Methods Used to Assist Birth

Most people labour and birth without any assistance. However, for some specific reasons your healthcare provider may recommend assistance to help you push your baby out once your cervix is fully dilated. If it's needed, your healthcare provider can assist you by using either vacuum or forceps. It is important for you to learn about the benefits, risks, and alternatives of using these procedures and their potential impact on breastfeeding, and to have a discussion with your healthcare provider to answer any questions before going into labour. This helps you to make an informed decision about your care.

• You have become too tired to effectively push your baby out^{1 2 3}
• You have pushed for a long time and the bay’s head has stopped moving through your pelvis^{2 3}

• Your baby's fetal heart rate is abnormal and your healthcare provider has concerns that your baby is not coping with contractions and pushing efforts^{1 2 3}
• You have a condition that prevents you from pushing (i.e., heart problems)^{1 2 3}

Benefits and Risks

The following are population level benefits and risks. It's important to speak with your healthcare provider to discuss how these may apply to your individual situation to make an informed decision for your care.

Benefits for You and Baby

• May help avoid a caesarean birth and the risks associated with it for both you and your baby.²

Risks for You

• Tears to the vagina, pelvic floor or anus^{1 2 5}
• Bladder and/or bowel incontinence^{2 5}
• May need an episiotomy¹
• Caesarean section if unable to give birth vaginally⁶

Risks for Your Baby

• Cuts or bruising on the scalp, head, and eyes^{1 2 4 5}
• Nerve problems in the face and arms²
• Cephalohematoma (i.e., bleeding between an inner layer of skin and the skull)^4 5
• Bleeding inside the skull²
• Neonatal jaundice⁴
• Breastfeeding challenges⁷

Alternatives

• It's important to consider how one intervention may lead to another intervention (cascade of interventions). This is the case for assisted vaginal birth. Avoid interventions that are not medically necessary. Use of epidurals³ and continuous electronic fetal monitoring⁶ increases the chance of assisted vaginal birth.

• If continuous fetal heart rate monitoring is suggested by your healthcare provider, ask for the reason that they feel it's necessary and discuss the option of using intermittent fetal heart rate monitoring (using a hand held doppler device to listen to the fetal heart for a minute every 15 - 30 minutes).⁶ For low-risk pregnancies, intermittent fetal heart rate monitoring in labour is the best practice.¹¹
• The midwifery-led model of care generally has lower rates of assisted birth intervenions.⁸

• Have good one-to-one labour support^1 3 5 6 and use alternative comfort methods to work with your contraction pain instead of an epidural. You may even be able to delay using the epidural with these methods if you plan on using one.

• Movement and position changes throughout labour can assist you to work with your contraction pain and help you wiggle and move your baby down and through your pelvis. Upright pushing positions can reduce the need for assisted birth.^{5 6}
• If you have an epidural lie on your side,^3 6 and use a peanut ball between your legs to help open your pelvis, and delay pushing.^{1 3 5} Use of oxytocin augmentation may assist with strengthening the contractions to help move the baby lower into the pelvis.^1 3 5
• Manual rotation, where the healthcare provider uses their hand to turn the baby’s head to a better position can be done.⁶ A Caesarean section is also an option.⁶

Vacuum and Forceps Procedures

The method chosen to assist with birth depends on the individual situation. There are risks associated with both methods. The choice of intervention needs to be individualized and the benefits of the chosen method should outweigh its risks.

Prior to an assisted vaginal birth, it must be confirmed that:

• Your cervix is fully dilated⁶

• Your membranes have been ruptured⁶

• Your bladder is empty⁶
• Your baby is low enough in the pelvis to be born through the vagina^{1 6}

• You have appropriate pain medication (i.e., epidural or local injection)⁶

• There is a backup plan for birth if the method is unsuccessful⁶

Vacuum

A vacuum extractor is a plastic cup-like instrument that is placed on your baby’s head and gentle suction is applied.^{1 4} Your healthcare provider gently pulls while you push during your contractions.^1 4 The vacuum extractor is removed once your baby crowns.

Forceps

Forceps are a pair of tong-like instruments that are placed around your baby’s head to guide your baby through the birth canal and to assist your pushing efforts.^{1 4} They are placed one at a time and locked in place to prevent squeezing your baby’s head.⁴ Your healthcare provider gently pulls or turns the baby's head while you push during your contractions.^{1 4} The forceps are removed once your baby crowns. With forceps, you will usually have some anesthetic, either an epidural, or a local injection.^1 4 An episiotomy may be needed.^{1 4}

Episiotomy

Episiotomy is a surgical incision (cut) in your perineum (the area between your vagina and anus)¹⁰ to make the vaginal opening larger for your baby to pass through.¹⁰ Your healthcare provider will repair the cut using dissolvable stitches after the birth of your baby.¹⁰ Routine episiotomy is not recommended.^{9 10}

Current best practice is to support the perineum and allow it to tear naturally rather than to perform an episiotomy.¹⁰ Tears are often smaller, are repaired more easily or not at all, heal more quickly, and are less painful than an episiotomy. An episiotomy will be considered if birth needs to occur quickly because the baby's heart rate is abnormal.^{9 10} An episiotomy is a surgical procedure that requires informed consent, so it's important to have a conversation with your healthcare provider to learn about the benefits, risks and alternatives before labour begins.

For more information, decision aids & tools

Ottawa Family Decision Guide
Making Informed Decisions About Your Care - other decision aids & tools

If you have specific questions

• Speak with your healthcare provider.

• If you are giving birth at LHSC, speak with the nurse at the London Health Sciences Centre (LHSC) Preadmission Clinic.