Operative Vaginal Delivery 
Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction: 
Operative vaginal delivery is when an 
obstetrician or other trained birth attendant uses a 
device to assist in the delivery in the second stage of 
labor.  This can be done for either maternal or fetal 
indications using either forceps or a vacuum 
extractor.  The use of either of these tools requires 
that the obstetric care provider be familiar with both 
proper use and the risks involved.  To minimize 
harm, operative vaginal delivery should be 
performed only by an experienced operator. 
Operative 
vaginal 
delivery 
may 
be 
recommended  for the following indications:  
● Prolonged second stage of labor 
● Arrest of descent 
● Suspicion of fetal compromise 
● Maternal exhaustion and inability to push 
● Maternal medical indications and need to 
avoid Valsalva (e.g. maternal cardiac 
disease) 
 
Operative vaginal delivery, when successful, 
can help avoid the need for Cesarean birth and its 
resulting risks and complications. Also, it can often 
achieve a faster delivery than a Cesarean.   
Standard forceps used for either an outlet or 
low forceps delivery (see Box 1) have the parts 
shown below: the handles, lock, shanks, cephalic 
curve which cups the fetal head, and the pelvic curve 
which navigates the curve of the maternal pelvis 
during delivery.  
 
Standard Forceps. Not shown, the pelvic curve is the angle 
between the handle and the cephalic curve, angulating toward 
or away from the viewer in this photo. Source: B. Seguy - Own 
work, CC BY-SA 3.0, 
https://commons.wikimedia.org/w/index.php?curid=12972140  
 
Operative vaginal deliveries are classified by 
the station of the fetal head at application and the 
degree of rotation necessary for delivery.  In general, 
the lower the fetal head and the less rotation required, 
the less risk to the mom and the fetus.  For the 
purposes of this document we will discuss outlet and 
low operative vaginal deliveries (see Box 1).  We 
will not discuss rotational forceps, mid forceps or 
high forceps (operative deliveries involving a baby at 
a higher station in the pelvis,) all of which require 
additional skills and expertise and could potentially 
put both the mom and the fetus at higher risk. 
 
Forceps used for rotation of the fetal head are 
called Kielland forceps.  These are different from the 
forceps described previously because they don’t 
have a pelvic curve.  They should not be used for 
delivery, just for rotation, thus will not be discussed 
here. 
When compared to vacuum delivery, forceps 
are more likely to lead to a successful vaginal 
delivery (failure rate 9%), and less likely to cause a 
fetal cephalohematoma.  Use of forceps is however 
associated with a higher rate of anal sphincter injury 
and associated fecal incontinence, and higher rate of 
3rd and 4th degree perineal lacerations (20%).  
Forceps are also more technically challenging to use 
than a vacuum.  Complications to the fetus of 
forceps-assisted birth include skin markings and 
lacerations, external ocular trauma, intracranial 
hemorrhage, 
subgaleal 
hemorrhage, 
retinal 
hemorrhage, facial nerve injury, skull fracture, and 
rarely, death.  
Outlet Forceps 
Fetal scalp is visible at the introitus 
without separating the labia 
Fetal skull has reached the pelvic 
floor 
Rotation does not exceed 45 degrees 
Low forceps 
Fetal skull is at station 2+ or more 
and  not yet reached the pelvic floor 
Rotation does not exceed 45 degrees 
Operative Vaginal Delivery 
Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Commercially available vacuum device which allows the 
operator to measure the vacuum pressure as it is being applied 
and to pull on the same handle.  
 
Vacuum delivery carries a decreased risk of 
3rd and 4th degree lacerations compared to forceps 
(10%) and is easier to learn to use.  The 
disadvantages and risks are that there is a greater risk 
of fetal cephalohematoma and higher failure rate in 
achieving a vaginal delivery (14%).  Complications 
to the fetus of a vacuum assisted birth are intracranial 
hemorrhage (epidural, subdural, intraparenchymal, 
subarachnoid), intraventricular hemorrhage, and 
subgaleal hemorrhage. 
 
Steps:  
 
In both types of operative vaginal delivery, 
attend to the following steps before beginning:  
● Determine the indication for operative vaginal 
delivery and obtain informed consent 
● Assess for absolute contraindications: Operative 
vaginal birth is contraindicated if the fetal head is 
not engaged in the maternal pelvis or if the 
position of the vertex cannot be determined, if the 
fetal size is suspected to be too large for the 
maternal pelvis, or if the fetus is suspected to 
have a bleeding disorder or osteogenesis 
imperfecta  
● Assess position: In order to determine the degree 
of rotation and thus ensure a patient can safely be 
offered an operative delivery, it is essential to 
identify the fetal position, or what direction the 
fetal head is oriented.  The anterior fontanelle is 
larger and forms a cross – the posterior fontanelle 
is smaller and forms a Y.  Another way to help 
assess position is to feel for which direction the 
fetal ear bends. 
 
