Q: What is an assisted delivery?
A: An assisted delivery is one that uses either forceps or a vacuum, or suction cup (see Helping your baby's birth), to help extract the baby from the birth canal if the baby is not making good progress or there are complications during the second stage of labor in a vaginal delivery. You will still be helping deliver your baby with your contractions, but the instrument used will be helping to guide the baby out of the birth canal.
Q: How is an assisted delivery carried out?
A: Assisted deliveries are carried out using either forceps or vacuum extraction by a doctor (or specially trained midwife). Forceps are metal instruments specially shaped to fit around the baby's head, whereas in the vacuum method, a vacuum is created by attaching a cuplike fitting to the head and using a mechanism to create suction to help draw your baby out.
Q: How do they decide whether to use vacuum or forceps? Will it be my choice?
A: Both forceps- and vacuum-assisted births are relatively safe procedures and, although each has pros and cons, it's best to be guided by the doctor, since the choice of instrument usually depends on the position of the baby and the doctor's preference or experience, although your opinion will be taken into consideration. Although forceps used to be the most widely used instrument, vacuum has increased significantly in popularity. Many consider vacuum easier to use and less likely to cause damage and tearing to the mother. However, this method is also more likely to cause swelling to the baby's head where the cup was placed.
Q: What is a “prolonged second stage” and does this mean that the delivery will be assisted?
A: It is difficult to define a “prolonged second stage” since it depends on certain factors, for example if it is your first baby, the position and size of the baby, if you have an epidural, if the contractions are effective and how often they are coming, how well you are pushing, and if the pelvis is an adequate size. There is some evidence to suggest that if the baby has progressed further into the pelvis, and there is no sign of distress, then there is no need to put a time limit on labor. However, it does tend to be the case that hospitals have guidelines as to how long they will allow a woman to push before deciding that intervention may be necessary. Usually, after about 2–3 hours, doctors may decide to assist the delivery to reduce the risk of fetal distress and of the mother becoming exhausted.
Q: I had a forceps delivery since in the end I was too tired to push. Is this likely to happen again?
A: An assisted delivery is more common during a first birth than in subsequent ones. The first pregnancy and birth causes the pelvic ligaments to stretch, which can make subsequent births easier, and the uterus is often more efficient in contracting the second and subsequent times around, which also means that labor is usually shorter. Often, even if the baby's head is not in the best position for birth, for example if the baby is in a posterior or transverse position, where the back of the head is toward the mother's spine and lower back, it may be delivered without assistance during a second delivery. Therefore, it is likely, but by no means certain, that you will have a normal vaginal delivery next time.
Q: Can I refuse to have forceps or vacuum extraction and what are the alternatives?
A: No one can go against your wishes if you do not want to have a particular procedure. However, it's usually best to have a flexible approach to labor. Although you may wish for certain things not to take place, the doctor or midwife is likely to have a good reason for wanting to perform a procedure and has you and your baby's best interests at heart. If an assisted delivery is suggested, asking the midwife or doctor to explain and support this decision can help you to come to terms with it. Usually the only other alternative to an assisted delivery would be a cesarean section; however, this may be difficult if the baby has gone too far into the pelvis.
Q: Will I have an anesthetic before they use the forceps?
A: Appropriate pain relief, such as a local anesthetic injection, or an epidural, will be given before the procedure. The doctor will then help pull the baby out while the mother pushes. The forceps and vacuum cup are removed after the head has been delivered, and the body is delivered normally.
Q: What can go wrong at an assisted birth?
A: Forceps and vacuum can cause bruising, swelling, and marks on the baby's head or face, although these usually resolve with no problems within a few days. In rare cases, cuts and severe bruising on the baby can occur. The pediatrician, a doctor who specializes in care of babies and children, may prescribe a mild analgesic to ease any discomfort that the baby may feel. There is also an increased risk of the baby developing jaundice, where the baby looks yellow due to the presence of the waste product bilirubin, particularly in cases of severe bruising. The levels of bilirubin will be checked if the doctor is concerned and the condition can be treated, if necessary.

For the mother, the two main concerns are that there is an increased risk of tearing or being cut during the procedure—and hence an increased risk of more bleeding (which can be managed)—and, rarely, damage may occur to the anal sphincter or rectum.

If the situation warrants an assisted delivery, the benefits of delivering babies by these methods far outweigh the risks. If the procedure is not successful, an emergency cesarean may be necessary.

Q: What is an episiotomy and why might this be done?
A: An episiotomy is a cut along the muscle between the vagina and anus, known as the perineum, to widen the area where the baby will be delivered . This is done only when absolutely necessary and will not be performed without your consent. There are several reasons why an episiotomy may be recommended, including if the baby is in distress, to speed up the delivery of the head; in cases of forceps or vacuum deliveries; if the baby's head is too large to pass through the vagina; if the perineum has not stretched sufficiently by the end of the second stage of labor to allow the smooth passage of the baby's head through the vagina; if there is a complication in the vaginal delivery of a breech baby; or if the mother is finding it difficult to control her pushing while the baby's head is crowning, which means she is more likely to tear significantly during the delivery.

Usually, local anesthetic is injected into the muscular area first and the procedure is performed at the strongest part of the contraction, since this distracts you from what is being done and assists with a quick delivery.

Q: The thought of having a cut down there is terrifying. What can I do to prevent this?
A: Some studies have shown that massaging your perineum regularly during pregnancy, using an unscented vegetable oil, can reduce the risk of tearing  since this helps to make the area more flexible and may consequently help stretch the area as the head is being born. Wash your hands thoroughly before massaging the perineum. Although an episiotomy may be a worrying prospect, if you are advised to have one, this may prevent uncontrolled tearing.
Q: Why might they do an emergency cesarean section?
A: Emergency cesareans are performed for several reasons. The baby may be showing signs of being distressed as evidenced by certain patterns displayed on the fetal monitor, in which case a cesarean may be recommended. Rarely, the umbilical cord comes down before the baby, a condition known as cord prolapse, and this is an emergency that requires immediate delivery by cesarean.
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