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OB Guideline 19: Operative Vaginal Delivery

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OB Guideline 19: Operative Vaginal Delivery

Related to: Clinical Guidelines, Communication, Informed Consent, Medication, Nursing, Obstetrics

The operative vaginal delivery1,2 guideline covers use of the vacuum extractor or forceps. 

The vacuum extractor or forceps should only be used if all of the following are met:

  1. The delivering clinician has clinical privileges to use a vacuum extractor or forceps.
  2. Capability to perform an emergency cesarean delivery is available if unexpected difficulties are encountered.
  3. Informed consent has been obtained and the patient agrees to the procedure.
  4. The fetal head (exclusive of any caput) has reached at least +2 cm (scale: -5 to +5) and clinical pelvimetry indicates that delivery without fetal or maternal trauma can reasonably be expected.
  5. The cervix is completely dilated and the membranes ruptured.
  6. The delivering clinician has assessed the station, position, and attitude of the fetal head as appropriate to permit an accurate cephalic application of the forceps blades, or vacuum cup.
  7. Adequate analgesia is provided.
  8. Urinary bladder is empty.

For use of the vacuum extractor:

  1. Gestational age must be 34 weeks or greater.
  2. Careful pelvic examination to rule out any maternal tissue trapped between the vacuum cup and fetal head.
  3. Vacuum extraction and commitment to vaginal delivery should be reevaluated in the event of:
    • failure of descent of the vertex with the first traction effort,
    • delivery that is not imminent after four traction efforts, or
    • vacuum cup detachment that occurs three times.

If the vacuum extractor or forceps fails to accomplish delivery despite proper application and technique, then a subsequent trial with the alternate instrument is appropriate only in carefully selected cases. If possible, a second opinion from another physician is recommended if a trial with the alternate instrument is planned. The consultant shall document his or her obstetrical evaluation and recommendation in the patient’s medical record (see Guideline 4).

The incidence of intracranial hemorrhage is highest among infants delivered by cesarean following a trial of vacuum or forceps, or a combination of vacuum and forceps. Therefore, a trial of operative vaginal delivery should be attempted only when the likelihood of success is high.

The clinician shall dictate a detailed operative note which should include:

  • the station and position of the fetal head,
  • the fetal status at the time of application of vacuum extractor or forceps,
  • indications, and
  • clinical rationale and substantive risks discussed with the patient.
  • For vacuum extractions, the note must also include:
  • the instrument used and pressure settings,
  • number of attempts, and
  • duration of the procedure.

In addition to a dictated detailed operative note, the delivering clinician should document the operative procedure in the patient’s medical record immediately following the delivery.


  1. ACOG/ACP Guidelines for Perinatal Care, Seventh Edition. Washington DC, October 2012.
  2. Operative vaginal delivery. ACOG Practice Bulletin 17. American College of Obstetricians and Gynecologists. June 2000. Reaffirmed 2012.
 << Guideline 18             Web Guideline Home Page              Guideline 20 >>

May 1, 2014
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