2025+FIGO良好实建议：辅助阴道分娩和第二产程

Abstract

Cesarean birth(CB) rates are increasing globally, with a current prevalence of 21.1% and a projected prevalence of 28.5% by 2030. Conversely, assisted vaginal birth(AVB) rates are declining, with reported rates of less than 10% in low- and middle-income countries(LMICs) and 10%-15% in high-income countries(HICs). In some African countries, AVB rates are as low as <1%. Declining AVB rates are attributable to lack of appropriate skills,equipment, and trained personnel, especially in LMICs,fear of litigation, and misconcep-tions that CB is safer, paucity of local guidelines and policies encouraging AVB, and in-creasingly accessible, acceptable, and safer CB techniques, amongst others. Optimizing appropriate care and decision making around CB and mode of birth is now a public health priority, especially given the significantly higher morbidity and mortality associ-ated with CB compared to vaginal birth. Increasing AVB rates can potentially reduce CB rates, therefore improving maternity safety. This paper reviews the current best evidence on AVB and makes recommendations for good practice, including indications and prerequisites for AVB, who to determine who is suitable for AVB, choice of instru-ment, sequential application of instrument, when to abandon AVB, analgesia, antibiotic prophylaxis and episiotomy for AVB, special situations such as fetal macrosomia, mater-nal viral infections, previous CB, and risks and benefits of AVB versus second stage CB.An AVB safety checklist is included to reduce the risk of complications. We conclude by recommending that all maternity care providers and skilled birth attendants, including obstetricians, obstetric trainees/residents,internus, and midwives, should be trained and competent to perform AVB, to potentially reduce the current CB epidemic and its as-sociated higher mortality and morbidity.

KEY WORDS

cesarean birth, forceps,instrumental delivery,maternity safety,vacuum delivery

For affiliations refer to page 10.

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1 | INTRODUCTION

Cesarean birth(CB) rates are increasing in all regions of the world.Current estimates show that 21.1% of women(29.7 million births) deliver by CB globally each year.1.2 This is almost double the global average rate of 12.1% reported in 2000, reflecting an average an-nual increase in global CB rate of 3.7% in the last two decades.2 Projections indicate that by 2030, the global average CB rate will increase to 28.5% from the current rate of 21.1%, with more than 38 million CBs annually. 1.3,4 At present, CB rates of up to 84%, 64%,53.1%, and 42.8% have been reported in private hospitals in parts of North Africa, sub-Saharan Africa (SSA), Southeastern Europe, Latin America, and the Caribbean, respectively. 1.3-6

Various reasons have been identified as being responsible for this global CB epidemic, including, but not limited to, an increase in maternal request for CBs, convenience of the obstetrician, fear of litigation, socioeconomic and educational disparities among women,previous negative blurting experiences of women and tokobobia (fear of childbirth), shortage of maternity staff and skilled birth personnel, and declining skills in assisted vaginal births(AVBs).3,4 Stemming from the unprecedented global increase in CB rate, opti-mizing appropriate and safe CB use has now become a public health priority, given the significantly higher morbidity and mortality asso-ciated with CB compared to vaginal birth. 7-9

<BeginOfPara>A significant proportion of CBs are performed during the final stages of vaginal labor due to fetal distress or prolonged second stage of labor. In this context, AVB is a viable option to expedite vag-inal birth and prevent CB. This paper focuses on recommendations for safe AVB in the second stage of labor.

2 | METHODOLOGY

The authors rated the quality of evidence and strength of rec-ommendations in this good practice paper using the Grading of Recommendations Assessment, Development and Evaluation(GRADE) approach. ${ }^{10}$ Strong recommendations are those for which we are confident that the benefits/desirable effects of an interven-tion outweigh of its risks/undesirable effects (strong recommenda-tion for an intervention) or that the risks/undesirable effects of an intervention outweigh its benefits/desirable effects (strong rec-ommendation against an intervention). A strong recommendation implies that most patients will be best served by the recommended intervention.

<BeginOfPara>Conditional recommendations are those for which the benefits-desirable effects probably outweigh the risks/undesirable effects(conditional recommendation for an intervention) or the risks/un-desirable effects probably outweigh the benefits/desirable effects(conditional recommendation against an intervention) but uncertainty exists. Conditional recommendations are those for which the balance between benefits/desirable effects and risks/undesirable effects is small, the quality of evidence is lower, and there is more variabil-ity in the values and preferences of individual patients. Conditional

<EndOfPara>recommendations imply that although most patients would prefer the recommended intervention, many would not. Different choices will be appropriate for different categories of patients, and maternity staff must support each patient in reaching a management decision that is consistent with the patient's values and preferences.

Recommendations based on evidence from randomized con-trolled trials(RCTs) and systematic reviews and meta-analyses of RCTs were rated as high quality, while evidence from observational studies(cross-sectional, cohort, and case-control studies) or sys-tematic reviews and meta-analyses of observational studies were rated as low quality. RCTs and systematic reviews and meta-analyses of RCTs with a high risk of bias and high level of heterogeneity were also rated as low quality.

