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J Matern Fetal Neonatal Med, 2014; 27(18): 1886–1891

! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.904282

ORIGINAL ARTICLE

Temporal trends and morbidities of vacuum, forceps, and combined

use of both
Alex Fong1, Erica Wu1, Deyu Pan2, Judith H. Chung1, and Dotun A. Ogunyemi3
1
Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, Orange, CA, USA, 2Charles Drew University of
Medicine and Science, Research – Life Sciences Institute, Los Angeles, CA, USA, and 3David Geffen School of Medicine, University of California,
Los Angeles, CA, USA

Abstract Keywords
Objective: To assess trends over time of operative vaginal delivery and compare delivery-related California, incidence, operative vaginal
morbidity between vacuum delivery, forceps delivery, or combined use of both in California. delivery, outcomes, population-based
Methods: California ICD-9 discharge data from 2001 to 2007 were used to identify cases study
of forceps and vacuum delivery.
Results: There was a decline in all operative delivery types (9.0% in 2001 to 7.6% in 2007), History
with the decline in the use of forceps most pronounced (7.26/1000 deliveries in 2001 to 3.85/
1000 in 2007). Higher rates of third/fourth degree lacerations, postpartum hemorrhage, manual Received 6 November 2013
extraction of placenta, pelvic hematoma requiring evacuation, cervical laceration repair, and Revised 21 February 2014
thromboembolic events were noted in forceps compared to vacuum deliveries. When both Accepted 11 March 2014
instruments were used, rates of third/fourth degree lacerations and postpartum hemorrhage Published online 9 April 2014
were increased. Operative delivery failure was highest in combined use compared to forceps or
vacuum alone.
Conclusion: The incidence of operative vaginal delivery in California is declining, with
decreasing use of forceps most notable. Several maternal morbidities are increased in forceps
and combined deliveries compared to vacuum deliveries. There is a significantly higher risk
of failure when two operative delivery methods are employed. These findings may be
contributing to the declining willingness of providers to perform operative vaginal delivery.

Introduction Much of the decline in the use of vacuum or forceps has

been attributed to provider and patient concern regarding their
The operative delivery rate in the United States has declined
safety and efficacy. Vacuum deliveries are generally asso-
dramatically over the last two decades, reaching a low of just
ciated with higher rates of neonatal injuries, such as
3.62% in 2010 [1]. With respect to vacuum deliveries, there
cephalohematomas and retinal hemorrhages, while forceps
has been a 44% decrease over a 14-year period, from a high of
deliveries are associated with significantly higher rates of
7.8% in 1996 to just 4.40% in 2010. There has been an even
maternal morbidity, such as third- and fourth-degree lacer-
more dramatic drop in the rate of forceps deliveries, which
ations, post-delivery pain, and hospital readmission [5–8].
fell by nearly 7-fold from 6.61% in 1990 to 0.98% in 2010 [1].
Data on the relative efficacy of each device, however, have
This decrease in operative deliveries is especially notable
been conflicting, and little is known regarding the combined
given that disorders of the second stage are increasingly being
use of both instruments during the same delivery. Deliveries
cited as an indication to perform cesarean deliveries [2,3].
where both devices are used are believed to comprise only a
The risks of the rising cesarean rate have been the subject of
small fraction of all operative deliveries, and the few studies
intense debate in recent years and have been accompanied
that have examined this population consist mostly of case
by initiatives to reverse its upward trend. In California, the
series done at single institutions and have yielded conflicting
cesarean delivery rate has surpassed the national rate, peaking
results [9]. While some have shown that multiple attempts at
at 33.2% in 2011 compared to the national rate of 32.8% [4].
operative delivery, using either the same or different devices,
are significantly associated with increased rates of neonatal
and maternal trauma, others have suggested that the combined
use may be safe when performed by a trained clinician in an
Address for correspondence: Alex Fong, MD, Clinical Fellow, Division appropriately selected patient population [9–14]. The object-
of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,
ive of this study was to use state-wide California hospital
University of California, Irvine, 101 The City Drive South, Building 56,
Suite 800, Orange, CA 92868, USA. Tel: 714-456-6807. Fax: 714-456- discharge data, representing a large, diverse population in a
7091. E-mail: alexf@hs.uci.edu variety of practice settings, to determine trends in operative
DOI: 10.3109/14767058.2014.904282 Operative delivery morbidities 1887

