No. 381-Assisted Vaginal Birth



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


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


      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.


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


      • 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


      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)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lemos A
        • Amorim MM
        • Dornelas de Andrade A
        • et al.
        Pushing/bearing down methods for the second stage of labour.
        Cochrane Database Syst Rev. 2017; CD009124
        • Wei SQ
        • Luo ZC
        • Qi HP
        • et al.
        High-dose vs low-dose oxytocin for labor augmentation: a systematic review.
        Am J Obstet Gynecol. 2010; 203: 296-304
        • Fraser WD
        • Marcoux S
        • Krauss I
        • et al.
        Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group.
        Am J Obstet Gynecol. 2000; 182: 1165-1172
        • Zhang J
        • Landy HJ
        • Branch DW
        • et al.
        Contemporary patterns of spontaneous labor with normal neonatal outcomes.
        Obstet Gynecol. 2010; 116: 1281-1287
        • Zhang J
        • Bernasko JW
        • Leybovich E
        • et al.
        Continuous labor support from labor attendant for primiparous women: a meta-analysis.
        Obstet Gynecol. 1996; 88: 739-744
        • Gagnon AJ
        • Waghorn K
        One-to-one nurse labor support of nulliparous women stimulated with oxytocin.
        J Obstet Gynecol Neonatal Nurs. 1999; 28: 371-376
        • Alfirevic Z
        • Devane D
        • Gyte GM
        • et al.
        Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour.
        Cochrane Database Syst Rev. 2017; CD006066
        • Cahill AG
        • Srinivas SK
        • Tita ATN
        • et al.
        Effect of immediate vs delayed pushing on rates of spontaneous vaginal delivery among nulliparous women receiving neuraxial analgesia: a randomized clinical trial.
        JAMA. 2018; 320: 1444-1454
        • Caughey AB
        • Cahill AG
        • Guise J-M
        • et al.
        Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery.
        Am J Obstet Gynecol. 2014; 210: 179-193
        • Gimovsky AC
        • Berghella V
        Randomized controlled trial of prolonged second stage: extending the time limit vs usual guidelines.
        Am J Obstet Gynecol. 2016; 214: 361.e1-361.e6
        • Boberg J
        • Rees S
        • Jacob S
        • et al.
        A randomized controlled trial of prophylactic early manual rotation of the occiput posterior fetal head at the beginning of the second stage of labor vs.
        expectant management in nulliparas. Am J Obstet Gynecol. 2016; 214: S63
        • Phipps H
        • de Vries B
        • Hyett J
        • et al.
        Prophylactic manual rotation for fetal malposition to reduce operative delivery.
        Cochrane Database Syst Rev. 2014; CD009298
        • CIHI Highlights of 2010-2011 Selected Indicators Describing the Birthing Process in Canada
        Canadian Institute for Health Information, Ottawa2012 (Available at:)
        • Betran AP
        • Ye J
        • Moller AB
        • et al.
        The increasing trend in Caesarean section rates: global, regional and national estimates: 1990–2014.
        PLoS One. 2016; 11e0148343
        • Caughey AB
        • et al.
        • American College of Obstericians and Gynecologists
        • Society for Maternal-Fetal Medicine
        Safe prevention of the primary cesarean delivery.
        Am J Obstet Gynecol. 2014; 210: 179-193
        • Skinner S
        • Davies-Tuck M
        • Wallace E
        • et al.
        Perinatal and maternal outcomes after training residents in forceps before vacuum instrumental birth.
        Obstet Gynecol. 2017; 130: 151-158
