Assisted Vaginal Deliveries

Service: Risk Management
Subject: Care
Setting: Obstetrics

The application of forceps or vacuum during the second stage of labour is intended to expedite spontaneous vaginal birth. Performed by trained, skilled and experienced practitioners under controlled, appropriate conditions, such instruments can be safely employed to manage challenging deliveries. However, maternal and/or neonatal harm can also result from their use. A recent Canadian study questioned if the goal of reducing cesarean delivery rates comes at a too high cost to patients, and noted “startling high rates of severe perineal trauma” (Ng, 2018). Hospitals and health regions often become involved in malpractice claims associated with vacuum-assisted vaginal delivery (VAVD) and forceps-assisted vaginal delivery (FAVD as a function of their oversight accountabilities for physicians credentialing, privileges and performance management. Hospitals and health regions may also be implicated in VAVD and FAVD malpractice claims as a result of resource challenges, including the absence of contingency plans that may be required during the course of obstetrical emergencies.

Common claim themes

System

  • Lack of availability and use of language and cultural translators for assisted vaginal delivery informed consent discussions.
  • Inconsistent definition and interpretation of a vacuum-related pop off (versus release of pressure during contraction and/or pulls) leading to record discrepancies between nurses and attending physicians.
  • VAVD and FAVD privileges granted and renewed without demonstrated evidence of skill. 
  • Delayed C-sections following failed assisted vaginal delivery due to:
    • Absence of formal second on-call or backup plan for anesthesia;
    • Physician decision to attend other deliveries once a C-section is called.

Knowledge judgment

  • Lack of team and practitioner situation awareness.
  • Assisted vaginal deliveries performed in the absence of maternal or fetal indication (e.g., after 15 minutes of pushing in the absence of clinical indications, due to practitioner convenience or call schedule).
  • Inconsistent practices and expectations surrounding anaesthesia, respiratory therapy and/or Code Pink (i.e., neonatal resuscitation) team attendance for assisted vaginal deliveries.
  • Misapplied forceps and vacuums (i.e., user error).
  • Failure to consider the need for a contingency or backup plan and internal resources in case of failed vacuum or forceps delivery.
  • Delays in abandoning ineffective assisted vaginal deliveries.
  • Informed consent not obtained prior to assisted vaginal delivery (e.g., procedure explained but not the risks).

Communication and documentation

  • Inadequate physician documentation related to assisted vaginal deliveries such as:
    • Informed consent;
    • Indications for VAVD and/or FAVD;
    • Fetal position and status prior to and during assisted vaginal delivery;
    • Number of attempts;
    • Management of shoulder dystocia (where applicable).

CASE study 1

A pregnant person (G3P2, full term) underwent VAVD attempts after twenty minutes into the second stage of labour. There were 3 pop offs over twenty minutes. The on call pediatrician was contacted to attend as the physician was switching over to forceps. There were an additional three FAVD attempts (one with traction) at which point an ‘urgent’ C-section was ordered. The fetal heart pattern was abnormal at the time of the C-section, which was one hour after the time was called. The infant sustained significant trauma and exhibited seizures immediately post birth. Peer expert review of the physician care and management was not supportive, in particular the physician’s decision to apply the vacuum so early on in the labour in the absence of clinical indications. Further, the experts questioned the physician’s decision to attend three other deliveries during the interim between the call for and the performance of the C-section in light of progressively worsening tracings. It was not clear from the health record whether the pregnant person was advised of the risks associated with sequential assisted vaginal delivery. Experts were critical of the primary and charge nurses’ failure to escalate care concerns during the assisted vaginal delivery as well as fetal deterioration after the C-section was called.