delivery over time and to compare delivery-related maternal Results

morbidity between vacuum, forceps, and combined deliveries.
There were 3 556 567 total women in the original cohort,
comprising all deliveries occurring in California during the
Methods study period. Of these, 284 357 were identified as operative
vaginal deliveries, giving an overall 8% rate of operative
This is a retrospective cohort study using California health
vaginal delivery in the unedited cohort. We eliminated cases
discharge data from 2001 to 2007. The data were provided
using the methodology described above, with the resultant
by the California Office of Statewide Health Planning and
subject breakdown shown in Figure 1. Ultimately, there were
Development (OSHPD). We used delivery codes to extract all
202 439 cases of vacuum delivery, 13 555 cases of forceps
women who delivered in a licensed general acute care hospital
delivery, and 710 cases where a combination of both vacuum
in California from 2001 to 2007. Data from the OSHPD
and forceps was used.
dataset have undergone previous validation in respect to
Figure 2 demonstrates operative vaginal delivery trends
pregnancy-related conditions and has been used in prior
over the study period, using all deliveries as the denominator.
publications [15,16]. The local Institutional review board
The rate of operative deliveries as a whole decreased over
granted exempt approval because of the de-identified, retro-
time, starting at a peak of 9.04%, and decreasing down to a
spective design of this study.
nadir of 7.13% of deliveries in 2005, but rising slightly to
ICD-9 coding was used to identify all cases in our cohort.
7.64% in 2007 (p50.001). The use of forceps continuously
Operative vaginal deliveries were divided into three classifi-
declined throughout the study period, starting at 7.26 of 1000
cations: (1) vacuum-assisted vaginal deliveries, (2) forceps-
deliveries in 2001 and decreasing by nearly 50% to 3.85
assisted vaginal deliveries, and (3) deliveries where a
of 1000 deliveries in 2007 (p50.001). Finally, cases of
combination of both forceps and vaginal delivery were
combined vacuum/forceps decreased as well, going from 3.55
used. Forceps deliveries were identified using ICD-9 proced-
of 10 000 deliveries in 2001 to 2.25 of 10 000 deliveries in
ure codes 72.0–72.39 (low forceps, mid forceps, and high
2007, with a nadir of 1.64 of 10 000 deliveries in 2005
forceps). Vacuum deliveries were identified using codes
(p50.001).
763.3, 72.71, and 72.79 (Delivery by vacuum extractor
When calculating trends using a denominator of all
affecting fetus or newborn, or vacuum extraction procedure
operative vaginal deliveries only, the use of forceps declined
with or without episiotomy). If a delivery had codes for both
over time from 7.8% of all operative vaginal deliveries in
vacuum delivery and forceps present, these were deemed
2001 to 4.8% in 2007 (p50.001). In contrast, the proportional
cases where combined vacuum/forceps was used. Any of the
use of vacuum among operative vaginal deliveries increased,
above cases were deemed operative delivery failures if they
comprising 91.8% of all operative deliveries in 2001 and
either concurrently coded for cesarean delivery or included
steadily climbing to 94.9% in 2007 (p50.001). Combined use
ICD-9 code 660.7 (failed forceps or vacuum).
of vacuum/forceps remained at very low levels, comprising
In order to ascertain codes for reproductive aged women,
only 0.2–0.4% of operative vaginal deliveries, but still
we eliminated cases515 and455 years of age. Cases missing
decreased overall throughout the study period.
age or race/ethnicity data were excluded as well. Trends in
Table 1 shows baseline characteristic comparisons between
operative vaginal delivery over the study period were
the three groups. There were significant differences in the
examined in two manners, first using all delivery types
three groups in all baseline characteristics (age, race/ethnicity,
(normal spontaneous vaginal, operative, cesarean, and others)
as the denominator and then using only operative vaginal
deliveries as the denominator. Statistical analyses used
included the Cochran–Armitage test for trends over time,
Kruskal–Wallis for the comparison of continuous variables,
and Chi-Square for categorical variables. Outcomes assessed
included third- and fourth-degree lacerations, bladder repair,
pelvic hematoma requiring evacuation, cervical laceration
repair, shoulder dystocia, manual placenta extraction, post-
partum hemorrhage, operative delivery failure, thrombo-
embolism, maternal death, and endometritis. We chose to
use vacuum delivery as the referent group, as our primary aim
was to compare forceps and combined use against vacuum,
which has traditionally been cited as the method with lowest
maternal morbidity [8]. We performed unconditional logistic
regression for the aforementioned outcomes with vacuum
extraction serving as the referent group. Covariates in the
multivariable model included age, race/ethnicity, insurance
status, hypertension, diabetes, and year of delivery. Values
were expressed as odds ratios with 95% confidence intervals.
p Values were significant at 50.05. SPSS 20.0 (Chicago, IL)
and JMP 10.0 (Cary, NC) were the statistical software
packages used in the analyses. Figure 1. Subject breakdown.
1888 A. Fong et al. J Matern Fetal Neonatal Med, 2014; 27(18): 1886–1891

Figure 2. Rate of vacuum, forceps, and combined vacuum/forceps from 2001 to 2007.