        • Gossett DR
        • Gilchrist-Scott D
        • Wayne DB
        • et al.
        Simulation training for forceps-assisted vaginal delivery and rates of maternal perineal trauma.
        Obstet Gynecol. 2016; 128: 429-435
        • Deering S
        Forceps, simulation, and social media.
        Obstet Gynecol. 2016; 128: 425-426
        • Dildy GA
        • Belfort MA
        • Clark SL
        Obstetric forceps: a species on the brink of extinction.
        Obstet Gynecol. 2016; 128: 436-439
        • Andrews SE
        • Alston MJ
        • Allshouse AA
        • et al.
        Does the number of forceps deliveries performed in residency predict use in practice?.
        Am J Obstet Gynecol. 2015; 213: 93.e1-93.e4
        • Vayssiere C
        • Beucher G
        • Dupuis O
        • et al.
        Instrumental delivery: clinical practice guidelines from the French College of Gynaecologists and Obstetricians.
        Eur J Obstet Gynecol Reprod Biol. 2011; 159: 43-48
        • WW J
        The science and art of obstetrics.
        J Am Med Assoc. 1887; 8: 584-585
        • Royal College of Obstetricians and Gynaecologists
        Royal College of Obstetricians and Gynaecologists, London2011
        • Rather H
        • Muglu J
        • Veluthar L
        • et al.
        The art of performing a safe forceps delivery: a skill to revitalise.
        Eur J Obstet Gynecol Reprod Biol. 2016; 199: 49-54
        • Maternal anatomy
        Cunningham F Leveno KJ Bloom SL Williams obstetrics. 24th ed. McGraw-Hill, New York2013
        • Vousden N
        • Cargill Z
        • Briley A
        • et al.
        Caesarean section at full dilatation: incidence, impact and current management.
        Obstet Gynaecol. 2014; 16: 199-205
        • Murphy DJ
        • Liebling RE
        • Verity L
        • et al.
        Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study.
        Lancet. 2001; 358: 1203-1207
        • Pretlove SJ
        • Thompson PJ
        • Toozs-Hobson PM
        • et al.
        Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review.
        BJOG. 2008; 115: 421-434
        • Liu S
        • Heaman M
        • Joseph KS
        • et al.
        Risk of maternal postpartum readmission associated with mode of delivery.
        Obstet Gynecol. 2005; 105: 836-842
        • Friedman AM
        • Ananth CV
        • Prendergast E
        • et al.
        Evaluation of third-degree and fourth-degree laceration rates as quality indicators.
        Obstet Gynecol. 2015; 125: 927-937
        • O'Mahony F
        • Hofmeyr GJ
        • Menon V
        Choice of instruments for assisted vaginal delivery.
        Cochrane Database Syst Rev. 2010; CD005455
        • Laine K
        • Pirhonen T
        • Rolland R
        • et al.
        Decreasing the incidence of anal sphincter tears during delivery.
        Obstet Gynecol. 2008; 111: 1053-1057
        • Hals E
        • Oian P
        • Pirhonen T
        • et al.
        A multicenter interventional program to reduce the incidence of anal sphincter tears.
        Obstet Gynecol. 2010; 116: 901-908
        • Society of Obstetricians and Gynaecologists of Canada
        25th ed. Society of Obstetricians and Gynaecologists of Canada, Ottawa2018
        • Hudelist G
        • Gelle'n J
        • Singer C
        • et al.
        Factors predicting severe perineal trauma during childbirth: role of forceps delivery routinely combined with mediolateral episiotomy.
        Am J Obstet Gynecol. 2005; 192: 875-881
        • Al-Suhel R
        • Gill S
        • Robson S
        • et al.
        Kjelland's forceps in the new millennium. Maternal and neonatal outcomes of attempted rotational forceps delivery.
        Aust N Z J Obstet Gynaecol. 2009; 49: 510-514
        • Tempest N
        • Hart A
        • Walkinshaw S
        • et al.