Case Study 2

A pregnant person (G2P0) underwent a trial of forceps after ineffective pushing efforts during the second hour of the second stage of labour. Ultimately, an emergency C-Section was necessitated, requiring a second operating room (OR) team to be called from an off-site location. The infant sustained significant skull trauma and severe anoxia following five forceps applications in a period of 15 minutes. Given the nature of the trauma, experts felt that the application of the forceps was ‘not good’. Experts were critical of the physician’s decision to apply forceps without an obvious and compelling reason (i.e., performed near shift change for ‘physician’s convenience’) and noted the healthcare team failed to confirm the fetal status during the trial of forceps. The experts were also critical of the physician’s decision to proceed following three failed attempts. From an organizational perspective, the experts felt the hospital had exhibited a marked lack of preparedness that resulted in the inability of healthcare team to respond to the obstetrical emergency and required a back-up OR team from a remote site.

Mitigation strategies

Reliable Care Processes

  • Implement program-wide interventions to promote spontaneous vaginal deliveries and decrease assisted vaginal deliveries (e.g., one-to-one support in labour, intermittent auscultation in low risk labour, delayed pushing with epidurals, increasing the time pushing with epidural and manual rotation).
  • Adopt a standardized current evidence based protocol, algorithm, and/or care bundle for vacuum and forceps deliveries that includes (but not limited to):
    • Criteria for a vacuum and forcep delivery;
    • Team-based backup plan and exit strategy to facilitate the effective coordination and communication for potential failed assisted vaginal deliveries;
    • Who needs to be present (e.g., personnel skilled in neonatal resuscitation).
  • Conduct debriefs with the team and the pregnant person following all assisted vaginal deliveries, including trials.

Communication and Documentation

  • Implement formal strategies to ensure access to translators and interpreters are available at all times for all laboring patients, especially for informed consent discussions.
  • Adopt a standardized VAVD and FAVD dictation aid and/or medical record template to support and promote timely and consistent physician documentation including (but not limited to):
    • Manual rotation attempts (where applicable) prior to assisted vaginal delivery;
    • Position and station of the fetal head;
    • Amount of moulding and caput present;
    • Assessment of pregnant person’s pelvis and fetal status;
    • Informed consent, including increased risk of trauma to the infant with sequential use of instruments;
    • The use of translators or interpreters (i.e., name and relationship to the maternal patient), including during the informed consent discussions;
    • Instruments used;
    • Indication for use and evidence that prerequisites fulfilled;
    • Duration of traction;
    • Traction and/or force used;
    • Maternal and neonatal complications.
  • Where in place, work with internal/external experts to incorporate assisted vaginal delivery dictation aid and/or medical record template and prompts into the electronic health record.

Strategies for physicians

  • As part of shared decision making, use clear, explicit and unbiased language when communicating with the pregnant person (and documenting) assisted vaginal delivery risks, benefits, alternatives and evidence.
  • Incorporate the following (but not limited to) in assisted vaginal delivery informed consent discussions (and documentation):
    • The overall and evolving clinical scenario for the pregnant person (i.e. a holistic understanding);
    • The likelihood the assisted vaginal delivery will be successful;
    • Foreseeable risks to the pregnant person and fetus associated with sequential assisted vaginal delivery (where considered);
    • Local hospital’s resources to launch a timely C-section.
  • Ensure the timely and consistent documentation of the rationale for:
  • Higher risk assisted vaginal deliveries conducted outside of a C-Section ready room;
  • Continuing the assisted vaginal delivery and/or not proceeding directly to C-Section in the presence of lack of descent or where delivery is not imminent following three contractions with correctly applied instrument (e.g., ‘rule of three’).

Education and Privileges

  • Implement a standardized process to ensure all:
    • Obstetrical trainees receive appropriate training and are deemed competent in assisted vaginal deliveries prior to independent practice;
    • Physicians granted privileges for VAVD and/or FAVD demonstrate the necessary skills, knowledge and experience on a continuous basis.
  • Implement formal multifaceted strategies to support and enhance physicians’ and obstetrical trainees ongoing VAVD and FAVD practice, skill and knowledge (e.g., participation in MOREOB, interdisciplinary workshops, in-situ simulations testing the backup plan and exit strategy and emergency skill drills; sharing of quality measures and indicators, learnings from periodic chart audits, extracts, analysis of reported incidents, and medical-legal matters). Encourage physicians to document (including dates and times) their participation with assisted vaginal delivery continuing education efforts.

