Original Research

Forceps Compared With Vacuum

Rates of Neonatal and Maternal Morbidity
Aaron B. Caughey, MD, MPP, Per L. Sandberg, MD, Marya G. Zlatnik, MD, MMS,
Mari-Paule Thiet, MD, Julian T. Parer, MD, PhD, and Russell K. Laros Jr, MD
OBJECTIVE: To compare perinatal outcomes between
forceps- and vacuum-assisted deliveries. Our hypothesis
was that the force vectors achieved in forceps delivery
will lead to fewer shoulder dystocias, but greater perineal
lacerations.
METHODS: This was a retrospective cohort study of
4,120 term, cephalic, singleton, nonrotational operative
vaginal deliveries at a single institution. Outcomes exam-
ined included rates of neonatal trauma, shoulder dysto-
cia, and perineal lacerations. Potential confounders, in-
cluding maternal age, birthweight, ethnicity, parity,
station at delivery, episiotomy, attending physician, an-
esthesia, and length of labor, were controlled for using
multivariate logistic regression.
RESULTS: Among the 2,075 (50.4%) forceps- and 2,045
(49.6%) vacuum-assisted deliveries, the rate of shoulder
dystocia was lower among women undergoing forceps
delivery (1.5% compared with 3.5%, P < .001), as was the
rate of cephalohematoma (4.5% compared with 14.8%,
P < .001), whereas the rate of third- or fourth-degree
perineal laceration was higher (36.9% compared with
26.8%, P < .001). These differences in perinatal compli-
cations persisted when controlling for the confounders
listed above. The adjusted odds ratio for shoulder dysto-
cia was 0.34 (95% confidence interval [CI] 0.200.57), for
cephalohematoma was 0.25 (95% CI 0.190.33), and for
third- or fourth-degree lacerations was 1.79 (95% CI
1.522.10) when comparing forceps to vacuum.
CONCLUSION: Vacuum-assisted vaginal birth is more
often associated with shoulder dystocia and cephalohe-
matoma. Forceps delivery is more often associated with
third- and fourth-degree perineal lacerations. These dif-
ferences in complications rates should be considered
among other factors when determining the optimal
mode of delivery.
(Obstet Gynecol 2005;106:90812)
LEVEL OF EVIDENCE: II-2
T
he modern-day vacuum extractor was first intro-
duced in 1954,
1
and its use slowly diffused into
obstetric practice during the ensuing three decades.
However, since the late 1980s the use of the vacuum
extractor has increased whereas the use of forceps has
decreased.
2,3
These trends of obstetric management
have occurred despite little evidence regarding which
form of assisted vaginal delivery is optimal in different
settings.
A recent meta-analysis included all of the pro-
spective randomized trials of forceps compared with
vacuum.
4
There were only 10 such studies, with
sample sizes ranging from 36
5
to 637.
6
This collection
of analyses revealed that vacuum extractors have a
higher rate of failure than forceps and lead to greater
rates of cephalohematoma and retinal hemorrhage.
They were also associated with a trend toward a
greater rate of 5-minute Apgar scores less than 7.
Forceps were associated with greater rates of perineal
injury and short-term postdelivery pain. A variety of
other outcomes were examined, and no differences
were demonstrated. However, most outcomes were
too underpowered in the analysis for any conclusions
to be drawn.
There have also been several large birth-certifi-
catebased analyses that have demonstrated higher
rates of cephalohematoma
79
and lower rates of peri-
neal laceration,
8,9
but no difference in intracranial
hemorrhage or perinatal mortality.
7,8
However, when
intracranial hemorrhage was subdivided further, an
From the Department of Obstetrics, Gynecology and Reproductive Sciences,
University of California, San Francisco; and the Department of Obstetrics and
Gynecology, California Pacific Medical Center, San Francisco, California.
Dr. Caughey is supported by the National Institute of Child Health and Human
Development, Grant # HD01262 as a Womens Reproductive Health Research
Scholar.
Corresponding author: Aaron B. Caughey, MD, MPP, MPH, Department of
Obstetrics and Gynecology, University of California, San Francisco, 505
Parnassus Avenue, Box 0132, San Francisco, CA 94143; e-mail:
abcmd@berkeley.edu.
2005 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/05
