Assisted Birth: Forceps and Ventouse

How common it is

RCOG puts the UK figure at "approximately 1 in 8 women", and notes this rises sharply for first births: "1 in 3 women having their first baby will have an assisted vaginal birth." The NHS gives the same overall rate — "about 1 in 8 births" — and adds that assisted delivery "is less common in women who've had a spontaneous vaginal birth before." The HSE reports "about 1 in 7 women in Ireland has an assisted birth."

RCOG also answers the question people ask next: having one assisted birth "does not mean you will need one in your next pregnancy". The HSE quantifies it — "about 8 out of 10 women who have an assisted birth will not need one for their next child."

Why it is offered

RCOG lists three main reasons: concerns about your baby's wellbeing during birth; labour not progressing as would usually be expected; and being unable to, or advised not to, push.

The NHS expands the list: an underlying health condition such as very high blood pressure that means you have been advised not to push; concerns about your baby's heart rate; your baby lying in an awkward position; your baby getting tired with concerns about distress; a premature vaginal birth, where "forceps can help protect your baby's head from your perineum"; and having had an epidural.

NICE frames it as an offer: forceps or ventouse are offered "if there is concern about the baby's wellbeing, there is a prolonged second stage or the woman requests assistance."

What happens in the room

The sequence RCOG describes is consistent across sources. With your consent, the obstetrician examines your abdomen and performs an internal examination "to confirm that an assisted vaginal birth is safe for you and your baby." You are usually asked to sit with your legs supported, and your bladder is emptied with a catheter.

Pain relief comes next. RCOG describes it as "either a local anaesthetic injection inside the vagina or a regional anaesthetic injection into your back (an epidural or a spinal)". The NHS puts it the same way: "You'll usually have a local anaesthetic to numb your vagina and the skin between your vagina and anus (perineum) if you have not already had an epidural." NICE adds a firm instruction: "Ensure the level of pain relief is acceptable to the woman before using forceps or ventouse during birth."

Consent is explicit. The NHS says your obstetrician or midwife "should discuss with you the reasons for having an assisted birth, the choice of instrument and how it will be carried out. Your consent will be needed before the procedure can be carried out." The HSE notes you will usually sign a consent form, though verbal consent is sometimes taken.

The pull itself

Both instruments work with your contractions, not instead of them. For a ventouse, RCOG describes the professional waiting "until you are having a contraction and then ask you to push while they pull to help you give birth. This may happen over several contractions." For forceps the description is identical in structure. You are still pushing.

The two instruments

Ventouse

A ventouse is "an instrument that uses suction to attach a plastic or metal cup on to your baby's head." The NHS adds that a soft or hard plastic or metal cup is attached by a tube to a suction device. RCOG notes a detail worth knowing in advance: "Sometimes the cup can detach itself, making a 'pop' sound. If this happens your healthcare professional may need to re-apply the cup to your baby's head before continuing."

Forceps

The NHS describes forceps as "smooth metal instruments that look like large spoons or tongs", curved to fit around the baby's head and joined at the handles. Some types "are specifically designed to turn the baby to the right position to be born", for example if your baby is facing upwards (occipito-posterior) or to one side.

How the choice is made

NICE says the choice of instrument is based "on a balance of clinical circumstance and practitioner experience." RCOG lists the factors: how well your epidural is working, the wellbeing of your baby, and the position of your baby's head. Both RCOG and the NHS give one specific rule: before 36 weeks, forceps may be preferred over ventouse, because forceps involve "less risk of injury to your baby's head which is softer at this stage of pregnancy."

If the first instrument does not work, RCOG says the professional "may then either recommend using the other instrument to help you have a vaginal birth or offer a caesarean". If neither works, an emergency caesarean is recommended.

Why some assisted births happen in theatre

This surprises people, so it is worth stating plainly. RCOG: if the birth is expected to be straightforward, it happens in the room you have laboured in. "If they think that the assisted vaginal birth may be more complicated or that there is a chance that it might not work, you will be advised to give birth in the operating theatre. This is so that you can have an immediate caesarean if necessary." The NHS says the same. Being wheeled to theatre is a contingency, not a verdict.

RCOG lists what makes an attempt less likely to succeed: a BMI over 30; being under 161cm tall; an estimated fetal weight over 4kg; the baby lying back-to-back at the end of labour; and the baby's head not being low in the birth canal.

Episiotomy, antibiotics and the paediatrician

An episiotomy is likely. The NHS says "it is likely a cut (episiotomy) will be needed to make the vaginal opening bigger", and NICE instructs teams to perform one where there is clinical need "such as birth with forceps or ventouse". Any tear or cut is repaired with dissolvable stitches.

Antibiotics are routine afterwards. NICE recommends offering "a single dose of intravenous co-amoxiclav (or a locally agreed alternative for women who are allergic to penicillin) within 6 hours after cord clamping."

A paediatrician or another practitioner skilled in newborn care is usually present. And the birth itself need not be clinical: the NHS notes that "depending on the circumstances, your baby can be delivered and placed on your tummy, and your birth partner may still be able to cut the cord if they want to." RCOG adds that if your baby is well "you may choose to have immediate skin to skin contact and/or delayed cord clamping."

The tear figures

These are the numbers to take into the conversation, quoted by both RCOG and the NHS. A third- or fourth-degree tear — one involving the muscle or wall of the anus or rectum — affects about 3 in 100 women having a vaginal birth, up to 4 in 100 after a ventouse birth, and between 8 and 12 in 100 after a forceps birth.

You may also need a catheter draining your bladder for up to 24 hours afterwards, and this is more likely if you have had an epidural.