Leijonhufvud et al reported a 20-fold increased risk of undergoing surgery for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) after a forceps delivery, compared to cesarean section (C/S). This epidemiologic finding, if taken uncritically, would lead inevitably to the conclusion that forceps are inherently dangerous. However, even if we acknowledge, in the interest of objectivity, that forceps affect the diameter of the presenting vertex with the thickness of the blades and thus, may put the pelvic floor muscles under greater tension than the vacuum extractor (VE), particularly in primigravida patients, there are other factors that contribute significantly to pelvic floor damage, which the study seems to ignore, such as the misuse of the instrument and, to a lesser extent, mismanagement of labor in the hours preceding the operative vaginal delivery. In fact, failure to take appropriate measures for the prevention of pelvic floor damage, such as the early removal of the forceps blades and the modified Ritgen maneuver to keep the fetal head flexed, may be more deleterious than the instrument itself. Furthermore, it is easy to understand the considerable damage that can be inflicted to the pelvic floor when “gentle” traction becomes inadvertently inordinate traction, a likely possibility in the presence of unrecognized cephalopelvic disproportion, particularly when forceps are used by the less trained (incidentally, the authors make no mention of the degree of expertise of the forceps users). Moreover, the excessive duration of the second stage of labor, as is frequently the case before a forceps delivery, and the length of time allotted for vigorous pushing, particularly when the perineum is tense, have been known to result in pelvic floor damage.

As for this study’s clinical implications, to view its findings, as some may be tempted to do despite the above-mentioned limitations, as sufficient reason for obstetricians to give up their forceps, would be, in my opinion, unwise for the following reasons: first, forceps can provide resolution whenever VE is not suitable or downright contraindicated, and preparation for a C/S cannot be made in a timely fashion. Second, the risk to the perineum when using forceps can be reduced considerably, if not eliminated, through better teaching of this instrument technique (regrettably, forceps use is not part of the obstetrics residency curriculum in many teaching programs) and through the use of technology designed to prevent the inadvertent application of excessive pull. Lastly, concern for the pelvic floor should not cause us to ignore that the alternative to forceps, VE, is not free of risks, although this instrument is admittedly less traumatic to the pelvic floor. In fact, can we satisfactorily balance the risk of SUI and POP secondary to forceps use against the risk for the baby secondary to VE use of life-threatening complications, such as a subgaleal hematoma or an intracranial hemorrhage, whose frequency has prompted the Food and Drug Administration to issue a public health advisory?

Incidentally, I would like to bring to the attention of those who consider fear of pelvic floor injury secondary to spontaneous or instrumental vaginal delivery a legitimate indication for a C/S (in a recent survey, 80% of obstetricians cited such a fear as the reason for electing a C/S ) the following considerations: can we satisfactorily balance the protective effect on the pelvic floor of a C/S against its risks, including infection, hemorrhage, thromboembolic events, cystotomy, placenta previa, and placenta accreta? And furthermore, what assurance can we give patients that a C/S will be wholly protective against SUI or POP 20-30 years later?