908 VOL. 106, NO. 5, PART 1, NOVEMBER 2005 OBSTETRICS & GYNECOLOGY
increase in subarachnoid hemorrhage was noted in
one analysis.
9
These studies are limited with respect to
causality because little is known about a variety of
confounding variables, including type and experience
of provider and indication for delivery. One of these
analyses also demonstrated a higher rate of shoulder
dystocia for vacuum-assisted vaginal delivery when
compared with either forceps delivery or vacuum and
forceps used sequentially.
8
The largest prospective
randomized controlled trial of forceps compared with
vacuum also identified a trend toward a higher rate of
shoulder dystocia among their vacuum-assisted vagi-
nal deliveries.
6
The proposed mechanisms for the differences in
these outcomes include the increased occupation of
space in the vagina, and thus greater distention of the
vagina walls and perineum by the forceps, leading to
increased perineal and vaginal lacerations. Alterna-
tively, the placement of the vacuum directly on the
scalp has been proposed to increase the rates of
cephalohematoma, retinal hemorrhage, and intracra-
nial hemorrhage,
7
although only the first two have
been demonstrated. Finally, the ability to pull harder
with forceps is proposed to explain the increased rate
of success. It is of note that this last theory should
actually support a higher rate of shoulder dystocia
among forceps as opposed to vacuum deliveries.
We propose, however, that it is not the total
magnitude of the resultant force vector that leads to
shoulder dystocia, but rather where it acts and in what
direction. The forceps are placed cradling the entire
fetal head, thus the resultant force vector applied to
the fetal head acts further caudally along the fetal
head, approximately half the distance of the blades
(Fig. 1), and closer to the fetal shoulders thorax.
Moreover, because of the placement around the fetal
head, force vectors can be generated ranging from
perpendicular to the ground to horizontal. Because
the resultant force vector used when delivering by
forceps is directed farther down the head and in a
more downward direction, it is likely to facilitate in
directing the anterior shoulder down and possibly
underneath the pubic symphysis. The vacuum, be-
cause it is attached directly in front of the posterior
fontanelle and the direction of its resultant force
vector is at most 45 degrees to the floor, actually may
lead to more traction force on the fetal head, pulling
the anterior shoulder into the pubic symphysis and
lodging it in this location.
Given this background and our proposed mech-
anism, we generated the hypothesis that forceps
should be associated with fewer shoulder dystocias
than vacuum. However, because of the generation of
greater downward force by the forceps, we hypothe-
sized that they would be associated with a higher rate
of perineal laceration.
METHODS
We designed a retrospective cohort study of all sin-
gleton neonates delivered beyond 37 weeks gesta-
tional age in the vertex presentation by nonrotational
forceps or vacuum from January 1, 1981, to Decem-
ber 1, 2001, at the Moffitt-Long Hospital at the
University of California, San Francisco. Exclusion
criteria included delivery before 37 weeks of gesta-
tion, fetal anomalies, noncephalic presentation, occi-
put transverse position, and multiple gestation. This
study was approved by the Investigational Review
Board at the University of California, San Francisco.
Our primary outcomes, shoulder dystocia and peri-
neal laceration, were entered into data entry sheets by
the delivering clinician and verified by trained ab-
stractors. Shoulder dystocia is defined at our institu-
tion as any delivery requiring additional maneuvers
to deliver the shoulders of the infant, including
McRoberts maneuver, suprapubic pressure, Woods
or Rubin maneuvers, or delivery of the posterior arm.
We also collected information on the following sec-
ondary outcomes: vaginal lacerations, cervical lacer-
ations, cephalohematoma, intracranial hemorrhage,
Erbs palsy, facial nerve palsy, neonatal jaundice,
skull, clavicle and humerus fractures, neonatal sei-
zures, Apgar scores, umbilical artery pH, umbilical