        A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour.
        BJOG. 2013; 120: 1277-1284
        • Le Ray C
        • Deneux-Tharaux C
        • Khireddine I
        • et al.
        Manual rotation to decrease operative delivery in posterior or transverse positions.
        Obstet Gynecol. 2013; 122: 634-640
        • Harvey MA
        • Pierce M
        • Alter JE
        • et al.
        Obstetrical anal sphincter injuries (OASIS): prevention, recognition, and repair.
        J Obstet Gynaecol Can. 2015; 37: 1131-1148
        • Farrell SA
        • Allen VM
        • Baskett TF
        Parturition and urinary incontinence in primiparas.
        Obstet Gynecol. 2001; 97: 350-356
        • Johanson RB
        • Heycock E
        • Carter J
        • et al.
        Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse.
        Br J Obstet Gynaecol. 1999; 106: 544-549
        • Bahl R
        • Strachan B
        • Murphy DJ
        Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study.
        BMJ. 2004; 328: 311
        • Handa VL
        • Blomquist JL
        • Knoepp LR
        • et al.
        Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth.
        Obstet Gynecol. 2011; 118: 777-784
        • Verreault N
        • Da Costa D
        • Marchand A
        • et al.
        PTSD following childbirth: a prospective study of incidence and risk factors in Canadian women.
        J Psychosom Res. 2012; 73: 257-263
        • Murphy DJ
        • Liebling RE
        • Patel R
        • et al.
        Cohort study of operative delivery in the second stage of labour and standard of obstetric care.
        BJOG. 2003; 110: 610-615
        • Murphy DJ
        • Pope C
        • Frost J
        • et al.
        Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study.
        BMJ. 2003; 327: 1132
        • Mawdsley SD
        • Baskett TF
        Outcome of the next labour in women who had a vaginal delivery in their first pregnancy.
        BJOG. 2000; 107: 932-934
        • Adams SS
        • Eberhard-Gran M
        • Sandvik AR
        • et al.
        Mode of delivery and postpartum emotional distress: a cohort study of 55,814 women.
        BJOG. 2012; 119: 298-305
        • Wood SL
        • Tang S
        • Crawford S
        Cesarean delivery in the second stage of labor and the risk of subsequent premature birth.
        Am J Obstet Gynecol. 2017; 217 (.e1–10): 63
        • Watson HA
        • Carter J
        • David AL
        • et al.
        Full dilation cesarean section: a risk factor for recurrent second-trimester loss and preterm birth.
        Acta Obstet Gynecol Scand. 2017; 96: 1100-1105
        • Walsh CA
        • Robson M
        • McAuliffe FM
        Mode of delivery at term and adverse neonatal outcomes.
        Obstet Gynecol. 2013; 121: 122-128
        • Towner D
        • Castro MA
        • Eby-Wilkens E
        • et al.
        Effect of mode of delivery in nulliparous women on neonatal intracranial injury.
        N Engl J Med. 1999; 341: 1709-1714
        • Bofill JA
        • Rust OA
        • Devidas M
        • et al.
        Neonatal cephalohematoma from vacuum extraction.
        J Reprod Med. 1997; 42: 565-569
        • Davis DJ
        Neonatal subgaleal hemorrhage: diagnosis and management.
        CMAJ. 2001; 164: 1452-1453
        • Baskett TF
        • Fanning CA
        • Young DC
        A prospective observational study of 1000 vacuum assisted deliveries with the OmniCup device.
        J Obstet Gynaecol Can. 2008; 30: 573-580
        • Teng FY
        • Sayre JW
        Vacuum extraction: does duration predict scalp injury?.
        Obstet Gynecol. 1997; 89: 281-285
      1. Ekeus C, Wrangsell K, Penttinen S, et al. Neonatal complications among 596 infants delivered by vacuum extraction (in relation to characteristics of the extraction). J Matern Fetal Neonatal Med 2017:1–7.

