Assisted vaginal birth (AVB) is to expedite birth for the benefit of the mother, baby or both whilst minimising maternal and neonatal morbidity. Forceps, ventouse (or ‘vacuum’) delivery and manual rotation (usually completed with non-rotational forceps) are the most common methods used in the UK. In the UK, operative delivery rates have varied between 10 and 15% (England 12.7% and Scotland 12.1% – data for 2021) but rates vary significantly across European countries (median 7.2%; range 2.1% [Slovakia] to 15.1% [Ireland and Spain] – data for 2015).

When a valid indication for vacuum-assisted birth exists, the relevant obstetric variables should be identified and carefully assessed to determine whether vacuum-assisted birth is appropriate and safe under the clinical circumstances and for the level of experience of the operator. This important decision-making process is considered in Chapters 2 and 3 of the book. This chapter focuses on a few selected technical matters that should, if followed, improve the efficacy and reduce the risk of vacuum-assisted birth.

The decision whether or not to recommend an assisted vaginal birth (AVB) is a complex one. Decision-making about the most appropriate mode of birth needs to take account of the key elements for a safe AVB which are that it needs to be conducted under optimal circumstances, in the most appropriate place and by a competent operator. Safety issues need to be balanced with the aim of providing a positive birth experience for the mother and her partner. The risks of maternal and neonatal morbidity are increased with AVBs, although with appropriate case selection and careful practice these risks are low. Careful attention needs to be paid to the indication for AVB and to clinical assessment prior to any attempt at a procedure.

In skilled hands, assisted vaginal birth (AVB) remains the most efficient and effective method of expediting birth in the second stage of labour. It is associated with fewer adverse maternal and neonatal outcomes compared to second stage emergency caesarean section. In this chapter we will focus on the history and role of AVB as it currently stands. We will review relevant literature, examine important areas of practice and suggest a way forward that aims to maintain AVB at the heart of obstetric practice in the twenty-first century. The need for such focus is clear – complications in the second stage of labour (fetal compromise, obstructed labour, maternal exhaustion, or maternal medical conditions exacerbated by the act of pushing) remain a major cause of maternal and neonatal mortality and morbidity across the world. Such complications are responsible for 4 to 13% of maternal deaths in Africa, Asia, Latin America and the Caribbean. In 2013 obstructed labour alone accounted for 0.4 deaths per 100,000 women worldwide.

This chapter deals with methods of analgesia and anaesthesia for AVB. Previous chapters have discussed the decision-making processes underpinning which type of birth is required and where to perform it; this chapter details the various types of analgesia and anaesthesia used in different situations.

AVB can be undertaken either in the labour room or in theatre. Estimation of the likelihood of vaginal birth proving successful is pivotal to informing decision-making in terms of analgesic and anaesthetic requirements.

The components of a good AVB are complex and layered. They go far beyond a degree of knowledge and technical ability. They encompass a range of cognitive and social skills that promote respect for women and their partners and enable an environment in which women feel safe and secure, acknowledging her rite of passage and the privilege of assisting at the birth of a new life. This chapter explores our understanding of these important ‘non-technical’ skills of a consummate accoucheur.

Maternity claims represent the highest value and second highest number of clinical negligence claims reported to NHS Resolution. The three most frequent categories of claim were those relating to management of labour (14.05%), caesarean section (13.24%) and cerebral palsy (10.65%). Two of these categories, namely cerebral palsy and management of labour, along with CTG interpretation, were also the most expensive and together accounted for approximately 70% of the total figure of £3.1 billion, paid out on or expected to be paid, for all maternity claims.

In 1915, Christian Kielland (1871–1941) first described his forceps to achieve birth from the mid-pelvis in cases of malrotation (OP and OT positions of the fetal head). Kielland (sometimes spelt Kjelland) described his forceps to be applied for a condition that would not be applicable today (the fetal head arrested in a high transverse or OP position), and in a manner which would be considered dangerous in modern practice. However, the instrument was adopted and adapted in the twentieth century and became popular for use by obstetricians in cases of malposition.

There are currently no precise figures for the incidence of caesarean section at full dilatation, but given that there are around 200,000 caesarean births in the UK each year with around 10% at full dilatation, it potentially affects around 20,000 births per year.