3 | PREVALENCE OF AVB

The global decline in rates of AVB is in sharp contrast to the ris-ing CB rates. Although 33.5 million of the 38 million global CBs projected to take place in 2030 are expected in low- and middle-income countries(LMICs), average AVB rates in these countries in SSA and Europe is less than 10%(7.98% in SSA and 6.1% in Europe).1,6,11 In some African countries, AVB rates are as low as 1% or less, even in tertiary health facilities. 12-15 A WHO Global Survey of 286565 deliveries in 24 countries(seven countries in Africa, eight in Latin America, and nine in Asia) revealed an overall AVB rate of 2.5%, with regional rates in the range of 0.1%-2.8% in Latin America and 1.2%-7.7% in Asia.16

Compared with LMICs, AVB rates in high-income countries(HICs) are slightly higher, but, as in LMICs, these are also declining.In the USA, the overall rate of AVB declined from 9.01% to 3.3%between 1992 and 2013, representing a 63% decrease over two de-cades. ${ }^{17,18}$ AVB rates are in the range of 10%-15% in the UK. ${ }^{19,20}$

The declining rates of AVB worldwide are generally attributable to the lack of appropriate skills, equipment, and trained personnel, espe-cially in LMICs, fear of litigation, misconceptions that CS is safer, pau-city of local guidelines and policies encouraging AVB, and increasingly accessible, acceptable, and safer CS techniques. ${ }^{13-15}$

4 | CLASSIFICATION AND PREREQUISITES FOR AVB

4.1 | Classification of AVB

According to the American College of Obstetricians and Gynecologists (ACOG) classification system of 1998, reaffirmed in 2000, 2015, and 2020, and adopted by the Royal College of Obstetricians and Gynaecologists (RCOG), Society of Obstetricians and Gynaecologists (SCOG), and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG),18,20-22 AVB is classified based on the station of the fetal head and the degree of rotation required for birth as follows:

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● Outlet: Fetal scalp is visible at the nitroutis without separating the labia; fetal skull has reached the pelvic floor; the fetal head is at or on the perineum; the sagittal suture is in an anteroposterior diam-eter or right or left occiput anterior or posterior position; rotation does not exceed 45°.

● Low: Fetal skull is at a station+2 or greater and not on the pelvic floor; it has two subdivisions:(a) rotation 45° or less and(b) rota-tion above 45°.

● Mid: Head is above station+2 but the head is engaged.

● High: Head is not engaged and the fetal head is above the ma-ternal ischial spines. This is no longer recommended in routine obstetric practice.20,21

Rotational births can be conducted in carefully selected patients by appropriately skilled operators. ${}^{23,24}$ Various studies, including systematic reviews and meta-analyses by Giacchino et al. and Al Wattar et al., have established the safety of rotational births, with low rates of neonatal and maternal complications that are comparable to emergency CB. ${}^{18,25-31}$ For fetuses in the occipito-posterior(OP) position, fewer complications are encountered with forceps birth after manual or forceps-assisted ro-tation from the OP to occipito-anterior(OA) position, than with forceps birth in the OP position without an attempt at rotation. ${}^{18,25,27,30}$

Rotational births require highly skilled operators, who may be lacking in some settings. Rotational birth with forceps appears to be more successful than rotational vacuum birth, with comparable neonatal outcomes. ${}^{26,30,31}$ Mid-cavity birth and OP position are as-sociated with a high likelihood of failure of AVB and CS ${}^{20,21,32,33}$ and this should be borne in mind when conducting these births.

4.2| Prerequisites for AVB

Maternal consent

Informed consent for AVB should be obtained and documented after counseling the woman on the indication for the procedure, the risks and benefits, as well as the risks and benefits of the alternative options of birth. Verbal consent is generally considered to be sufficient for AVB performed in the labor room setting; for a trial of AVB in the operating theater, written consent is generally obtained. ${}^{34}$

Bladder emptying

The bladder should be emptied. If an indwelling Foley's catheter is in place, the catheter balloon should be deflated and catheter removed to avoid urethral injury during AVB.

Abdominal examination

A careful abdominal examination and/or ultrasound evaluation should be performed to confirm fetal lie, presentation, and descent.

Vaginal examination

A careful vaginal examination should be carried out to determine the following:

● The maternal pelvis is clinically deemed to be adequate.

● The position and station of the fetal head(ultrasound can be a useful adjunct).

● The fetal head is engaged.

● Cephalopelvic disproportion/obstruction must be excluded.

● The cervix is fully dilated and the fetal membranes are ruptured.

#

The anesthetist should be informed to provide appropriate maternal analgesia for the procedure.

Episiotomy

An episiotomy is not always indicated, and the need to perform it should depend on the clinical judgment of the operator.

Skill for neonatal resuscitation

Presence of a neonatologist/personnel skilled in neonatal resuscitation.

Requisite skill

The operator should have the requisite knowledge, experience, and skill to perform AVB.

Setting for AVB

AVB should be conducted in a setting with appropriate functioning equipment, a team experienced in AVB, appropriate birth bed, ad-equate lighting, and later facilities for an emergency CB in case the AVB is unsuccessful.

