les mains de mamanForceps & Ventouse Births

Forceps and ventouse births (also called vacuum extraction/suction cup) are referred to as ‘assisted’ or ‘instrumental’ births. There are clinical guidelines that UK midwives and doctors use in the maternity services and these identify when it is advisable to assist a woman to birth her baby. For mothers who are having their first baby; it is recommended that birth should take place within three hours of being in the ‘active’ second stage of labour (ie the pushing phase). Where the woman has been pushing for two hours and there are strong uterine contractions, but no progress has been made – especially where the baby’s head is not visible at the entrance to the vagina; the doctor will advise that the baby is delivered by forceps or ventouse. Where women are having their second or subsequent baby, this time limit is reduced by one hour. Therefore, if they haven’t delivered their baby after an hour’s good pushing then an assisted birth will also be advised.

The time frames are slightly different however, if a woman has an epidural in labour. This is because once full cervical dilatation has been confirmed (ie the cervix is 10 cm dilated) time is allowed for the baby to move lower down the birth canal. It is usual to allow an hour to pass before women are encouraged to start active pushing. Exceptions to this are where the baby’s head is already visible at the entrance to the vagina, or the woman has the urge to push. Where women have an epidural, the time frame for giving birth is within four hours of confirming full dilatation of the cervix – this applies to all women, regardless of whether they have given birth previously.

For many women, their labour starts spontaneously and progresses without interference culminating in a vaginal birth. This is termed a ‘normal delivery’. However, an increase in the use of medical interventions and the number of babies being born by caesarean section means that some women are unable to achieve the normal birth that they’d hoped for. Similarly, some women will require help to give birth despite having straightforward uneventful pregnancies and progressing normally in labour. In fact, about one in eight women in the UK will end up having an assisted birth with forceps or the ventouse. Both methods are safe and are conducted by health care professionals who have received specialist training in their use.

In some maternity units, midwives have undertaken additional training to become ventouse midwife practitioners.

 

When might forceps and the ventouse be used?

There are a number of situations where the doctor will advise you that your baby needs help to birth. These are:

  • Where there is fetal distress and there are concerns about your baby’s heart rate and pattern
  • Your baby is lying in an awkward position eg where your baby is in a back-to-back – occipito-posterior (OP) position or is looking to one side – occipito-lateral (OL). Where this is the case, the baby’s head will need to be rotated (turned) before they can be born vaginally
  • Where you are distressed and/or too exhausted to push any longer or there is a medical reason to avoid physical strain/muscular exertion eg heart or neurological conditions.

 

When can’t forceps or the ventouse be used?

There are certain situations when it is not possible or it is inadvisable to use forceps or the ventouse to assist childbirth. Where the doctor has concerns about your or your baby’s health and wellbeing; they will recommend that your baby is delivered without delay. However, in the following circumstances, they will recommend that your baby is delivered by emergency caesarean section:

  • Where your baby has fetal distress but your cervix isn’t fully dilated
  • Where your baby is lying in an awkward position
  • Where your baby is of above average birth weight (large baby!)
  • Where the baby’s head or bottom is not ‘engaged’ (in the pelvis)
  • Ventouse can’t be used when labour starts before 34 weeks’ gestation because the bones of the baby’s skull are still soft.

 

What are forceps?

Forceps are smooth metal slightly curved instruments that look a bit like a pair of salad servers (spoons) or ‘tongs’; they have interlocking handles that join together. Their curved shape enables them to fit neatly around the baby’s head and follow the shape of the mother’s pelvis. There are three types of forceps commonly in use:

  • Neville-Barns forceps – used when the baby’s head is low down in the pelvis
  • Rhodes forceps – used when the baby’s head is positioned slightly higher
  • Keilland forceps – used to rotate the baby’s head from a back-to-back (occipito-posterior (OP) position) to a forward facing (occipito-anterior (OA) position).

Forceps births may be performed in the Delivery Suite theatre. This is just in case the baby’s head does not descend down the birth canal and cannot be delivered vaginally. Should this happen, the doctor can then proceed to delivering your baby by caesarean section without unnecessary delay. This will all be explained to you at the time and is part of the information given by the doctor when seeking your informed consent.

The use of forceps has however, reduced significantly with doctors favouring the ventouse in assisting vaginal births.

 

What is the ventouse?

The ventouse is suction apparatus comprising a cup, traction (pulling) device and vacuum system that is commonly used to assist you in giving birth. It involves placing a small suction cup (made of soft or hard plastic or metal) onto your baby’s head while they are still in the birth canal. There are two types of ventouse available:

  • A silastic cup – attached to a machine that creates a vacuum on the baby’s head; similar to the action of a sink plunger
  • A kiwi – a little hand-operated device that has the same effect.

By applying negative pressure suction, a vacuum is produced and this firmly attaches the suction cup against the surface of the baby’s head. Once the baby’s head has been delivered this vacuum is released and the cup is then removed.

 

What does the research say?

Studies have shown that when comparing ventouse with forceps-assisted births:

  • Ventouse births are less successful than forceps because traction cannot be applied as effectively – the ventouse cup can fall off
  • Ventouse births cause less injury/trauma to the muscles and skin of the vagina and perineum (the area of skin between the vagina and bottom – anus)
  • Mothers who’ve had a ventouse birth report less pain at delivery and during the first 24 hours post birth, compared to mothers who’ve had a forceps birth
  • The ventouse is associated with an increased incidence of cephalhaematoma, (bruising on the baby’s scalp), but NOT long term complications
  • Ventouse births are associated with fewer caesarean births, because where the ventouse fails, doctors will often use forceps to deliver the baby. By comparison, a failed forceps delivery results in a caesarean section.