artery base excess, and neonatal intensive care unit
(NICU) admission. The following data were also
collected and examined as potential confounders:
maternal age, ethnicity, education, body mass index,
diabetes mellitus (both preconceptional and gesta-
Fig. 1. Component and resultant force vectors exerted by
forceps and vacuum extractor. A. Forceps: The force vector
is applied farther down fetal head. The force vector ranges
from perpendicular to outward. B. Vacuum: The force
vector is applied at fetal vertex. The force vector ranges
from approximately 45 down to outward.
Caughey. Forceps or Vacuum: Obstetric Complications. Obstet
Gynecol 2005.
VOL. 106, NO. 5, PART 1, NOVEMBER 2005 Caughey et al Forceps or Vacuum: Obstetric Complications 909
tional), length of labor, station at delivery, position at
delivery, obstetric provider(s), year of delivery, parity,
anesthesia, and birthweight.
The data were then compiled and analyzed using
STATA 7 software (StataCorp, College Station, TX).
Univariate analyses of the primary predictor, forceps
compared with vacuum, were performed examining
the primary and secondary outcomes of interest and
compared using the
2
test. Because the rates of many
of the neonatal complications were low, a summary
variable called severe complications was created
that included birth trauma (including skull fracture,
brachial plexus injury, facial nerve palsy), neonatal
seizures, and intracranial hemorrhage. For each of
these primary and secondary outcomes a multivariate
logistic regression was performed, including the po-
tential confounders. The confounders contributions
to the model were tested using the maximum likeli-
hood ratio test, and they were only kept in the model
if they were statistically significant. Statistical signifi-
cance was defined as P .05.
RESULTS
During the study period, there were 4,120 women
who met the inclusion and exclusion criteria outlined
above. Of these, 2,075 (50.4%) delivered by forceps
and 2,045 (49.6%) delivered by vacuum-assisted vag-
inal delivery. The women who underwent forceps-
assisted vaginal delivery were more likely to be aged
younger than 35 years, nulliparous, and have Medic-
aid insurance, an episiotomy, and epidural analgesia
(Table 1). When the primary outcomes were exam-
ined, we found that the rate of shoulder dystocia was
lower among women undergoing forceps delivery
(1.5%) compared with those undergoing vacuum-
assisted vaginal delivery (3.5%, P .001). The rate of
third- or fourth-degree lacerations was higher among
forceps deliveries (36.9%) compared with vacuum-
assisted vaginal deliveries (26.8%, P .001). Among
the secondary outcomes, the rates of 5-minute Apgar
scores less than 7, cephalohematoma, admissions to
NICU, and neonatal jaundice were higher among
women undergoing vacuum-assisted vaginal delivery
(Table 2), whereas vaginal lacerations, cervical lacer-
ations, and facial nerve palsy were higher among
women undergoing forceps deliveries. No differences
were seen in umbilical artery blood gases, intracranial
hemorrhage, or other types of neonatal trauma.
In multivariate analyses, when controlling for
potential confounders, most of the significant univar-
iate findings persisted (Table 3), with adjusted odds
ratios (AOR) that did not cross unity. Shoulder dys-
tocia was lower among women with a forceps delivery
(AOR 0.34, 95% confidence interval [CI] 0.200.57),
and both vaginal lacerations and third- and fourth-
degree perineal lacerations were higher (AOR 1.79,
95% CI 1.522.10). A vacuum-assisted vaginal deliv-
ery was still associated with higher rates of 5-minute
Apgar scores less than 7, cephalohematoma, admission
to the NICU, and neonatal jaundice. However, the
differences in the rates of cervical laceration and facial
nerve palsy were no longer statistically significant.
To examine the effects of forceps compared with
vacuum among women of differing parity, subgroup
analyses were performed. Among nulliparous pa-
tients, the prior observed differences in the primary
outcomes persisted, with women undergoing forceps
deliveries having a lower rate of shoulder dystocia
(1.4% compared with 3.1%, P .001) and higher rates
of third- and fourth-degree perineal laceration (40.9%
