Forceps delivery linked to lower brain injury risk

Robin Wulffson MD's picture
forceps delivery, vacuum extraction, cesarean section, birth trauma, seizures
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BALTIMORE, MD—The word “forceps” is currently a fearsome buzzword for many pregnant women and their partners. Several decades ago, when an assisted delivery was indicated forceps were applied to maneuver the head through the birth canal. Subsequently, vacuum extraction became popular, replacing forceps to a large extent. The vacuum extractor is a suction device, which grips the fetal head and delivery is facilitated by the obstetrician exerting traction on a handle. Many deemed this to be a safer method for an assisted delivery. However, a new study contradicts that thinking; it suggested that a forceps delivery is less traumatic to the fetal head than either vacuum extraction or cesarean section.

In the U.S., the rate of forceps deliveries has been steadily declining in the past two decades. In 2007, less than 1% of infants were delivered with forceps, vs. 5% in 1990. Another trend in recent years is a marked increase in the cesarean section rate in the United States.

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The study, which was published in the December issue of the journal Obstetrics & Gynecology reported that forceps deliveries may lead to fewer newborn seizures compared with vacuum extraction or cesarean section. The study was conducted by Dr. Erika F. Werner and colleagues at Johns Hopkins School of Medicine in Baltimore. The researchers focused their study on the risk of seizures and cerebral (brain) bleeding. Using data on more than 400,000 first deliveries, they found that newborns delivered by forceps were 45% less likely to suffer a seizure than those born via vacuum extraction or cesarean section. However, the study also found that infants delivered via cesarean section were less likely to suffer a subdural hemorrhage (bleeding beneath the membrane that surrounds the brain). Dr. Werner added that the risks of any of those complications were low, regardless of the method of delivery.

The study found that of more than 15,000 infants delivered with forceps, 0.12% had a seizure at birth, compared to approximately 0.3% of newborns delivered by vacuum extraction or cesarean section. Rates of subdural hemorrhage and intraventricular (cavities within the brain) hemorrhage were even lower. Although the findings are observational and cannot prove one method is superior to another, they challenge the perception that cesarean sections are generally safer than forceps. Dr. Werner noted that it is possible that the underlying reason for the delivery method is playing a role in her findings. She explained that cesarean sections or vacuum extractions may be selected for "sicker babies. She added, “But, I don't completely believe that's the explanation." She noted that an obstetrician can typically deliver a baby more quickly with forceps than with either a cesarean section of a vacuum extraction may help explain the lower seizure risk.

As previously mentioned, cesarean sections were less likely to cause subdural bleeding than either forceps or vacuum deliveries. Just under 0.1% of those babies had a subdural hemorrhage, vs. 0.14% of forceps-delivered neonates and 0.19% of vacuum-delivered infants. The researcher noted that newborn seizures are more likely to cause long-term problems than is subdural bleeding; therefore, the seizure risk may carry more weight. Dr. Werner noted, however, obstetricians may not necessarily be comfortable with forceps.

The current study included New York City women who delivered between 1995 and 2003, and it showed a similar pattern. Forceps deliveries declined over time, to 2% of births in 2003. Vacuum-assisted birth went in the opposite direction, accounting for almost 6% of births in 2003. Dr. Werner noted that that trend is most likely be related to training: currently, obstetricians are being trained to use vacuum devices, but not forceps. It is unclear exactly why training has changed over the years, Dr. Werner noted - especially given the lack of evidence that vacuum extraction is better for the infant. She added that if their study had included births from more recent years, it would be likely that even fewer deliveries would have been done by forceps.

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