Assisted Vaginal Birth

Abstract

Can assisted vaginal birth be avoided? Encourage women to have continuous support during labour as this can reduce the need for assisted vaginal birth. Grade of recommendation: A Inform women that epidural analgesia may increase the need for assisted vaginal birth although this is less likely with newer analgesic techniques. [New 2020] Grade of recommendation: A Inform women that administering epidural analgesia in the latent phase of labour compared to the active phase of labour does not increase the risk of assisted vaginal birth. [New 2020] Grade of recommendation: A Encourage women not using epidural analgesia to adopt upright or lateral positions in the second stage of labour as this reduces the need for assisted vaginal birth. Grade of recommendation: A Encourage women using epidural analgesia to adopt lying down lateral positions rather than upright positions in the second stage of labour as this increases the rate of spontaneous vaginal birth. [New 2020] Grade of recommendation: A Recommend delayed pushing for 1–2 hours in nulliparous women with epidural analgesia as this may reduce the need for rotational and midpelvic assisted vaginal birth. Grade of recommendation: B Do not routinely discontinue epidural analgesia during pushing as this increases the woman’s pain with no evidence of a reduction in the incidence of assisted vaginal birth. [New 2020] Grade of recommendation: A There is insufficient evidence to recommend any particular regional analgesia technique in terms of reducing the incidence of assisted vaginal birth. [New 2020] Grade of recommendation: A There is insufficient evidence to recommend routine oxytocin augmentation for women with epidural analgesia as a strategy to reduce the incidence of assisted vaginal birth. [New 2020] Grade of recommendation: A There is insufficient evidence to recommend routine prophylactic manual rotation of fetal malposition in the second stage of labour to reduce the risk of assisted vaginal birth. [New 2020] Grade of recommendation: B How should assisted vaginal birth be defined? Use a standard classification system for assisted vaginal birth to promote safe clinical practice, effective communication between health professionals and audit of outcomes. Grade of recommendation: D When should assisted vaginal birth be recommended/contraindicated? Operators should be aware that no indication is absolute and that clinical judgment is required in all situations. Grade of recommendation: D Suspected fetal bleeding disorders or a predisposition to fracture are relative contraindications to assisted vaginal birth. [New 2020] Grade of recommendation: ✓ Blood borne viral infections in the woman are not an absolute contraindication to assisted vaginal birth. [New 2020] Grade of recommendation: D The use of a vacuum is not contraindicated following a fetal blood sampling procedure or application of a fetal scalp electrode. [New 2020] Grade of recommendation: B Operators should be aware that there is a higher risk of subgaleal haemorrhage and scalp trauma with vacuum extraction compared with forceps at preterm gestational ages. Vacuum birth should be avoided below 32 weeks of gestation and should be used with caution between 32+0 and 36+0 weeks of gestation. [New 2020] Grade of recommendation: C What are the essential conditions for safe assisted vaginal birth? Safe assisted vaginal birth requires a careful assessment of the clinical situation, clear communication with the woman and healthcare personnel, and expertise in the chosen procedure ( Table 3 ). Grade of recommendation: D Does ultrasound have a role in assessment prior to assisted vaginal birth? Ultrasound assessment of the fetal head position prior to assisted vaginal birth is recommended where uncertainty exists following clinical examination. [New 2020] Grade of recommendation: A There is insufficient evidence to recommend the routine use of abdominal or perineal ultrasound for assessment of the station, flexion and descent of the fetal head in the second stage of labour. [New 2020] Grade of recommendation: C What type of consent is required prior to attempting assisted vaginal birth? Women should be informed about assisted vaginal birth in the antenatal period, especially during their first pregnancy. If they indicate specific restrictions or preferences then this should be explored with an experienced obstetrician, ideally in advance of labour. Grade of recommendation: ✓ For birth room procedures verbal consent should be obtained prior to assisted vaginal birth and the discussion should be documented in the notes. Grade of recommendation: ✓ When midpelvic or rotational birth is indicated, the risks and benefits of assisted vaginal birth should be compared with the risks and