Professional Documents
Culture Documents
Temporal Trends and Morbidities of Vacuum, Forceps, and Combined Use of Both
Temporal Trends and Morbidities of Vacuum, Forceps, and Combined Use of Both
com/jmf
ISSN: 1476-7058 (print), 1476-4954 (electronic)
ORIGINAL ARTICLE
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.
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.
insurance type, presence of hypertension, diabetes, and length groups (32.3% and 33.4%). Women who underwent vacuum
of stay). There were fewer women (14.9%) of advanced delivery were also less likely to have private insurance,
maternal age in the vacuum delivery group than the combined hypertensive disease, or diabetes, and had the shortest length
and forceps groups (16.3% and 17.7%, respectively). A higher of stay by 0.2 d.
proportion of women who had vacuum deliveries were Differences in delivery-related morbidity between vacuum,
Hispanic (43.0%) compared to the combined and forceps 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.
Forceps deliveries were more likely to be associated providers and their patients [5,8]. Another possibility is that
with third/fourth lacerations (adjusted OR 2.07, 95% CI in cases of fetal distress, providers and patients are unwilling
1.98–2.16), pelvic hematoma (adjusted OR 2.06, 95% CI to accept the liability and risk associated with operative
1.45–2.92), cervical laceration repair (adjusted OR 1.73, delivery, and thus prefer to proceed directly to cesarean
95% CI 1.27–2.36), manual placenta extraction (adjusted OR delivery [3]. A study by Zwecker et al. found that higher
1.34, 95% CI 1.17–1.54), postpartum hemorrhage (adjusted malpractice premiums influenced a lower rate of operative
OR 1.51, 95% CI 1.39–1.63), thromboembolism (adjusted OR vaginal delivery [17]. Finally, this decline in operative
2.96, 95% CI 1.01–8.70), and endometritis (adjusted OR 1.54, delivery may be contributing to the well-known rise in
95% CI 1.19–2.00). In contrast, forceps deliveries were less cesarean delivery rate over the last few decades, which was
likely to be associated with shoulder dystocia (adjusted OR similarly reflected in our population. An analysis of cesarean
0.70, 95% CI 0.62–0.78) and operative delivery failure delivery rates in our cohort demonstrated an increase from
(adjusted OR 0.87, 95% CI 0.81–0.94). Combined use of 25.3% in 2001 to 32.5% in 2007.
vacuum/forceps, when compared against vacuum alone, was One final consequence of the decline in operative vaginal
associated with significantly higher odds of third/fourth deliveries is its impact on residency training. A survey study
degree lacerations (adjusted OR 2.86, 95% CI 2.43–3.36), of residency training programs across the nation by Powell
postpartum hemorrhage (adjusted OR 1.81, 95% CI 1.33– et al. demonstrated that only about half of chief residents felt
2.46), and operative delivery failure (adjusted OR 2.81, 95% competent performing forceps deliveries [18]. Nationally,
CI 2.27–3.48). The rate of operative delivery failure was younger trainees are not obtaining the comfort level to
14.4% when both instruments were used, compared to lower continue this practice in the future [19]. Using data from the
rates with forceps (5.1%) and vacuum (5.7%) alone. Accreditation Council for Graduate Medical Education resi-
dency case logs, the median number of vacuum and forceps
deliveries occurring throughout residency training dropped
Discussion
from 19 and 21 in 2003, to 6 and 16 cases, in 2012,
Our study showed that the rate of all operative delivery types respectively [20]. As such, our findings, in addition to views
(vacuum, forceps, combined vacuum/forceps) in California supported in the literature, stress the importance of trainees’
significantly decreased during the study period. While the education in the use of operative vaginal delivery [19,21].