compared with 30.7%, P .001). These results were
confirmed by multivariate analyses; when comparing
forceps to vacuum, the differences were AOR of 0.39
(95% CI 0.230.65) for shoulder dystocia and AOR of
1.48 (95% CI 1.281.73) for third- and fourth-degree
perineal laceration. However, among multiparas the
difference persisted only for shoulder dystocia.
Women with forceps deliveries had a lower rate of
shoulder dystocia (1.7% compared with 4.5%, P
Table 1. Maternal and Obstetric Characteristics
Between Forceps and Vacuum Deliveries
Forceps Vacuum
Variable n 2,075 n 2,045 P
Maternal age 35 15.5 19.1 .002
Ethnicity .292
African-American 11.7 10.7
Asian 33.6 36.2
Hispanic 10.5 9.6
Caucasian 44.2 43.5
Medicaid insurance 39.4 24.4 .001
Nullipara 77.7 74.3 .009
Obese (BMI 29) 6.2 6.5 .665
GDM 3.3 3.3 .999
OP position 12.4 12.3 .936
Birth weight 4,000 g 10.7 11.1 .679
2nd stage 3 h 38.8 38.9 .913
Episiotomy 68.0 50.9 .001
Induction 15.9 15.8 .884
Augmentation 44.8 43.5 .437
Epidural use 84.5 76.3 .001
Station .001
Mid (0, 1) 1.9 2.3
Low (2, 3, 4) 89.3 84.9
Outlet (5) 8.8 12.8
BMI, body mass index; GDM, gestational diabetes mellitus; OP,
occiput posterior.
Values are %.
910 Caughey et al Forceps or Vacuum: Obstetric Complications OBSTETRICS & GYNECOLOGY
.012), but no statistically significant difference in the
rate of third- and fourth-degree lacerations (19.6%
compared with 15.7%, P .107). In multivariate
analyses, comparing forceps with vacuum for shoul-
der dystocia, the outcome was different (AOR 0.41,
95% CI 0.180.96), but for third- and fourth-degree
perineal laceration it was not (AOR 1.19, 95% CI
0.811.69).
DISCUSSION
We found lower rates of shoulder dystocia among
women with forceps deliveries as compared with
women undergoing vacuum-assisted vaginal delivery,
consistent with our proposed hypothesis. We also
found higher rates of perineal and vaginal lacerations
among the women who had forceps deliveries. In
addition to the differences in our primary outcomes,
we also found that women undergoing forceps deliv-
ery had infants with lower rates of cephalohematoma,
5-minute Apgar score less than 7, admission to the
NICU, and neonatal jaundice.
When we examined these outcomes by parity, we
found the differences in the primary outcomes of
shoulder dystocia and third- and fourth-degree peri-
neal laceration persisted for nulliparas. However,
among multiparas, although they still had higher rates
of shoulder dystocia among women undergoing vac-
uum-assisted vaginal delivery, there was no statisti-
cally significant difference noted in third- and fourth-
degree perineal lacerations. This difference could
simply be attributed to the overall higher rates of
perineal laceration among nulliparas. However, the
clinical effect seems to differ, with adjusted odds ratios
of 1.5 among nulliparas and only 1.2 among multip-
aras. Thus, it may be that the downward vector
produced with forceps leads to a greater increase in
perineal trauma among nulliparas than it does in
multiparas.
Our findings of greater shoulder dystocia as well
as several measures of short-term neonatal morbidity
among the neonates of women delivered by vacuum-
assisted vaginal delivery are of concern. Several of
these differences have been noted in small random-
ized trials of forceps compared with vacuum. Despite
these findings, the rate of vacuum use seems only to
be increasing. Moreover, one recent analysis con-
cluded from its analysis of birth certificates that
Delivery by vacuum extraction is at least as safe as
delivery by forceps.
8
Such a conclusive statement is
supported neither by our study nor the broader
literature.
4,6,9
Our study is not without limitations. A nonran-
domized, retrospective, cohort study can be compro-
Table 3. Multivariate Comparison of Maternal and
Neonatal Morbidity Between Forceps
and Vacuum Deliveries
Outcomes*
Forceps
Compared
With Vacuum P
Shoulder dystocia 0.34 (0.200.57) .001
3rd or 4th degree 1.79 (1.522.10) .001
Vaginal laceration 1.77 (1.492.11 .001
Cervical laceration 1.36 (0.832.24) .221
UA pH 7.0 1.53 (0.643.68) .339
UA BE 12 1.16 (0.701.93) .557
5-min Apgar 7 0.67 (0.460.98) .042
Cephalohematoma 0.25 (0.190.33) .001
Serious neonatal
complications