benefits of secondstage caesarean birth for the given circumstances and skills of the operator. Written consent should be obtained for a trial of assisted vaginal birth in an operating theatre. [New 2020] Grade of recommendation: ✓ Who should perform assisted vaginal birth? Assisted vaginal birth should be performed by, or in the presence of, an operator who has the knowledge, skills and experience necessary to assess the woman, complete the procedure and manage any complications that arise. Grade of recommendation: D Advise obstetric trainees to achieve expertise in spontaneous vaginal birth prior to commencing training in assisted vaginal birth. Grade of recommendation: ✓ Ensure obstetric trainees receive appropriate training in vacuum and forceps birth, including theoretical knowledge, simulation training and clinical training under direct supervision. [New 2020] Grade of recommendation: ✓ Competency should be demonstrated before conducting unsupervised births. [New 2020] Grade of recommendation: ✓ Complex assisted vaginal births should only be performed by experienced operators or under the direct supervision of an experienced operator. Grade of recommendation: D Who should supervise assisted vaginal birth? An experienced operator, competent at midpelvic births, should be present from the outset to supervise all at rotational or midpelvic assisted vaginal birth. Grade of recommendation: D should assisted vaginal birth and assisted vaginal births have a of and procedures can be in a birth [New 2020] Grade of recommendation: C Assisted vaginal births that have a higher risk of should be a trial and be in a where to caesarean birth can be Grade of recommendation: C What should be used for assisted vaginal birth? The operator should the appropriate to the clinical circumstances and their of Grade of recommendation: ✓ Operators should be aware that forceps and vacuum extraction are with benefits and to complete the birth with a is likely with vacuum perineal trauma is likely with [New 2020] Grade of recommendation: A Operators should be aware that vacuum have a higher rate of a incidence of scalp [New 2020] Grade of recommendation: A births should be performed by experienced the of the clinical circumstances and expertise of the The rotational manual rotation by direct forceps or and rotational vacuum Grade of recommendation: C When should birth be and should a vacuum procedure be birth where there is no evidence of descent with during of a by an experienced operator. [New 2020] Grade of recommendation: ✓ birth in the of with a of to the fetal head to the can be used to the head of the [New 2020] Grade of recommendation: ✓ If there is descent with the first of a the operator should the application is the fetal position has or there is experienced operators should and a second operators should the clinical and or discontinue the [New 2020] Grade of recommendation: ✓ birth there have of the experienced operators should support to the woman has the of a assisted vaginal birth. [New 2020] Grade of recommendation: The application for birth is recommended as reduces the of the procedure with no in and outcomes. [New 2020] Grade of recommendation: The use of is with an risk of trauma to the the operator to the risks of a caesarean birth following vacuum extraction with the risks of forceps birth following vacuum Grade of recommendation: B should be aware of the following birth use of and should the this to appropriate of the Grade of recommendation: should be aware of the risk of obstetric following use of [New 2020] Grade of recommendation: C When should forceps birth be and should a forceps procedure be forceps birth where the forceps be the not or there is a of descent with [New 2020] Grade of recommendation: B rotational forceps birth rotation is not with [New 2020] Grade of recommendation: B forceps birth birth is not following of a by an experienced operator. [New 2020] Grade of recommendation: B If there is descent with the first or of the the operator should the application is the position has or there is experienced operators should and a second operators should the clinical and or discontinue the [New 2020] Grade of recommendation: ✓ should be aware of the following a at forceps birth and should the this to appropriate of the [New 2020] Grade of recommendation: ✓ should be aware of the risk of fetal head at caesarean birth following a at birth forceps and should be to the fetal head using [New 2020] Grade of recommendation: ✓ What is the role of in at assisted vaginal birth? should be with the woman as of the for assisted vaginal birth. [New 2020] Grade of recommendation: ✓ the of evidence to support routine or use of at assisted vaginal birth, the should be to the circumstances at the and the preferences of the