overall operative delivery rate in California remained greater Our findings regarding maternal morbidities echo the
than the national average (going from 9.0% of all deliveries findings of other studies that have found that, compared to
in 2001 to 7.6% in 2007, compared to the national decrease vacuum deliveries, forceps deliveries are associated with
from 7.0% to 4.3% from 2000 to 2007), the rate of forceps greater rates of third- and fourth- degree lacerations
deliveries in California remained less than the national [5,8,13,22]. We also found that forceps deliveries are
average. According to National Vital Statistics data, the significantly associated with other maternal morbidities that
national rate of forceps decreased from 21 per 1000 births to have been less studied, such as pelvic hematoma requiring
7 per 1000 births from 2000 to 2007. According to our data, evacuation, cervical laceration, manual placenta extraction,
California’s rate of forceps was nearly two to three times thromboembolism and endometritis. This remained true after
lower than the national average during this period (7.3 per controlling for maternal age, ethnicity, and other comorbid-
1000 births in 2001 to 3.8 per 1000 births in 2007) [1]. ities of pregnancy. As has been previously postulated, the
The exact reasons for the decline in operative vaginal increased rate of maternal trauma with forceps is likely due
deliveries, and for the especially steep decline in the use of to the greater amount of space that is required for forceps
forceps have been debated. For example, the known associ- deliveries, which are more likely to distend the vaginal walls
ation of forceps with maternal trauma and pelvic floor and result in a greater number of lacerations [5]. Forceps,
dysfunction may make this option less appealing to both however, were also associated with a lower rate of operative
1890 A. Fong et al. J Matern Fetal Neonatal Med, 2014; 27(18): 1886–1891
delivery failure, indicating that they still may be the preferred Statewide data from California also consists of an extremely
choice in appropriately chosen patients. diverse patient population that delivered in a variety of
In our study, combined deliveries comprised only 0.33% different practice settings, lending greater generalizability to
of all operative deliveries. While prior studies have primarily our results.
reported on neonatal outcomes of combined operative In conclusion, the rate of operative delivery in California
deliveries, we focused on maternal outcomes which revealed appears to be decreasing, with forceps declining most
a higher rate of third/fourth degree lacerations, postpartum precipitously. Additionally, California has consistently
hemorrhage, and operative delivery failure [13,14]. The demonstrated a lower rate of forceps use than the national
association of combined deliveries with these specific average. Forceps deliveries have higher maternal morbidity
outcomes again stresses the importance of an appropriately but a lower failure rate compared to vacuum, while combined
selected patient population when considering the application operative deliveries have the highest rates of morbidity and
of a second instrument [9]. The American College of failure. Given the decline in operative delivery, future efforts
Obstetricians and Gynecologists, in its practice bulletin on must focus on how best to train new physicians to perform
operative vaginal delivery, also recommends against using both vacuum and forceps deliveries, which are becoming
multiple instruments ‘‘unless there is a compelling and increasingly rare, and to determine which patients are the
justifiable reason’’ [23]. most appropriate candidates for either procedure.
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 Declaration of interest
a validation study using OSHPD data from 1992 to 1993 There are no declarations of interest to disclose by any of the
and found that the coding accuracy of forceps and vacuum authors.
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 References
diabetes, preeclampsia, and preterm labor, but was less
1. Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data for
sensitive for other conditions such as anemia, obesity, and 2010. National Vital Statistics Report 2012;61:10.
tobacco use [24]. Other limitations of the study due to its 2. Barber EL, Lundsberg LS, Belanger K, et al. Indications
ICD-9 coded nature include inability to account for variables contributing to the increasing cesarean delivery rate. Obstet
such as body mass index, birth weight, neonatal morbidity, Gynecol 2011;118:29–38.
3. Boyle A, Reddy UM. Epidemiology of cesarean delivery: the scope
or gestational age at delivery. Aspects such as the experience of the problem. Semin Perinatol 2012;36:308–14.
of providers and all indications for delivery were potential 4. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data
confounding factors which cannot be accounted for. A recent for 2011. Natl Vital Stat Rep 2012;61:1–20.
5. Caughey AB, Sandberg PL, Zlatnik MG, et al. Forceps compared
publication by Vintzileos et al. has also suggested the use
with vacuum: rates of neonatal and maternal morbidity. Obstet
of a comparability scoring system in observational studies in Gynecol 2005;106:908–12.
order to improve interpretation of results and allow for 6. Liu S, Heaman M, Joseph KS, et al. Risk of maternal postpartum
statistical adjustment. Unfortunately, our limited data set did readmission associated with mode of delivery. Obstet Gynecol
not provide sufficient data points to discern certain aspects 2005;105:836–42.
7. Fitzpatrick M, Behan M, O’Connell PR, O’Herlihy C. Randomised
used in the scoring system (e.g. health care providers details), clinical trial to assess anal sphincter function following forceps or
therefore incorporation of this technique was not possible. vacuum assisted vaginal delivery. BJOG 2003;110:424–9.
