Forceps and vacuum extractors are used when vaginal delivery is not progressing as it should or there is fetal distress. When physicians follow medical standards and use forceps and vacuum extractors correctly, these devices can help to safely deliver a baby. However, many physicians lack experience or are not careful in the use of these devices, with devastating effects on the newborn baby. Forceps and vacuum extractors can cause trauma to the baby’s head, resulting in skull fractures and brain bleeds that can cause death or permanent injury in the baby, such as cerebral palsy (CP) and hypoxic-ischemic encephalopathy (HIE). In addition, physicians may attempt the use of forceps and vacuum extractors instead of opting for an emergency C-section. When a baby must be quickly delivered because they are in distress, a C-section often is the best and safest method. When physicians are not skilled in the use of delivery devices or are not careful, they may misuse the instruments, prolonging labor, and worse, injuring the baby.
When Can Forceps Be Used?
A common reason that physicians use forceps is when the mother is fatigued and can no longer push. Forceps can be used when the head is essentially crowning, but just won’t come out. The device looks like salad tongs. The tongs are placed on each side of the baby’s head, close to the ears and cheeks. During each contraction, the physician should gently guide the baby’s head downward and out of the birth canal. It is crucial for the physician to have thorough knowledge about and skill in forceps use. If the tongs are incorrectly placed or applied unevenly to the baby’s head, the strain could cause compression of the infant’s delicate head, and skull fractures and/or tearing and rupture of blood vessels can occur. Further damage can be caused by brain swelling. Fractures, brain bleeds, and brain swelling are extremely dangerous in a baby.
There are several conditions that must be in place before a physician may use forceps for delivery. These standards of care include the following:
- The cervix must be fully dilated.
- The baby’s head must be engaged.
- The membranes must be ruptured.
- The presentation and position (including head position and tilt) of the baby must be known. If any of these are uncertain, an ultrasound should be performed prior to forceps use. Additionally, the fetal size must have been estimated, showing acceptable dimensions.
- The mother’s bladder must be empty.
- The risks of and the alternatives to the procedure must have been fully explained to the mother.
- There must be a willingness to abandon attempts if the forceps are not working/labor is prolonged.
- The physician must have experience and be skilled in forceps use.
- Anesthesia in the mother must be satisfactory.
When Shouldn’t Forceps Be Used?
If any of the prerequisites mentioned above are not in place, a forceps delivery is contraindicated. Most contraindications to forceps delivery are related to the potential for unacceptable risks, and they include:
- The baby is less than 34 weeks’ gestation. There is an increased risk of brain bleeds at these ages.
- Cephalopelvic Disproportion (CPD) (when a baby’s head is too large for the mother’s pelvis).
- Fetal demineralization disease, connective tissue disorders, fetal bleeding diatheses.
- If a baby cannot be delivered by forceps, the physician must move on to a C-section. It is against standards of care to switch to a vacuum extractor if forceps are not facilitating delivery.
When Can Vacuum Extractors Be Used?
Vacuum extractors are used more frequently than forceps. A vacuum extractor is a soft cup vacuum that sticks to the baby’s head and helps guide the head out and under the mother’s pelvic bone. During vacuum extraction, the mother’s feet are placed above or at the same level as her hips, often in stirrups. The cup on the baby’s head uses suction to draw skin from the scalp into the cup, with the mother assisting the process by pushing.
Correct placement of the cup over the top, center portion of the baby’s head is crucial. As with forceps use, the mother’s cervix must be fully dilated, the baby’s head must be engaged and the head must be at the perineum, and the position of the baby must be known.
Vacuum extraction should only be attempted when a specific obstetric indication is present. The major indications for vacuum extraction include the following:
- The mother is exhausted
- There is a prolonged second stage of labor
- Fetal status is nonreassuring, meaning the baby’s heart rate is showing that the baby is in distress, which almost always means the baby is being oxygen-deprived
- A maternal illness is present, such that “bearing down” or pushing efforts would be risky (e.g., cardiac or neurological disease is present)
When Shouldn’t Vacuum Extractors Be Used?