The evidence to support use of at assisted vaginal birth in terms of is for nulliparous women and for birth [New 2020] Grade of recommendation: B When a the should be at a the head is the [New 2020] Grade of recommendation: B prophylactic be A prophylactic of and should be recommended following assisted vaginal birth as reduces or compared to [New 2020] Grade of recommendation: A of and are Grade of recommendation: ✓ be women assisted vaginal birth for risk and the need for Grade of recommendation: D What analgesia should be given birth? the of women should be and Grade of recommendation: A What should be for of the birth? Women should be about the risk of that they are aware of the of in the [New 2020] Grade of recommendation: The and of the first should be and [New 2020] Grade of recommendation: C A should be is Grade of recommendation: ✓ Recommend that women who have regional analgesia for a trial of assisted vaginal birth in have an in the birth to should be to the [New 2020] Grade of recommendation: ✓ women to reduce the risk of at 3 Grade of recommendation: B How can be for the and continuous support during labour and birth have the to reduce following birth. [New 2020] Grade of recommendation: ✓ women before to the indication for assisted vaginal birth, of any complications and for births. is where the woman is by the who performed the Grade of recommendation: ✓ and support to women who have a birth and to about their The the birth should be [New 2020] Grade of recommendation: ✓ Do not with an the [New 2020] Grade of recommendation: ✓ women with at to professionals as the [New 2020] Grade of recommendation: D What should women be given for Inform women that there is a of a spontaneous vaginal birth in following assisted vaginal birth. [New 2020] Grade of recommendation: B for women who have a or perineal or who have Grade of recommendation: ✓ What type of should be for assisted vaginal birth? for assisted vaginal birth should the and of the a for and for in to Use of a is [New 2020] Grade of recommendation: ✓ blood should be and following all at assisted vaginal birth. [New 2020] Grade of recommendation: ✓ including assisted vaginal birth, obstetric and complications should an as of effective risk [New 2020] Grade of recommendation: ✓ How should be should that the of the woman, and is [New 2020] Grade of recommendation: ✓ have a of a to be with [New 2020] Grade of recommendation: ✓ should to and in and should to of necessary to any and where [New 2020] Grade of recommendation: ✓ should a safe and to support their and [New 2020] Grade of recommendation: ✓ The of this is to the use of forceps and vacuum extraction for rotational and assisted vaginal births. to safe for the of clinical should in the use of vacuum and forceps for birth and at technique for rotational birth. The of this procedures and to assisted vaginal birth. Assisted vaginal birth by vacuum or forceps is used to birth for and fetal the between and of all women birth by assisted vaginal in nulliparous women birth by vacuum or with in 3 There has a in the rate of caesarean births in the second stage of this may about assisted vaginal birth or a of clinical The of births by vacuum and performed by personnel, in a safe for the woman and Women who achieve an assisted vaginal birth rather than have a caesarean birth with their first are likely to have an vaginal birth in and should be aware that as subgaleal fracture and can in and that complications are likely to with rotational and at assisted vaginal The of a caesarean birth in the second stage of labour can be and in and a is required between assisted vaginal birth and caesarean birth. have the of the the has the of informed and a of the of have the risk of a where are in to a who The of and has of a of with is in this that the of this have and using standard for The the of the of of of and the of and for The of all The using the including all and and this with a terms vaginal and The to and in the for using the in the and the for and The strategy is to as and are evidence are and as about the assessment of evidence and the of may be in Encourage women to have continuous support during labour as this can reduce the need for assisted vaginal birth. Grade of recommendation: A Inform women that epidural analgesia may increase the need for assisted vaginal birth although this is less likely with newer techniques. Grade of recommendation: A Inform women that administering epidural analgesia in the latent phase of labour compared to the active phase of labour does not increase the risk of assisted vaginal birth. Grade of recommendation: A Encourage women not using epidural analgesia to adopt upright or lateral positions in the second stage of labour as this reduces the need for assisted vaginal