If it were employed, however, it is possible that the 8. Johanson RB, Menon BK. Vacuum extraction versus forceps
confidence intervals of the results may be affected [25]. for assisted vaginal delivery. Cochrane Database Syst Rev
2000:CD000224.
Due to the low number of cases (n ¼ 710) of combined 9. Ezenagu LC, Kakaria R, Bofill JA. Sequential use of instruments at
vacuum/forceps delivery, we were unable to detect statistic- operative vaginal delivery: is it safe? Am J Obstet Gynecol 1999;
ally significant differences in select maternal morbidities. 180:1446–9.
For example, morbidities such as pelvic hematoma, cervical 10. Revah A, Ezra Y, Farine D, Ritchie K. Failed trial of vacuum or
forceps – maternal and fetal outcome. Am J Obstet Gynecol 1997;
laceration, and thromboembolism did not occur with enough 176:200–4.
frequency to be able to detect differences between the groups. 11. Alexander JM, Leveno KJ, Hauth JC, et al. Failed operative vaginal
There were also a small number of operative deliveries delivery. Obstet Gynecol 2009;114:1017–22.
(n ¼ 3767) where we were unable to identify whether a 12. Murphy DJ, Liebling RE, Patel R, et al. Cohort study of operative
delivery in the second stage of labour and standard of obstetric care.
vacuum or forceps was used. This was due to the coding using BJOG 2003;110:610–15.
ICD-9 code 669.5 (forceps or vacuum extractor delivery 13. Murphy DJ, Macleod M, Bahl R, Strachan B. A cohort study of
without mention of indication). However, the large number of maternal and neonatal morbidity in relation to use of sequential
cases we did have in our final analysis (n ¼ 216 704) makes instruments at operative vaginal delivery. Eur J Obstet Gynecol
Reprod Biol 2011;156:41–5.
it unlikely that these additional cases would have significantly 14. Gardella C, Taylor M, Benedetti T, et al. The effect of sequential
impacted our results. use of vacuum and forceps for assisted vaginal delivery on neonatal
The large nature of our study allowed us to determine and maternal outcomes. Am J Obstet Gynecol 2001;185:896–902.
trends over time in the use of vacuum and forceps in 15. Schmitt SK, Sneed L, Phibbs CS. Costs of newborn care in
California: a population-based study. Pediatrics 2006;117:154–60.
California gave sufficient power to detect significant associ- 16. Gilbert WM, Danielsen B. Pregnancy outcomes associated with
ations with a variety of maternal outcomes, and allowed intrauterine growth restriction. Am J Obstet Gynecol 2003;188:
for adjustment for a number of potential confounders. 1596–9; discussion 1599–601.
DOI: 10.3109/14767058.2014.904282 Operative delivery morbidities 1891
17. Zwecker P, Azoulay L, Abenhaim HA. Effect of fear of litigation 21. Goetzinger KR, Macones GA. Operative vaginal delivery: current
on obstetric care: a nationwide analysis on obstetric practice. Am J trends in obstetrics. Womens Health (Lond Engl) 2008;4:281–90.
Perinatol 2011;28:277–84. 22. Damron DP, Capeless EL. Operative vaginal delivery: a compari-
18. Powell J, Gilo N, Foote M, et al. Vacuum and forceps training son of forceps and vacuum for success rate and risk of rectal
in residency: experience and self-reported competency. J Perinatol sphincter injury. Am J Obstet Gynecol 2004;191:907–10.
2007;27:343–6. 23. American College of Obstetricians and Gynecologists. ACOG
19. Gei AF. Prevention of the first cesarean delivery: the role Practice Bulletin number 17, Operative vaginal delivery.
of operative vaginal delivery. Semin Perinatol 2012;36: Washington, DC; 2000.
365–73. 24. Yasmeen S, Romano PS, Schembri ME, et al. Accuracy of obstetric
20. Case logs statistical reports. Accreditation Council for Graduate diagnoses and procedures in hospital discharge data. Am J Obstet
Medical Education. Available from: https://www.acgme.org/ Gynecol 2006;194:992–1001.
acgmeweb/tabid/274/DataCollectionSystems/ResidentCaseLog 25. Vintzileos AM, Ananth CV, Smulian JC. The use of a comparability
System/CaseLogsStatisticalReports.aspx [last accessed 20 Feb scoring system in reporting observational studies. Am J Obstet
2014]. Gynecol 2014;210:112–16.
Copyright of Journal of Maternal-Fetal & Neonatal Medicine is the property of Taylor &
Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.