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Maternal and neonatal trauma during forceps and vacuum delivery must not be overlooked

BMJ 2023; 383 doi: (Published 19 October 2023) Cite this as: BMJ 2023;383:e073991
  1. Giulia M Muraca, assistant professor12,
  2. Laura E Ralph, patient partner3,
  3. Penny Christensen, community advocate4,
  4. Rohan D’Souza, associate professor1,
  5. Roxana Geoffrion, associate professor5,
  6. Sarka Lisonkova, associate professor56,
  7. K S Joseph, professor56
  1. 1Departments of Obstetrics and Gynecology and Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
  2. 2Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Sweden
  3. 3Patient author, Canada
  4. 4Public representative, Birth Trauma Canada, Saint John, New Brunswick, Canada
  5. 5Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
  6. 6School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to: G M Muraca muracag{at}

Giulia Muraca and colleagues argue that Canada’s high rates of maternal and neonatal trauma following operative vaginal delivery warrant urgent recognition, transparency, and action

Operative vaginal deliveries—forceps and vacuum assisted deliveries—are recommended as safe, acceptable alternatives to caesarean delivery for women in the second stage of labour when descent of the fetal head is arrested, there is imminent risk to the baby, or there are conditions that contraindicate pushing (expulsive) efforts.123 Although available data on maternal and neonatal mortality and morbidity show no clear advantage of operative vaginal delivery over caesarean delivery, such comparisons often fail to recognise the impact of maternal trauma, the most common injury associated with operative vaginal delivery.3 This is particularly pertinent in Canada, which has the highest rate of maternal trauma after operative vaginal deliveries among high income countries (fig 1).4

Fig 1

Rate of obstetric anal sphincter injury from operative vaginal deliveries (forceps and vacuum assisted combined) in 24 Organisation for Economic Cooperation and Development (OECD) countries, 20194 *OECD=average among the 24 OECD countries

Each year, more than 35 000 singleton infants are born after attempted operative vaginal delivery in Canada. One in four (25.3%) attempted forceps deliveries and one in eight (13.2%) attempted vacuum deliveries result in maternal (obstetric) trauma, most commonly obstetric anal sphincter injury.5 Additionally, severe neonatal trauma occurs in one in 105 (9.6/1000) infants following attempted forceps or vacuum birth, with brachial plexus injury the most common trauma and neonatal death the most serious adverse outcome.56

Initiatives to decrease caesarean deliveries in North America that include scaling up training and use of operative vaginal deliveries need to acknowledge the serious safety concerns related to operative vaginal deliveries and ensure that women are informed of the risks of forceps, vacuum, and second stage caesarean …

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