4.3 | Recommendations on type of AVB

1. High AVB is not recommended in contemporary obstetric prac-tice(strong, low).

2. Rotational births are recommended in carefully selected patients,when performed by appropriately skilled operators(conditional,low). Mid-cavity birth and OP position are associated with a high likelihood of failure and subsequent CB, and this should be borne in mind when conducting these births(strong, low).

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3. A rotational forceps birth is generally considered to be more suc-cessful than a rotational vacuum birth, with comparable neonatal outcomes, and is therefore recommended if appropriate instru-ment and a skilled operator are available(strong, low).

4. For the fetus in an OP position, manual or forceps-assisted rota-tion from the OP to OA position is recommended before forceps birth, rather than forceps birth in the OP position without an at-tempt at rotation(strong, low).

5| INDICATIONS AND CONTRAINDICATIONS TO AVB

5.1| AVB indications

Fetal and maternal indications for AVB include suspected fetal hy-poxia/fetal heart rate abnormalities in second stage of labor, cord prolapse in second stage of labor, delayed second stage of labor, maternal exhaustion in second stage of labor, and maternal medi-cal conditions that contraindicate repetitive Valsalva maneuvers or bearing down. These conditions include cardiac disease, severe res-peratory disease, severe hypertension, cerebral vascular disease or arteriovenous malformation or aneurysm, risk of aortic dissection,reproliferative retinopathy, as well as neurological conditions such as myasthenia gravis and spinal cord injury.18,20-22,24,35 In these clinical situations, forceps is preferred over vacuum.35

None of the indications for AVB are absolute; all indications should be considered and weighed against the clinical situation,ma-ternal and fetal status, as well as availability of skill and equipment.Clinical judgment, personalized care, and an individualized approach are required in all clinical situations.

5.2| Definition of delayed/prolonged second stage of labor for AVB

Opinions on the time duration that constitutes delayed/prolonged second stage of labor before embarking on AVB varies in guidelines and recommendations. RANZCOG advises that the upper time limit of the second stage before embarking on AVB for delayed/pro-longed second stage of labor should be decided by the senior clini-cian supervising the labor, considering the patient and the clinical situation.22 The French College of Obstetricians and Gynecologists(CNGOF) recommends that AVB should be considered if the fetus fails to descend after 30 min of pushing with adequate uterine con-tractions and a normal fetal heart rate. ${}^{24}$

On the other hand, the RCOG recommends AVB for shortening the second stage of labor in nulliparous women when the duration of the second stage of labor exceeds 2h without epidural analgesia or 3h with epidural analgesia, and 1h without or 2h with epidural analgesia in parous women.20 The RCOG definition of a prolonged second stage of labor aligns with that of the ACOG and WHO, and this is the definition adopted and recommended by FIGO.23,36,37

5.3| Contraindications to AVB

Contraindications to AVB include a less than fully dilated cervix, un-known fetal head position, fetal bleeding disorders(e.g. alloimmune thrombocytopenia, hemophilia, von Willebrand's disease), and fetal bone demineralization disorders that predispose to fracture(e.g. os-teogenesis imperfecta and other skeletal dysplasias).20,21,38 When AVB is indicated in case of suspected bleeding disorders in the fetus,forces are recommended.20,35 Vacuum is not contraindicated after a fetal scalp blood sampling procedure or application of a fetal scalp electrode.20

Forces are used in face presentation and birth of the aftercoming head during vaginal brech birth, while vacuum is contraindicated in face and non-vertex presentations.39 Vacuum is not recommended for preterm birth below 34 weeks(and should be used with caution at 34-36 weeks) owing to risks of cephalohematoma, intracranial hemorrhage, subgaleal hemorrhage, and neonatal jaundice; forceps should be used for preterm delivery below 34 weeks.20,22,35,38,39

5.4| Recommendations on AVB indications and contraindications

1. AVB is indicated when there is fetal compromise in the second stage of labor, delayed/prolonged second stage of labor, and shortening of the second stage of labor for maternal benefits(conditional, low).

2. When AVB is indicated for maternal medical conditions contrain-dicating maternal Valsalva maneuver or bearing down, forceps are recommended over vacuum(strong, low).

3.AVB is recommended for a delayed/prolonged second stage of labor when the duration of the second stage of labor exceeds 2h without or 3h with epidural analgesia in nulliparous women, and in porous women, 1h without or 2h with epidural analgesia(con-ditional, low).

4.No indication for AVB should be considered absolute. Sound clini-cal judgment and personalized care is required in all situations(str, low).

5. Contraindications to AVB include fetal bleeding disorders and fetal bone demineralization disorders. When AVB is indicated in case of suspected bleeding disorders in the fetus, forceps(rather than vacuum) are recommended(strong, low).

6. Vacuum is not contraindicated after a fetal scalp blood sampling procedure or application of a fetal scalp electrode(conditional,low).

7. Vacuum is contraindated in face and non-vertex presentations;forceps should be used to birth fetuses with face presentation and the aftercoming head during vaginal breech birth(strong, low).

