Vaginal-operative Birth

Abstract

Purpose This is an official guideline issued by the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The guideline aims to provide guidance and support for indication-based decisions in the context of vaginal-operative deliveries and the performance of these procedures. The intention is not to provide rigid standards for vaginal-operative deliveries but to show the range within which obstetric activities correspond to the current state of scientific knowledge and current clinical practice.

Methods This S2k-guideline was developed based on the structured consensus of representative members from different medical professions who were commissioned by the guidelines program of the DGGG, OEGGG and SGGG.

Recommendations The guideline provides recommendations on measures to avoid vaginal-operative births, the conditions in which these births should be carried out, the information provided to patients, the indications, contraindications, classifications, and choice of instruments, the procedure, antibiotic prophylaxis, complications, postnatal examinations, documentation and legal aspects, debriefing, and training and simulations.

Keywords

guideline - vaginal-operative birth - forceps - vacuum - vacuum-assisted birth - forceps-assisted birth

I  Guideline Information

Guidelines program of the DGGG, OEGGG and SGGG

Information on the program is available at the end of the guideline.

Citation format

Vaginal-operative Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry Number 015/023, 11/2023). Geburtsh Frauenheilk 2025; 85: 143–168

Guideline documents

The complete long version of this guideline in German, a list of the conflicts of interest of all the authors and a list of the references are available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-023.html

Guideline authors

See [Tables 1] and [2].

Author	AWMF professional society
Abele Harald, Prof. Dr. med.	DGGG
Jakubowski Peter, Dr. med.	DGGG

Author Mandate holder	DGGG working group/AWMF/non-AWMF professional society/organization/association
Abele Harald, Prof. Dr. med.	DGGG (AGG)
Bamberg Christian, Prof. Dr. med.	DEGUM
Bogner Gerhard, PD Dr. med.	OEGGG
Desery Katharina	Mother Hood e. V.
Fazelnia Claudius, Dr. med.	OEGGG
Hamza Amr Sherif, PD Dr. med.	DEGUM
Heihoff-Klose Anne, Dr. med.	DGPGM
Jakubowski Peter, Dr. med.	DGGG
Janning Luise, B. Sc.	DGHWI
Jückstock Julia, PD Dr. med.	DGGG (AGG)
Kimmich Nina, PD Dr. med.	SGGG
Kyvernitakis Ioannis, Prof. Dr. med.	DGPM
Lütje Wolf, Dr. med.	DGPFG
Reister Frank, Prof. Dr. med.	DGPM
Reitter Anke, PD Dr. med.	DGGG (AGG)
Seeger Sven, Dr. med.	DGPGM
Seehafer Peggy, M. A.	DGHWI
Springer Laila, PD Dr. med.	GNPI
Wallwiener Stephanie, Prof. Dr. med.	DGPFG

The following professional societies/working groups/organizations/associations stated that they wished to contribute to the guideline text and participate in the consensus conference and nominated representatives to attend the conference ([Table 2]).

Abbreviations

ACOG: American College of Obstetricians and Gynecologists

aOR: adjusted odds ratio

CI: confidence interval

cm: centimeter(s)

CTG: cardiotocography

EDA: epidural anesthesia

e.g.: for example

etc.: et cetera

GW: weeks of gestation

h: hours

i. a.: inter alia

I: level of the ischial spines

IQTIG: Institute for Quality Assurance and Transparency in the Healthcare Sector

ml: milliliter(s)

OP: operation(s)

OR: odds ratio

RCOG: Royal College of Obstetricians and Gynaecologists

RR: relative risk

s/p: status post
 

II  Guideline Application

Purpose and objectives

Up to 10% of all births are vaginal-operative deliveries (using a vacuum- or forceps-assisted approach). The indications for vaginal-operative delivery and the techniques vary.

The purpose of this guideline was to develop evidence-based recommendations for the indications and techniques of vaginal-operative births and to optimize neonatal and maternal outcomes.

Targeted areas of care

• Inpatient care

• Outpatient care (non-hospital birth)

• Day-patient care

Target user group/target audience

The recommendations in this guideline are aimed at gynecologists in private practice, hospital-based gynecologists, neonatologists, and midwives and provide information to pediatricians, anesthetists, nursing staff and other health professionals providing obstetric care.

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/representatives of the participating medical professional societies, working groups, organizations, and associations as well as the boards of the DGGG, SGGG and OEGGG and the DGGG Guidelines Commission in October 2023 and was thereby approved in its entirety. This guideline is valid from 1 November 2023 through to 31 October 2028.

III  Methodology

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches.