Position of fetal head: In these diagrams, maternal sacrum is 
on the bottom and pubic symphysis is at the top.  Fetal occiput 
is used as the reference point.  The anterior fontanelle is larger 
and forms a cross; the posterior fontanelle is smaller and forms 
a “Y.” OA – Occiput anterior, OP – Occiput posterior, LOT - 
Left Occiput Transverse, LOA - Left Occiput Anterior, ROP - 
Right Occiput Posterior 
Source: By Mikael Häggström - Own work, Public Domain, 
https://commons.wikimedia.org/w/index.php?curid=8982011  
 
● Assess the final prerequisites checklist:  
○ Cervix is fully dilated and membranes are 
ruptured 
○ Fetal head is engaged 
○ Position of fetal head is known 
○ Estimated 
fetal 
weight 
has 
been 
performed and assessment that the pelvis 
is adequate for vaginal birth (if the fetus 
is estimated to be too large for the 
maternal pelvis, this can lead to a 
shoulder dystocia) 
○ Maternal bladder has been emptied with 
an in-and-out catheterization. 
○ Willingness to abandon the attempt, with 
back-up plan in place (i.e. Cesarean) in 
case of failure to deliver 
○ Adequate anesthesia* 
Operative Vaginal Delivery 
Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
* Though regional anesthesia is ideal, we recognize 
this is often unobtainable in resource-limited 
settings; in this case, a pudendal block would be a 
good alternative option if available 
 
Choose your instrument: forceps vs. vacuum.  
This may simply depend on availability or on the 
comfort level and expertise of the practitioner.  There 
are some special circumstances that would favor one 
method over the other:   
● In cases where the fetus is less than 34 weeks 
gestational 
age, 
vacuum 
delivery 
is 
contraindicated and forceps is the preferred 
option.   
● In cases where the position of the baby is occiput 
transverse, standard forceps delivery would be 
contraindicated, and vacuum would be the 
preferred choice. 
 
Ensure the mother is in dorsal lithotomy 
position in a bed where the bottom can come off or 
lower at the foot, allowing you easy access to the 
perineum while she still has footrests, such as 
stirrups.   
 
Forceps Delivery: 
Apply the forceps in the following manner: 
1. Articulate the forceps together outside of the 
patient to make sure the set fits together 
correctly 
2. Perform a “ghost application” outside of the 
patient to envision the way the forceps need 
to be applied depending on the position of the 
fetal head 
3. Separate the forceps blade that will 
ultimately fall on the patient’s left side 
(shown below). Dangle this forcep vertically 
in your left hand with the fingerguard facing 
the mother.  This should be done with a very 
light touch.  Using your right hand, place 
your hand in the vagina alongside the fetal 
parietal bone and guide the forcep to cup the 
fetal head.   
 
 
Place your right hand in the vagina alongside the fetal parietal 
bone and guide the forcep to cup the fetal head.  Source: World 
Health Organization Surgery at the District Hospital 
Obstetrics, Gynecology, Orthopedics and Traumatology 
https://apps.who.int/iris/handle/10665/40002 
 
4. Using your left hand, gently bring the handle 
of the forceps in a large arc from 12:00 to 
9:00 on a clock face while  guiding the forcep 
around the fetal head with your right thumb. 
Operative Vaginal Delivery 
Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
 
With your left hand, gently bring the handle of the forceps 
downwards in a large arc from 12:00 to 9:00 positions while  
guiding the forcep around the fetal head with your right thumb 
(not shown.) Source: World Health Organization Surgery at the 
District Hospital Obstetrics, Gynecology, Orthopedics and 
Traumatology https://apps.who.int/iris/handle/10665/40002 
 
CAUTION: Only light pressure should be 
necessary to insert forceps properly; use of any 
more pressure than this likely indicates incorrect 
placement and could cause fetal and maternal 
injury. 
5. Place the right forcep using your right hand 
to hold the handle while placing the forcep 
from 12:00 to 3:00 in a large arc on a clock 
face.  The left hand should be used to place 
the forcep to cup the fetal head and thumb to 
guide the forcep into the vagina.   
 
