Care of the Woman Experiencing Operative Vaginal and Cesarean Birth



Care of the Woman Experiencing Operative Vaginal and Cesarean Birth


Donna R. Frye

Sarah Branan







Part 1 Operative Vaginal Birth

Although most women desire and set a goal for spontaneous vaginal birth, complications may arise, necessitating consideration of other options to facilitate birth such as application of forceps or vacuum, or cesarean section. Operative vaginal birth, assisted by vacuum or forceps, is a modification in the mode of delivery implemented by the primary care provider in certain circumstances in order to reduce maternal or fetal risk. While the overall rate of operative vaginal birth has decreased (3.5% of all births), vacuum-assisted births have increased. Vacuum-assisted births account for 4% of all vaginal births, while forceps-assisted births represent 1%.1


Vacuum-Assisted Birth (Vacuum Extraction)

Vacuum-assisted birth is achieved by the use of a vacuum cup attached to the fetal head (occiput). Suction is used to create negative pressure developing an artificial caput (chignon), and ensuring a snug fit of the cap onto the head (Fig. 15.1). The birth attendant uses gentle traction while the woman actively pushes with contractions to help the fetal head descend and shorten the second stage of labor.






FIGURE 15.1 Vacuum extraction. (From Pillitteri, A. (2007). Maternal & child health nursing: Care of the childbearing & childrearing family (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.)


Vacuum may be used in a variety of situations. Some of the most common scenarios are summarized in Display 15.1.

For vacuum-assisted birth to be successful1,2,3:



  • The fetus must be in a vertex (cephalic) presentation, engaged, with the head position known



  • The membranes must be ruptured to ensure proper placement


  • The woman’s cervix should be completely dilated to avoid potential lacerations


Contraindications to vacuum use include1,2,3:



  • face or breech presentation


  • evidence of CPD as determined by the obstetric provider


  • fetal osteogenesis imperfecta


  • gestational age less than 34 weeks


  • estimated fetal weight less than 2,500 g or greater than 4,000 g


  • live fetus with a known bleeding disorder


The newborn commonly experiences cup marks, bruising, and minor lacerations (Fig. 15.2). These effects are lessened with the use of a soft cup.3,4






FIGURE 15.2 Caput succedaneum. (From Pillitteri, A. (2007). Maternal & child health nursing: Care of the childbearing & childrearing family (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.)

Other risks include1,3:



  • cephalohematoma


  • subgaleal hematoma


  • retinal hemorrhage


  • intracranial hemorrhage


  • skull fractures


NOTE: Scalp avulsions, abrasions, blistering, bruising, and other trauma are more likely to occur when the vacuum is applied for a prolonged period of time (longer than 20 minutes) or with excessive suction (maximum pressure force should not be longer than 10 minutes).5,6

BE PREPARED: Shoulder dystocia may be more frequently encountered with mid pelvic vacuum extraction and has a higher risk of brachial plexus injury than forceps-assisted or cesarean births.1

Maternal complications are rare, but may include pain, bladder trauma, perineal lacerations, and soft tissue injuries to the vulva, vagina, cervix, and anal sphincter.2,5 Perineal wound infections, vaginal bleeding, uterine atony, and anemia may also result from vacuum-assisted birth.1,7


The nurse’s role in a vacuum-assisted birth is twofold: educating the woman and family about the procedure and assisting the provider. Nursing actions are summarized in Display 15.2.



Vacuum is generally preferred to forceps for operative vaginal birth because it is easier to apply and there is less associated maternal trauma. Provider preference training and frequency of use are also considerations.5,6



Forceps-Assisted Birth

Obstetrical forceps are metal blades designed to curve around the fetal head and help to facilitate birth. Forceps are shaped to fit the fetal head and maternal pelvis using blades that are curved to provide the best traction in a variety of situations. The blades are joined with a locking pin, screw, or groove to limit compression of the fetal skull.2,7,8

Incidence of forceps-assisted birth varies according to birthing facility and the skill and experience of the provider. The incidence has decreased in the last few decades as providers opt for the use of the vacuum or cesarean section.7,9


