Forceps and Vacuum Extractor Injuries
Doctors may use forceps or vacuum extractors to help guide the baby down the birth canal during a strained or stalled vaginal delivery. Delivery assistance instruments should only be used by highly-trained personnel (1). Improper use can lead to trauma, brain bleeding, hemorrhage, and a wide range of disabilities. There are very strict standards for when and how these instruments should be used. In fact, the FDA has released a Public Health Advisory against the use of vacuum extractors because of the increased risk of severe complications after their use (2).
Despite the most careful planning and preparation, problems can arise during labor and delivery, especially during the pushing stage. In these instances, the medical team may decide that the use of a tool is necessary in order to quickly deliver the baby in a procedure called an assisted delivery.
What is an assisted delivery?
An assisted delivery (sometimes also known as an operative vaginal delivery) is a birth in which a medical professional ‘assists’ the mother during labor using either forceps or a vacuum extractor to help deliver the baby. Assisted deliveries may occur when the mother is exhausted from pushing, when there has been a prolonged labor, or if birth complications arise. Assisted delivery comes with risks, including skull and brain trauma to the baby if the assistive device is used improperly.
Circumstances under which assisted delivery with forceps or vacuum extractors may be indicated include (1,3):
- If the uterus is not producing strong enough contractions to push the baby out.
- If fetal monitoring shows that the baby may not be getting enough oxygen and needs to be delivered quickly.
- If the baby is not progressing through the birth canal and/or is stuck.
- If a mother is exhausted from a long labor and can no longer push or if there are maternal health concerns (eg: heart condition, very high blood pressure) that make it unwise for her to push.
What are forceps and vacuum extractors?
Both forceps and vacuum extractors are used in instrument-assisted delivery.
- Forceps resemble large salad tongs. The blades of the device are placed on either side of the baby’s head near the ears and cheeks. As each contraction occurs, the doctor guides the baby’s head downward, out of the birth canal. Because the baby’s head and neck are fragile, it’s important that the physician does not apply too much pressure and does not twist the baby’s neck. Correct placement of the blades is also imperative, as even a normal amount of pressure can cause catastrophic injury if the forceps are incorrectly placed on particularly vulnerable spots of the baby’s head (1).
- A vacuum extractor uses a small, soft cup that is applied to the top and back of the baby’s head. A tube runs from the cup to a vacuum pump that provides suction. During a contraction, the physician pulls or applies gentle traction to the baby’s head while suction from the vacuum assists in pulling the head out of the birth canal. The suction cup must be placed in a specific location on the baby’s head to reduce the risk of brain bleeds and trauma. Also, excessive suction must be avoided (1).
When either forceps or a vacuum extractor is used properly, the infant can be delivered relatively quickly and should not sustain injury. If used improperly, however, the brain injury can be extensive and permanent. Assisted delivery injuries can cause serious birth trauma that may result in permanent disabilities like hypoxic-ischemic encephalopathy (HIE), cerebral palsy, and more.
Forceps & vacuum extractor injuries
There are certain guidelines that obstetricians and other medical practitioners must follow when using forceps and vacuum extractors in order for them to be safe and effective. It is also important that these tools are used at the right stage of delivery, and that they are handled by a medical professional with extensive experience in using them. Mistakes occur when guidelines are not followed or the clinician is not sufficiently experienced in the use of these tools. These mistakes include (1, 3):
- Using too much suction with a vacuum or too much pressure or force with forceps.
- Incorrect placement of the vacuum extractor suction cup or forceps blades.
- Prolonged use of a vacuum (eg: for more than 20 minutes) or exceeding the recommended number of attempts (three).
- Using forceps or a vacuum when the baby is too large (macrosomic), premature, or if there is cephalopelvic disproportion (when the baby’s head too big to fit through the mother’s pelvis).
- Twisting or excessive pulling on the baby.
- Using the tools at the incorrect time during delivery. For example, when the baby’s head is not yet engaged (which means it has not yet passed through the pelvis) or when the cervix is not fully dilated.
- Sequential use of forceps and vacuum.
Placement of forceps and vacuum extractors
Correct placement of the forceps tongs is critical. If they are applied unevenly or in the wrong location to the baby’s head, the strain could cause compression of the head as well as hemorrhages and fractures. Other potential problems include facial bone distortions, brain swelling, brain damage, and strokes, which could generate other secondary issues such as seizures/epilepsy and ischemia (1,3).