This guideline was classifed as: S2k

Grading of recommendations

The grading of evidence based on the systematic search, selection, evaluation, and synthesis of an evidence base which is then used to grade the recommendations is not envisaged for S2k guidelines. The individual statements and recommendations are only differentiated by syntax, not by symbols ([Table 3]).

Description of binding character	Expression
Strong recommendation with highly binding character	must/must not
Regular recommendation with moderately binding character	should/should not
Open recommendation with limited binding character	may/may not

Statements

Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is not possible to provide any information about the level of evidence for these statements.

Achieving consensus and level of consensus

At structured NIH-type consensus conferences (S2k/S3 level), authorized participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by a repeat vote. Finally, the level of consensus is determined, based on the number of participants ([Table 4]).

Symbol	Level of consensus	Extent of agreement in percent
+++	Strong consensus	> 95% of participants agree
++	Consensus	> 75 – 95% of participants agree
+	Majority agreement	> 50 – 75% of participants agree
–	No consensus	< 51% of participants agree

Expert consensus

As the term already indicates, this refers to consensus decisions taken relating specifically to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).

IV  Guideline

1  Epidemiology – incidence – risk factors

According to the data of the IQTIG, the rate of vaginal-operative births in Germany was 6.82% in 2015 and had increased to 7.05% by 2020. 95.8% of vaginal-operative births in 2020 were vacuum-assisted and 4.2% were forceps-assisted. In 2017, the rate of vaginal-operative births in Switzerland was 11.1%. The percentage of forceps-assisted births was 0.1%. In Austria, 11.1% of all liveborn neonates both in 2020 and in 2021 were born by vacuum or forceps-assisted delivery.

There are no meta-analyses or systematic reviews of all the risk factors for vaginal-operative birth. [Table 5] summarizes the results of systematic evaluations of pregnancy risks and the perinatal risks of vaginal-operative birth obtained from different clinical studies.

Risk factor	RR or OR	95% CI
Nulliparity	OR 6.74	4.5 – 10.1
S/p vaginal-operative birth	OR 3.9	2.5 – 5.9
Occiput-posterior presentation	RR 2.63	2.2 – 3.2
Fetal weight > 4000 g (forceps)	OR 6.5	1.6 – 26.9
Fetal weight > 4000 g (vacuum)	OR 1.056	1.04 – 1.07
Induction of labor (forceps)	OR 2.1	1.4 – 3.1
Induction of labor in nulliparous women	aOR 1.8	1.28 – 2.54
Status post caesarean section	RR 1.1	1.05 – 1.16
Prolonged latent phase of labor > 420 minutes (forceps)	OR 2.3	1.3 – 4.2
Protracted expulsion phase	OR 1.6	1.1 – 2.4

2  Measures to avoid or reduce vaginal-operative births

Consensus-based recommendation 2.E1
Expert consensus	Level of consensus +++
Where possible, a midwife should provide continuous (1 : 1) care during the active stage of labor, i. a. to reduce the likelihood of a vaginal-operative birth.

Consensus-based recommendation 2.E2
Expert consensus	Level of consensus ++
With a view to reducing vaginal-operative births, the person giving birth should only be encouraged to actively push during normal physiological labor once the leading part of the fetus has engaged with the pelvic floor (time to push).

Consensus-based recommendation 2.E3
Expert consensus	Level of consensus ++
Women with no EDA should be encouraged in the second stage of labor to adopt an upright (vertical) position as this reduces the probability of a vaginal-operative birth.

3  Conditions for vaginal-operative birth

Consensus-based statement 3.S1
Expert consensus	Level of consensus +++
No studies have defined the minimum hospital standards for safe vaginal-operative births.

No studies have set minimum standards (with regards to spatial, staffing and instrumental conditions) which need to be in place for safe vaginal-operative births. The Royal College of Obstetricians and Gynaecologists (RCOG) has issued the following statements, which have been largely replicated in many guidelines:

A: Vaginal examination (classification)

• The cervix is completely open. The amniotic sac is also open or will be opened directly.

• A basic condition is that the fetal head (leading edge) has reached the middle of the pelvis (up to 2 cm below the ischial spines) or the pelvic outlet (more than 2 cm below the ischial spines). If the fetal head is in a higher station, a caesarean section should be considered as a real alternative to vaginal-operative delivery, and the decision to proceed with a vaginal-operative delivery must be justified. The station and position of the head have been determined.

• Cephalohematoma and skull configuration have been estimated to be moderate.

• The maternal pelvis has been estimated to be sufficiently wide (to exclude disproportion).

• The contractions permit a vaginal-operative approach.

