The aim of this guideline is to provide evidence-based recommendations on the use of forceps and vacuum extraction for both rotational and non-rotational operative vaginal births. In order to provide safe care for the full range of clinical scenarios, obstetricians should develop competency in the use of both vacuum and forceps for non-rotational birth and at least one specialist technique for rotational birth. The scope of this guideline includes indications, procedures and governance issues relating to operative vaginal birth.
Two new developments have occurred since the publication of the 2011 guideline: i) the Montgomery ruling has emphasised the importance of informed consent; and ii) a number of high profile manslaughter convictions on the grounds of gross negligence have highlighted the risk of a criminal conviction, where serious shortcomings are identified in medical care provided to a patient who dies. The Royal College of Obstetricians and Gynaecologists (RCOG) has also received reports of a number of neonatal fatalities associated with traumatic birth-related injuries. It is in this context that the safety aspects of this guideline have been reviewed and updated.
Update June 2023: Following several recent adverse incidents, the College wishes to remind clinicians of their key obligations to promote the safe use of Kielland's rotational forceps.
Assisted vaginal birth promotes benefits to both mother and the baby when used appropriately and safely. We have no doubt that clinicians use Kielland’s forceps with a high degree of caution, and respect the skill and expertise required to facilitate a safe birth. Misuse or incorrect application of Kielland’s forceps can, however, result in serious complications for both mother and baby.
Rotational births using Kielland’s forceps should only be performed by experienced operators or under the direct supervision of an experienced operator. The operator is required to define fetal head position and identify the position of the occiput correctly, in order to safely undertake a rotational birth. In this regard, an ultrasound assessment of the fetal head position prior to application of forceps is more reliable than clinical examination and is advisable.
While ultrasound scan is not directly mandated prior to all assisted births, it should be noted that recent concerns arose following inaccurate assessment of the fetal head position by clinicians prior to starting the procedure. Procedure should also be discontinued where rotation is not easily achieved with gentle pressure, after confirming correct application.
RCOG Green-top Guideline No. 26 on Assisted Vaginal Birth, published in 2020, provides the evidence-based recommendations to support practitioners around use of instruments for assisted vaginal births, and promotes support for the availability of intrapartum ultrasonography for clinicians in their daily practice.
This guideline developed as part of the regular programme of Green-top Guidelines, as outlined in our document Developing a Green-top Guideline: Guidance for developers, and prior to the emergence of COVID-19.
This is the fourth edition of this paper.
Please note that the information provided in this update will be considered for update by the RCOG Guidelines Committee 3 years after publication, with an intermediate assessment of the need to update 2 years after publication.
Developer declaration of interests
Dr DJ Murphy: personal fees from legal expert reports during the conduct of the study.
Dr R Bahl: none declared.
Dr BK Strachan: none declared.