Instrumental delivery: clinical practice guidelines from the French College of Gynaecologists and Obstetricians

Routine use of a partograph is associated with a reduction in the use of forceps, but is not associated with a reduction in the use of vacuum extraction (Level A). Early artificial rupture of the membranes, associated with oxytocin perfusion, does not reduce the number of operative vaginal deliveries (Level A), but does increase the rate of fetal heart rate abnormalities (Level B). Early correction of lack of progress in dilatation by oxytocin perfusion can reduce the number of operative vaginal deliveries (Level B). The use of low-concentration epidural infusions of bupivacaine potentiated by morphinomimetics reduces the number of operative interventions compared with larger doses (Level A). Placement of an epidural before 3-cm dilatation does not increase the number of operative vaginal deliveries (Level A). Posterior positions of the fetus result in more operative vaginal deliveries (Level B). Manual rotation of the fetus from a posterior position to an anterior position may reduce the number of operative deliveries (Level C). Walking during labour is not associated with a reduction in the number of operative vaginal deliveries (Level A). Continuous support of the parturient by a midwife or partner/family member during labour reduces the number of operative vaginal deliveries (Level A). Under epidural analgesia, delayed pushing (2h after full dilatation) reduces the number of difficult operative vaginal deliveries (Level A). Ultrasound is recommended if there is any clinical doubt about the presentation of the fetus (Level B). The available scientific data are insufficient to contra-indicate attempted midoperative delivery (professional consensus). The duration of the operative intervention is slightly shorter with forceps than with a vacuum extractor (Level C). Nonetheless, the urgency of operative delivery is not a reason to choose one instrument over another (professional consensus). The cup-shaped vacuum extractor seems to be the instrument of choice for operative deliveries of fetuses in a cephalic transverse position, and may also be preferred for fetuses in a posterior position (professional consensus). Vacuum extraction deliveries fail more often than forceps deliveries (Level B). Overall, immediate maternal complications are more common for forceps deliveries than vacuum extraction deliveries (Level B). Compared with forceps, operative vaginal delivery using a vacuum extractor appears to reduce the number of episiotomies (Level B), first- and second-degree perineal lesions, and damage to the anal sphincter (Level B). Among the long-term complications, the rate of urinary incontinence is similar following forceps, vacuum extraction and spontaneous vaginal deliveries (Level B). Anal incontinence is more common following forceps delivery (Level B). Persistent anal incontinence has a similar prevalence regardless of the mode of delivery (caesarean or vaginal, instrumental or non-instrumental), suggesting the involvement of other factors (Level B). Rates of immediate neonatal mortality and morbidity are similar for forceps and vacuum extraction deliveries (Level B). It appears that difficult instrumental delivery may lead to psychological sequelae that may result in a decision not to have more children (Level C). The rates of neonatal convulsions, intracranial haemorrhage and jaundice do not differ between forceps and vacuum extraction deliveries (Levels B and C). Rapid sequence induction with a Sellick manoeuvre (pressure to the cricoid cartilage) and tracheal intubation with a balloon catheter is recommended for any general anaesthesia (Level B). Training must ensure that obstetricians can identify indications and contra-indications, choose the appropriate instrument, use the instruments correctly, and know the principles of quality control applied to operative vaginal delivery. Nowadays, traditional training can be accompanied by simulations. Training should be individualized and extended for some students.