B: Preparation of the parturient

• The parturient has been informed about the procedure and the alternatives as appropriate for her situation and has agreed (informed consent).

• The information given to the parturient is documented in the birth report.

• It is important to gain the trust of the parturient and her active support during the vaginal-operative birth is requested.

• Good analgesia must be in place.

• The bladder should be empty. Any inlying bladder catheter has been removed.

C: Preparation of medical staff

• The operator has been trained in the method.

• Sufficient staffing resources are available to care for mother and baby.

• The necessary equipment is complete and ready for use (especially to provide primary care to the neonate).

• There must be an emergency plan in place in the event that the vaginal-operative birth is unsuccessful.

• Complications of vaginal-operative birth (maternal and fetal) must be anticipated.

4  Information

Consensus-based recommendation 4.E4
Expert consensus	Level of consensus +++
The pregnant woman should ideally have access to basic information about vaginal-operative delivery in good time before the birth (e.g., during birth planning or during antenatal classes, etc.).

Consensus-based recommendation 4.E5
Expert consensus	Level of consensus +++
A vaginal-operative birth must be carried out with the informed consent of the parturient as appropriate to the situation.

Consensus-based recommendation 4.E6
Expert consensus	Level of consensus +++
Informed consent to a vaginal-operative birth must be recorded (e.g., in the OP report or partograph). Any deviations must be specifically justified.

Consensus-based recommendation 4.E7
Expert consensus	Level of consensus +++
If a caesarean section is a real alternative when the parturient is provided with information, this must be noted and recorded and the decision of the parturient must be complied with.

Consensus-based statement 4.S2
Expert consensus	Level of consensus +++
The written medical explanation why the vaginal-operative delivery is indicated represents a case-by-case decision.

5  Indications

Consensus-based statement 5.S3
Expert consensus	Level of consensus +++
Knowing when a vaginal-operative birth is indicated requires a certain level of expertise.

The basic goal of vaginal-operative delivery is to accelerate the birth. This means that vaginal-operative delivery is indicated in the following situations:

• dystocia or prolonged expulsion phase

• (impending) fetal hypoxia/acidosis (pathological CTG or fetal scalp blood testing confirms suspicion of fetal acidosis)

• maternal exhaustion

• wish to limit the stress of pushing (e.g., due to cardiopulmonary or cerebrovascular disease)

6  Contraindications

Consensus-based statement 6.S4
Expert consensus	Level of consensus +++
Any relative contraindications must be taken into consideration if a vaginal-operative birth is indicated.

7  Classification

Consensus-based recommendation 7.E8
Expert consensus	Level of consensus +++
A classification should be done prior to carrying out a vaginal-operative birth to transparently document the level of difficulty and chances of success.

Consensus-based statement 7.S5
Expert consensus	Level of consensus +++
There are differences between the classification of vacuum-assisted births and forceps-assisted births as a classification system has only been established for forceps-assisted births.

The categories of the ACOG for forceps-assisted births are:

• A: Mid forceps delivery: The leading edge of the fetal skull is at least at the level of the ischial spines (I + 0), but still higher than I + 2, i.e., the fetal station is between I + 0 and I + 1.5.

• B: Low forceps delivery: The leading edge is just above the pelvic floor, at least at I + 2, i.e., at least 2 cm caudal to the level of the ischial spines. Rotation of the fetal head may have already occurred (straight sagittal suture) or has not yet occurred (sagittal suture is in anteroposterior diameter or transverse position); depending on the situation, the fetus will be born by forceps-assisted delivery with or without manual rotation.

• C: Outlet forceps delivery: The leading edge is at the pelvic outlet (introitus) or the head is already crowning. Internal rotation of the fetal head is complete or nearly complete.

([Table 6])

High	Vaginal-operative birth is not recommended if the fetal head is above the ischial spines.
Mid	Leading edge of the fetal skull is between the level of the ischial spines and 2 cm below the level of the ischial spines.
Low	Leading edge of the fetal skull (not the scalp) is at fetal station + 2 cm or lower but not on the pelvic floor.
Outlet	Scalp is visible at the introitus without separating the labia.
	Fetal skull has reached the pelvic floor.
	Sagittal suture is in anteroposterior diameter or right or left in occiput-anterior or posterior position (rotation not more than 45°).
	Fetal skull is at or on the perineum.

Consensus-based recommendation 7.E9
Expert consensus	Level of consensus +++
An additional ultrasound examination can be done intrapartum to classify the vaginal-operative birth and evaluate the chances of success.

7.1  Clinical diagnosis of fetal station

Consensus-based recommendation 7.E10
Expert consensus	Level of consensus +++
The fetal station of the leading edge should be determined by palpation, using the De Lee classification to indicate the number of centimeters above (−) or below (+) the level of the ischial spines.