8. Vacuum is not recommended for preterm birth(PTB) below 34 weeks, and should be used with caution at 34-36 weeks,owing to risks of cephalohematoma, intracranial hemorrhage,subaleal hemorrhage, and neonatal jaundice; forceps should be used to birth preterm fetuses below 34 weeks(strong, low).

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6 | CONDUCT OF AVB

6.1 | CONDUCT OF AVB?

If the increasing global rate of CB is to be addressed, we recommend that all obstetricians, obstetric trainees, residents, and interns, re-ceive appropriate comprehensive training and achieve competency in performing AVB. Consideration can also be given to training mid-wives and other cadres of maternity staff, depending on the local context, given the fact that AVB is one of the seven components of basic emergency obstetric and newborn care. ${}^{40}$

All operators performing AVB should have the relevant knowl-edge, experience, skill, and expertise, be able to assess the clini-cal situation, and manage any complications that arise. Obstetric trainees/residents and interns should have achieved expertise in spontaneous vaginal births(SVBs) before being trained in AVB. All operators should first conduct AVBs under direct supervision of more experienced and senior operators, and the operator's compe-tency confirmed before conducting unsupervised AVBs. Complex and high-risk AVBs should be performed by or under the direct su-pervision of more experienced and senior operators.

Theoretical, simulation, and clinical training in AVB should be routine practice in maternity units and residency training pro-grams, with regular personal and institutional audits of practice and outcomes.

6.2 | Choice of instrument: Forceps or vacuum?

The obstetric forceps preceded the vacuum by many decades, and has historically remained the preferred instrument for operative vag-inal birth in many settings to date. 41,42 However, in some countries,including the UK and many low-resource settings, the vacuum is in-creasingly being used in preference to the forceps. 35,42 Generally,and traditionally, the forceps are more popular in Anglo-Saxon coun-tries, whereas the vacuum is predominantly used in French-speaking and European countries.43 Vacuum is the most frequently used in-strument for AVB in many resource-poor settings mostly due to its ease of use and availability. ${ }^{14}$

<BeginOfPara>A recent Cochrane review by Verma et al. ${ }^{44}$ on the choice of instrument for AVB evaluated evidence from 31 RCTs including 5574 women. They reported that forces apids had a lower failure(rel-ative risk [RR]: 0.58, 95\% confidence interval [Cl]: 0.39-0.88) and fetal trauma (cephalhematoma: RR: 0.41, 95\% CI: 0.30-0.56; ret-inal hemorrhage: RR:0.66,95\% CI: 0.46-0.94; and jaundice: RR:0.70,95\% CI: 0.53-0.92) rates than vacuum, but greater risk of third- or fourth-degree perineal tears (odps ratio [OR]: 1.83, 95\%Cl: 1.32-2.55), and higher pain relief requirements. There were no differences in incidence of postpartum hemorrhage (PPH) (RR:1.71, 95\% CI: 0.59-4.95; P=1.00) and rates of low Apgar scores(RR:0.83, 95\% CI: 0.46-1.51; P=0.96) or low umbilical artery pH(RR:1.33, 95\% CI: 0.91-1.93; P=0.79) comparing forceps and vac-uum. Given the comparable effectiveness and outcomes of both

<EndOfPara>forces and vacuum, the choice of instrument should depend on the skill, experience, clinical judgment, and preference of the op-erator, as well as the clinical context. ${ }^{18,20-22}$

6.3 | Analgesia for AVB

A Cochrane review by Nikpoor et al. ${ }^{45}$ in 2013 aimed to assess the effectiveness and safety of different analgesic agents for AVB.They included four trials involving 388 women and found insuf-ficient evidence to support the recommendation of any analgesic agent as the most effective for providing pain relief during AVB.The trials included had high or unclear risks of bias and were of low quality. Each of these trials was conducted before 1980, and the assessed analgesic agents are not commonly used in modern clinical practice. Recommendations by the RCOG, SOGC, and RANZCOG support the use of regional analgesia or a pudend block for mid-cavity or rotational delivery, and a perineal block,for low or outlet delivery. ${ }^{20-22}$ If an effective epidural analgesia has already been instituted during labor, this may suffice or be reinforced. ${ }^{24}$

6.4 | Episiotomy for AVB

Current evidence, including a Cochrane review by Jiang et al., does not support routine episiotomies for all AVBs.18,20,24,36,39,46-48 The need to perform an episiotomy during AVB should be determined by the clinical judgment of the provider, and when indicated, a mediolateral episiotomy is recommended, as a midline episiotomy is associated with a higher risk of obstetric anal sphincter injury(OASI).18,36,39

A mediolateral episotomy should be initiated when the fetal head is distending the perineum, and at an angle of 60° away from the mid-line, to minimize blood loss and reduce the incidence of OASI. ${}^{20,49}$ The protective role of a mediolateral episotomy against OASI during AVB appears to be stronger for nulliparous women compared with porous women, and for forceps birth compared with vacuum. ${}^{49-52}$