Table 1. Baseline characteristics of subjects undergoing combined vacuum and forceps deliveries, vacuum deliveries, and forceps deliveries.

Subjects undergoing Subjects undergoing Subjects undergoing

combined vacuum vacuum alone (n ¼ 202 439) forceps alone
Baseline characteristic and forceps (n ¼ 710) n (prevalence) (n ¼ 13 555) p value
Age (years) 50.001
15–19 65 (9.2%) 21 727 (10.7%) 1241 (9.2%)
20–24 156 (22.0%) 47 967 (23.7%) 2993 (22.1%)
25–29 174 (24.5%) 51 929 (25.7%) 3253 (24.0%)
30–34 199 (28.0%) 50 579 (25.0%) 3675 (27.1%)
35–39 86 (12.1%) 25 032 (12.4%) 1950 (14.4%)
40–44 27 (3.8%) 4953 (2.4%) 420 (3.1%)
45+ 3 (0.4%) 252 (0.1%) 23 (0.2%)
Advanced maternal age (35 years) 116 (16.3%) 30 237 (14.9%) 2393 (17.7%) 50.001
Race/ethnicity 50.001
Non-Hispanic Caucasian 359 (50.6%) 81 672 (40.3%) 6895 (50.9%)
Non-Hispanic Black 12 (1.7%) 6344 (3.1%) 335 (2.5%)
Native American / Eskimo / Aleut 1 (0.1%) 252 (0.1%) 10 (0.1%)
Asian / Pacific Islander 109 (15.4%) 27 217 (13.4%) 1787 (13.2%)
Hispanic 229 (32.3%) 86 954 (43.0%) 4528 (33.4%)
Private insurance 435 (61.3%) 104 763 (51.8%) 7869 (58.1%) 50.001
Hypertensive disease 25 (3.5%) 6371 (3.1%) 570 (4.2%) 50.001
Diabetes 41 (5.8%) 9671 (4.8%) 747 (5.5%) 50.001
Length of stay (days) 2.4 ± 0.9 2.2 ± 1.2 2.4 ± 1.5 50.001
Expressed as mean ± standard deviation.

insurance type, presence of hypertension, diabetes, and length
of stay). There were fewer women (14.9%) of advanced
maternal age in the vacuum delivery group than the combined
and forceps groups (16.3% and 17.7%, respectively). A higher
proportion of women who had vacuum deliveries were
Hispanic (43.0%) compared to the combined and forceps
groups (32.3% and 33.4%). Women who underwent vacuum
delivery were also less likely to have private insurance,
hypertensive disease, or diabetes, and had the shortest length
of stay by 0.2 d.
Differences in delivery-related morbidity between vacuum,
forceps, and combined use of both are shown in Table 2.
DOI: 10.3109/14767058.2014.904282 Operative delivery morbidities 1889
Table 2. Differences in delivery-related morbidity between vacuum, forceps, and combined use of both.

Vacuum alone Forceps alone Combined vacuum and forceps

Rate of morbidity* Adjusted Rate of morbidity* Adjusted Rate of morbidity* Adjusted
Outcome variable (no. of cases) odds ratio (no. of cases) odds ratio (no. of cases) odds ratio
Third/fourth degree lacerations 12.8 (25 917) 1.0 23.6 (3202) 2.07 (1.98–2.16) 30.4 (216) 2.86 (2.43–3.36)
Bladder repair (per 1000) 7.1 (1440) 1.0 5.8 (79) 0.80 (0.64–1.00) 1.4 (1) 0.19 (0.03–1.35)
Pelvic hematoma requiring 1.3 (262) 1.0 2.7 (36) 2.06 (1.45–2.92)  
evacuation (per 1000)
Cervical laceration repair 1.9 (385) 1.0 3.3 (45) 1.73 (1.27–2.36)  
Shoulder dystocia 3.4 (6906) 1.0 2.5 (335) 0.70 (0.62–0.78) 3.7 (26) 1.05 (0.71–1.56)
Manual placenta extraction 1.1 (2234) 1.0 1.6 (222) 1.34 (1.17–1.54) 1.5 (11) 1.26 (0.70–2.30)
Postpartum hemorrhage 3.4 (6856) 1.0 5.2 (699) 1.51 (1.39–1.63) 6.2 (44) 1.81 (1.33–2.46)
Operative delivery failure 5.7 (11 516) 1.0 5.1 (693) 0.87 (0.81–0.94) 14.4 (102) 2.81 (2.27–3.48)
Thromboembolism (per 10 000) 9.9 (20) 1.0 29.5 (4) 2.96 (1.01–8.70)  
Death (per 10 000) 3.0 (6) 1.0 14.8 (2) 4.92 (0.98–24.65)  
Endometritis (per 1000) 3.2 (648) 1.0 4.7 (64) 1.54 (1.19–2.00) 1.4 (1) 0.46 (0.07–3.30)