7.2  Importance of ultrasound in vaginal-operative birth

Consensus-based recommendation 7.E11
Expert consensus	Level of consensus +++
An ultrasound examination should be done prior to vaginal-operative delivery if palpation does not permit exact assessment of the position of the back and the position and rotation of the head in the birth canal.

8  Choice of instrument

Consensus-based recommendation 8.E12
Expert consensus	Level of consensus +++
The operators must be familiar with the advantages and disadvantages of each instrument used for vaginal-operative delivery. The choice of the most appropriate instrument depends on the clinical situation and the operatorʼs own level of experience.

Consensus-based statement 8.S6
Expert consensus	Level of consensus +++
Vacuum-assisted delivery is associated with a higher rate of unsuccessful vaginal-operative births compared to forceps-assisted births. However, the risk of maternal injury is significantly higher with forceps-assisted delivery compared to vacuum-assisted birth.

Consensus-based statement 8.S7
Expert consensus	Level of consensus +++
Use of a silicone/rubber suction cap is associated with higher rates of unsuccessful vaginal-operative deliveries but has a lower incidence of neonatal scalp injuries compared to metal cups.

Consensus-based statement 8.S8
Expert consensus	Level of consensus +++
Using a hand vacuum pump system reduces the rate of postpartum hyperbilirubinemia but increases the rate of unsuccessful vaginal-operative births compared to metal cups.

Consensus-based recommendation 8.E13
Expert consensus	Level of consensus +++
The Odón device must only be used in the context of a scientific study.

9  Procedure

9.1  Logistics

9.1.1  Material resources

Consensus-based recommendation 9.E14
Expert consensus	Level of consensus +++
The necessary materials to carry out a vaginal-operative birth and to control potential maternal and neonatal/fetal complications must be available without delay and available in surplus (failsafe).

9.1.2  Staff/professional resources

Consensus-based recommendation 9.E15
Expert consensus	Level of consensus ++
During a vaginal-operative birth, an obstetrician must be present to provide care during the vaginal-operative delivery and to manage possible complications. Additional qualified staff (see below) should be available where possible.

Consensus-based recommendation 9.E16
Expert consensus	Level of consensus +++
Qualified medical staff trained to provide primary neonatal care must be present during the vaginal-operative birth or at least available on very short notice. Depending on the circumstances, additional medical staff (e.g., anesthetist, operating team, neonatologist, etc.) will already need to be informed ahead of the vaginal-operative birth.

9.1.3  Spatial/local resources and infrastructure

Consensus-based recommendation 9.E17
Expert consensus	Level of consensus +++
Every facility for vaginal-operative births must also have the necessary rooms and organizational structures to carry out (emergency) caesarean sections.

Consensus-based recommendation 9.E18
Expert consensus	Level of consensus +++
Vaginal-operative births must generally be carried out in a delivery room.

Consensus-based recommendation 9.E19
Expert consensus	Level of consensus +++
In cases where there is an increased risk that the vaginal-operative birth will be unsuccessful, meaning that the birth may need to be completed by (emergency) caesarean section (trial vacuum and trial forceps), the assisted delivery should be attempted with everything already in readiness for an emergency caesarean section.

9.2  Analgesia

Consensus-based statement 9.S9
Expert consensus	Level of consensus +++
Carrying out a vaginal-operative birth without adequate analgesia may be associated with a negative birth experience.

Consensus-based recommendation 9.E20
Expert consensus	Level of consensus +++
If a vaginal-operative birth is indicated and the parturient is not receiving epidural or spinal analgesia, a pudendal nerve block or local perineal infiltration may be considered, especially for forceps-assisted delivery.

9.3  Forceps-assisted birth

A detailed description of forceps-assisted delivery with illustrations is available in the long German-language version of the guideline.

Consensus-based recommendation 9.E21
Expert consensus	Level of consensus +++
When the forceps are placed properly, the blades of the forceps can be closed without resistance. If the forceps can only be closed by exerting force, the blades will need to be repositioned.

Consensus-based recommendation 9.E22
Expert consensus	Level of consensus +++
A properly positioned forceps must not slip. This must be checked by doing a trial traction.

9.4  Vacuum-assisted birth

A detailed description of vacuum-assisted delivery with illustrations is available in the long German-language version of the guideline.

Consensus-based recommendation 9.E23
Expert consensus	Level of consensus +++
The suction cup must be placed on the fetal pivot point centrally in the birth canal.

