Obstetric forceps: when to use them

Obstetric forceps are an instrument for instrumental vaginal delivery, that is, to expedite the birth of a baby through the natural birth canal during the second stage of labor. Modern concepts consider them not in isolation, but rather alongside vacuum extraction as options for assisted vaginal birth, when labor needs to be completed more quickly than would otherwise occur naturally. [1]

It's important to understand that forceps are not a "just-in-case" rescue procedure. They are used only when vaginal birth is still possible and expected to be safe, and the benefits of accelerating labor outweigh the risks of further delay. NICE specifically requires that such a decision be made based on the urgency of the situation, the examination findings, the likelihood of success, the location of the procedure, the need for additional pain relief, and the woman's preferences. [2]

The modern role of forceps has become narrower than in old textbooks. It is no longer a method for "any difficult birth" or a way to overcome mechanical incompatibility. On the contrary, the use of forceps is permissible only after confirmation that the head is already low in the womb, the cervix is fully dilated, the water has broken, the position of the head is clear, and there are no obstacles to a safe vaginal delivery. [3]

The idea of "high" forceps is not routinely supported in modern practice. International sources emphasize that operative vaginal delivery with forceps is typically performed at a low position of the glans, typically at station +2 and below, and high forceps are no longer recommended in routine practice. This is an important difference from older materials, where the very topic of high forceps was still discussed as a living part of obstetric technique. [4]

When properly selected, forceps remain an essential obstetric skill because, in some situations, they allow for a more rapid completion of labor and avoidance of a more complex cesarean section in the second stage. However, the safety of this method depends entirely on patient selection, accurate knowledge of the position of the fetal head, operator experience, and a willingness to abandon the attempt if conditions are less than ideal. [5]

Concept	Modern meaning
Obstetric forceps	A tool to speed up vaginal birth in the second stage of labor
Place of the method	An alternative to vacuum extraction and, in some cases, an alternative to caesarean section in the 2nd stage
The main principle	Not to “forcefully end labor,” but to safely speed it up under the right conditions
Where is it used most often?	With the inserted head in a low position
What is outdated?	The idea of widespread use of high forceps in routine practice

The table summarizes the current position of the method. [6]

When are tongs actually used?

Modern indications for the use of forceps generally coincide with those for any instrumental vaginal delivery. The main reasons are a prolonged second stage of labor, suspected deterioration in fetal condition, and the need to shorten the second stage for the mother's sake. NICE formulates this practically: forceps or vacuum are offered if there is concern for the baby's well-being, if the second stage is prolonged, or if the woman requires assistance to complete the birth. [7]

A prolonged second stage of labor is not assessed using a single overall figure, but rather takes into account parity and the presence of epidural analgesia. NICE states that without epidural analgesia, in first-time mothers, after 1 hour of active pushing, the situation should be reassessed. If birth is not expected after 2 hours of pushing, a decision on the mode of delivery is required; for multiparous mothers, the thresholds are shorter. A passive phase is acceptable with epidural analgesia, but even there, there are clear considerations for a more thorough review and decision on further management. [8]

The second major group of indications are signs of possible fetal distress. If the baby's heart rate becomes alarming and there is reason to believe that delaying birth is dangerous, instrumental termination of labor may be the quickest option. This is not to say that forceps are "better" than any other method per se, but rather that at a given moment, they may be the fastest way to complete a vaginal birth. [9]

The third group of indications relates to the mother's condition. These include situations where continued vigorous pushing is undesirable or when the woman can no longer push effectively due to exhaustion. Modern sources cite cardiac pathology, certain neurological conditions, and maternal exhaustion as examples. Essentially, the purpose of forceps in such cases is not to "cure" the problem, but to shorten the period of intense pushing. [10]

Finally, context is important. Forceps are used not because labor is "difficult in general," but because labor has already reached a stage where vaginal completion is feasible and potentially safe. If signs of obstruction, a non-involved fetal head, an unknown position, or obvious disproportion make the procedure questionable, modern tactics shift toward cesarean section rather than more aggressive traction. [11]

Main indication	What does this mean in practice?
Prolonged 2nd stage of labor	The head is not moving forward fast enough despite pushing and re-evaluating the situation
Suspected deterioration of fetal condition	The baby needs to be born faster.
The need to reduce pushing for the sake of the mother	Cardiac, neurological causes, severe exhaustion, inability to push effectively
Request for assistance in completing labor	Permissible only if safety conditions are maintained
Not an indication	Attempting to "push" a mechanical obstacle or an unknown position of the head through the forceps

Table based on NICE and MSD Manual. [12]

What conditions must be met before applying forceps?

