Operative Vaginal Birth (OVB)

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Operative Vaginal Birth — Forceps & Vacuum Delivery

Operative vaginal birth (OVB) uses forceps or a vacuum (ventouse) cup applied to the fetal head to expedite delivery in the second stage of labour. Done well, it can avoid an emergency caesarean at full dilatation — but it is a genuine procedure with real prerequisites, real contraindications, and a real point at which the safest decision is to stop and move to theatre rather than persist.

🎯 AT A GLANCE — WHEN IT'S APPROPRIATE

Common Indications

Maternal: prolonged second stage, maternal exhaustion, ineffective pushing, or a need to avoid prolonged expulsive effort (e.g., significant cardiac disease, severe hypertension)

Fetal: suspected fetal compromise in the second stage, or to expedite delivery of a second twin

GREEN: clear indication, head low and in a straightforward position — outlet or low delivery, favourable

AMBER: mid-cavity station or uncertain position — needs an experienced operator and a low threshold to reassess

RED: a prerequisite isn't met, or a contraindication is present — do not proceed; plan caesarean instead

✅ PREREQUISITES — CONFIRM EVERY ONE

1

Cervix fully dilated, membranes ruptured

2

Head engaged, position known, and no suspected disproportion

3

Adequate analgesia, bladder empty (catheterized if needed)

4

Informed consent obtained and documented

5

A genuine willingness and plan to abandon and move to caesarean if it doesn't progress

Forceps

Better for rotational deliveries and certain positions (e.g., face presentation, after-coming head of breech)

Higher risk of maternal perineal/sphincter trauma

Lower risk of fetal scalp injury than vacuum

Vacuum (Ventouse)

Lower maternal trauma risk; needs active maternal pushing alongside traction

Higher risk of neonatal scalp injury (cephalhaematoma; rarely subgaleal haemorrhage)

Avoid under ~34 weeks, and avoid for face presentation

📏 CLASSIFICATION BY STATION

Outlet: scalp visible at the introitus without separating the labia; skull on the pelvic floor

Low: leading bony point at station ≥+2 cm, not yet on the pelvic floor

Mid: head engaged, but leading point above station +2 cm — higher risk; needs an experienced operator, and caesarean is preferred if there's any doubt

🚨 DO NOT PROCEED — CONTRAINDICATIONS

Unengaged fetal head, or cervix not fully dilated

Suspected cephalopelvic disproportion

Known or suspected fetal bleeding disorder, or bone fragility condition — vacuum is contraindicated

Face presentation — vacuum is contraindicated (forceps may be considered if mentoanterior)

Preterm gestation (roughly <34 weeks) for vacuum, given the fragile preterm fetal skull

🛠️ SAFE TECHNIQUE

Apply the instrument correctly before any traction — correct application is what makes the attempt both safer and more likely to succeed

Pull only during a contraction, synchronized with maternal pushing — not as a continuous steady pull

Reassess descent after each attempt; stop if there's no progressive descent

Anticipate shoulder dystocia and postpartum haemorrhage — both are more common after an operative vaginal birth, so be ready, not surprised

An episiotomy is commonly used but not mandatory for every case — individualize

Maternal Complications

Perineal and vaginal trauma, including third/fourth-degree (sphincter) tears

Postpartum haemorrhage, urinary retention

Longer-term pelvic floor dysfunction — worth counselling about

Neonatal Complications

Vacuum: cephalhaematoma, scalp abrasion, rarely subgaleal haemorrhage

Forceps: facial bruising, usually transient facial nerve palsy, rarely skull injury

Know When To Stop

The Rule of Three

3

PULLS WITHOUT
DESCENT = ABANDON

An operative vaginal birth is not an all-or-nothing commitment. If correctly applied traction brings no progressive descent after a defined number of attempts, the safest move is to stop and proceed to caesarean — not to try harder, and not to switch instruments as a way of trying again.

Always have theatre and a caesarean-ready team available before starting — not arranged only after things don't go to plan

Sequential attempts with different instruments by an inexperienced operator carry more risk than one well-chosen attempt by an experienced one — call for senior help early if there's any uncertainty

Document the indication, instrument, number of pulls, and findings clearly

Debrief the mother afterward, especially if the birth felt frightening or didn't go as expected

Reminder: recognizing the right moment to stop and change plan is itself a clinical skill — not a failure of the attempt.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary for structured teaching and triage; exact prerequisites, instrument choice, and abandonment thresholds vary by guideline and institution — follow local protocol and operator competency requirements.