birth. Grade of recommendation: A Encourage women using epidural analgesia to adopt lying down lateral positions rather than upright positions in the second stage of labour as this increases the rate of spontaneous vaginal birth. Grade of recommendation: A Recommend delayed pushing for 1–2 hours in nulliparous women with epidural analgesia as this may reduce the need for rotational and midpelvic assisted vaginal birth. Grade of recommendation: B Do not routinely discontinue epidural analgesia during pushing as this increases the woman’s pain with no evidence of a reduction in the incidence of assisted vaginal birth. Grade of recommendation: A There is insufficient evidence to recommend any particular regional analgesia technique in terms of reducing the incidence of assisted vaginal birth. Grade of recommendation: A There is insufficient evidence to recommend routine oxytocin augmentation for women with epidural analgesia as a strategy to reduce the incidence of assisted vaginal birth. Grade of recommendation: A There is insufficient evidence to recommend routine prophylactic manual rotation of fetal malposition in the second stage of labour to reduce the risk of assisted vaginal birth. Grade of recommendation: B Use a standard classification system for assisted vaginal birth to promote safe clinical practice, effective communication between health professionals and audit of outcomes. Grade of recommendation: D abdominal and vaginal are required to the classification for assisted vaginal birth. may the that the is than the of the fetal head not be the a position where to of the fetal head may be the fetal is at or A classification system for the of this and in the Table Operators should be aware that no indication is absolute and that clinical judgment is required in all situations. Grade of recommendation: D Suspected fetal bleeding disorders or a predisposition to fracture are relative contraindications to assisted vaginal birth. Grade of recommendation: ✓ Blood borne viral infections in the are not an absolute contraindication to assisted vaginal birth. Grade of recommendation: D Vacuum extraction is not contraindicated following a fetal blood sampling procedure or application of a fetal scalp electrode. Grade of recommendation: B Operators should be aware that there is a higher risk of subgaleal haemorrhage and scalp trauma with vacuum extraction compared with forceps at preterm gestational ages. Vacuum birth should be avoided below 32 weeks of gestation and should be used with caution between 32+0 and 36+0 weeks of gestation. Grade of recommendation: C may be for conditions of the the or Table The requires clinical judgment the and fetal preferences of the woman and experience of the A of nulliparous women demonstrated that 3 hours of the second stage and There no evidence of in this where fetal and obstetric The in Table are for The of to should of the risks and benefits of pushing of an assisted vaginal birth of a second stage caesarean birth. indication is absolute and should be The to may be where or and and vacuum extraction are contraindicated before of the can be used for the head of the The vacuum is contraindicated with a Safe assisted vaginal birth requires a careful assessment of the clinical situation, clear communication with the woman and healthcare personnel, and expertise in the chosen procedure 3 ). Grade of recommendation: D should be aware that ultrasound assessment of the fetal head position prior to assisted vaginal birth is than clinical examination. Grade of recommendation: A There is insufficient evidence to recommend the routine use of abdominal or perineal ultrasound for assessment of the station, flexion and descent of the fetal head in the second stage of labour. Grade of recommendation: C Women should be informed about assisted vaginal birth in the antenatal period, especially during their first pregnancy. If they indicate specific restrictions or preferences then this should be explored with an experienced obstetrician, ideally in advance of labour. Grade of recommendation: ✓ For birth room procedures verbal consent should be obtained prior to assisted vaginal birth and the discussion should be documented in the notes. Grade of recommendation: ✓ When midpelvic or rotational birth is indicated, the risks and benefits of assisted vaginal birth should be compared with the risks and benefits of second stage caesarean birth for the given circumstances and skills of the operator. Written consent should be obtained for a trial of assisted vaginal birth in an operating theatre. Grade of recommendation: ✓ Assisted vaginal birth should be performed by, or in the presence of, an operator who has the knowledge, skills and experience necessary to assess the woman, complete the procedure and manage