Several mandatory conditions must be met before forceps can be applied. The MSD Manual lists the main ones: full cervical dilation, an inserted fetal head at station +2 or lower, amniotic fluid leakage, a known fetal head position, an empty bladder, and clinical confidence that the pelvic dimensions allow for vaginal delivery. These include adequate pain relief, informed consent, and the neonatal team's readiness to deliver the baby if necessary. [13]

One of the key conditions is a precise understanding of the position of the fetal head. This is essential for a conventional direct procedure, but critical for rotary forceps. The RCOG specifically reminds that before using rotary forceps, especially Kielland's forceps, the position of the occiput must be reliably determined. Moreover, ultrasound assessment of the position of the head is more reliable than clinical examination and is therefore considered desirable. [14]

Equally important is confirmation of the absence of obstruction. NICE recommends that if the second stage is prolonged, there are no signs of obstructed labor before any active decisions are made. This is crucial: forceps are not designed to overcome a significant mechanical obstruction. If an obstruction is present, attempting to pull with the instrument only increases the risk to the woman and the baby. [15]

The location of the procedure is also important. The RCOG states that if a simple assisted vaginal birth is planned, labor can continue in the same delivery room. However, if a more complex situation is expected or there is a significant risk of failure, it is better to transfer the woman to the operating room in advance so that a caesarean section can be performed immediately if necessary. This is not a "safety precaution," but a modern safety standard. [16]

Thus, the question of "when to use forceps" cannot be separated from the question of "under what conditions is it generally acceptable?" In practice, good indications without fulfilling the conditions do not necessarily mean forceps can be used. Modern obstetric logic is strict here: safety and success rate come first, then the instrument. [17]

Mandatory condition	Why is this important?
Full dilation of the cervix	Otherwise, the risk of neck injury and unsuccessful attempt increases.
Inserted and low-lying head	The method is designed for a low position of the head
The poured out waters	Necessary for safe instrument contact with the head
The position of the head is precisely known	Without this, there is a higher risk of incorrect application and injury.
Empty bladder	Reduces the risk of injury and makes the procedure easier to perform
Adequate pain relief and consent	The procedure should not be performed without adequate pain relief and discussion of the strategy.
Readiness to change the plan immediately	If the attempt fails, there is no time to waste

The table summarizes the necessary prerequisites for a safe procedure. [18]

Forceps, vacuum extraction or cesarean section: how to choose

In modern obstetric practice, forceps and vacuum extraction are not contrasted as "good" and "bad" methods. NICE recommends choosing an instrument based on the clinical situation and the practitioner's experience. This is a crucial statement: even a technically sound instrument becomes a poor choice if the operator lacks confidence in using it in a given situation. [19]

There are, however, several consistent differences between the methods. A recent AJOG review indicates that the likelihood of successful completion of delivery with the first instrument chosen is higher with forceps than with vacuum extraction. In other words, vacuum extraction is more likely to be a failed first attempt, after which the plan must be modified. This doesn't make vacuum a bad method, but it does explain why, in some clinical situations, the choice immediately leans toward forceps. [20]

On the other hand, forceps are generally associated with a higher rate of maternal perineal trauma. According to the RCOG, severe grade 3 or 4 perineal lacerations occur in approximately 4% of women after vacuum extraction and in 8-12% after forceps deliveries. The MSD Manual also emphasizes that significant perineal trauma and neonatal bruising are more common with forceps, while cephalohematoma, jaundice, and retinal bleeding are more common with vacuum extraction. [21]

There are also specific situations in which forceps may be superior. The RCOG recommends that in preterm births of less than 36 weeks, forceps may be preferred over ventouse, as a vacuum in a more immature baby increases the risk of soft tissue injury to the head. This is not a universal rule for all preterm births, but it is an important example of how the choice of instrument depends not only on the position of the head but also on gestational age. [22]

Another key point is caution regarding the sequential use of two instruments. Current reviews and guidelines warn that the sequential use of vacuum and forceps is associated with a higher risk of injury, especially to the baby, and should not become a routine tactic. Therefore, if one method fails, the team must quickly reassess the risks: whether to continue with a different instrument or proceed to a cesarean section. [23]

Comparison	Forceps	Vacuum extraction
The probability of successful completion of labor with the first instrument	Usually higher	Usually lower
Perineal trauma in mother	More often	Less often
Severe perineal lacerations	Higher risk	Lower risk
Bruises and soft tissue trauma to the child's face	More often	Less often
Cephalohematoma and subgaleal trauma	Less often	More often
Use before 36 weeks	Often preferable	Less preferable

The table summarizes a modern comparison of forceps and vacuum.[24]

How the procedure works and what makes it safer

Modern procedures begin not with instruments, but with a conversation. NICE and RCOG emphasize the importance of an informed decision: the woman needs to be explained why the birth needs to be accelerated, what options are available, the differences between forceps, vacuum, and caesarean section, the urgency, and the limitations of the current situation. If the woman in labor refuses forceps or vacuum, the remaining safe options and their feasibility should be discussed. [25]