0.98 (0.611.58) .949

NICU admission 0.69 (0.490.97) .033
Neonatal jaundice 0.74 (0.600.92) .006
UA, umbilical artery; BE, base excess; NICU, neonatal intensive
care unit.
Values are adjusted odds ratio (95% confidence interval). The
baseline group is patients delivered by vacuum.
* Controlling for maternal age, ethnicity, Medicaid insurance,
parity, body mass index, diabetes mellitus, fetal position and
station, birthweight, length of labor, episiotomy, year of deliv-
ery, attending provider, induction of labor, and epidural use.
Maternal age, birthweight, length of labor, and year of delivery
were controlled for as continuous variables.

All patients with Erbs palsy, facial nerve palsy, skull, clavicular
fracture, or intracranial hemorrhage.
Table 2. Comparison of Maternal and Neonatal
Morbidity Between Forceps and Vacuum
Deliveries
Forceps Vacuum
Outcomes n 2,075 n 2,045 P
Shoulder dystocia 1.5 3.5 .001
3rd or 4th degree 36.9 26.8 .001
Vaginal laceration 28.6 22.2 .001
Cervical laceration 3.0 1.5 .001
UA pH 7.0 0.9 0.8 .669
UA BE 12 1.9 1.6 .440
5-min Apgar 7 2.8 4.1 .021
Cephalohematoma 4.5 14.8 .001
Serious neonatal
complications* 1.7 2.1 .389
Skull fracture 0.05 0.1 .314
Clavicle fracture 0.6 0.9 .269
Erbs palsy

0.5 0.7 .393

ICH 0.2 0.4 .272
Facial nerve palsy

0.4 0.1 .037

NICU admission 3.7 5.7 .002
Neonatal jaundice 10.7 13.3 .010
UA, umbilical artery; BE, base excess; ICH, intracranial hemor-
rhage; NICU, neonatal intensive care unit.
Values are %.
* These were nerve palsies noted by pediatricians at delivery.

All patients with Erbs palsy, facial nerve palsy, skull, clavicular
fracture, or intracranial hemorrhage.
VOL. 106, NO. 5, PART 1, NOVEMBER 2005 Caughey et al Forceps or Vacuum: Obstetric Complications 911
mised by having multiple confounding variables. We
attempted to control for these confounders using
multivariate techniques in our analysis. Not only did
we control for confounders, such as station, birth-
weight, episiotomy, and parity, that have been asso-
ciated with the outcomes of analysis, but we also
controlled for year of delivery and obstetric provider
in an attempt to control for the more intangible
factors surrounding forceps and vacuum delivery. Of
course, we could not control for the decision-making
process that clinicians undergo when choosing which
instrument to assist in operative vaginal delivery.
Although we were adequately powered to examine
our primary outcomes of shoulder dystocia and per-
ineal lacerations, we were underpowered to examine
some of our secondary outcomes, such as the more
rare neonatal complications. Another possible limita-
tion pertains to the generalizability of our study
population to that of all pregnant women. The pa-
tients in our study were managed at an academic
center in California where the majority of the provid-
ers use both instruments, and deliveries are in con-
junction with a resident provider. Other than this, our
patient population represented a wide spectrum of
ethnicities, ages, and educational levels. Furthermore,
when we controlled for the various maternal charac-
teristics, our findings were robust.
Determination of which instrument to use for an
operative vaginal delivery should entail weighing the
risks and benefits of the instrument to both the
mother and the fetus. It seems that among nulliparas,
the substantial benefit of vacuum to the maternal
perineum should be weighed against the increased
risk of shoulder dystocia and cephalohematoma. In-
terestingly, among multiparas, there seems to be no
benefit from decreased perineal trauma, whereas the
increased risk to the neonate persists. To examine
these outcomes, a large, multicenter, randomized trial
should be performed. Another important aspect of
the decision regarding which instrument to use is
provider comfort with these two modes of operative
vaginal delivery. If providers are not trained in the
use of forceps, they will not be able to provide this
form of operative vaginal delivery, nor make a choice
between the two types of operative vaginal delivery.
Because we do not know which is better, and either
may be the instrument of choice in particular clinical
situations, it is imperative that providers continue to
be trained in the use of forceps as well as vacuum.
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