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JOGC

No. 381-Assisted Vaginal Birth

      Abstract

      Objectives

      To provide evidence-based guidelines for safe and effective assisted vaginal birth.

      Outcomes

      Prerequisites, indications, contraindications, along with maternal and neonatal morbidity associated with assisted vaginal birth.

      Evidence

      Medline database was searched for articles published from January 1, 1985, to February 28, 2018 using the key words “assisted vaginal birth,” “instrumental vaginal birth,” “operative vaginal delivery,” “forceps delivery,” “vacuum delivery,” “ventouse delivery.” The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventive Health Care.

      Validation

      These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada.

      Recommendations

      • 1
        The need for assisted vaginal birth can be reduced by: dedicated and continuous support during labour (I-A), oxytocin augmentation of inadequate labour (I-A), delayed pushing in women with an epidural (I-A), increased time pushing in nulliparous women with an epidural (I-B), as well as optimization of fetal head position through manual rotation (I-A).
      • 2
        Encouraging safe and effective assisted vaginal birth by experienced and skilled care providers may be a useful strategy to reduce the rate of primary Caesarean delivery (II-2B).
      • 3
        Safe and effective assisted vaginal birth requires expertise in the chosen method, comprehensive assessment of the clinical situation alongside clear communication with the patient, support people, and health care personnel (III-B).
      • 4
        Practitioners performing assisted vaginal birth should have the knowledge, skills, and experience necessary to assess the clinical situation, use the selected instrument, and manage complications that may arise from assisted vaginal birth (II-2B).
      • 5
        Obstetrical trainees should receive comprehensive training in assisted vaginal birth and be deemed competent prior to independent practice (III-B).
      • 6
        When assisted vaginal birth is deemed to have a higher risk of not being successful, it should be considered a trial of assisted vaginal birth and be conducted in a location where immediate recourse to Caesarean delivery is available (III-B).
      • 7
        The physician should determine the instrument most suitable to the clinical circumstances and their level of skill. Vacuum and forceps are associated with different short- and long-term benefits and risks. Unsuccessful delivery is more likely with vacuum than forceps (I-A).
      • 8
        Planned sequential use of instruments is not recommended as it may be associated with an increased risk of perinatal trauma. If an attempted vacuum is unsuccessful, the physician should consider the risks of proceeding to an attempted forceps delivery versus Caesarean section (II-2B).
      • 9
        Restrictive use of mediolateral episiotomy is supported in assisted vaginal birth (II-2B).
      • 10
        A debrief should be done with the patient and support people immediately following an attempted or successful assisted vaginal birth. If this is not possible, ideally this should be done prior to hospital discharge and include the indication for assisted vaginal birth, management of any complications, and the prognosis for future deliveries (III-B).
      • 11
        In a subsequent pregnancy, patients should be encouraged to consider spontaneous vaginal birth. However, care planning should be individualized and patient preference respected (II-3B).

      Key Words

      Abbreviations:

      AVB (assisted vaginal birth), CI (confidence interval), CPD (cephalopelvic disproportion), NICU (neonatal intensive care unit), OA (occiput anterior), OASIS (obstetrical anal sphincter injury), OP (occiput posterior), OR (odds ratio), OT (occiput transverse), PPH (postpartum hemorrhage), PTSD (post-traumatic stress disorder), RR (relative risk), SVB (spontaneous vaginal birth)
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      Linked Article

      • Regarding SOGC Guideline No. 381-Assisted Vaginal Birth
        Journal of Obstetrics and Gynaecology Canada Vol. 42Issue 4
        • Preview
          We read, with interest and concern, the recommendations and supporting evidence regarding both the risk of maternal trauma and the role of episiotomy when performing forceps-assisted vaginal births in the recently published Society of Obstetricians and Gynaecologists of Canada (SOGC) Assisted Vaginal Birth Guideline.1
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