 

What happens at an assisted birth?

The doctor will explain to you why they are recommending that your baby’s birth is assisted using forceps or the ventouse. They will ensure that you understand what their concerns are so you can give your informed consent. Where your baby is distressed and needs to be delivered without delay, the doctor and midwife will still gain your consent beforehand; however, a more detailed discussion will be deferred until after your baby has been born. For additional information also see our article, ‘Monitoring your baby’s heart rate in labour’.

 

Positioning ready for the birth

The midwife will help you into the ‘lithotomy’ position; this is where the backrest of the bed is lowered so you are more reclined and each leg is supported by a lithotomy pole. Your legs are raised with both knees bent; each leg is then supported on a leg rest from behind the knee joint downwards. This enables you to relax your legs and bottom, and although you may feel a bit apprehensive at the time, the lithotomy poles are actually reasonably comfortable. The end of the delivery bed will then be removed and the doctor will apply drapes/paper sheeting which helps to preserve your modesty!

To ensure that the forceps or ventouse are correctly positioned, the doctor will need to perform a vaginal examination to see which way your baby is facing. They will do this by feeling the suture lines on the baby’s head – these sutures allow the bones of the baby’s skull to overlap slightly at birth. They also help the midwife and doctor to identify the baby’s position inside the uterus (womb).

 

Bladder care

It is important that your bladder is emptied before having an assisted birth, because a full bladder can easily be damaged and can hinder the descent of the baby’s passage down the birth canal. The doctor will insert an ‘in & out’ catheter (fine tube) into your bladder to drain any urine. Sometimes a catheter will be left in place for the first 24 hours following the birth. This is often the case where women have had an epidural because they are numb and have no sensation to pass urine. This means they don’t know when their bladder is full and they can experience difficulty emptying their bladder properly. A catheter also enables any swelling around the birth canal to subside; where there is a lot of swelling this can also interfere with passing urine. See also our article, ‘Caring for your bladder after childbirth’.

 

Pain relief

The doctor will always ensure that you have adequate pain relief before conducting a forceps or ventouse birth. Many of the women who end up needing an assisted birth have often been in labour for a long time already and/or their baby is known to be an awkward position, so may already have an epidural in place. For more detailed information see our article, ‘Pain relief options for labour and birth’. However, if the woman doesn’t have an epidural; local anaesthetic will be injected to numb the vagina and perineum before the forceps or ventouse is used.

 

Having a forceps birth

Having identified your baby’s position, the doctor will carefully apply the forceps blades, one each side of the baby’s head (called blades but NO sharp edges!). Once the forceps have been positioned and joined at the handles, the doctor will wait for the next uterine contraction. With each contraction, the doctor/midwife will encourage you to push while the doctor maintains a gentle steady traction (pull) on the forceps.

As already mentioned, there are different types of forceps with some specifically designed to rotate the baby into the best position for a vaginal birth. Sometimes the doctor will use forceps to rotate the baby’s head and then use the ventouse to help deliver them vaginally. It is best practice that if the baby’s head hasn’t been delivered after three pulls with the forceps; they are delivered by caesarean section. The same principle applies if the ventouse cup falls off three times, or there is no decent of the baby with traction.

 

Having a ventouse birth

Once the ventouse has been applied and is firmly attached to the baby’s head, the woman is asked to push with each contraction. At the same time, the doctor/midwife applies a gentle steady traction which carefully guides the baby down through the birth canal. Sometimes an episiotomy (cut in the perineum) will need to be performed to allow extra space for the baby’s head and to minimise tears. However, research studies show that women who have ventouse births are less likely to sustain vaginal tears.

 

Perineal care

Should you tear or need an episiotomy at birth; this will be sutured (stitched) once the placenta (afterbirth) has been delivered. The stitches are made of a dissolvable material so won’t need to be removed postnatally. At the time of suturing, you may also be given a pain-relieving drug in the form of a suppository that is gently inserted into your back passage. Regular pain relief will also be prescribed to help keep you comfortable during the early postnatal period. The good news is that this area of your body has a very rich blood supply, so heals quickly. For more detailed information on perineal care see our associated articles, ‘Healing ways’ and ‘Severe perineal trauma: Third and Fourth degree tears’.

 

Will my baby be hurt?

The majority of babies born using forceps or the ventouse are born in a very good condition and suffer no ill-effects. A paediatrician (baby doctor) will be present for the birth. They will be able to check your baby over as soon as they have been born. If there aren’t any concerns with your baby’s health, they can be delivered onto your abdomen (tummy) and held skin-to-skin. See also our article, ‘Bonding with your new baby’.

 

Minor birth trauma

Forceps can leave small bruising marks on your baby’s face and/or on their scalp – these can be very noticeable but usually disappear quite quickly. Where there is a lot of bruising you may also notice that your baby develops jaundice – a yellow tinge to their skin. For more detailed information we suggest that you also read our article, ‘Jaundice in the newborn (neonatal jaundice)’.

The ventouse can leave a small circular swelling on the top of the baby’s head where the vacuum cup was applied. This is called a chignon and usually disappears within 24 hours post birth. However, the ventouse cup can also leave bruising on your baby’s head; this is called a cephalhaematoma and will take a week or so to disappear. This is also more likely to cause your baby to develop jaundice.

 

And finally…

Failing to achieve the normal birth you’d hoped for can be a massive disappointment. However, assisted births are only performed where there is a clinical need to do so – ie for the sake of the mother’s and/or her baby’s health and wellbeing, and to prevent any concerns becoming more serious.

The most important thing is that your baby is born safely and in a good condition.

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