There are several instances in which vacuum extraction should never be performed.
- The baby is less than 34 weeks gestation, which puts a baby at high risk of having a brain bleed.
- Face or non-vertex presentation.
- Prior scalp sampling or multiple attempts at fetal scalp electrode placement are contraindications because these procedures increase the risk of bleeding under the skin of the head or external bleeding from the scalp wound.
- Additional contraindications include suspected CPD, fetal demineralization disease, connective tissue disorders, and fetal bleeding diatheses.
Safe Delivery When Vacuum Extractors or Forceps are Used
Before or during delivery, the mother must be given the opportunity to provide informed consent. This means that the physician must explain the risks of and alternatives to any procedure that is about to be performed. Any physician performing a delivery must be skilled in fetal heart rate monitoring and interpretation so that they are aware of when a baby is in distress or when distress is impending. In addition, a physician performing a delivery must be skilled in performing emergency C-sections, and must have the equipment and capacity to perform this in the room where the mother is attempting to deliver a baby.
Vacuum extraction must be limited to the following:
- A total time of 10 minutes of traction or 15-30 total minutes. Total time is from the very start of the procedure until the baby is out.
- Three contractions for the descent phase (the part of the procedure from the time of cup application until the baby’s head is descended to the outlet of the pelvis).
- Three contractions for the outlet extraction phase.
- 2 to 3 pop-offs of the cup.
- It is important to note that low birth weight and premature fetuses have more delicate bones and soft tissue and are very susceptible to injury. The extraction pressures applied to these infants should be greatly reduced to avoid trauma and injury.
If a baby is distressed, a C-section is usually the fastest and best way to quickly deliver. If a physician wants to use forceps or a vacuum extractor to facilitate a vaginal delivery, they must be skilled in use of the chosen device. A mother should not be afraid to ask her physician if she has the capacity to deliver a baby by emergency C-section at the delivery site. If delivery devices are considered, a mother should ask her physician how many times she has used whichever device she is considering.
Vacuum Extractors, Forceps, and Medical Malpractice
Due to the risks involved with forceps and vacuum extractors, it is imperative that physicians be very skilled in their use, and they must understand which device is the most appropriate for each situation. Physicians must be ready to move on to a C-section delivery when forceps or vacuum extractor delivery is not proceeding as it should. Standards of care must be followed at all times. Failure to act skillfully and in a timely manner during delivery is negligence. If negligence leads to injury of the mother or baby, it is medical malpractice.
The Importance of C-Section Delivery
In any labor and delivery situation, the physician must be prepared to quickly move on to a C-section delivery when an operative vaginal delivery is not progressing as it should. If one device is not affecting prompt delivery of the baby, the physician must not attempt to use a different operative delivery device. Some conditions that require the baby to be delivered immediately include fetal distress, uterine rupture, and cord prolapse.
Sometimes physicians fail to perform an emergency C-section when one is indicated, or they wait too long to perform one. Other times, the C-section may be ordered, but the physician lacks skill in the procedure, or the hospital is ill-equipped for it. Delay in performing a C-section can lead to permanent injuries in the baby, such as cerebral palsy and hypoxic-ischemic encephalopathy. Indeed, in many cases, a C-section is the safest way to deliver the baby. Thus, it is critical that physicians be skilled and prepared for the procedure.
Legal Help for Forceps and Vacuum Extractor Injuries
Children injured during forceps and vacuum extractor deliveries may go on to require therapy, special education services, assistive technology, and other resources. If you believe your child or loved one was injured as the result of negligent actions by a physician or medical professional, you may be entitled to compensation through a medical malpractice lawsuit. We encourage you to contact us today for a free legal consultation.
Reiter & Walsh, P.C. is one of the only law firms in the United States exclusively handling birth injury cases. We focus solely on helping families like yours obtain the resources they need, and our niche focus allows us to win even the most medically and legally complex cases.
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