Consensus-based recommendation 9.E24
Expert consensus	Level of consensus +++
After initial creation of a slight suction, the birth canal must be inspected and palpated to ensure that no maternal soft tissues have been trapped. After this, the vacuum pressure must be raised to the required level prior to beginning delivery of the infant.

Consensus-based recommendation 9.E25
Expert consensus	Level of consensus +++
During vacuum-assisted birth, measured traction must be applied synchronously to contractions to exploit the parturientʼs expulsive contractions along the line of the birth canal.

Consensus-based recommendation 9.E26
Expert consensus	Level of consensus +++
If the fetus fails to descend and delivery is still not imminent after about three contraction-synchronous tractions, the decision whether to proceed with this vaginal-operative approach requires critical evaluation. Cancelling the approach should be considered if necessary.

Consensus-based recommendation 9.E27
Expert consensus	Level of consensus +++
Good communication with the parturient and protection of the birth canal are essential during vaginal-operative delivery.

9.5  Episiotomy in vaginal-operative birth

9.5.1  Episiotomy and maternal morbidity

Consensus-based statement 9.S10
Expert consensus	Level of consensus ++
The decision for or against an episiotomy includes considerations such as higher grade perineal tears and other undesirable maternal short-term and long-term morbidities (e.g., postpartum hemorrhage, pain, increased need of analgesics, infections, postnatal sexual dysfunction, birth trauma in a subsequent birth, etc.) caused by an episiotomy.

9.5.2  Episiotomy and higher degree perineal tears

Consensus-based statement 9.S11
Expert consensus	Level of consensus +++
An episiotomy is not a routine procedure to avoid higher degree perineal tears during vaginal-operative birth.

Consensus-based statement 9.S12
Expert consensus	Level of consensus +++
The benefits of a mediolateral episiotomy are greatest for primiparous women and during forceps-assisted deliveries, especially if additional risk factors are present (e.g., occiput-posterior position, higher fetal birthweight).

Consensus-based recommendation 9.E28
Expert consensus	Level of consensus +++
An episiotomy performed during vaginal-operative birth must extend in a mediolateral direction (the angle to the midline for an episiotomy of the stretched perineum is 45 – 60 degrees).

Consensus-based statement 9.S13
Expert consensus	Level of consensus +++
It is not clear whether a routine mediolateral episiotomy carried out in a primiparous woman during vacuum-assisted delivery reduces the risk of anal sphincter injury. Whether an episiotomy is done depends on the obstetric situation and the preference of the parturient.

Consensus-based recommendation 9.E29
Expert consensus	Level of consensus +++
During forceps-assisted birth, a mediolateral episiotomy should be considered in primiparous women to avoid injury to the anal sphincter.

Consensus-based recommendation 9.E30
Expert consensus	Level of consensus +++
An episiotomy during vacuum-assisted birth should be avoided in multiparous women (with the exception of women who are s/p higher grade birth trauma or s/p caesarean section).

9.5.3  Episiotomy in women who are s/p higher degree perineal tear

Consensus-based recommendation 9.E31
Expert consensus	Level of consensus +++
A mediolateral episiotomy during vaginal-operative delivery may be considered in a woman who is s/p higher degree perineal tear.

9.5.4  Episiotomy in women who are s/p caesarean section

Consensus-based recommendation 9.E32
Expert consensus	Level of consensus ++
A mediolateral episiotomy should be considered for a woman who is s/p caesarean section because of the increased risk of a higher degree perineal injury during vaginal-operative delivery.

9.6  Fundal pressure during vaginal-operative birth

Consensus-based statement 9.S14
Expert consensus	Level of consensus +++
There is no evidence to support the routine use of fundal pressure during vaginal-operative delivery. The decision to use fundal pressure is taken on a case-by-case basis, must be based on strict diagnostic criteria, and should adhere to the conditions for fundal pressure described in the S3 guideline Vaginal Birth at Term.

9.7  Difficult vaginal-operative births

Consensus-based recommendation 9.E33
Expert consensus	Level of consensus +++
Vaginal-operative births should be completed in three tractions where possible, although more tractions may be used if the birth process is progressing without complications.

Consensus-based statement 9.S15
Expert consensus	Level of consensus +++
No evidence-based statements can be made about the length of time from the first traction to delivery of the infant in vaginal-operative births.

Consensus-based recommendation 9.E34
Expert consensus	Level of consensus +++
If the baby fails to descend after the initial tractions, the correct application of the instrument and the fetal position have been checked and it has been ascertained that the contractions are adequate and the parturient is actively supporting the delivery, abandoning the assisted delivery method or switching to a different method of operative delivery should be considered.