A clinical reassessment is then performed. The RCOG states in its patient information that before assisted vaginal birth, an abdominal and vaginal examination is performed, the safety of the procedure for mother and baby is confirmed, and the woman is typically asked to lie down with her legs supported and the bladder is emptied with a catheter. Anesthesia can be local, epidural, or spinal – the choice depends on the situation and existing analgesia. [26]

The actual delivery occurs synchronously with contractions and pushing. Forceps are applied to the baby's head, and traction is used to complete the birth. An episiotomy is sometimes necessary, but not automatically: NICE recommends performing it when clinically necessary, including during forceps-assisted or vacuum-assisted deliveries, or if fetal compromise is suspected. [27]

The safety of the procedure depends heavily on the location and the preparedness of the team. If a more complex procedure is anticipated or there is a real risk of failure, the birth is best performed in an operating room. It's also easier to immediately proceed to a cesarean section if the attempt is unsuccessful. Furthermore, a neonatal specialist is often present in case the baby requires additional assistance immediately after birth. [28]

At this stage, attention doesn't end after birth. NICE recommends offering the woman one dose of intravenous co-amoxiclav within 6 hours of cord clamping, or a topical alternative if she is allergic to penicillin, to reduce the risk of infectious complications after instrument-assisted birth. Blood loss, perineal lacerations, the need for suturing, and the baby's condition are then assessed. [29]

Stage	What needs to be done
Before the procedure	Discuss urgency, options, risks, and obtain consent
Re-evaluation	Confirm the position of the head, the safety of vaginal completion of labor, and the readiness of the team
Preparation	Empty the bladder and provide adequate pain relief.
During the procedure	Work in sync with contractions and pushing, and perform an episiotomy if necessary
After birth	Assess injuries, bleeding, the child's condition, and consider infection prevention.

The table reflects the current sequence of actions. [30]

Risks for mother and baby, recovery, and when the method is justified

Women who deliver using forceps are more likely than those who deliver spontaneously to experience heavier bleeding immediately after birth, the need for an episiotomy, vaginal and perineal tears, and a longer hospital stay. The RCOG specifically warns that heavier bleeding is more common immediately after an assisted vaginal birth, and the risk of severe perineal tears is particularly high after a forceps birth. [31]

Forceps are not innocuous for the baby either. They are more often associated with bruises, soft tissue abrasions, and certain types of localized trauma to the face and head. Vacuum delivery carries a higher risk of scalp injury, caput succedaneum, cephalohematoma, and subgaleal hematoma. Most of these complications are not catastrophic, but they are possible, which is why modern obstetrics so strictly ties instrument selection to the operator's experience and the accuracy of case selection. [32]

However, it would be a mistake to portray forceps as an inherently "bad" method. When chosen correctly, they can be a less risky solution than attempting to prolong the second stage or performing a difficult caesarean section on an already very low-lying fetus. The RCOG clearly states that a caesarean section late in labor can, in some circumstances, be more complex and increase the risk of harm to both mother and baby compared to a successful assisted vaginal birth. [33]

Therefore, the question is not whether forceps are "good in themselves," but whether the specific case was appropriate. Forceps are justified when the second stage is prolonged or the baby needs to be delivered quickly, when the head is already low, its position is clear, there are no obstacles to vaginal delivery, the operator is experienced, and the team is ready to quickly change the plan. They are not justified when they are used as a substitute for a full assessment of obstructed labor, an unknown position of the head, or unpreparedness for an emergency cesarean section. [34]

This is precisely the modern conclusion the reader should be taking. Obstetric forceps are not used "for generally difficult births," but in strictly limited, well-evaluated situations during the second stage of labor, when it is necessary to quickly and safely complete a vaginal birth. This is a highly effective and, at the same time, highly responsible tool: it is useful only where all safety conditions are met. [35]

Situation	The tongs are more likely to be justified	The tongs are probably not justified
Prolonged 2nd period with a low inserted head	Yes	No, if the head is high
The need to quickly complete labor due to concerns about the fetus	Yes	No, if the head position is unclear
Maternal exhaustion or undesirability of further pushing	Yes	No, if there are signs of obstruction
The expected chance of successful vaginal delivery	Yes	No, if failure is likely and there is no readiness for an immediate caesarean section
Experienced operator and a ready team	Yes	No, if the skill or conditions are not sufficient

The table summarizes the limits of reasonable application of the method. [36]

Result

The most important thing today is not the instrument design or the "significance of the operation in obstetrics," but the indications, mandatory conditions, informed consent, comparison with vacuum extraction, and an honest discussion of the risks.

In short, obstetric forceps are used when it is necessary to expedite birth in the second stage of labor, when the fetal head is already low and inserted, its position is known, the conditions for vaginal completion of labor are realistic, and the use of forceps in this situation is safer or faster than continuing to wait or switching to a cesarean section. In all other situations, modern medicine demands not courage, but rather abandoning an inappropriate attempt. [38]