Guideline sources The following summarized guidelines for the evaluation and management of assisted vaginal delivery are prepared by our editorial team based on guidelines from the European Association of Perinatal Medicine (EAPM 2022), the Royal College of Obstetricians and Gynaecologists (RCOG 2020), the American College of Obstetricians and Gynecologists (ACOG 2020), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2019; 2018), and the World Health Organization (WHO 2015). 1 2 3 4 5 6 Guidelines 1. Classification and risk stratification https://web.pathway.md/diseases/recdwpSswFSfKW1N5 1/6 6/23/23, 3:12 AM Assisted vaginal delivery Pathway Classification: use a standard classification system for assisted vaginal delivery to promote safe clinical practice, effective communication between health professionals, and audit of outcomes. B 2. Diagnostic investigations Ultrasound: Obtain ultrasound assessment of the fetal head position before assisted vaginal delivery where uncertainty exists following clinical examination. A Insufficient evidence to recommend routine abdominal or perineal ultrasound for assessment of the station, flexion, and descent of the fetal head in the second stage of labor. I 3. Medical management Antibiotic prophylaxis: As per RCOG 2020 guidelines, administer a single prophylactic dose of IV amoxicillin and clavulanic acid following assisted vaginal delivery. A As per ACOG 2015 guidelines, do not administer routine antibiotic prophylaxis in patients undergoing operative vaginal birth. D Analgesia: offer regular NSAIDs and paracetamol routinely in the absence of contraindications. A Postpartum thromboprophylaxis: reassess patients after assisted vaginal delivery for VTE risk and the need for thromboprophylaxis. B 4. Nonpharmacologic interventions Psychological support: ensure shared decision-making and good communication, and provide positive continuous support during labor and birth to reduce psychological morbidity after birth. B Show 4 more 5. Therapeutic procedures Indications for assisted vaginal delivery: As per RCOG 2020 guidelines, recognize that no indication is absolute and clinical judgment is required in all situations. B As per SOGC 2019 guidelines, consider encouraging the use of safe and effective assisted vaginal delivery by experienced and skilled care providers as a strategy to reduce the rate of primary Cesarean delivery. C https://web.pathway.md/diseases/recdwpSswFSfKW1N5 2/6 6/23/23, 3:12 AM Assisted vaginal delivery Pathway Contraindications for assisted vaginal delivery: as per RCOG 2020 guidelines, recognize that suspected fetal bleeding disorders or a predisposition to fracture are relative contraindications to assisted vaginal delivery. B Show 3 more Choice of instrument: As per RCOG 2020 guidelines, decide on the choice of the instrument most appropriate to the clinical circumstance and the operator's level of skills. B Show 2 more As per SOGC 2019 guidelines, determine the instrument most suitable to the clinical circumstance and physician's level of skill. Recognize that vacuum and forceps are associated with different short- and long-term benefits and risks, and unsuccessful delivery is more likely with the vacuum. A Show 2 more Considerations for assisted vaginal delivery, general principles: As per RCOG 2020 guidelines, ensure a careful assessment of the clinical situation, clear communication with the patient and healthcare personnel, and expertise in the chosen procedure for safe assisted vaginal delivery. B Show 5 more As per SOGC 2019 guidelines: Ensure appropriate expertise in the chosen method, comprehensive assessment of the clinical situation alongside clear communication with the patient, support people, and healthcare personnel for safe and effective assisted vaginal delivery. B Attempt a trial of assisted vaginal delivery performed in a location where immediate recourse to Cesarean delivery is available if assisted vaginal delivery is deemed to have a higher risk of not being successful. B Considerations for assisted vaginal delivery (vacuum extraction): discontinue vacuum- assisted birth if there is no evidence of progressive descent with moderate traction during each pull of a correctly applied instrument by an experienced operator. B Show 7 more Considerations for assisted vaginal delivery (forceps use): discontinue attempted forceps delivery where the forceps cannot be applied easily, the handles do not approximate easily, or if there is a lack of progressive descent with moderate traction. B Show 5 more 6. Surgical interventions Episiotomy: As per EAPM 2022 guidelines, perform episiotomy by indication