*Expressed as incidence per 100 deliveries, unless otherwise specified.

Forceps deliveries were more likely to be associated
with third/fourth lacerations (adjusted OR 2.07, 95% CI
1.98–2.16), pelvic hematoma (adjusted OR 2.06, 95% CI
1.45–2.92), cervical laceration repair (adjusted OR 1.73,
95% CI 1.27–2.36), manual placenta extraction (adjusted OR
1.34, 95% CI 1.17–1.54), postpartum hemorrhage (adjusted
OR 1.51, 95% CI 1.39–1.63), thromboembolism (adjusted OR
2.96, 95% CI 1.01–8.70), and endometritis (adjusted OR 1.54,
95% CI 1.19–2.00). In contrast, forceps deliveries were less
likely to be associated with shoulder dystocia (adjusted OR
0.70, 95% CI 0.62–0.78) and operative delivery failure
(adjusted OR 0.87, 95% CI 0.81–0.94). Combined use of
vacuum/forceps, when compared against vacuum alone, was
associated with significantly higher odds of third/fourth
degree lacerations (adjusted OR 2.86, 95% CI 2.43–3.36),
postpartum hemorrhage (adjusted OR 1.81, 95% CI 1.33–
2.46), and operative delivery failure (adjusted OR 2.81, 95%
CI 2.27–3.48). The rate of operative delivery failure was
14.4% when both instruments were used, compared to lower
rates with forceps (5.1%) and vacuum (5.7%) alone.
Discussion
Our study showed that the rate of all operative delivery types
(vacuum, forceps, combined vacuum/forceps) in California
significantly decreased during the study period. While the
overall operative delivery rate in California remained greater
than the national average (going from 9.0% of all deliveries
in 2001 to 7.6% in 2007, compared to the national decrease
from 7.0% to 4.3% from 2000 to 2007), the rate of forceps
deliveries in California remained less than the national
average. According to National Vital Statistics data, the
national rate of forceps decreased from 21 per 1000 births to
7 per 1000 births from 2000 to 2007. According to our data,
California’s rate of forceps was nearly two to three times
lower than the national average during this period (7.3 per
1000 births in 2001 to 3.8 per 1000 births in 2007) [1].
The exact reasons for the decline in operative vaginal
deliveries, and for the especially steep decline in the use of
forceps have been debated. For example, the known associ-
ation of forceps with maternal trauma and pelvic floor
dysfunction may make this option less appealing to both
providers and their patients [5,8]. Another possibility is that
in cases of fetal distress, providers and patients are unwilling
to accept the liability and risk associated with operative
delivery, and thus prefer to proceed directly to cesarean
delivery [3]. A study by Zwecker et al. found that higher
malpractice premiums influenced a lower rate of operative
vaginal delivery [17]. Finally, this decline in operative
delivery may be contributing to the well-known rise in
cesarean delivery rate over the last few decades, which was
similarly reflected in our population. An analysis of cesarean
delivery rates in our cohort demonstrated an increase from
25.3% in 2001 to 32.5% in 2007.
One final consequence of the decline in operative vaginal
deliveries is its impact on residency training. A survey study
of residency training programs across the nation by Powell
et al. demonstrated that only about half of chief residents felt
competent performing forceps deliveries [18]. Nationally,
younger trainees are not obtaining the comfort level to
continue this practice in the future [19]. Using data from the
Accreditation Council for Graduate Medical Education resi-
dency case logs, the median number of vacuum and forceps
deliveries occurring throughout residency training dropped
from 19 and 21 in 2003, to 6 and 16 cases, in 2012,
respectively [20]. As such, our findings, in addition to views
supported in the literature, stress the importance of trainees’
education in the use of operative vaginal delivery [19,21].
Our findings regarding maternal morbidities echo the
findings of other studies that have found that, compared to
vacuum deliveries, forceps deliveries are associated with
greater rates of third- and fourth- degree lacerations
[5,8,13,22]. We also found that forceps deliveries are
significantly associated with other maternal morbidities that
have been less studied, such as pelvic hematoma requiring
evacuation, cervical laceration, manual placenta extraction,
thromboembolism and endometritis. This remained true after
controlling for maternal age, ethnicity, and other comorbid-
ities of pregnancy. As has been previously postulated, the
increased rate of maternal trauma with forceps is likely due
to the greater amount of space that is required for forceps
deliveries, which are more likely to distend the vaginal walls
