Operative Vaginal Delivery: Past, Present, and Future

The incidence of operative vaginal delivery (OVD) in the United States has been declining, and OVD is currently performed in approximately 4.5% of vaginal deliveries. In addition, it has been observed that the proportion of forceps deliveries is declining as compared with vacuum extraction. The Northeast United States has the lowest rate of forceps use, whereas the use of forceps remains highest in the South; this may be due to training differences among providers. There are several hypotheses as to why a decline in OVD has occurred during the past half-century. One reason is that cesarean delivery (CD) has become much safer with the ease of accessibility of blood products, improved antibiotics, and better anesthetic options. Another important factor has been the almost universal application of continuous fetal heart rate monitoring during the second stage of labor. In addition, OVD has likely decreased because of a fear of litigation and patient misconception. The result of diminished use of OVD is fewer providers capable of teaching new generations of obstetricians how to use these specialized instruments. Given these trends, there is an emerging gap between the present paradigm and ideal practice of OVD. The goal of this article is to address this gap and better enable practicing obstetricians to elect OVD or CD on the basis of the available evidence.