        • Suwannachat B
        • Lumbiganon P
        • Laopaiboon M
        Rapid versus stepwise negative pressure application for vacuum extraction assisted vaginal delivery.
        Cochrane Database Syst Rev. 2012; CD006636
        • Demissie K
        • Rhoads GG
        • Smulian JC
        • et al.
        Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis.
        BMJ. 2004; 329: 24-29
        • Caughey AB
        • Sandberg PL
        • Zlatnik MG
        • et al.
        Forceps compared with vacuum: rates of neonatal and maternal morbidity.
        Obstet Gynecol. 2005; 106: 908-912
        • Watts P
        • Maguire S
        • Kwok T
        • et al.
        Newborn retinal hemorrhages: a systematic review.
        J AAPOS. 2013; 17: 70-78
        • Holden R
        • Morsman DG
        • Davidek GM
        • et al.
        External ocular trauma in instrumental and normal deliveries.
        Br J Obstet Gynaecol. 1992; 99: 132-134
        • Falco NA
        • Eriksson E
        Facial nerve palsy in the newborn: incidence and outcome.
        Plast Reconstr Surg. 1990; 85: 1-4
        • Duval M
        • Daniel SJ
        Facial nerve palsy in neonates secondary to forceps use.
        Arch Otolaryngol Head Neck Surg. 2009; 135: 634-636
        • Dupuis O
        • Silveira R
        • Dupont C
        • et al.
        Comparison of “instrument-associated” and “spontaneous” obstetric depressed skull fractures in a cohort of 68 neonates.
        Am J Obstet Gynecol. 2005; 192: 165-170
        • Hughes CA
        • Harley EH
        • Milmoe G
        • et al.
        Birth trauma in the head and neck.
        Arch Otolaryngol Head Neck Surg. 1999; 125: 193-199
        • Werner EF
        • Janevic TM
        • Illuzzi J
        • et al.
        Mode of delivery in nulliparous women and neonatal intracranial injury.
        Obstet Gynecol. 2011; 118: 1239-1246
        • Ngan HY
        • Miu P
        • Ko L
        • et al.
        Long-term neurological sequelae following vacuum extractor delivery.
        Aust N Z J Obstet Gynaecol. 1990; 30: 111-114
        • Committee on Practice Bulletins-Obstetrics
        ACOG practice bulletin no. 154 summary: operative vaginal delivery.
        Obstet Gynecol. 2015; 126: 1118-1119
        • Gardella C
        • Taylor M
        • Benedetti T
        • et al.
        The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes.
        Am J Obstet Gynecol. 2001; 185: 896-902
        • Edgar DC
        • Baskett TF
        • Young DC
        • et al.
        Neonatal outcome following failed Kiwi OmniCup vacuum extraction.
        J Obstet Gynaecol Can. 2012; 34: 620-625
        • Murphy DJ
        • Macleod M
        • Bahl R
        • et al.
        A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study.
        BJOG. 2008; 115 (discussion 702–3): 1695-1702
        • Stedenfeldt M
        • Oian P
        • Gissler M
        • et al.
        Risk factors for obstetric anal sphincter injury after a successful multicentre interventional programme.
        BJOG. 2014; 121: 83-91
        • Hirsch E
        • Haney EI
        • Gordon TE
        • et al.
        Reducing high-order perineal laceration during operative vaginal delivery.
        Am J Obstet Gynecol. 2008; 198: 668.e1-668.e5
        • Leduc D
        • Senikas V
        • Lalonde AB
        • et al.
        Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage.
        J Obstet Gynaecol Can. 2009; 31: 980-993
        • Liabsuetrakul T
        • Choobun T
        • Peeyananjarassri K
        • et al.
        Antibiotic prophylaxis for operative vaginal delivery.
        Cochrane Database Syst Rev. 2014; CD004455
        • Glavind K
        • Bjork J.
        Incidence and treatment of urinary retention postpartum.
        Int Urogynecol J Pelvic Floor Dysfunct. 2003; 14: 119-121
        • Chan WS
        • Rey E
        • Kent NE
        • et al.
        Venous thromboembolism and antithrombotic therapy in pregnancy.
        J Obstet Gynaecol Can. 2014; 36: 527-553
        • Liston R
        • Sawchuck D
        • Young D
        • et al.
        Fetal health surveillance: antepartum and intrapartum consensus guideline.
        J Obstet Gynaecol Can. 2007; 29: S3-56
        • Garofalo M
        • Abenhaim HA
        Early versus delayed cord clamping in term and preterm births: a review.
        J Obstet Gynaecol Can. 2012; 34: 525-531
        • Bahl R
        • Strachan BK
        Mode of delivery in the next pregnancy in women who had a vaginal delivery in their first pregnancy.
        J Obstet Gynaecol. 2004; 24: 272-273
        • Fynes M
        • Donnelly V
        • Behan M
        • et al.
        Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study.
        Lancet. 1999; 354: 983-986

      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
        • Full-Text
        • PDF