6.5 | Antibiotic prophylaxis after AVB

There is now evidence of prophylactic antibiotics adminis-tration after AVB. A Cochrane review ${ }^{53}$ included two studies involv-ing 3813 women who underwent either vacuum or forceps birth.One study involving 393 women compared intravenous cefotetan with no treatment, while the other study(the ANODE trial) involv-ing 3420 women compared a single dose of intravenous amoxicil-lin and clavulanic acid with a placebo. The authors concluded that prophylactic intravenous antibiotics were effective in reducing in-fectious morbidities after AVB, including superficial (RR: 0.53, 95%Cl: 0.40-0.69) and deep perineal wound infection (RR: 0.46, 95%Cl: 0.31-0.69) or serious infectious complications (RR: 0.44, 95%

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CI:0.22-0.89), in women undergoing AVB. Prophylactic antibiotics slightly improved perineal pain and recovery, and possibly reduced costs, readmission to a maternal hospital, and overall improved ma-ternal health-related quality of life.

The prophylactic antibiotics in the prevention of infection after operative vaginal birth(ANODE) trial ${}^{54}$ randomly assigned 1719 women to receive aomoxicillin and clavulanic acid, and 1708 women to placebo(seven women withdrew from the study). Significantly fewer women who were allocated to amoxicillin and clavulanic acid had a subsequent confirmed or suspected infection (180/1619, 11%)than women allocated to placebo(306/1606, 19%; RR: 0.58, 95% CI:0.49-0.69; P<0.0001). At 6 weeks postpartum, the proportions of women with perineal infection, perineal pain, use of pain relief for perineal pain, need for additional perineal care, and wound break-down were significantly lower among women allocated to the amox-icillin and clavulanic acid group compared with the placebo group.

6.6 | When should forceps and vacuum be abandoned?

A study by Sakowicz et al. ${ }^{55}$ to determine the association between the number of vacuum pop-offs and adverse neonatal outcomes re-viewed 1730 women who underwent vacuum birth. In total, 1293 women had no pop-offs,240 had one pop-off,128 had two pop-offs,and 69 had three or more pop-offs. Having any vacuum pop-offs was associated with increased odds of adverse neonatal outcomes,including neonatal scalp/facial lacerations, intracranial hemorrhage,seizures, central nervous system depression, and admission to the neonatal intensive care unit(NICU). However, the relationship be-tween adverse neonatal outcomes and the number of pop-offs was not consistent.

A multicenter prospective cohort study of 5325 women who had AVB(3594 with vacuum and 1731 with forceps) reported that an increasing number of vacuum pop-offs was associated with an increased risk of severe perineal lacerations(OR: 1.65, 95% CI:1.10-2.49 for three or more pop-offs vs. no pop-off) and failed AVB(OR: 11.64, 95% CI: 7.07-19.16 for three or more pop-offs vs. no pop-off).56 Duration of vacuum application correlated with failed AVB(OR: 6.49, 95% CI: 3.58-11.79 for 12 or more minutes vs.0-2min) and composite adverse neonatal outcomes(OR: 3.89,95% CI: 1.60-9.47 for 12 or more minutes vs. 0-2min). The number of forceps pulls, but not the duration of forceps application, was as-sociated with failed AVB(OR: 3.24, 95% CI: 1.59-6.61 for three or more pulls vs. one pull). Both the number of forceps pulls(OR: 1.16,95% CI: 0.54-2.48 for three or more pulls vs. one pull) and duration of forceps application(OR: 5.37, 95% CI: 1.49-19.32 for 12 or more minutes vs.0-2min) were associated with composite adverse neo-natal outcomes.

<BeginOfPara>A prospective cohort study of 393 women who required op-erative birth in the second stage of labor(184 of the women had successful AVB using forceps, vacuum, or both, 107 had failed AVB and then CB, and 102 had immediate CB) reported that the majority

<EndOfPara>(151/184, 82%) of the AVBs were completed within three pulls.57 More than three pulls at attempted AVB was associated with in-creased neonatal trauma for both completed(adjusted odds ratio [AOR]: 4.2, 95% CI: 1.6-9.5) and failed AVBs (AOR: 7.2, 95% CI: 2.1-24.0). Neonates birthed with more than three pulls were at in-creased risk of NICU admission for both completed (AOR: 1.89,95%CI: 0.31-11.56) and failed AVBs (AOR: 6.1,95% CI: 1.6-22.8).

