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Assisted vaginal delivery

Key sources
The following summarized guidelines for the evaluation and management of assisted vaginal delivery are prepared by our editorial team based on guidelines from the European Association of Perinatal Medicine (EAPM 2022), the Royal College of Obstetricians and Gynaecologists (RCOG 2020), the American College of Obstetricians and Gynecologists (ACOG 2020), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2019; 2018), and the World Health Organization (WHO 2015).
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Guidelines

1.Classification and risk stratification

Classification: use a standard classification system for assisted vaginal delivery to promote safe clinical practice, effective communication between health professionals, and audit of outcomes.
B
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2.Diagnostic investigations

Ultrasound
Obtain ultrasound assessment of the fetal head position before assisted vaginal delivery where uncertainty exists following clinical examination.
A
Insufficient evidence to recommend routine abdominal or perineal ultrasound for assessment of the station, flexion, and descent of the fetal head in the second stage of labor.
I

3.Medical management

Antibiotic prophylaxis: as per RCOG 2020 guidelines, administer a single prophylactic dose of IV amoxicillin and clavulanic acid following assisted vaginal delivery.
A

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4.Nonpharmacologic interventions

Psychological support: ensure shared decision-making and good communication, and provide positive continuous support during labor and birth to reduce psychological morbidity after birth.
B
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5.Therapeutic procedures

Indications for assisted vaginal delivery: as per RCOG 2020 guidelines, recognize that no indication is absolute and clinical judgment is required in all situations.
B

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  • Contraindications for assisted vaginal delivery

  • Choice of instrument

  • Considerations for assisted vaginal delivery (general principles)

  • Considerations for assisted vaginal delivery (vacuum extraction)

  • Considerations for assisted vaginal delivery (forceps use)

6.Surgical interventions

Episiotomy: as per EAPM 2022 guidelines, perform episiotomy by indication only,
B
including in order to shorten the second stage of labor when there is suspected fetal hypoxia,
B
, prevent obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries.
B
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7.Patient education

Antenatal counseling: inform patients about assisted vaginal delivery in the antenatal period, especially during their first pregnancy, and if they indicate specific restrictions or preferences then explore this with an experienced obstetrician, ideally in advance of labor.
B
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More topics in this section

  • Postpartum counseling

8.Preventative measures

Prevention of assisted vaginal delivery: as per RCOG 2020 guidelines, ensure continuous support during labor to reduce the need for assisted vaginal birth.
A
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9.Follow-up and surveillance

Prevention of urinary retention: counsel patients about the risk of urinary retention ensuring that they are aware of the importance of bladder emptying in the postpartum period.
B
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10.Quality improvement

Documentation: document the following regarding assisted vaginal delivery using a standardized form:
detailed information on the assessment
decision making and conduct of the procedure
a plan for postnatal care
sufficient information for counseling in relation to subsequent pregnancies
B
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More topics in this section

  • Health professional training