and result in a greater number of lacerations [5]. Forceps,
however, were also associated with a lower rate of operative
1890 A. Fong et al.
delivery failure, indicating that they still may be the preferred
choice in appropriately chosen patients.
In our study, combined deliveries comprised only 0.33%
of all operative deliveries. While prior studies have primarily
reported on neonatal outcomes of combined operative
deliveries, we focused on maternal outcomes which revealed
a higher rate of third/fourth degree lacerations, postpartum
hemorrhage, and operative delivery failure [13,14]. The
association of combined deliveries with these specific
outcomes again stresses the importance of an appropriately
selected patient population when considering the application
of a second instrument [9]. The American College of
Obstetricians and Gynecologists, in its practice bulletin on
operative vaginal delivery, also recommends against using
multiple instruments ‘‘unless there is a compelling and
justifiable reason’’ [23].
Although the use of ICD-9 codes can be susceptible to
coding inaccuracies, the coding of mode of delivery should
be quite accurate in our data set. Yasmeen et al. performed
a validation study using OSHPD data from 1992 to 1993
and found that the coding accuracy of forceps and vacuum
deliveries had a 96–99% positive predictive value and
89–95% sensitivity. Coding was found to still be quite
accurate in conditions such as chorioamnionitis, gestational
diabetes, preeclampsia, and preterm labor, but was less
sensitive for other conditions such as anemia, obesity, and
tobacco use [24]. Other limitations of the study due to its
ICD-9 coded nature include inability to account for variables
such as body mass index, birth weight, neonatal morbidity,
or gestational age at delivery. Aspects such as the experience
of providers and all indications for delivery were potential
confounding factors which cannot be accounted for. A recent
publication by Vintzileos et al. has also suggested the use
of a comparability scoring system in observational studies in
order to improve interpretation of results and allow for
statistical adjustment. Unfortunately, our limited data set did
not provide sufficient data points to discern certain aspects
used in the scoring system (e.g. health care providers details),
therefore incorporation of this technique was not possible.
If it were employed, however, it is possible that the
confidence intervals of the results may be affected [25].
Due to the low number of cases (n ¼ 710) of combined
vacuum/forceps delivery, we were unable to detect statistic-
ally significant differences in select maternal morbidities.
For example, morbidities such as pelvic hematoma, cervical
laceration, and thromboembolism did not occur with enough
frequency to be able to detect differences between the groups.
There were also a small number of operative deliveries
(n ¼ 3767) where we were unable to identify whether a
vacuum or forceps was used. This was due to the coding using
ICD-9 code 669.5  (forceps or vacuum extractor delivery
without mention of indication). However, the large number of
cases we did have in our final analysis (n ¼ 216 704) makes
it unlikely that these additional cases would have significantly
impacted our results.
The large nature of our study allowed us to determine
trends over time in the use of vacuum and forceps in
California gave sufficient power to detect significant associ-
ations with a variety of maternal outcomes, and allowed
for adjustment for a number of potential confounders.
J Matern Fetal Neonatal Med, 2014; 27(18): 1886–1891
Statewide data from California also consists of an extremely
diverse patient population that delivered in a variety of
different practice settings, lending greater generalizability to
our results.
In conclusion, the rate of operative delivery in California
appears to be decreasing, with forceps declining most
precipitously. Additionally, California has consistently
demonstrated a lower rate of forceps use than the national
average. Forceps deliveries have higher maternal morbidity
but a lower failure rate compared to vacuum, while combined
operative deliveries have the highest rates of morbidity and
failure. Given the decline in operative delivery, future efforts
must focus on how best to train new physicians to perform
both vacuum and forceps deliveries, which are becoming
increasingly rare, and to determine which patients are the
most appropriate candidates for either procedure.
Declaration of interest
There are no declarations of interest to disclose by any of the
authors.
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