Maternal and Child Health After Forceps or Vacuum Delivery

Abstract & Commentary

Synopsis: There is no evidence to suggest that the use of either a vacuum extractor or forceps is more or less likely to be associated with adverse outcomes for the mother or her child five years after delivery.

Source: Johanson RB, et al. Br J Obstet Gynaecol 1999;106:544-549.

To determine whether there were differences in maternal or pediatric outcomes in women delivered by forceps or vacuum extraction, Johanson and associates performed a five-year follow-up study of a cohort of women who had been delivered in a randomized controlled trial performed in England. Most were low or outlet deliveries with the fetus in the occiput anterior position. Questionnaires were sent to women asking about bowel and urinary dysfunction and child development, including the child’s vision. Nearly 75% of the questionnaires were returned (228/306), including 113 women who had been delivered by vacuum extraction and 115 who had been delivered by forceps. In response to questions about loss of bowel or bladder control, no significant differences were noted between the groups. However, adverse symptoms were relatively common with 47% of the women reporting urinary incontinence of varying severity, 44% describing bowel urgency, and 20% noting loss of bowel control "sometimes" or "frequently." Overall, the incidence of childhood developmental problems was low, with no significant differences between the groups. Thirteen percent of the 158 children who had had eye examinations had visual problems. Most of these were refraction errors, far sightedness, or amblyopia, and all but a few were associated with a positive family history for this problem.

Johanson et al conclude there is no evidence to suggest that the use of either a vacuum extractor or forceps is more or less likely to be associated with adverse outcomes for the mother or her child five years after delivery .

Comment by Steven G. Gabbe, MD

When considering whether to use forceps or a vacuum extractor for an assisted vaginal delivery, the obstetrician is most likely to use the instrument with which he or she is most comfortable. It has been assumed that the vacuum extractor, while less traumatic for the mother, may be associated with more neonatal risk including cephalohematomas and retinal hemorrhages.

Maternal bladder and bowel function after a normal or assisted vaginal delivery have not been well studied. Johanson et al now present data from a large prospective randomized controlled trial of vacuum extraction and forceps. At the time of delivery, significant maternal injuries including third-degree perineal tears or lacerations of the upper vagina were more common in women delivered with forceps (12/115, 10%) when compared to vacuum extraction (6/113, 5%). However, at five years of follow-up, there were no significant differences between the study groups.

Regardless of the method of delivery, women frequently reported bowel or urinary bladder dysfunction. Johanson et al do emphasize that some of these problems may be related to factors other than birth trauma and note that they have observed a high incidence of similar problems in women having a spontaneous vaginal delivery. Certainly, the information on pediatric outcome is reassuring.

Based on the data of Johanson et al, which of the following outcomes is more common in women delivered by forceps?

a. Urinary bladder dysfunction

b. Bowel dysfunction

c. Perineal and vaginal lacerations

d. Childhood visual problems

e. Childhood developmental problems