Consensus-based statement 9.S16
Expert consensus	Level of consensus +++
Detachment of the vacuum extractor (cup detachment) during vacuum-assisted birth increases neonatal morbidity and is associated with a higher rate of unsuccessful attempts at delivering the baby.

Consensus-based recommendation 9.E35
Expert consensus	Level of consensus +++
In principle, the serial use of different instruments for vaginal-operative birth is possible but this must be weighed up very carefully in view of the potential for fetal and maternal trauma.

Consensus-based recommendation 9.E36
Expert consensus	Level of consensus +++
If there is a higher risk that the vaginal-operative delivery will be unsuccessful, the option of secondary caesarean section as a real alternative must be discussed with the birthing woman because of the higher fetal and maternal risk of complications.

Consensus-based statement 9.S17
Expert consensus	Level of consensus +++
A caesarean section following an unsuccessful attempt at vaginal-operative delivery can be technically difficult and is associated with a higher risk of maternal and fetal complications.

Consensus-based recommendation 9.E37
Expert consensus	Level of consensus +++
When a caesarean section is carried out following an unsuccessful attempt at vaginal-operative delivery, the birth canal must be inspected.

Consensus-based recommendation 9.E38
Expert consensus	Level of consensus +++
During the vaginal-operative birth, the operator must be familiar with methods to deliver the baby if the fetal head is impacted in the pelvis and must know the appropriate treatment for possible maternal complications if the vaginal-operative attempt at delivery has to be discontinued and a caesarean section has to be carried out.

9.8  Special situations

9.8.1  Vaginal-operative birth of the second twin in cephalic presentation

Consensus-based statement 9.S18
Expert consensus	Level of consensus +++
Compared to singleton pregnancies, incomplete rotation of the head of the second twin is unlikely to be due to disproportion between the maternal pelvis and the fetal head and more likely to be due to dystocia. In this situation, a vaginal-operative birth (high vacuum, forceps birth) may be considered even if the station of the fetal head is above the level of the ischial spines.

9.8.2  Vaginal-operative birth and preterm infants

Consensus-based recommendation 9.E39
Expert consensus	Level of consensus +++
Vacuum-assisted births should be avoided before 34 + 0 GW because of the increased risk of intra- or extracranial fetal bleeding.

Consensus-based recommendation 9.E40
Expert consensus	Level of consensus ++
If a vaginal-operative birth is indicated for a preterm infant before 34 + 0 GW, the infant must be born by forceps-assisted delivery as the morbidity rates of preterm infants delivered by forceps are not higher compared to infants born at term.

Consensus-based recommendation 9.E41
Expert consensus	Level of consensus ++
A low forceps delivery must not be a routine procedure for vaginal delivery of a preterm infant, even when delivering very small preterm neonates.

9.8.3  Vaginal-operative birth in breech presentation

Consensus-based recommendation 9.E42
Expert consensus	Level of consensus ++
A vaginal-operative approach using forceps may be considered in cases where delivery of the head is more difficult due to breech presentation if manual maneuvers to deliver the fetal head were unsuccessful.

9.8.4  Rotational forceps

Consensus-based recommendation 9.E43
Expert consensus	Level of consensus +++
Delivery by rotational forceps should only be carried out in accordance with strict diagnostic criteria; if in doubt, it should not be carried out.

10  Antibiotic prophylaxis

Consensus-based recommendation 10.E44
Expert consensus	Level of consensus +++
Antibiotic prophylaxis may be administered after vaginal-operative birth at the discretion of the treating medical staff.

Consensus-based recommendation 10.E45
Expert consensus	Level of consensus +++
Antibiotic prophylaxis must be administered in cases with high-level birth injury after vaginal-operative birth (grade 3 or 4 perineal tear) or extensive injury to the birth canal.

11  Complications

11.1  Maternal complications

11.1.1  Birth canal tears

Consensus-based statement 11.S19
Expert consensus	Level of consensus +++
Vacuum-assisted birth appears to be more benefical than forceps-assisted birth with regards to reducing birth canal tears.

Consensus-based statement 11.S20
Expert consensus	Level of consensus +++
The choice of suction cup in a vacuum-assisted birth does not affect the maternal pattern of injury (this also applies to higher level birth injuries).

11.1.2  Higher degree perineal tears

Consensus-based recommendation 11.E46
Expert consensus	Level of consensus ++
Vacuum-assisted birth should be preferred to forceps-assisted birth to avoid higher level perineal tears.

11.1.3  Pelvic floor damage/levator avulsion

Consensus-based statement 11.S21
Expert consensus	Level of consensus ++
Vacuum-assisted delivery appears to be more beneficial with regards to pelvic floor injury compared to forceps-assisted delivery.