 
 
Placement of the right forceps is the mirror image of the above: 
guide the forcep to cup the fetal head with your left hand, then 
bring the handle downward in a gentle arc proceeding from the 
12:00 to 3:00 positions. As before, only light pressure is needed 
for this maneuver.Source: World Health Organization Surgery 
at the District Hospital Obstetrics, Gynecology, Orthopedics 
and 
Traumatology 
https://apps.who.int/iris/handle/10665/40002 
 
6. Once both forceps are placed, perform the 
following check to ensure they are placed 
correctly: fetal sagittal suture should lie 
midline between the forceps so that the 
forceps are lying on the parietal bones of the 
fetal head equally. 
Operative Vaginal Delivery 
Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
As shown here, the fetal sagittal suture lies in the midline 
between the forceps. The cephalic curve of each side of the 
forceps engages the parietal bones equally. Source: World 
Health Organization Surgery at the District Hospital 
Obstetrics, Gynecology, Orthopedics and Traumatology 
https://apps.who.int/iris/handle/10665/40002 
 
7. Ensure the blades lock together correctly but 
do not squeeze them yet to apply force.  
8. When prepared to deliver, instruct the mother 
to push while you use the forceps. 
9. If right handed, use your right hand to grip 
both forceps handles with your palm facing 
upward and pull horizontally.  Use your left 
hand to apply force downward on the shank 
of the forceps.  The overall direction of the 
force should be slightly downward and out.  
The red arrow below shows what should be 
the overall direction of force and the caption 
describes the correct hand position for a right 
handed person.  Hands should be reversed if 
the individual performing the delivery is left 
handed. 
 
At the Blue arrow, the operator’s dominant hand grasps the 
handle with palm upwards. At the Green arrow, the operator’s 
other hand exerts downward force. The resulting direction of 
fetal movement is shown by the Red arrow. Source: World 
Health Organization Surgery at the District Hospital 
Obstetrics, Gynecology, Orthopedics and Traumatology 
https://apps.who.int/iris/handle/10665/40002 
 
10. Once the head is crowning, stop pulling 
horizontally and start pulling upwards at an 
angle 45 degrees from the floor.  Either the 
delivering practitioner or an assistant should  
guard the perineum to protect from tearing 
during delivery of the fetal head. 
 
Once the head is crowning, the direction of traction changes to 
upwards at 45 degrees. Source: World Health Organization 
Surgery at the District Hospital Obstetrics, Gynecology, 
Orthopedics 
and 
Traumatology 
https://apps.who.int/iris/handle/10665/40002 
Operative Vaginal Delivery 
Lindsey E. Zamora 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
11. Once the fetal head is delivered, remove the 
forceps in the order and direction they were 
applied and complete the delivery in a 
standard fashion. 
 
Vacuum Delivery: 
Apply the vacuum in the following manner:  
1. Determine the flexion point of the fetal 
head.  To be most successful with a vacuum 
delivery and minimize any risk of trauma to 
the fetus or mother, placement of the 
vacuum on the flexion point is essential.  To 
do this, feel for the fetal sutures and 
determine where the anterior and posterior 
fontanelles are located.  The flexion point is 
directly over the sagittal suture and 6 cm 
behind the anterior fontanelle.   In practical 
terms, the vacuum should be placed as far 
posterior as possible on the fetal head and 
not over the anterior fontanelle.  This 
maintains the fetal head in flexed position 
and minimizes risk to the baby. 
 
 
Proper application of the vacuum cup relative to the sagittal 
suture and fontanelles. Practically, this should be in the 
midline, as far posteriorly as possible. Ideally it is in the area 
shown by the Green circle, or at least in the approximately 
6cm space between the anterior and posterior fontanelles, not 
over the anterior fontanelle or to either side. Source: Primary 
Surgery Volume 1, https://global-help.org/products/primary-
surgery/  
 
 
 
Effect of proper vacuum cup placement on flexion of the head: 
when placed posteriorly, in the midline, the head flexes 
forward when traction is applied, facilitating passage through 
the birth canal. When traction is applied too far forward or to 
one side, the neck flexes in a way that is counterproductive.  
Source: Primary Surgery Volume 1, https://global-
help.org/products/primary-surgery/  
 
 
2. Place the vacuum cup.  When placing the 
cup, the practitioner should be careful to 
avoid trapping maternal tissue between the 
cup and the fetal head.   
 
Placement of the vacuum cup. Avoid entrapping maternal 
tissue here. Source: https://hetv.org/resources/reproductive-
health/impac/Procedures/Vacuum_extraction_P27_P31.html 
 
 
3. After placement of the vacuum cup, suction 
should be applied.  Cups that have the pump 
Operative Vaginal Delivery 
Lindsey E. Zamora 
 
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integrated into the handle of the device like 
the Kiwi® pictured in the introduction can 
be operated with one person.  If the pump is 
not integrated into the handle, an assistant 
will need to be utilized to generate the 
suction.  Suction should be generated 
rapidly within 1-2 minutes in order to reduce 
the total duration of the procedure.  Vacuum 
suction pressures of 500 to 600 mmHg are 
recommended during traction, although 
pressures in excess of 450 mmHg are rarely 
necessary.  Lower pressures can increase the 
risk of “pop-offs” but pressures beyond 
600mm Hg increase the risk of fetal injury.  
The theory that the vacuum is "designed to 
pop-off before damage occurs" is false and 
should not be used to justify use of higher 
pressures.  The maximum negative pressure 
should not exceed 600 mmHg. 
 