Based on the above evidence, it is recommended that a correctly applied vacuum(the vacuum cup should be placed over the flexion point, which is 3cm anterior to the posterior fontanelle and 6cm posterior to the anterior fontanelle, along the sagittal suture) should be discontinued after three pulls without descent of the fetal head or two pop-offs have occurred or after 20min of application has elapsed. ${}^{22,24,57,58}$ Forceps should be abandoned after three pulls of a correctly applied forceps if there is no progressive descent of the fetal head with each pull and birth is not imminent. ${}^{20,57,59}$ Traction should be applied in the direction of the pelvic curvature without shearing and rotational forces. Traction force in the range of 0.6-0.8kg/m2 is considered optimal.38,39

6.7 | Sequential application of forceps and vacuum

The sequential use of forceps and vacuum during AVB is not rou-tinely recommended, as it can be associated with increased risk of both maternal and neonatal trauma and morbidity, and higher likelihood of failed AVB.37,60-63 A large retrospective population-based cohort study by Gardella et al.62 to determine the effect of sequential use of vacuum and forceps for AVB on neonatal and maternal outcomes compared 3741 vaginal births by both vacuum and forceps, 3741 vacuum births, and 3741 forceps births to 11223 SVBs. Compared with SVBs, sequential use of vacuum and forceps had neonatal outcomes, including significantly higher rates of intracranial hemorrhage(RR: 3.9, 95% CI: 1.5-10.1), brachial plexus(RR: 3.2, 95% CI: 1.6-6.4) and facial nerve(RR: 13.3, 95%CI:4.7-37.7) injuries, seizure(RR: 13.7, 95% CI: 2.1-88.0), low 5-min Apgar score(RR: 3.0, 95% CI: 2.2-4.0), and assisted ventilation(RR: 4.8, 95% CI: 2.1-11.0). Maternal outcomes were also worse in the sequential instrument group, including fourth-degree(RR:11.4,95% CI:6.4-20.1) and other lacerations, hematoma(RR: 6.2,95% CI: 2.1-18.1), and PPH(RR: 1.6, 95% CI: 1.3-2.0). The relative risk of sequential vacuum and forceps use was greater than the sum of the individual relative risks of each instrument for hema-toma, perineal and vaginal lacerations, facial nerve injury, seizure,and intracranial hemorrhage.

Towner et al. ${}^{63}$ evaluated the rates of intracranial hemor-hrage in 387 799 infants birthed spontaneously, 59354 by vac-uum extraction, 15945 with the use of forceps, and 2817 with the combined use of forceps and vacuum extraction. Intracranial hemorrhage occurred in 1 of every 256 neonates birthed by the combined use of forceps and vacuum, a rate that was 7.4 times(95% CI: 3.9-14.0) the rate associated with SVB and 3.4 times(95%CI: 1.7-6.6) that associated with vacuum extraction alone. Rates

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of facial nerve and brachial plexus injuries, convulsions, central nervous system depression, and mechanical ventilation were also higher in neonates birthed by both forceps and vacuum compared to SVB and vacuum alone.

Another retrospective population-based cohort study by Fong et al.60 evaluated outcomes for 202439 vacuum births, 13555 for-eps births, and 710 births using both forceps and vacuum. They documented that when a combination of forceps and vacuum was used, third/fourth-degree perineal lacations were increased com-pared to the use of both vacuum(OR: 2.77, 95% CI: 2.36-3.26) and forceps(OR: 1.39, 95% CI: 1.80-1.64) only. PPH was also increased compared to the use of vacuum(OR: 1.81, 95% CI: 1.33-2.47), and the failure rate was higher in the combined instrument group at 3.66%(OR: 1.85, 95% CI: 1.22-2.79) than the forceps only group(2.14%).Similarly, Murphy et al.,61 in a cohort study of 1360 women who had AVB, of which 138 had sequential use of instruments, con-cluded that compared with single-instrument use, sequential use of instruments was associated with increased rates of third- and fourth-degree tears(17.0% vs.8.4%;AOR:2.1,95% CI:1.2-3.5),uri-nary incontinence(8.0% vs.3.2%;AOR:2.6,95% CI:1.3-5.4), and umbilical artery pH less than 7.10(13.8% vs. 5.0%; AOR: 3.3, 95%CI: 1.7-6.2).

Based on the available evidence, we do not recommend routine sequential use of instrument for AVB. Second-stage CB should be considered in cases of failed forceps or vacuum, except in situations where the operator judges sequentially instruments to be safer than proceeding to a second-stage CB.

6.8| Complications of AVB

Forces are generally associated with more maternal than neonatal injuries, whereas neonatal trauma is generally more common with vacuum. A Cochrane review that included 32 studies involving 6597 women found that forceps were less likely than vacuum to fail to achieve a vaginal birth(RR: 0.65, 95% CI: 0.45-0.94).41 However, forceps were associated with more subsequent CB, and significantly more third- or fourth-degree perineal tears(with or without episiotomy), vaginal trauma, use of general anesthesia,and flatus incontinence or altered continentia. Facial injury in the fetus was also more likely with forceps. Cephalohematoma was more likely with vacuum. Vacuum with metal cup was more likely to result in a successful vaginal birth than the soft cup, but with more associated cases of fetal scalp injury and cephalohematoma.Aside from fetal scalp injury and cephalohematoma, there were no significant differences in other neonatal outcomes comparing vacuum with metal cup and vacuum with soft cup. Blood loss and shoulder dystocia with forceps birth and vacuum birth were comparable. Neonatal outcomes, including low Apgar scores,low umbilical pH, neonatal admission or length of hospital stay,death, or severe morbidity, were also comparable between the two groups. Fetal intracranial hemorrhage, subgaleal hemorrhage,retinal hemorrhage, and neonatal jaundice/hyperbilirubinemia are

complications of AVB that are seen more commonly with vacuum than with forceps.64-66 Correct application of the instrument and knowing when to abandon the procedure are very key in mitigating complications of AVB.

