisted delivery” does carry some risks, when employed properly, those risks should be lower than the risks of the presenting problem. It is clearly a situation in which you trust your doctor to “make the call”.

To deliver a baby with forceps, the baby should be “low” in the pelvis (the top of the head should be visible) and the position of the head should be such that the baby’s face is pointed directly up or down. The mother should push when the doctor pulls; to increase the expulsive force and minimize the amount of traction needed. Episiotomy is common, if not the rule for most doctors. Often a baby born with the help of forceps will have red marks or bruises on the cheeks or side of the head….these usually heal quickly without problems.

Vacuum extractors also have a place in modern obstetrics. Although a recent FDA warnings cited rising complications from overuse, many exhausted mothers have been safely assisted with the vacuum extractor. Although the modern vacuum extractor is made of soft plastic-type materials and seems innocuous, its use is associated with some iatrogenic risk. The vacuum extractor consists of a soft, bell-shaped cup which applies to the top and back of the baby’s head. A tube connects the cup to a vacuum pump, and negative pressure keeps the cup in place. During a contraction, the mother pushes and the doctor or midwife applies traction.

Ask your doctor or midwife if they use forceps or vacuum extractors. Generally speaking, if they deliver more than 5% of their patients this way, they are probably overusing the technology. Certainly, doctors working in high-risk obstetrical settings (“teritary care referral centers” and university hospitals) may find justifiable occasions to use these technologies more often. However, this is technology that should be used sparingly and in well-chosen situations under certain conditions. Doctors who work in collaboration with midwives, in which the midwives attend most of the “normal” births, may have justifiably higher rates of assisted deliveries when their “statistics” do not include the births attended by their midwifery partners.