Monitoring and Measuring

  • Implement formal strategies to monitor and measure the effectiveness, efficiency and adherence to local assisted vaginal protocols, algorithms and evidence based practice, including (but not limited to):
    • Adoption of formal program-wide and practitioner-specific quality measures and indicators (e.g., proportion of assisted vaginal deliveries with adherence to local protocol and current evidence based practice; number of higher-risk forceps deliveries performed in C-Section ready room);
    • Learnings from provincial perinatal birth registry data (where available);
    • Learnings from perinatal near miss and harm incidents involving assisted vaginal deliveries (e.g., chart audits, trigger tools, incident reports, team debriefs, critical incident and quality of care committee reviews, medical legal claims).

References

  • HIROC claims files.
  • American Academy of Pediatrics. (2014). Neonatal encephalopathy and neurologic outcome. (2nd Ed.). Report of the American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy, 133(5):e1482-e1488.
  • Caughey AB, Cahill AG, Guise JM, et al. (214). Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 210(3):179-93.
  • American College of Obstetricians and Gynecologists. (2018). Fetal heart rate monitoring during labor: Frequently asked questions: Labor, delivery, and postpartum care.
  • Bailey R. (2009). Intrapartum fetal monitoring. Am Fam Physician. 80(12): 1388-1396.
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  • Canadian Institute for Health Information and Canadian Patient Safety Institute. (2018). Hospital Harm Improvement Resource – Obstetric Trauma.
  • CRICO. (2017). Appendix B: Sample documentation of Operative Vaginal Delivery.
  • CRICO. (2017). Clinical Guidelines for Obstetrical Services at CRICO-Insured Institutions.
  • CRICO. (2017). OB Guideline 1: Operative Vaginal Delivery.
  • ECRI Institute. (2012). Obstetrics and neonatal safety. Healthcare Risk, Quality, & Safety Guidance – Guidance. 
  • ECRI Institute. (2019). Obstetrical liability. Healthcare Risk, Quality, & Safety Guidance – Guidance. 
  • Hobson S, Cassell K, Windrom R, et al. (2018). No. 381-Assisted Vaginal Birth. J Obstet Gynaecol Can. 41(6): 870–882. 
  • Institute for Healthcare Improvement. (2012) How-to Guide: Prevent obstetrical adverse events. Cambridge, MA: Institute for Healthcare Improvement. 
  • Healthcare Insurance Reciprocal of Canada and the Canadian Medical Protective Association. (2018). Delivery in focus: Strengthening obstetrical care in Canada. Ottawa, ON: The Canadian Medical Protective Association.
  • Lisonkova S, Lavery JA, Ananth CV, et al. (2016). Temporal trends in obstetric trauma and inpatient surgery for pelvic organ prolapse: an age-period-cohort analysis. Am J Obstet Gynecol. 215(2): 208.e1-12.
  • Muraca GM, Lisonkova S, Skoll A, et al. (2018). Ecological association between operative vaginal delivery and obstetric and birth trauma. Can Med Assoc J. 190(24): E734-41.
  • Muraca GM, Sabr Y, Lisonkova S, et al. (2017). Perinatal and maternal morbidity and mortality after attempted operative vaginal delivery at midpelvic station. Can Med Assoc J. 189(22):E764-72.
  • Murphy D, Strachan B, Bahl R. (2020). Assisted Vaginal Birth. BJOG: An International Journal of Obstetrics & Gynaecology, 127(9): 1-43.
  • NHS Litigation Authority. (2012). Ten years of maternity claims: An analysis of NHS litigation authority data.
  • Wen SW, Liu S, Kramer MS, et al. (2001). Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries. Am J Epidemiol.153(2):103-7.