6.9| AVB checklist

To reduce the risk of complications and adverse outcomes dur-ing AVB, we recommend the use of an AVB checklist(Table S1),which can be adapted to local contexts. The checklist should be completed for women in the second stage of labor who are antici-pated to require AVB. Prerequisites for a successful AVB such as adequacy of maternal pelvis, full cervical dilatation, engagement of the fetal head, known fetal head position and station, empty bladder, analgesia, and requisite skills, should be confirmed and recorded. Presence of multiple risk factors for difficulty/failure such as previous AVB complications/adverse outcomes, previous CB, high maternal body mass index(BMI, calculated as weight in kilograms divided by the square of height in meters), abnormal maternal pelvis/pelvic problems, fetal macrosomia, fetal mal-presentation, and malposition requiring rotation, should prompt consideration for a trial of AVB in theater, second-stage CB, or dis-cussion with a senior/more experienced obstetrician on the risks and benefits of AVB versus second-stage CB.

6.10| Recommendations on conduct of AVB

1. Obstetricians, obstetric trainees/residents, and interns(and midwives in some local contexts) should be trained to com-petence in performing AVB(strong, low).

2. Obstetric trainees/residents and interns should be assessed to have achieved expertise in SVBs before being trained in AVB(strong, low).

3. All practitioners should first conduct AVB under direct supervi-sion of more experienced and senior operators, and the opera-tor's competency confirmed before conducting unsupervised AVB(strong, low).

4. Complex and high-risk AVBs should be performed by experi-enced, senior obstetricians(strong, low).

5. The choice of forceps or vacuum for AVB should depend on the skill,experience,clinical judgment, and preference of the opera-tor, as well as the clinical context and availability of the instru-ment; forceps and vacuum have comparable effectiveness and outcomes(strong, high).

6. Analgesia for AVB should be discussed with the woman, de-pending on local availability of analgesia(conditional, low).

7. Regional analgesia or a pudendal block is suitable for all AVBs,although a perineal block may be adequate for a low or outlet birth(conditional, low).

8. If an effective epidural analgesia has already been instituted during labor, this can be reinforced for AVB(conditional, low).

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9. Routine episiotomy for all AVBs is not recommended(strong,high). The need for an episiotomy during AVB should be deter-mined by the clinical judgment of the operator, and when indi-cated, a mediolateral episiotomy is recommended to reduce the risk of OASI(strong, low).

10. A mediolateral episiotomy should be initiated when the fetal head is distending the perineum and be performed at an angle of 60° away from the midline, to minimize blood loss and re-duce the incidence of OASI(strong, low). The protective role of a mediolateral episiotomy against OASI during AVB appears to be stronger for nulliparous women compared with parous women,and for forceps birth compared with vacuum(conditional, low).

11. A single prophylactic dose of 1.2g intravenous amycillin and clavulanic acid is recommended after AVB to reduce maternal infectious morbidity(strong,high).

12. A correctly applied vacuum should be discontinued after three pulls without descent of the fetal head, or two pop-offs have occurred or after 20min of application has elapsed(conditional, low).

13. Forceps should be abandoned after three pulls of a closedly ap-plied forceps if there is no progressive descent of the fetal head with each pull, and if birth is not imminent (conditional, low).

14. Sequential application of forceps and vacuum is not recom-mended, as it can be associated with significant maternal and neonatal trauma and morbidity(strong, low), except in cases where the operator judges sequential instrument to be safer than proceeding to a second-stage CB (conditional, low).

<EndOfPara>the control group, forceps and vacuum were, respectively, associ-ated with a four-fold(RR: 3.7, 95% CI: 2.5-5.4) and two-fold(RR:1.6,95% CI 0.6-4.6) increased risk of birth injury in the macrosomic group. Similarly, compared with the control group, SVB was associ-ated with a four-fold(RR: 3.9, 95% CI: 3.5-5.0) greater risk of birth injury, and CB, a two-fold(RR: 2.2, 95% CI: 0.5-8.8) greater risk, in the macrosomic group. Forceps birth in the group with birth weights above 4000g was associated with a 7.3-fold increase in the risk of persistent birth injury at 6 months(95% CI: 6.5-8.2) compared with the lower birth weight group. This risk of persistent injury was com-parable with the increased risk with SVB and birth weights greater than 4000g(RR: 7.7, 95% CI: 7.4-8.1). The authors estimated that up to 258 elective CBs would have to be performed for fetal macroso-mia to prevent one persistent birth injury.