Similar problems can occur if the suction cup of the vacuum extractor is not placed correctly (about three centimeters back from the fontanel). Also, if the vacuum extractor pops off three times during use, the physician should move on to C-section to deliver the baby (1, 3).
FDA statement on vacuum extractor injuries
The vacuum extractor has come under scrutiny in recent years as its use and resulting injuries have increased. In fact, the FDA cited its concerns in a Public Health Advisory on vacuum-assisted delivery devices (2):
“This is to advise you that vacuum-assisted devices may cause serious or fatal complications…While no instrumented delivery is risk-free, we are concerned that some health care professionals who use vacuum assisted delivery devices, or those who care for these infants following delivery, may not be aware that the device may produce life-threatening complications.”
Whether a vacuum extractor or forceps are used, it is the responsibility of the medical professionals to inform the mother of the risks, ensure that the instrument is used appropriately and that the mother and infant are properly monitored both during and after birth in order to prevent injuries.
Brain bleeds stemming from forceps & vacuum extractor use
If forceps and vacuum extractors are used improperly, they can cause brain damage due to oxygen deprivation and trauma.
One of the most common potential indications of improper forceps or vacuum extractor use is brain bleeds after the use of these instruments. There are multiple brain bleeds that can occur, including (1,3):
- Subdural hemorrhage or subdural hematoma is a ruptured blood vessel in the subdural space (the area between the surface of the brain and the thin layer of tissue that separates the brain from the skull). These bleeds are usually accompanied by seizures, high levels of bilirubin in the blood, rapid swelling of the head, and retinal hemorrhages.
- Subarachnoid hemorrhage is bleeding below the innermost of the two membranes that cover the brain and may produce seizures, lethargy, and apnea.
- Cerebral hemorrhage is bleeding that occurs within the brain tissue itself.
- Intraventricular hemorrhage is the most serious and is seen with premature infants and infants with a low birth weight where immature blood vessels are prone to weakening. The bleeding occurs in the brain’s ventricular system, where spinal fluid is produced.
- Cephalohematoma is bleeding that occurs between the skull and its covering (periosteum) and appears as a raised bump. These usually resolve within a few days with no permanent damage to the baby.
Potential signs of forceps & vacuum extractor misuse
The signs of improper forceps or vacuum extractor use can appear immediately or in the days, weeks, or months following the child’s birth. Babies may have one or more of the following signs or symptoms (4):
- Sluggishness (lethargy)
- Difficult feedings
If a baby has any of these signs or symptoms in the presence of a suspected brain bleed, it is very important that the baby has CT scans or MRIs done to confirm the bleed and help guide the course of the child’s treatment.
Legal help for forceps and vacuum extractor injuries
If your baby had a forceps or vacuum extractor-assisted birth and now has a birth injury, the skilled attorneys at Reiter & Walsh ABC Law Centers can help. Birth injury cases require specific, extensive knowledge of both law and medicine. In order to achieve the best results, our team believes it’s critical to specifically and exclusively handle birth injury cases. With over 100 years of joint legal experience, our team has the education, qualifications, results, and accomplishments necessary to succeed. We’ve handled cases involving dozens of different complications, injuries, and instances of medical malpractice related to obstetrics and neonatal care. Our clients hail from all over the United States. Contact our birth injury attorneys and nurses in any of the following ways, and we’ll set up your free case review.
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Video: Forceps and vacuum extractor use during delivery
- Wegner, E. K., & Bernstein, I. M. (2017, November). Operative vaginal delivery. Retrieved from https://www.uptodate.com/contents/operative-vaginal-delivery.
- FDA Public Health Advisory: Need for Caution when Using Vacuum Assisted Delivery Devices. (n.d.). Retrieved from https://www.thefreelibrary.com/FDA+Public+Health+Advisory%3A+Need+for+Caution+when+Using+Vacuum…-a056456763.
- Ali, U. A., & Norwitz, E. R. (2009). Vacuum-Assisted Vaginal Delivery. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672989/.
- McKee-Garrett, T. M. (2017, October). Neonatal birth injuries. Retrieved from https://www.uptodate.com/contents/neonatal-birth-injuries.