Forceps are used for a variety of situations, similar to the indications for use of the vacuum (Display 15.1). Forceps may also be used in cases of malpresentation for rotation of the fetal head. Other indications for use of forceps instead of the vacuum are listed in Display 15.3. Under these conditions, forceps are considered safer than vacuum-assisted birth.2,6,10,11



Although vacuum-assisted birth is now more common, forceps have some advantages, including:



  • decreased failure rate


  • expedites vaginal birth at a more rapid rate


  • allows the provider to rotate the fetal head to an occiput anterior position to facilitate birth


There are different classifications of forceps applications for use in various situations and are dependent on fetal station.



  • Outlet forceps are used when the fetal head is visible at the vaginal introitus without separating the labia to guide and control the birth.


  • Low forceps are used when the leading part of the fetal head is at least +2 station.


  • In midforceps application, the fetal head is engaged but above +2 station.

Figure 15.3 illustrates the application of outlet forceps on the fetal head. Midforceps application is not frequently done except in emergent situations due to increased maternal and newborn morbidity. However, it may be considered by the physician if it is determined to be a more rapid approach to birth than a cesarean section in an emergent situation.

NOTE: High forceps applications are no longer a part of current obstetric practice due to the incidence of maternal and fetal injury.2,12

There are a variety of forceps in use today. The more common types and their uses are found in Display 15.4. As with vacuum-assisted birth, for forceps to be safely attempted, the provider should be knowledgeable and experienced with the type of forceps and credentialed to perform the procedure and a cesarean birth if there is a failed attempt. In addition, the physician must verify the following:



  • membranes are ruptured


  • cervix is completely dilated


  • the fetal head is engaged (Note: this may be difficult if excessive caput is present)


  • the fetal head position is known



  • the fetal presenting part is vertex (if face presentation, chin should be anterior)


  • cephalopelvic disproportion should not be suspected by the provider






FIGURE 15.3 Forceps-assisted delivery: application of the forceps to the fetal head. (From Orshan, S. A. (2008). Maternity, newborn, & women’s health nursing. Philadelphia, PA: Lippincott Williams & Wilkins.)

In preparation for a forceps birth, the nurse should make sure the woman’s bladder is empty and she has adequate pain management/anesthesia. If the physician anticipates a potentially difficult attempt, an anesthesiology provider, surgical team, and individuals capable of neonatal resuscitation should be readily available.1,7,12,13 Nursing considerations in care of the woman undergoing a forceps-assisted birth are similar to those of vacuum-assisted birth. They are summarized in Display 15.2.


Morbidity after forceps-assisted birth is associated with fetal station and the degree of rotation required to effect birth (the higher the station and degree of rotation increases maternal and fetal morbidity). Risks include:



  • Fetal/newborn



    • facial nerve palsy


    • intracranial hemorrhage


  • Maternal



    • lacerations—vagina, cervix, perineum


    • episiotomy extension


    • uterine atony and postpartum hemorrhage


    • hematoma formation


    • bladder dysfunction and urinary retention


    • fecal incontinence

NOTE: Notify the primary care provider if the woman develops complications from operative vaginal birth.5

The woman may require more analgesia in the postpartum period and a longer hospital stay than with a spontaneous or vacuum-assisted birth. For additional information regarding immediate postpartum care, review Module 17.


Clinical Considerations of Operative Vaginal Birth

If forceps birth is attempted but not achieved, then a cesarean section may be indicated.


While studies are limited, evidence appears to be against multiple attempts to deliver the baby vaginally with different instruments. A failed attempt at vacuum extractions followed by an attempt to deliver with forceps is often associated with an increase in maternal and newborn injury.1 However, the sequential use of instruments is a provider decision, balancing the risks and benefits of neonatal and maternal morbidity. Each hospital should develop an interprofessional plan of care that addresses when attempts at an operative vaginal birth should be discontinued. Best practice recommendations include2,12:

Nov 6, 2018 | Posted by in GYNECOLOGY | Comments Off on Care of the Woman Experiencing Operative Vaginal and Cesarean Birth
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