Methods Used to Assist Birth

Most women labour and birth without any assistance. However, there are some specific reasons for which your healthcare provider may recommend assistance to help you push your baby out once your cervix is fully dilated. If it's needed, your healthcare provider can assist you by using either a vacuum extractor or forceps. It is important to have a conversation with your healthcare provider about the risks and benefits of these procedures, the potential impact on breastfeeding, and their practice preferences before going into labour. This will help you to make an informed decision about your care.

• You have become too tired to effectively push your baby out^{1 2}

• Your baby's fetal heart rate is abnormal and your healthcare provider has concerns that your baby is not coping with contractions and pushing efforts^{1 2}
• You have a condition that prevents you from pushing (i.e., heart problems)^{1 2}

Benefits and Risks

The following are population level benefits and risks. In order to make an informed decision, it's important to speak with your healthcare provider to discuss how these may apply to your individual situation.

Benefits for You

• May help avoid a caesarean birth²

Benefits for Your Baby

• May be life saving²

Risks for You

Vacuum

• Tears to the vagina or to the pelvic floor^{1 2}
• Bladder and/or bowel dysfunction.²
• Failure to give birth vaginally.²

Forceps

• Tears to the vagina or to the pelvic floor^{1 2}

• May need an episiotomy¹

• Bladder and/or bowel dysfunction²

• Failure to give birth vaginally²

Risks for Your Baby

Vacuum

• Scalp lacerations (cuts) and bruising^1 2
• Facial nerve palsy²
• Cephalohematoma (i.e., bleeding between an inner layer of skin and the skull)²
• Intracranial and/or retinal hemorrhage²
• Skull fractures²
• Neonatal jaundice²
• Challenges starting breastfeeding

Forceps

• Injury to the head, face, neck, and/or eyes²
• Scalp or facial lacerations (cuts) and bruising^{1 2}
• Facial nerve palsy²
• Cephalohematoma (i.e., bleeding between an inner layer of skin and the skull)²
• Intracranial and/or retinal hemorrhage²
• Skull fractures²
• Neonatal jaundice²
• Challenges starting breastfeeding

Alternatives

It's important to consider how one intervention may lead to another intervention. This is the case for assisted vaginal birth. Use of epidurals and continuous electronic fetal monitoring increases the likelihood of assisted vaginal birth.³

If continuous fetal heart rate monitoring is suggested by your healthcare provider, ask for the reason that they feel it's necessary and discuss the option of using intermittent fetal heart rate monitoring (using a hand held doppler device to listen to the fetal heart for a minute every 15 - 30 minutes). For low-risk pregnancies, intermittent fetal heart rate monitoring in labour is the best practice.

Look at alternative comfort methods to work with your contraction pain instead of an epidural. You may even be able to delay using the epidural with these methods if you planned on using one.

Movement and position changes throughout labour can assist you to work with your contraction pain and help you wiggle and move your baby down and through your pelvis.³

Vacuum and Forceps Procedures

The method chosen to assist with birth depends on the individual situation.² There are risks associated with all of the methods.² The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other.² The benefits of the chosen method should outweigh its risks.²

Prior to an assisted vaginal birth, it must be confirmed that:

• Your cervix is fully dilated²

• Your membranes have been ruptured²

• Your pelvis can accommodate the birth of your baby²

• Your bladder is empty²
• Your baby is low enough in the pelvis to be born through the vagina^1 2

• You have appropriate pain medication (i.e., epidural or local injection)²

• There is a backup plan for birth if the method is unsuccessful²

Vacuum Extractor

A vacuum extractor is a plastic cup-like instrument that is placed on your baby’s head and gentle suction is applied.^1 2 Your healthcare provider gently pulls while you push during your contractions.^{1 2} The vacuum extractor is removed once your baby crowns.

Forceps

Forceps are a pair of tong-like instruments that are placed around your baby’s head to guide your baby through the birth canal and to assist your pushing efforts.^{1 2} They are placed one at a time and locked in place to prevent squeezing your baby’s head.² Your healthcare provider gently pulls or turns the baby's head while you push during your contractions.^{1 2} The forceps are removed once your baby crowns. With forceps, you will usually have some anesthetic, either an epidural, or a local injection.¹ An episiotomy may be needed.¹

Episiotomy

Episiotomy is a surgical incision (cut) in your perineum (the area between your vagina and anus)^{1 2} to make the vaginal opening larger for your baby to pass through.² A local anesthetic injection will be given if an epidural is not being used. Episiotomies are not common but may be used with forceps or vacuum, if excessive tearing of your skin seems likely. Your healthcare provider will repair the cut using dissolvable stitches after the birth of your baby.

Current best practice is to support the perineum and allow it to tear naturally rather than to perform an episiotomy.² Tears are often smaller, are repaired more easily or not at all, heal more quickly, and are less painful than an episiotomy.² An episiotomy will only be considered if birth needs to occur quickly or if a very large tear can be prevented by doing an episiotomy.² If an episiotomy is needed, a diagonal incision (cut) is made.² This has been shown to decrease the risk of extensive tearing.²

For more information, decision aids & tools

Ottawa Family Decision Guide
Making Informed Decisions About Your Care - other decision aids & tools

If you have specific questions

• Speak with your healthcare provider

• If you are giving birth at LHSC, speak with the nurse at the London Health Sciences Centre (LHSC) Preadmission Clinic.