Commercially available suction devices such as the Kiwi ® can 
be operated by one person.  
 
 
A suction device such as this one can be made using a pump, 
tubing, an airtight bottle, a pressure gauge, and a vacuum cup. 
This device needs two people to operate, one to maintain 
suction with the pump and the other to deliver using the vacuum 
cup. Source: World Health Organization Surgery at the District 
Hospital 
Obstetrics, 
Gynecology, 
Orthopedics 
and 
Traumatology https://apps.who.int/iris/handle/10665/40002 
 
4. Traction should be applied only during 
maternal pushing and in the direction of the 
pelvic axis, i.e. horizontally and slightly 
downward toward the maternal rectum 
similar 
to 
the 
direction 
of 
force 
recommended for a forceps delivery above.  
If the vacuum used has a central stem, the 
stem should be kept perpendicular to the 
plane of the vacuum cup to prevent pop offs. 
 
Traction, during maternal pushing, is horizontally and 
downwards. Once the head is crowning, traction, is upwards at 
45 degrees, as described above with forceps delivery. Source: 
Sunday E. Adaji and Charles A. Ameh, “Operative Vaginal 
Deliveries in Contemporary Obstetric Practice”  
https://www.intechopen.com/chapters/33797  
 
5. Once vacuum is applied, the cup should not 
be twisted. This can lead to fetal scalp injury. 
Operative Vaginal Delivery 
Lindsey E. Zamora 
 
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6. Traction can be maintained slightly between 
contractions or relieved.  Neither tactic has 
been shown to change delivery outcomes or 
risks to the mother and fetus.   
7. Once the head is crowning, stop pulling 
horizontally and start pulling upwards at an 
angle 45 degrees from the floor.  Either the 
delivering practitioner or an assistant should 
guard the perineum to protect from tearing 
during delivery of the fetal head. 
8. Once delivery of the fetal head has been 
achieved, release pressure from the vacuum 
and remove it.  Complete the delivery in a 
standard fashion.  
9. Vacuum 
delivery 
attempt 
should 
be 
abandoned if 3 pop offs occur, more than 20 
minutes has elapsed regardless of number of 
popoffs, or there is any evidence of fetal scalp 
trauma.  These are general guidelines.  If 
steady progress is being made and delivery is 
imminent after 20 minutes, it may be prudent 
to continue with vacuum delivery.  Similarly, 
if less than 20 minutes has passed and no 
progress has been made, the attempt should 
be abandoned and preparations made for a 
Cesarean birth.  
 
Cautions: 
If forceps delivery attempt is unsuccessful 
after application and attempt at traction, vacuum 
delivery should not be attempted.  Similarly if 
vacuum delivery is unsuccessful after application 
and attempt at traction, forceps should not be 
attempted.  Attempt at another method is not 
recommended due to increased risk to the fetus.  If 
an attempt at placing either forceps or vacuum is 
unsuccessful and no traction has occurred, it is 
reasonable to attempt the other technique.  
After delivery with either forceps or vacuum, 
both mother and baby should be examined for 
injuries: 
● Mother: Examine cervix and vagina 
● Baby: Examine for scalp lacerations and 
bruising as well as symptoms of internal 
bleeding 
Ensure that complete records of delivery are 
kept including length of operative delivery, type of 
instrument used, pressure applied in the case of 
vacuum and number of pop-offs. 
 
Pitfalls:  
• 
Failure of operative vaginal delivery necessitates 
prompt Cesarean birth.  Failure of either method, 
as mentioned above, necessitates Cesarean, not 
attempt at the other method. 
• 
In the case of any operative vaginal delivery, 
there should be someone in attendance who is 
trained in neonatal resuscitation. 
• 
Vacuum traction and torsion can cause life-
threatening complications.  For this reason, it is 
important to familiarize yourself with the device 
prior to use, and not utilize more pressure than 
recommended.   
• 
If forceps are not able to be placed properly and 
articulated properly at the lock, no attempt 
should be made to delivery.  Incorrect placement 
of forceps increases risk of injury to the fetus. 
• 
It is no longer recommended to perform a 
prophylactic episiotomy in the case of operative 
vaginal delivery.  If episiotomy is performed, it 
is reasonable to give prophylactic antibiotics.   
• 
If 3rd or 4th degree laceration occurs, it is 
reasonable to give prophylactic antibiotics. 
• 
In the case of an occiput transverse (OT) 
position, head can be manually rotated and 
forceps attempted if successful, or vacuum can be 
applied.  If a vacuum delivery is attempted, 
ensure vacuum is placed on the flexion point of 
the fetal head; head will often autorotate to 
occiput anterior during delivery. 
 
Lindsey E. Zamora, MD, MPH 
Vanderbilt University Medical Center 
USA 
