Instrumental delivery — MSF Essential obstetric and newborn care

What this guideline says

GMJ summary

This section of the MSF Essential Obstetric and Newborn Care guideline provides practical instruction on instrumental delivery using vacuum extractors or forceps. Both instruments require identical conditions: full cervical dilation, regular uterine contractions, engaged foetal head, accurate head position diagnosis, ruptured amniotic sac, and empty bladder. The choice between vacuum and forceps depends on operator skill and experience.

Vacuum extraction is indicated for failure to progress despite good contractility, foetal distress during delivery, resistant perineum, or difficult caesarean extraction. Key contra-indications include breech/transverse/face/brow presentation, prematurity below 34 weeks (soft skull bones), unengaged head, and incomplete dilation. The technique emphasizes proper cup positioning near the posterior fontanelle, checking for trapped tissue before traction, synchronizing traction with contractions, and limiting attempts.

Critical safety limits include: maximum 20 minutes of suction (typically birth occurs within 15 minutes), no more than 3 cup detachments, and no more than 3 traction attempts without progress. Failure mandates caesarean section. Forceps require special expertise and can be used when the mother cannot push or in mentum anterior face presentation, with similar indications and contra-indications to vacuum extraction.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Both vacuum and forceps require: full dilation, regular contractions, engaged head, ruptured membranes, and empty bladder
2. Vacuum extractor is contra-indicated in preterm neonates <34 weeks due to soft skull bones
3. Position vacuum cup as close as possible to posterior fontanelle; always check for trapped cervical or vaginal tissue before traction to prevent massive haemorrhage
4. Apply traction synchronized with uterine contractions; direction varies from downward to horizontal to vertical as head progresses
5. Do not apply suction for more than 20 minutes (typically birth occurs in <15 minutes); risk of scalp necrosis with prolonged application
6. Maximum 3 attempts at cup re-application if detachment occurs; maximum 3 traction attempts without progress
7. If instrumental delivery fails after appropriate attempts, perform caesarean section
8. Forceps can be used when vacuum cannot: mentum anterior face presentation or when mother cannot push actively

Conditions required for instrumental delivery (vacuum extractor or forceps)

Table extracted from the guideline

Source: Médecins Sans Frontières, Instrumental delivery — MSF Essential obstetric and newborn care. Reproduced in summary form.

From the guideline

Verbatim

“Do not apply suction for more than 20 minutes: the indication is probably incorrect, and there is a risk of scalp necrosis.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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