11.1.4  Urinary and fecal incontinence

Consensus-based statement 11.S22
Expert consensus	Level of consensus +++
The incidence of urinary incontinence is not significantly higher after vaginal-operative birth compared to spontaneous delivery. However, anal incontinence occurs more often after vaginal-operative birth (especially after forceps-assisted birth).

11.1.5  Bladder voiding dysfunction/urinary retention

Consensus-based recommendation 11.E47
Expert consensus	Level of consensus +++
Women should be informed about the increased risk of bladder voiding dysfunction after vaginal-operative birth. The nursing staff must ensure that bladder voiding occurs.

Consensus-based recommendation 11.E48
Expert consensus	Level of consensus +++
The first micturition after a vaginal-operative birth should be recorded, including the time of urination.

Consensus-based recommendation 11.E49
Expert consensus	Level of consensus +++
If there is a suspicion that bladder emptying is inadequate or if there is a risk of bladder voiding dysfunction, the post-void residual volume should be determined (for example, by ultrasound).

Consensus-based statement 11.S23
Expert consensus	Level of consensus +++
Women with an epidural catheter or one who received opioid-based analgesia during delivery may have a higher post-void residual volume, which may make it necessary to check the post-void residual volume.

Consensus-based recommendation 11.E50
Expert consensus	Level of consensus +++
Placement of a transurethral permanent catheter for 12 h after vaginal-operative birth is not a routine measure but may be considered in the context of bladder voiding dysfunction.

11.1.6  Sexual dysfunction

Consensus-based statement 11.S24
Expert consensus	Level of consensus +++
Sexual dysfunction may occur after vaginal-operative delivery.

11.1.7  Postpartum hemorrhage

Consensus-based statement 11.S25
Expert consensus	Level of consensus +++
There is no statistically significant difference in the incidence of postpartum bleeding between vacuum-assisted and forceps-assisted births.

Consensus-based statement 11.S26
Expert consensus	Level of consensus +++
The serial use of instruments during vaginal-operative birth increases the risk of postpartum hemorrhage.

11.1.8  Psychiatric impairment/satisfaction

Consensus-based recommendation 11.E51
Expert consensus	Level of consensus +++
Psychiatric impairment/dissatisfaction may occur more often after vaginal-operative birth and should be specifically inquired about.

11.1.9  Pain/analgesia requirements

Consensus-based statement 11.S52
Expert consensus	Level of consensus +++
Postpartum pain and analgesic requirements are about the same for vacuum-assisted and forceps-assisted deliveries.

11.1.10  Thromboembolic events

Consensus-based statement 11.S53
Expert consensus	Level of consensus +++
Thromboprophylaxis after vaginal-operative birth is not a routine clinical measure but represents a decision taken on a case-by-case basis which needs to be justified.

11.1.11  Rehospitalization

Consensus-based statement 11.S54
Expert consensus	Level of consensus +++
Rehospitalizations due to complications occur more commonly after vaginal-operative births compared to spontaneous births, especially after forceps-assisted delivery.

11.2  Neonatal complications

Consensus-based recommendation 11.E55
Expert consensus	Level of consensus ++
Because of possible neonatal complications which can occur in the context of a vaginal-operative birth, a person trained to manage adaptation disorders and neonatal adverse outcomes must be present during the initial primary care provided to the neonate.

Consensus-based statement 11.S56
Expert consensus	Level of consensus ++
Serial use of a ventouse or forceps during vaginal-operative birth and failed vaginal-operative delivery are associated with higher neonatal morbidity.

Consensus-based statement 11.S27
Expert consensus	Level of consensus +++
Forceps-assisted birth has advantages compared to vacuum-assisted delivery with regards to neonatal complications. The same applies to soft cups compared to metal cups. Due to a lack of studies it is not possible to assess hand vacuum pump systems in this context.

12  Postnatal examinations

12.1  The mother

12.1.1  Examination in the delivery room

Consensus-based recommendation 12.E57
Expert consensus	Level of consensus ++
After a vaginal-operative birth, a detailed inspection and palpation of the birth canal including rectal palpation must be carried out to check for genital tear injuries and higher grade perineal tears in particular.

Consensus-based recommendation 12.E58
Expert consensus	Level of consensus +++
The first urination after the vaginal-operative birth should be recorded. If there is a suspicion of incomplete bladder emptying or urinary retention, the post-void residual volume of urine should be determined.

