I am not a doctor, midwife, other health professional, this is not medical advice, etc etc
First off — I'm not even going to attempt to argue that c-sections are inherently bad, or anything of the sort — they can certainly be life-saving in an emergency, a high-risk pregnancy, or when other attempts at assisted delivery have failed. My issue isn't with c-section per se, but with the decline in attempts at vacuum delivery, and particularly forcep delivery. I'm certainly biased here though — I was delivered with forceps back in the 80s after 30~ hours of labor left my mother too exhausted to continue, had she had the c-section they were discussing, it would likely have meant my brother would've had to be a c-section as well. And as much as I tease him and whatnot (I mean, he is my younger brother) I don't know that she'd have decided to have another kid if she'd have had to have a c-section. Nobody tell him, but I kinda like having a brother to harass. Anyways!
Indications for forceps versus vacuum delivery are more or less the same, and include such things as maternal exhaustion, while for c-section they include more serious risks (e.g. uterine rupture) and failed attempt(s) at forcep/vacuum delivery. As a result, it can be difficult to sort out cause and effect when it comes to the risks — particularly the risks of c-section. For that reason, I'm not going to discuss c-section risks beyond to say that it is major surgery and thus I do not agree with elective c-section except when the doctor(s) involved predict an emergency c-section if an elective one isn't performed. Instead, I want to talk about the risks of forceps and vacuum delivery, and the fall in attempting either before performing a c-section in the cases where that's a viable option.
As for those risks the only measure where an assisted delivery had a lower risk than an unassisted delivery was that a forceps delivery was less likely to result in central nervous system depression. Other than that, both forms of assisted delivery carried higher risks than unassisted delivery, but this should come as no surprise really, you wouldn't be doing an assisted delivery if an unassisted delivery was possible. Things that may be surprising — unassisted delivery, forcep delivery and vacuum delivery all carried about the same risk of neonatal death.
Comparing forceps delivery to vacuum delivery, the former carried a lower risk of cephalhematoma (basically a nasty bruise between the skull and its protective layer); intracranial hemorrhage, contra cephalhematoma, which is outside the skull, this is bleeding inside the skull (particularly subarachnoid hemorrhage, but even then it occurred in ~1 out of every 1,000 births), and, of course, central nervous system depression. Vacuum delivery carried a lower risk of facial-nerve injury and third-/fourth-degree perineal lacerations than forceps delivery did.
In summary, our analysis of maternal and infant outcomes in vaginal deliveries assisted by vacuum extraction or forceps does not suggest that vacuum extraction is superior to forceps or vice versa. Each instrument appears to have its own advantages and disadvantages.1
The was a Canadian study, now let's look at an Indian study that found that "[u]sing outlet forceps the overall rates of maternal and perinatal morbidity and mortality are negligible and even comparable to spontaneous vaginal delivery." That's fairly impressive when you consider that comparing vaginal delivery to forceps delivery isn't like comparing, say, hospital birth to home birth — it isn't something an expectant mother elects to do, but something that is done because it has become necessary.
So, we can say that the forceps application with all criteria’s fulfilled in a expert hand is an Art of Obstetrics and not a dangerous Instruments. [sic]2
Meanwhile, a US study found that when looking at specific risks to predict neurological outcome forceps delivery fared best.
When seizure, intraventricular hemorrhage, and subdural hemorrhage were examined collectively to best predict neurologic outcome, forceps-assisted vaginal deliveries had an overall reduced risk compared with both vacuum-assisted vaginal deliveries (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40–0.90) and cesarean deliveries (OR 0.68, 95% CI 0.48–0.97).3
In short, the general consensus seems to be that both forceps and vacuum delivery are safe, and forceps delivery may be safer than vacuum — but only if the forceps are in the hands of someone trained in their use. And thus, my final point here will be that more doctors should be trained in the use of forceps, when to use them, and when to proceed directly to c-section. Currently, at least in the US, it seems that c-section is the go to approach for a complicated delivery, even if forceps or vacuum delivery may be indicated and potentially safer for mother and baby alike. But we'll look at the c-section rate in part 2 as this is getting long.
Edit: Silly me forgot to mention the funniest "risk" of forceps and vacuum delivery! The baby's pliable skull can mold to the shape of the instrument, meaning my earliest photos I look like a conehead. Can't call it a risk when it's purely cosmetic and will sort itself out in under a week, pretty funny though.
- Shi Wu Wen, Shiliang Liu, Michael S. Kramer, Sylvie Marcoux, Arne Ohlsson, Reg Sauvé, and Robert Liston "Comparison of Maternal and Infant Outcomes between Vacuum Extraction and Forceps Deliveries" Am. J. Epidemiol. (2001) 153 (2): 103-107 doi:10.1093/aje/153.2.103 ↩
- Gunvant Vasihnav, and Jolly Vasihnav. "Outlet Forceps in Modern Era, a Dangerous Instrument or an Art of Obstetrics?" Medicine Science. (2012) 1 (3): 171-176. PDF ↩
- Werner, Erika F. MD, MS; Janevic, Teresa M. PhD; Illuzzi, Jessica MD, MS; Funai, Edmund F. MD; Savitz, David A. PhD; Lipkind, Heather S. MD, MS "Mode of Delivery in Nulliparous Women and Neonatal Intracranial Injury" Obstetrics & Gynecology. (2011) 118 (6): 1239-1246 doi: 10.1097/AOG.0b013e31823835d3 (behind paywall) Unsurprisingly, c-section carried the lowest risk of vaginal tearing ↩