The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes

OBJECTIVE: To determine the risk of neonatal and maternal disease associated with the sequential use of vacuum and forceps compared with spontaneous vaginal delivery. STUDY DESIGN: Using Washington state birth certificate data linked to hospital discharge records, we compared 3741 vaginal deliveries by both vacuum and forceps, 3741 vacuum deliveries, and 3741 forceps deliveries to 11,223 spontaneous vaginal deliveries. RESULTS: Compared with spontaneous vaginal deliveries, deliveries by sequential use of vacuum and forceps had significantly higher rates of intracranial hemorrhage (relative risk [RR], 3.9; 95% confidence interval [CI], 1.5 to 10.1), brachial plexus (RR, 3.2; 95% Cl, 1.6 to 6.4), facial nerve injury (RR, 13.3; 95% Cl, 4.7 to 37.7), seizure (RR, 13.7; 95% Cl, 2.1 to 88.0), depressed 5-minute Apgar score (RR, 3.0; 95% Cl, 2.2 to 4.0), assisted ventilation (RR, 4.8; 95% Cl, 2.1 to 11.0), fourth-degree (RR, 11.4; 95% Cl, 6.4 to 20.1 among multiparous women) and other lacerations, hematoma (RR, 6.2; 95% Cl, 2.1 to 18.1 among multiparous women), and postpartum hemorrhage (RR, 1.6; 95% Cl, 1.3 to 2.0). The relative risk of sequential vacuum and forceps use was greater than the sum of the individual relative risks of each instrument for intracranial hemorrhage, facial nerve injury, seizure, hematoma, and perineal and vaginal lacerations. CONCLUSION: Sequential use of vacuum and forceps is associated with increased risk of both neonatal and maternal injury.