any complications that arise. Grade of recommendation: D Advise obstetric trainees to achieve expertise in spontaneous vaginal birth prior to commencing training in assisted vaginal birth. Grade of recommendation: ✓ Ensure obstetric trainees receive appropriate training in vacuum and forceps birth, including theoretical knowledge, simulation training and clinical training under direct supervision. Grade of recommendation: ✓ Competency should be demonstrated before conducting unsupervised births. Grade of recommendation: ✓ Complex assisted vaginal births should only be performed by experienced operators or under the direct supervision of an experienced operator. Grade of recommendation: D The of assisted vaginal birth is to spontaneous vaginal birth, birth with a of or An of the of the birth the fetal head and the of labour is a to a is recommended that achieve experience in spontaneous vaginal birth before commencing training in vacuum or forceps birth. An experienced operator, competent at midpelvic births, should be present from the outset to supervise all at rotational or midpelvic assisted vaginal birth. Grade of recommendation: D and assisted vaginal births have a of and procedures can be in a birth Grade of recommendation: C Assisted vaginal births that have a higher risk of should be a trial and be in a where to caesarean birth can be Grade of recommendation: C The operator should the appropriate to the clinical circumstances and their of Grade of recommendation: ✓ Operators should be aware that forceps and vacuum extraction are with benefits and to complete the birth with a is likely with vacuum perineal trauma is likely with Grade of recommendation: A Operators should be aware that vacuum have a higher rate of a incidence of scalp Grade of recommendation: A births should be performed by experienced the of the clinical circumstances and expertise of the The rotational manual rotation by direct forceps or and rotational vacuum Grade of recommendation: C can be as there have no for rotational assisted vaginal birth. birth with the forceps as and requires specific expertise and to rotational forceps manual rotation by direct forceps or vacuum extraction and rotational vacuum birth. skills in this may reduce the need for second stage caesarean births and training should be for the labour The operator should the their birth where there is no evidence of descent with during of a by an experienced operator. Grade of recommendation: ✓ birth in the of with a of to the fetal head to the can be used to the head of the Grade of recommendation: ✓ If there is descent with the first of a the operator should the application is the fetal position has or there is experienced operators should and a second operators should the clinical and or discontinue the Grade of recommendation: ✓ birth there have of the experienced operators should support to the woman has the of a assisted vaginal birth. Grade of recommendation: ✓ The application for birth is recommended as reduces the of the procedure with no in and outcomes. Grade of recommendation: ✓ The use of is with an risk of trauma to the the operator to the risks of a caesarean birth following vacuum extraction with the risks of forceps birth following vacuum Grade of recommendation: B should be aware of the following birth use of and should the this to appropriate of the Grade of recommendation: ✓ should be aware of the risk of following use of Grade of recommendation: C the operator should be aware of the for the chosen and the following a at vacuum birth, where there have or use of than need to for of may not be at the of The use of should not be by an operator direct supervision and should be avoided forceps birth where the forceps be the not or there is a of descent with Grade of recommendation: B rotational forceps birth rotation is not with Grade of recommendation: B forceps birth birth is not following of a by an experienced operator. Grade of recommendation: B If there is descent with the first or of the the operator should the application is the position has or there is experienced operators should and a second operators should the clinical and or discontinue the Grade of recommendation: ✓ should be aware of the following a at forceps birth and should the this to appropriate of the Grade of recommendation: ✓ should be aware of the risk of fetal head at caesarean birth following a at forceps birth and should be to the fetal head using Grade of recommendation: ✓ is to the fetal head in advance of caesarean birth where forceps birth has should be aware of the risk of fetal head and to the head is required to the of and for fetal head at caesarean birth. should be with the woman as of the for assisted vaginal birth. Grade of recommendation: ✓ the of evidence to support