Assisted Birth: Forceps and Ventouse Explained

Most women will have heard of forceps or ventouse, but unless you have experienced an assisted birth before, you may not really know what happens when one is recommended.

It can sometimes feel as though things change quite quickly. You may have been pushing your baby down yourself and then suddenly an obstetrician is talking to you about giving your baby some additional help to be born. There may be more people in the room, different conversations taking place and decisions that need to be made.

An assisted vaginal birth is still a vaginal birth. The difference is that an obstetrician uses either forceps or a vacuum cup, known as a ventouse, to help your baby through the final part of the birth. You may also hear the word Kiwi. A Kiwi is a type of vacuum cup used for an assisted birth.

In the UK, around 1 in 8 women have an assisted vaginal birth, according to the Royal College of Obstetricians and Gynaecologists (RCOG), and it is more common when having a first baby.

Why might an assisted birth be recommended?

There are several reasons why an assisted birth may be recommended. Your baby may be very close to being born but need some help with the final part of the journey. You may have been pushing for some time without enough progress, or there may be concerns about how your baby is coping with labour and a recommendation that birth needs to happen more quickly.

NICE guidance recommends offering forceps or ventouse when there is concern about the baby's wellbeing, when there is a prolonged second stage of labour or when the woman requests assistance. The guidance also says that the assessment should take into account the urgency of the situation, the likelihood of an assisted birth being successful, the location, pain relief and, importantly, the woman's preferences.

This is why I think it is important that you understand why an assisted birth is being recommended in your particular situation, rather than simply hearing that forceps or a ventouse are needed.

What actually happens if forceps or ventouse are recommended?

An assisted birth will generally take place on labour ward. If you are on a midwifery-led birthing unit and an assisted birth is recommended, you would usually be transferred to labour ward. I have seen forceps used on a birthing unit in exceptional circumstances, but this is not what I would normally expect.

In some circumstances, an assisted birth may be recommended in theatre. This is more likely when the obstetric team feels there is a greater chance that the assisted birth may not be successful and a caesarean birth could be needed. RCOG describes this as a trial of assisted vaginal birth, where the birth is attempted in theatre so that a caesarean can be carried out if necessary.

Before anything happens, the obstetrician will assess you and your baby and explain why an assisted birth is being recommended and which instrument they feel is most appropriate. Your baby's position and how far down the head has come are important, as is how urgently your baby needs to be born. The choice between forceps and ventouse is based on the individual clinical circumstances and the experience of the practitioner. NICE specifically recommends taking both of these things into account.

Pain relief should also be discussed with you. Depending on the circumstances and any pain relief already in place, this may include local anaesthetic, an epidural or a spinal anaesthetic. NICE guidance states that the level of pain relief should be acceptable to the woman before forceps or ventouse are used.

I am still there to support you and your partner. If we move from the birthing unit to labour ward, I can continue supporting you alongside the hospital team. If you need to go to theatre, it can be different. Whether I can accompany you into theatre, and then into recovery afterwards, will depend on the individual hospital and the circumstances at the time. I can always ask whether I am able to come with you, but I cannot guarantee that I will be permitted to.

If I cannot go into theatre with you, that does not mean my support simply ends. I can support you and your partner before you go, help you both understand what is happening as far as possible, and continue supporting you again afterwards when I am able to rejoin you.

What is a ventouse or Kiwi?

A ventouse is a vacuum-assisted birth. A cup is placed onto your baby's head and held in position using suction. A Kiwi is a type of vacuum cup, so although you may hear both words used, they are referring to the same method of assisting your baby to be born.

Once the cup is securely in place, during a contraction you will normally be encouraged to push while the doctor applies controlled traction to the cup. Your contractions, your pushing and the traction from the doctor work together to help your baby move down and be born. This may take place over several contractions.

The cup can sometimes leave swelling or a raised area on your baby's head afterwards. This will usually settle, and your baby will be checked following the birth.

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  A room on labour ward

What happens with forceps?

Forceps are smooth, curved metal instruments designed to fit carefully around your baby's head. Once they are correctly positioned, you will usually be asked to push with your contraction while the doctor applies controlled traction to help guide your baby through the final part of the birth. This may also take place over several contractions.

There are different clinical circumstances where forceps may be more appropriate than a ventouse. Your baby's position, gestation, wellbeing and how urgently birth needs to happen can all be relevant. For example, RCOG explains that forceps may be preferred to ventouse when an assisted birth is required before 36 weeks because of the increased vulnerability of a premature baby's head.

The obstetrician should explain which instrument they are recommending and why they believe it is the most appropriate option for you and your baby.

Will I need an episiotomy?

