Evidence regarding long-term neurodevelopmental outcomes in children born by operative delivery is reassuring. In an older study, Seidman and colleagues (1991) evaluated more than 52,000 Israeli Defense Forces dratees at age 17 years and found that regardless of delivery mode, rates of physical or cognitive impairments were similar. Wesley and associates (1992) noted similar intelligence scores among 5-year-olds following spontaneous, forceps, or vacuum deliveries. Murphy and coworkers (2004) found no association between forceps delivery and epilepsy in a cohort of more than 21,000 adults. In their epidemiological review, O'Callaghan and colleagues (2011) found no association between cerebral palsy and operative delivery. Last, Bahl and associates (2007) noted that the incidence of neurodevelopmental morbidity was similar in those undergoing successul forceps delivery, failed forceps with cesarean delivery, or cesarean delivery without forceps.
Data regarding midforceps deliveries are for the most part reassuring. Broman and coworkers (1975) reported that infants delivered by midforceps had slightly higher intelligence scores at age 4 years compared with those of children delivered spontaneously. Using the same database, however, Friedman and associates (1977, 1984) analyzed intelligence scores at or after age 7 years. They concluded that children delivered by midforceps had lower mean intelligence quotients compared with those delivered by outlet forceps. In yet another report from this database, Dierker and colleagues (1986) compared long-term outcomes of children delivered by midforceps with those delivered by cesarean after dystocia. he strength of this study is the appropriateness of the control group. hese investigators reported that delivery by midforceps was not associated with neurodevelopmental disability. Last, Nilsen (1984) evaluated 18-year-old men and found that those delivered by Kielland forceps had higher intelligence scores than those delivered spontaneously, by vacuum extraction, or by cesarean.
If an attempt to perform an operative delivery is expected to be diicult, then it should be considered a trial. Moving the woman to an operating room for this attempt, which could be followed by immediate cesarean delivery if operative delivery fails, has merit. If forceps cannot be satisfactorily applied, then the procedure is stopped and either vacuum extraction or cesarean delivery is performed. With the former, if the fetus does not descend with traction, the trial should be abandoned and cesarean delivery performed.
With such caveats, cesarean delivery after an attempt at operative vaginal delivery was not associated with adverse neonatal outcomes if there was a reassuring fetal heart rate tracing (Alexander, 2009). A similar study evaluated 122 women who had a trial of midcavity forceps or vacuum extraction in a setting with full preparations for cesarean delivery (Lowe, 1987). Investigators found no significant diference in immediate neonatal or maternal morbidity compared with that of 42 women delivered for similar indications by cesarean but without such a trial. Conversely, in 61 women who had "unexpected" vacuum or forceps failure in which there was no prior preparation for immediate cesarean delivery, neonatal morbidity was higher.
Some factors associated with operative delivery failure are persistent occiput posterior position and birthweight >4000 g (Ben-Haroush, 2007; Verhoeven, 2016). However, Palatnik and associates (2016) found that risk factors poorly predicted success. In general, to avert morbidity with failed forceps or vacuum delivery, the American College of Obstetricians and Gynecologists (2015) cautions that these trials should be attempted only if the clinical assessment suggests a successful outcome. We also emphasize proper training.