The incidence of assisted delivery is about 15%-20%. Assisted delivery refers to a delivery that is assisted by an obstetrician or very occasionally a midwife with the use of either forceps or a vacuum extraction technique called Ventouse.
An epidural will double the chance of needing assistance in delivery – mainly because of reduced sensation and the lack of intense urge to push down. This can mean that it is harder for the woman to push the baby out alone and she may need help in delivering it.
The most common reason for assisting delivery is because of failure to progress or push out the baby spontaneously once the pushing stage of labour has commenced. This failure to progress during the pushing stage can be the result of a number of things- lack of sensation, not pushing effectively, holding back for fear of pooing, a full bladder or bowel, being too tired or sometimes the baby can be in a difficult position making it’s exit more difficult. Occasionally, it is simply that the baby is too big for the mother’s pelvis (Cephalopelvic Disproportion.)
The maximum time that you should be pushing is approximately 2 hours, but sometimes after 1 hour it can become apparent that the baby will not come out spontaneously.
The other indication for assisted delivery may be for fetal reasons such as fetal distress, bleeding, or maternal reasons such as raised blood pressure, cardiac disease – if the mother is not fit enough to push.
The reason that delivery is often assisted is that prolonged pushing in the second stage may cause significant extra damage to the pelvic floor and may be associated with the baby being born in poor condition, distressed and or with a lack of oxygen. So, put simply, forceps or Ventouse can be used to speed up the delivery of the baby.
An obstetrician will be called if a woman is pushing close to 2 hours and/or is failing to progress. He or she will carefully assess whether the conditions are suitable for an assisted delivery. The decision is made after careful consideration of the benefits and risks to mother and baby and the patient will always be consulted and involved in the decision.
The Ventouse is made up of a small suction cap attached to a small vacuum pump with a handle for pulling with.
This is the most commonly used technique for assisting delivery and is often preferred to forceps as there is less risk of damage to the pelvic floor compared with forceps delivery. This is because the Ventouse does not take up any extra room in the vagina, so an episiotomy is not always needed.
Most commonly this is performed in the delivery room unless there are particular concerns about the mother’s or baby’s condition or if it is thought it may not be successful and a caesarean section might be necessary. If this is the case it may be done in the operating theatre so that preparations can be made for a Caesarean section if necessary.
Your legs will be placed in stirrups to put you into the optimum position. A suction cap is applied to the back of the baby’s head after the doctors carefully assess the position of the baby in the pelvis. After the cap is applied, the doctor will use a pump to suck the air out of the cap- this can be a little noisy so do not be alarmed. The doctor pulls as the woman pushes with her contractions. This is not as effective if she cannot feel her contractions because of an epidural.
You do not have to have an epidural and in fact for optimum chances for success you need the mother to take an active role in the pushing, which can be easier if she has not had an epidural. Some sensation is really useful in helping the woman to push effectively. Usually delivery is achieved over the course of the next 5-15 minutes. After the first few contractions the obstetrician can usually tell if the procedure is going to be successful.
The side effects of using a Ventouse are that the baby will have an extra swelling on the back of its head over the site of the vacuum cup which normally lasts about 10-15 minutes. This can look a little alarming at first especially if the baby’s head has already become elongated due to the powers of labour and coming down the birth canal. There is usually some local bruising and a red mark which will disappear over the next few days. This extra bruising is associated with an increased chance of jaundice, which is usually mild, over the next few days – but this will not affect the baby’s feeding or development. Sometimes there may be some superficial cuts to the babies skin, but again these will disappear quickly and are unlikely to be of consequence. More serious damage is very unusual. You may be worried that the doctor can pull too hard with the Ventouse, but this is not possible, the Ventouse cap will come off the baby’s head if there is too much pressure, thus preventing any damage
If Ventouse is not successful, the Doctor may decide to try using forceps or he may think it is a better idea to go straight for a caesarean section as repeated use of instruments can increase the risk of injury to the baby.
Forceps look like giant stainless steel salad tongs and have large spoon-like ends to cradle the baby’s head whilst helping to pull it out.
This method is less commonly used than 30 years ago but there are still indications for the careful use. This will depend on the position of the baby in the birth canal, the shape of the baby’s head and the experience of the obstetrician. Sometimes the baby’s head is very swollen and the Venteuse is not safe or effective in this situation.
This procedure does require a good level of pain relief and usually an episiotomy. An episiotomy is where a cut is made through the vagina to enlarge the opening so that the forceps can be put in and around the baby’s head.
The bladder needs to be emptied with a catheter and the position of the baby must be carefully determined. The forceps are carefully applied along the side of the baby’s head and the obstetrician will apply gentle traction as the mother bears down with the contraction. Again, the doctor can usually tell within a few contractions of the procedure is going to be successful.
Delivery may be undertaken in theatre so that preparations can be made for a caesarean section if needed. If there is genuine concern that forceps may not be successful then the patient will be fully prepared for caesarean section at the same time so that this can be done quickly if needed. This is called a “trial of forceps in theatre”. This is more likely to be required if the baby is in an occipital posterior position (back to back).
All assisted deliveries will be attended by a paediatrician and it is not unusual for the baby to require some resuscitation.
One of the complications of forceps delivery is that is likely to be some superficial marking on the side of the babies face which will clear up over the next few days. Cuts to the skin are unusual but if they occur they will likely heal without scarring. More serious complications are unlikely.
The baby can be delivered onto the mother’s tummy unless it needs to be resuscitated. She can normally hold the baby whilst she is being stitched up- this can take anywhere between 5 and 30 minutes depending on the extent of the episiotomy.
Any assisted delivery is followed by careful inspection of the birth canal and vagina to assess the extent of any damage.
All forms of assisted delivery may be associated with an increased chance of bleeding after delivery. This may be due to increased trauma to the birth canal or relaxation of the uterus after a long labour.
Assisted deliveries are more common with first babies. About 90 percent will be able to push the baby out spontaneously next time – so just because your first baby was born with the help of forceps it does not mean this will be necessary for the second.
Why Ventouse or why Forceps?
If the baby is less than 34 weeks then Ventouse will not be used as it may damage baby’s soft skull.
Although Forceps may have a higher success rate they are more painful for the woman and are more likely to damage to the pelvic floor or perineum compared to a Ventouse birth.
The Obstetrician may have a preference of one over the other in which case he will most likely chose the instrument he or she is most comfortable with.
Occasionally if the bay’s head is very swollen due to the forces of nature and the passage of the head through the birth canal, then Ventouse may not be advisable. Under these circumstances the preferred method of delivery is likely to be Forceps rather than Ventouse.