OB Guideline 18: Operative Vaginal Birth

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

1. The delivering clinician has clinical privileges to use a vacuum extractor or forceps.
2. Capability to perform an emergency cesarean birth is available if unexpected difficulties are encountered.
3. Informed verbal 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 birth 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.
9. A pre-procedure huddle should be performed to plan the vacuum or forceps delivery, including

• Stopping and evaluating commitment to OVD if there is no progress after each pull.
• Stopping and evaluating commitment to OVD if undelivered with vacuum or forceps after 15 minutes. Persisting beyond 15 minutes with either instrument is not recommended.
• Stopping if there are three pop-offs with vacuum.
• Contingency plan in place for cesarean delivery if vaginal delivery is unsuccessful.

For use of the vacuum extractor:

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

If the vacuum extractor or forceps fails to accomplish birth 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 their obstetrical evaluation and recommendation in the patient’s medical record (see Guideline 4).

Sequential use of vacuum extractor and forceps has been associated with an increased risk of neonatal complications and should not be routinely used. A trial of operative vaginal birth should be attempted only when the likelihood of success is high, with the operator prepared to abandon the attempt if appropriate descent does not occur. If a trial of vacuum or forceps is unsuccessful, prompt cesarean birth is indicated unless vaginal birth is imminent.

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

• The station and position of the fetal head
• The fetal status at the time vacuum extractor or forceps application
• Indications
• 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
• Duration of the procedure

For forceps delivery, the note must also include:

• Confirmation of fetal position after the placement of the forceps blades
• The number of pulls applied (with a qualitative assessment of the degree of effort)

If the operative note is dictated, then the delivering clinician should document the operative procedure in the patient’s medical record immediately following the birth.

1. Operative Vaginal Birth: ACOG Practice Bulletin, Number 219. Obstet Gynecol. 2020;135(4):e149-e159. Reaffirmed 2025. doi:10.1097/AOG.0000000000003764
2. American Academy of Pediatrics; American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 8th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.