Guidelines for operative vaginal birth

Objective: To provide guidelines for operative vaginal birth in the management of the second stage of tabour. Options: Nonoperative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth. Outcome: Reduced fetal and maternal morbidity and mortality. Evidence: MEDLINE and Cochrane databases were searched using the key words "vacuum" and "birth" as welt as "forceps" and "birth" for literature published in English from January 1970 to June 2004. The level of evidence and quality of recommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination. Recommendations: (1) Nonoperative interventions such as one-to-one support, partogram use, oxytocin use, and delayed pushing in women using epidurals will decrease need for operative birth (I-A). (2) Manual rotation may be used alone or in conjunction with instrumental birth with little or no increased risk to the pregnant woman or to the fetus (III-B). (3) Routine episiotomy is not necessary for an assisted vaginal birth (II-B). (4) When operative intervention in the second stage of tabour is required, the options, risks, and benefits of vacuum, forceps, and Caesarean section must be considered. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other (II-B). (5) Failure of the chosen method, vacuum and/or forceps, to achieve delivery of the fetus in a reasonable time should be considered an indication for abandonment of the method (III-C). (6) Adequate clinical experience and appropriate training of the operator are essential to the safe performance of operative deliveries. Hospital credentialing boards should grant privileges for performing these techniques only to an appropriately trained individual who demonstrates adequate skills (III-C). Validation: The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.