Forceps and Vacuum Extractors May Increase Risk of Injury to Mothers and Babies

In the United States and Canada, C-section delivery has become more common over the past few decades. In contrast, there has been a decline in operative vaginal deliveries (those which involve tools such as forceps or vacuum extractors). Because of this inverse relationship, some have suggested that performing more operative deliveries could be a good way of decreasing the frequency of C-sections, and that this would improve birth outcomes. However, recent research has indicated that operative vaginal deliveries pose a substantial threat to the safety of mothers and babies.

Giulia M. Muraca and colleagues recently published in the Canadian Medical Association Journal (CMAJ), describing the results of a population-level study on how mode of delivery influences the likelihood of obstetric trauma (injury to the mother) and birth trauma (injury to the baby).

Methods: Data from 1,938,913 Births

Muraca et al. (2018) used data compiled from hospital deliveries in the Canadian provinces of Alberta, Manitoba, Ontario, and Saskatchewan between April 2004 and March 2015. They included all live singleton births that occurred between 37 and 41 weeks of gestation; in total, 1,938,913 deliveries. The main outcomes under consideration were obstetric trauma and severe birth trauma.

Results: Operative Vaginal Deliveries Increase Risk of Negative Birth Outcomes

Muraca et al.’s research showed a positive association between the rate of operative vaginal delivery and the rate of obstetric trauma. They also found a positive association between the rate of operative vaginal delivery and severe birth trauma, although this was only observed in nulliparous women. In other words, their research suggests that tools such as forceps and vacuum extractors can increase the likelihood of obstetric trauma, as well as that of birth trauma for women who are delivering their first baby.

Interestingly, they found that among those who had operative vaginal deliveries, the rates of obstetric trauma and severe birth trauma had increased over time. Obstetric trauma was especially common among a) nulliparous women who had forceps deliveries and b) parous women who had operative deliveries after having previously had a baby via C-section. The most common form of obstetric trauma was anal sphincter injury.

Additionally, the rate of severe birth trauma in operative deliveries increased over time among a) nulliparous women and b) parous women who had not had C-sections.

The authors note that the increase in negative outcomes of operative vaginal deliveries over time “may be due to a decline in expertise, to poor selection of candidates for operative vaginal delivery, or perhaps to operative vaginal delivery being reserved for the most severe cases.”

The Takeaway

Higher rates of operative vaginal delivery were associated with higher rates of obstetric trauma, as well as higher rates of severe birth trauma suffered by babies of nulliparous women. Moreover, among women having operative vaginal deliveries, the risk of obstetric trauma and severe birth trauma has increased over time.


Muraca, Giulia M., et al. “Ecological Association between Operative Vaginal Delivery and Obstetric and Birth Trauma.” CMAJ, CMAJ, 18 June 2018,

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