An episiotomy is a cut made in the perineum to create additional space for your baby to be born. Episiotomy is more common with an assisted vaginal birth, particularly with forceps, but whether one is needed will depend on the individual circumstances.

RCOG explains that women having an assisted vaginal birth are more likely to need an episiotomy or experience a vaginal tear. NICE guidance says an episiotomy should be performed when there is a clinical need, which can include a forceps or ventouse birth or concerns about the baby's wellbeing.

If an episiotomy is recommended, this should be explained to you and your consent obtained. Appropriate pain relief should be given before an episiotomy is performed, except in an emergency involving acute concerns about the baby's wellbeing.

After your baby is born, any episiotomy or tear will be assessed and repaired with stitches where necessary.

Can I still ask questions and make decisions?

Absolutely. The fact that an obstetrician is recommending an assisted birth does not mean that you stop being involved in decisions about your care.

I would want you to understand why an assisted birth is being recommended, how urgently your baby needs to be born, why a particular instrument is being suggested and what the alternatives are in your individual circumstances. Sometimes there is time for a longer conversation. Sometimes there is more urgency and decisions need to be made quickly.

My role is not to make that decision for you or to speak over the obstetric team. I am there to support you, help you understand the information being given and make sure that, as far as the situation allows, you remain involved in what is happening to you and your baby.

NICE guidance specifically says that the woman and her birth companion should be told why birth needs to be expedited and what the options are. It also states that if a woman declines forceps or ventouse, her remaining options should be discussed and her decision supported. Those options may be limited by clinical safety or how urgently the baby needs to be born.

What if the assisted birth does not work?

An assisted vaginal birth is not guaranteed to be successful. Sometimes, despite everybody working together, the ventouse or forceps does not achieve the birth.

This is something I think many women may not realise. RCOG explains that if the first instrument chosen is not effective, the obstetrician may recommend using the other instrument or offer a caesarean birth, depending on the individual circumstances. If neither instrument is effective in helping the baby to be born, an emergency caesarean birth will be recommended.

Using more than one instrument is not a decision that is taken lightly. There are additional considerations for both mum and baby, so the obstetrician will assess what is happening at that moment, how urgently the baby needs to be born and whether attempting another assisted birth is appropriate.

This is also one of the reasons an assisted birth may occasionally take place in theatre. If the team believes the assisted birth could be more complicated or there is a greater possibility that it may not be successful, being in theatre means that a caesarean can be carried out without the delay of transferring there first.

I am still supporting you and your partner throughout this. This is one of the times when continuity of care can really matter. If the situation changes and you need to go to theatre, I will ask whether I can accompany you. Whether I can be with you in theatre or recovery will depend on the hospital and the circumstances, so I would never promise that I can stay physically beside you at every stage. If I am unable to go with you, I can continue my support as soon as I am able to rejoin you.

What might an assisted birth mean for my baby?

Most babies born following an assisted vaginal birth are well and do not experience long-term problems. Depending on which instrument is used, there may be temporary marks, bruising or swelling on your baby's head or face. RCOG provides more detailed information about the possible effects of both ventouse and forceps on babies.

Depending on the reason for the assisted birth and the circumstances surrounding it, a paediatrician may be present when your baby is born in case your baby needs any additional support.

If your baby is well, having an assisted birth does not automatically prevent immediate skin-to-skin contact or delayed cord clamping. RCOG confirms that these can still be options when baby is well following an assisted birth.

What happens after an assisted birth?

Once your baby is safely born, the focus moves to both of you. Your baby will be assessed, and you will be checked for any tears or an episiotomy that needs repairing. NICE also recommends offering antibiotics following a forceps or ventouse birth to reduce the risk of postnatal infection. Your physical recovery will also continue to be checked during the postnatal period.

You may feel relieved, emotional, exhausted or slightly overwhelmed by everything that has just happened. Your partner may feel much the same. Sometimes an assisted birth can happen relatively calmly, and sometimes the room can become very busy very quickly.

I can continue supporting you during those first hours when I am able to remain with you or rejoin you. I can support you with feeding, help you get comfortable and talk through what has happened. If your partner has found the experience frightening or overwhelming, I am there for them too.

Sometimes the questions come later. Once the adrenaline has settled and you have had some time with your baby, you may start thinking about particular moments during the birth and wondering why something happened or why a particular decision was made. We can talk about that too.

An assisted birth can be a very positive experience, but it can also be an intense one. You do not need to understand or remember every detail while you are in labour or lying there with your brand-new baby in your arms. What matters to me is that you and your partner feel supported, that things are explained as clearly as possible and that you remain part of the conversation about your care.

For more detailed professional guidance, you can read the RCOG Green-top Guideline No. 26: Assisted Vaginal Birth.