An obstetric toolbox: Important to maintain, to share, and to evaluate

Thank you for the opportunity to read the important and thought-provoking discussion between Grindheim et al. and Iqbal et Al-Maslamani regarding instrumental delivery and its impact on fear of childbirth, in which both sides raise valid points.^1-3 I would like to offer a few reflections on the topic.

As Iqbal and Al-Maslamani point out, instrumental delivery can negatively affect birth outcomes, both medically (e.g., pelvic floor injuries) and in terms of subjective experience (e.g., contributing to secondary fear of childbirth). At the same time, the same concerns apply to a prolonged second stage, which—even in cases of spontaneous birth—may be associated with various risks, as well as to second-stage cesarean sections.

Instrumental delivery undoubtedly helps avoid some complications of second-stage cesarean and can even be life-saving.⁴ As Grindheim et al. correctly remind us, spontaneous vaginal delivery is sometimes no longer an option. However, determining exactly when this is the case is a matter of clinical judgment—and this judgment is not always straightforward. Research on intrapartum care is challenging; randomization is often not feasible or ethically justifiable, and decisions to proceed with instrumental delivery often rely more on local tradition or individual obstetricians' preferences than on clear evidence.

In Bergen, the proportion of instrumental vaginal deliveries is relatively high, as is the use of forceps. 11% of primiparous women give birth via assisted vaginal delivery in Bergen, compared to 5% in Sweden.^1-5 Is this difference due to variations in the population characteristics, intrapartum management, or indications for instrumental delivery—for example, local opinions on acceptable length of the second stage or approaches to pushing? Which practice leads to better short- and long-term outcomes, including patient experience?

To conclude, forceps, vacuum, and even second-stage cesarean sections all have an important place in obstetrics, but each also carries some drawbacks. Ongoing careful and multidimensional evaluation of intrapartum management and its outcomes is essential to better understand when each intervention is appropriate—and when supportive care and watchful waiting may still be an option.