only, B including in order to shorten the second stage of labor when there is suspected fetal hypoxia, B , prevent obstetric https://web.pathway.md/diseases/recdwpSswFSfKW1N5 3/6 6/23/23, 3:12 AM Assisted vaginal delivery Pathway anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries. B Show 3 more As per RCOG 2020 guidelines, consider performing mediolateral episiotomy, discussed with the patient, as part of the preparation for assisted vaginal delivery. C Show 2 more As per SOGC 2019 guidelines, consider performing mediolateral episiotomy for assisted vaginal delivery, restricted to selected cases. C 7. Patient education Antenatal counseling: inform patients about assisted vaginal delivery in the antenatal period, especially during their first pregnancy, and if they indicate specific restrictions or preferences then explore this with an experienced obstetrician, ideally in advance of labor. B Show 2 more Postpartum counseling: Provide a debrief and support to the patient immediately following an attempted or successful assisted vaginal delivery and, if this is not possible, debrief before hospital discharge including the indication for assisted vaginal delivery, management of any complications, and the prognosis for future deliveries. B Encourage patients to consider spontaneous vaginal birth in a subsequent pregnancy. Individualize care planning and respect patient preferences. B 8. Preventative measures Prevention of assisted vaginal delivery: As per RCOG 2020 guidelines, ensure continuous support during labor to reduce the need for assisted vaginal birth. A Show 8 more As per SOGC 2019 guidelines, consider providing the following to reduce the need for assisted vaginal birth: dedicated and continuous support during labor B oxytocin augmentation of inadequate labor B delayed pushing in patients with an epidural B prolonged pushing in nulliparous patients with an epidural B optimization of fetal head position through manual rotation. B 9. Follow-up and surveillance https://web.pathway.md/diseases/recdwpSswFSfKW1N5 4/6 6/23/23, 3:12 AM Assisted vaginal delivery Pathway Prevention of urinary retention: counsel patients about the risk of urinary retention ensuring that they are aware of the importance of bladder emptying in the postpartum period. B Show 4 more 10. Quality improvement Documentation: Document the following regarding assisted vaginal delivery using a standardized form: detailed information on the assessment decision making and conduct of the procedure a plan for postnatal care sufficient information for counseling in relation to subsequent pregnancies. B Show 2 more Health professional training: As per RCOG 2020 guidelines: Ensure that obstetric trainees achieve expertise in spontaneous vaginal delivery before commencing training in assisted vaginal delivery. B Ensure that obstetric trainees receive appropriate training in vacuum and forceps birth, including theoretical knowledge, simulation training, and clinical training under direct supervision. Ensure competency is demonstrated before conducting unsupervised births. B As per SOGC 2019 guidelines: Ensure that practitioners performing assisted vaginal delivery have the knowledge, skills, and experience necessary to assess the clinical situation, use the selected instrument, and manage complications that may arise from assisted vaginal delivery. B Provide comprehensive training in assisted vaginal delivery in obstetrical trainees and ensure that they are competent before proceeding to independent practice. B References 1. D J Murphy, B K Strachan, R Bahl et al. Assisted Vaginal Birth: Green-top Guideline No. 26. BJOG. 2020 Aug;127 9):e70-e112. Open 2. Committee on Practice Bulletins Obstetrics with the assistance of Alan M. Peaceman, MD. Operative Vaginal Birth: ACOG Practice Bulletin, Number 219. Obstet Gynecol. 2020 Apr;135 4):e149-e159. Open 3. Yvonne M Cargill, Catherine Jane MacKinnon. No. 148 Guidelines for Operative Vaginal Birth. J Obstet Gynaecol Can. 2018 Feb;40 2):e74-e80. Open 4. No authors listed. WHO Recommendations for Prevention and Treatment of Maternal Peripartum Infections. Geneva: World Health Organization; 2015. Open 5. Sebastian Hobson, Krista Cassell, Rory Windrim et al. No. 381 Assisted Vaginal Birth. J Obstet Gynaecol Can. 2019 Jun;41 6 870 882. Open https://web.pathway.md/diseases/recdwpSswFSfKW1N5 5/6 6/23/23, 3:12 AM Assisted vaginal delivery Pathway 6. Katariina Laine, Branka M Yli, Vanessa Cole et al. European guidelines on perinatal care- Peripartum care Episiotomy. J Matern Fetal Neonatal Med. 2022 Dec;35 25 8797 8802. Open https://web.pathway.md/diseases/recdwpSswFSfKW1N5 6/6