An operative vaginal delivery is a vaginal birth where a doctor uses an instrument, either forceps or a vacuum device, to help guide the baby out of the birth canal. It’s performed when labor has stalled during pushing or when there’s a medical reason to speed up delivery. About 96% of attempted operative vaginal deliveries succeed, making cesarean section unnecessary in the vast majority of cases.
Why It’s Done
The most common reason for an operative vaginal delivery is a prolonged second stage of labor, meaning the pushing phase has gone on too long without enough progress. This can happen because the baby is in an awkward position, the mother is exhausted, or contractions aren’t strong enough to move the baby the rest of the way down. It may also be used when the baby shows signs of distress and needs to be delivered quickly, or when the mother has a medical condition that makes prolonged pushing risky, such as certain heart or neurological problems.
Before the procedure can begin, three conditions need to be met: the cervix must be fully dilated, the membranes (the “water”) must have ruptured, and the baby’s head must be low enough in the birth canal, at a station of +2 or lower. If the baby’s head is still too high, operative vaginal delivery isn’t an option and a cesarean is typically performed instead.
Forceps Delivery
Obstetric forceps are curved, spoon-shaped metal instruments that cradle the sides of the baby’s head. The doctor places one blade at a time along the baby’s cheeks, locks them together, and applies gentle traction during contractions to guide the baby through the birth canal. Different forceps designs exist for different situations. Simpson forceps work best when the baby’s head has been molded into a longer shape from prolonged labor, while Elliot forceps suit a rounder, unmolded head. For babies in unusual positions that require rotation, Kielland forceps have a sliding lock that allows the doctor to turn the baby’s head. Piper forceps are a specialized type used during breech deliveries to protect and deliver the baby’s head last.
Forceps deliveries are classified by how far down the baby’s head is and how much rotation is needed. An outlet forceps delivery involves minimal rotation (less than 45 degrees) with the head already very low. A low forceps delivery means the head is well descended but may need more rotation. A mid-forceps delivery, where the head is higher in the pelvis, is the most complex and least common.
Vacuum-Assisted Delivery
A vacuum extractor uses a soft or rigid cup placed on the top of the baby’s head. Once positioned, suction is gradually increased, pulling a small mound of scalp tissue into the cup to create a firm grip. The doctor then applies traction during contractions while the mother pushes. Between contractions, the suction pressure is reduced and traction stops. Once the baby’s head crowns (becomes visible at the vaginal opening), the suction is released, the cup is removed, and the rest of the delivery proceeds normally.
Soft, bell-shaped cups made of silicone or plastic are the most common type used in the United States. They cause fewer scalp injuries and are easier to apply, though they pop off more often. Rigid mushroom-shaped cups generate more traction force and are reserved for more difficult deliveries, such as when the baby is larger, facing the wrong direction, or has significant scalp swelling from prolonged labor.
Vacuum extraction is far more common than forceps. In a large study of nearly 48,000 operative vaginal deliveries, 93.2% used vacuum and only 6.8% used forceps.
Success Rates
Overall, about 96% of operative vaginal deliveries succeed. Vacuum attempts have a higher success rate of 97.3%, while forceps attempts succeed 82.4% of the time. The lower forceps success rate partly reflects the fact that forceps tend to be used in more complex situations. When an operative vaginal delivery fails, the birth is completed by cesarean section.
Pain Management During the Procedure
If you already have an epidural from labor, your provider will typically increase the dose (“top up”) to provide enough numbness for the delivery. If you don’t have an epidural, a pudendal block (a local anesthetic injection near the vaginal nerves) combined with numbing of the vulvar area can provide enough relief for a straightforward delivery. More complex deliveries, particularly those requiring rotation, usually need a spinal or epidural block for adequate pain control.
Risks for the Mother
The most significant maternal risk is tearing of the perineum, the tissue between the vagina and the anus. In one large study of over 3,500 assisted vaginal deliveries, nearly 89% of women had a second-degree tear (involving muscle tissue), 6.4% had a third-degree tear (reaching the anal sphincter muscle), and 0.3% had a fourth-degree tear (extending through the anal sphincter completely). Other possible complications include vaginal or vulvar hematomas (collections of blood under the skin) and injury to the urinary tract. These risks are higher than with a spontaneous vaginal delivery but vary depending on the instrument used, the baby’s position, and how long pushing lasted before the procedure.
Risks for the Baby
Most babies delivered operatively do well, but there are specific injuries to be aware of. Cephalohematoma, a collection of blood between the skull bone and its covering, occurred in about 2.3% of deliveries in one study, and was strongly associated with vacuum extraction. Babies delivered by vacuum had roughly 16.5 times the odds of developing a cephalohematoma compared to those born spontaneously. A prolonged second stage of labor independently increases this risk as well. Most cephalohematomas resolve on their own within weeks without treatment.
Vacuum deliveries also leave a temporary swelling on the scalp called a chignon, which forms where the suction cup was placed. This is expected and disappears within a day or two. Soft-tissue bruising and minor scalp abrasions are common with both instruments. Brachial plexus injuries, which affect the nerves controlling the baby’s arm and hand, are a rarer but more serious concern.
Recovery After an Operative Vaginal Delivery
Recovery is similar to recovery after any vaginal delivery, though perineal soreness tends to be more pronounced because tears are more common and often more extensive. If you had stitches from a tear or episiotomy, the wound typically hurts for a few weeks, with larger tears taking longer to heal. Vaginal discharge (lochia) starts bright red, gradually darkens, then turns yellow or white before stopping over the course of four to six weeks.
Some urinary leaking is normal after delivery, particularly after an operative birth that stretches the pelvic floor. This usually improves within a week, though it can last longer. Pelvic floor exercises (Kegels) help restore muscle tone and bladder control. To do them, tighten your pelvic muscles as if you’re trying to lift something with them, hold for three seconds, then relax for three seconds. Work up to 10 to 15 repetitions, at least three times a day. Starting these exercises early in recovery, even if it feels uncomfortable at first, helps strengthen the muscles that support your bladder, uterus, and rectum.