Consensus-based recommendation 12.E59
Expert consensus	Level of consensus +++
Postpartum bladder voiding dysfunction is present if no spontaneous micturition is possible at around 4 hours after the birth or after removal of a bladder catheter and a residual volume of urine of > 150 ml is measured. Postpartum bladder voiding dysfunction must be monitored. A transurethral permanent catheter should be placed for about 24 hours if the residual volume of urine is ≥ 500 ml.

12.1.2  Examinations in puerperium

Consensus-based recommendation 12.E60
Expert consensus	Level of consensus +++
Care must be taken to ensure regular micturition and defecation during puerperium.

Consensus-based recommendation 12.E61
Expert consensus	Level of consensus +++
Therapy (using a permanent urinary catheter, if necessary) must be initiated if urinary retention or incomplete bladder emptying is diagnosed during puerperium.

Consensus-based recommendation 12.E62
Expert consensus	Level of consensus +++
After vaginal-operative delivery, the new mother should be made aware of possible pelvic floor problems and possible therapeutic steps.

Consensus-based recommendation 12.E63
Expert consensus	Level of consensus +++
After a vaginal-operative delivery, the new mother should be asked about possible psychological stresses and assigned to receive adequate care if she is found to be suffering from psychological stress.

12.1.3  Examinations in the context of standard postpartum follow-up

Consensus-based recommendation 12.E64
Expert consensus	Level of consensus +++
Women showing signs of post-traumatic stress (after vaginal-operative birth) in the first weeks postpartum must be offered professional support and guidance.

Consensus-based recommendation 12.E65
Expert consensus	Level of consensus +++
Women with incontinence symptoms or pelvic floor dysfunction must be offered a further clinical and, if necessary, instrumental diagnostic workup and adequate therapy.

Consensus-based recommendation 12.E66
Expert consensus	Level of consensus +++
Education and counselling about the birth mode and the risk of recurrence of pelvic floor injury in a subsequent delivery should be part of the follow-up examination at the end of puerperium and during any debriefing after a vaginal-operative birth.

12.2  The neonate

Consensus-based recommendation 12.E67
Expert consensus	Level of consensus +++
After a vaginal-operative birth, the neonateʼs state of health must be evaluated by a specialist trained in the postnatal adaptation of neonates (and especially trained to deal with birth trauma).

Consensus-based recommendation 12.E68
Expert consensus	Level of consensus +++
In every case of neonatal birth trauma after vaginal-operative delivery, careful consideration must be given to whether a pediatrician should be called in for assessment.

Consensus-based statement 12.S28
Expert consensus	Level of consensus +++
Direct skin contact, breastfeeding, or the administration of paracetamol are effective methods to reduce the pain of neonatal birth trauma.

13  Documentation and legal considerations

Consensus-based recommendation 13.E69
Expert consensus	Level of consensus +++
The quality of the documentation plays a central role in medicolegal disputes, which is why vaginal-operative births must be documented in a manner which can be understood by third parties.

14  Debriefing

Consensus-based statement 14.S29
Expert consensus	Level of consensus ++
Debriefing after a vaginal-operative birth which includes a discussion of the birth experience may contribute to the psychological health of the woman/family.

Consensus-based recommendation 14.E70
Expert consensus	Level of consensus +++
A debriefing regarding the vaginal-operative birth should be available for all women and their families/attendants, ideally while the woman is still in hospital.

15  Training and simulation

Consensus-based statement 15.S30
Expert consensus	Level of consensus +++
Education and training on how to perform vaginal-operative deliveries are fundamental for providing the best possible levels of fetomaternal care.

Consensus-based statement 15.S31
Expert consensus	Level of consensus +++
The low numbers of forceps-assisted births underlines the need for simulation training and for opportunities to practice this method using simulation manikins to ensure safe applications in practice.

15.1  Current status of training curricula

Consensus-based statement 15.S32
Expert consensus	Level of consensus +++
There are no evidence-based minimum figures which define competence to carry out a vaginal-operative birth independently and professionally.

15.2  Training and simulation

Consensus-based statement 15.S33
Expert consensus	Level of consensus +++
In addition to learning from clinical case studies, video-based courses, hands-on practice and simulation-based courses offer an opportunity to train all methods of vaginal-operative birth.

15.3  Potential monitoring of quality parameters

Consensus-based statement 15.S34
Expert consensus	Level of consensus +++
Collecting and reflecting on quality parameters permits the source of mistakes to be recognized at an organizational level and countermeasures to be initiated.

The literature on which this guideline is based in listed in the long German-language version of the guideline under https://register.awmf.org/de/leitlinien/detail/015-023

Conflict of Interest

The conflicts of interest of all the authors are listed in the long German-language version of the guideline.

Publication History

Received: 05 August 2024

Accepted: 16 September 2024

Article published online:
06 February 2025