routine or use of at assisted vaginal birth, the should be to the circumstances at the and the preferences of the The evidence to support use of at assisted vaginal birth in terms of is for nulliparous women and for birth Grade of recommendation: B When a the should be at a the head is the Grade of recommendation: B A prophylactic of and should be recommended following assisted vaginal birth as reduces or compared to Grade of recommendation: A of and are Grade of recommendation: ✓ The trial a trial at obstetric in the Women who birth by forceps or vacuum at weeks or with no indication for of in the and no contraindications to prophylactic and to receive a of prophylactic and or The of women who higher than of A of women to the and a or of than women who to the of The trial that women who a prophylactic of and a of 3 hours assisted vaginal birth less likely to have a or than women who less likely to experience a of including perineal perineal and perineal less likely to any or or any in to about their compared with the The trial evidence of of prophylactic assisted vaginal birth, with in to the women assisted vaginal birth for risk and the need for Grade of recommendation: D the of women should be and Grade of recommendation: A Women should be about the risk of that they are aware of the of in the Grade of recommendation: ✓ The and of the first should be and Grade of recommendation: C A should be is Grade of recommendation: ✓ Recommend that women who have regional analgesia for a trial of assisted vaginal birth in have an in the birth to should be to the Grade of recommendation: ✓ women to reduce the risk of at 3 Grade of recommendation: B Women who have regional analgesia for a trial of assisted vaginal birth should be an for hours birth with the to by to Grade of recommendation: ✓ are required to for the and of and continuous support during labour and birth have the to reduce following birth. Grade of recommendation: ✓ women before to the indication for assisted vaginal birth, of any complications and for births. is where the woman is by the who performed the Grade of recommendation: ✓ and support to women who have a birth and to about their The the birth should be Grade of recommendation: ✓ Do not with an the Grade of recommendation: ✓ women with at to professionals as the Grade of recommendation: D Inform women that there is a of a spontaneous vaginal birth in following assisted vaginal birth. Grade of recommendation: B for women who have a or perineal or who have Grade of recommendation: ✓ for assisted vaginal birth should the and of the a for and for in to Use of a is Grade of recommendation: ✓ blood should be and following all at assisted vaginal birth. Grade of recommendation: ✓ including assisted vaginal birth, obstetric and complications should an as of effective risk Grade of recommendation: ✓ any clinical the of the and the of the birth to the to of the woman and in the period, to and to in births. An of the procedure be including in the and of the is by an of can be in should that the of the woman, and are Grade of recommendation: ✓ have a of a to be with Grade of recommendation: ✓ should to and in and should to of necessary to any and where Grade of recommendation: ✓ should a safe and to support their and Grade of recommendation: ✓ all health have a of a to be and with is in the from in the should a safe and in can from are in assisted vaginal birth assisted vaginal An of the of in is all are by in from of has no of has no of of for the and are to as in the of the including the and are and receive no direct for their in the The only to this is the who receive for the for the for standard this is standard as and in about appropriate for specific is using a of this can be in of the at are not to an of or be with to and to the and in is that this of to routine is to of clinical uncertainty where may be The evidence used in this using the below and the in a with a A of evidence including as to the and of or evidence from as or A of evidence including as to the and of or evidence from as of or or or with a risk of or and a that the is 3 or or evidence from as or with a risk of or and a that the is or with a risk of or and a risk that the is not of the of and D and A D and and of of A A A A Safe trauma B and A The of the and B are to any of A any of for this is The is the of the of the The be for 3 with an assessment of the need to The of and as an to clinical present and of clinical practice, for by and and health The a particular clinical procedure or be by the or in the of clinical by the and the and that are or by as they are not to be a of from the or should be documented in the at the the is vaginal birth strategy vaginal birth strategy The is not for the or of any by the than should be to the for the