Fetal macrosomia is not an absolute contraindication to AVB.However, when there is known fetal macrosomia, AVB should be conducted cautiously, bearing in mind the higher risk of shoulder dystocia and increased likelihood of failure, necessitating skills in ob-stetric maneuvers to relieve the shoulder dystocia or an immediate recourse to CB. ${}^{18,20-22}$

7.2 | Maternal viral infections and AVB

AVB is not absolutely contraindicated in women with HIV, hepatitis B,and hepatitis C infections. ${ }^{20}$ A Cochrane review of 32 studies in-cluding 6597 women did not find data relating to the vertical trans-mission of HIV and AVB. ${ }^{41}$ However, a population-based surveillance study of 251 babies delivered by forceps or vacuum to HIV-positive women reported that only one infant had confirmed HIV infection at 18 months of age. ${ }^{69}$ For this one case, other significant risk factors for vertical transmission, including maternal drug adherence issues and breastfeeding, were identified, and the authors could not deter-mine whether the infection occurred intrapartum.

7 | SPECIAL/HIGH-RISK SITUATIONS

7.1 | Fetal macrosomia and AVB

In their systematic review and meta-analysis including more than 12000 macrosonate neonates(weight >5kg), Rossi et al.67 found that AVB occurred equally in both macrosom and normal-weight neonates weighing less than 4kg. They did not evaluate or compare the risk of injury associated with AVB in macrosomic and lower birth weight neonates.

To evaluate the risk of AVB with fetal macrosomia, Kolderup et al. ${ }^{68}$ compared the birth outcomes of 2924 macrosomia infants(birth weights $>4000g)$ with those of 16711 controls with birth weights in the range of 3000-3999g. In the macroscopic group,forceps were associated with a 1.3-fold (95% CI: 1.0-1.6), 2.6-fold(95% CI: 1.7-4.0), and 4.2-fold (95% CI: 3.6-5.0) greater risk of birth injury compared with vacuum, SVB, and CB, respectively. On the other hand, vacuum birth was associated with a 1.2-fold (95% CI:0.4-3.7) and 5.6-fold greater risk of birth injury compared with SVB and CS, respectively. Forceps birth correlated with a four-fold greater risk of persistent birth injury at age 6 months compared with SVB (RR: 3.7, 95% CI: 1.8-7.5) or CB (RR: 4.3, 95% CI: 3.9-4.8). No vacuum-related birth injuries persisted at 6 months. Compared with

Observational evidence suggests that vacuum birth may facil-itate mother-to-child transmission of herpes simplex virus(HSV)infection. A review of 699 infants delivered by vacuum to asymp-tomatic women with HSV infection reported confirmed HSV in-fection in 11 of infants, giving a prevalence of neonatal HSV infection in vacuum-assisted births of 7/1000 live births compared to 0.95/1000 in women who had normal vaginal birth or CB (RR:7.45, 95% Cl: 1.99-27.42; P=0.0001).70 Of the 11 infected infants,five developed HSV infection at the site of vacuum application. If the fetal scalp is lacerated during a vacuum birth, the HSV may gain ac-cess through the lacerated scalp and enhance the acquisition and the early appearance of cutaneous infection in infants exposed to HSV shedding in the genital tract of asymptomatic mothers. ${}^{41,70}$ In cases of maternal infection with HIV, hepatitis B and C, and HSV, difficult AVB should be avoided, as this increases the risk of fetal skin abra-sion or/and scalp injury, facilitating viral transmission from mother to child. ${}^{20,41}$ When indicated, vacuum with soft or silastic cups should be used in these categories of women. ${}^{41,71}$

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7.3 | AVB after a previous CS

Current guidelines do not generally recommend AVB in women un-dergoing a trial of labor after cesarean birth(VBAC).18,20-22,24,72-75 However, there is increasing evidence to suggest that a trial of AVB can be offered in women undergoing VBAC. Krizman et al.76 conducted a secondary analysis of the Maternal-Fetal Medicine Units Network CB registry and reported a high success rate of AVB in the setting of VBAC,with similar neonatal and maternal outcomes to second-stage repeat CB. Their analysis included 1837 women who underwent operative intervention in the second stage of labor during VBAC. Of the 1837 included women, 608 had a vacuum birth, 743 had a forceps birth,while 486 had a repeat CB in the second stage of labor. Participants in the AVB groups were more likely to have had a prior vaginal birth(vacuum 34.2%; forceps 34.3%) than the repeat CB group(22.6%;P<0.0001).The success rate of forceps and vacuum births was 90.4%and 92.6%, respectively. Maternal composite morbidity(including uterine rupture/dehiscence, surgical injury[enterotry, cystotomy,other], death, endometriitis, transfusion, hystectomy, thromboem-bolism,wound complication, and anal sphincter lacerations) was high-est among forceps births(32.3% vs. 24.3% vacuum; 22.0% repeat CB,P=0.0001).Forcesk birth was associated with an increased risk of blood transfusion(3.4% vs. 1.3% vacuum; 1.9% repeat CB; P=0.03).Compared with repeat CB,AVB was associated with an increased risk of anal sphincter laceration(22.7% forceps, 15.5% vacuum, 0% repeat CB; P=0.01).Repeat CB was associated with a significantly higher incidence of surgical injury, endometritis, and wound complications than forceps or vacuum birth. Neonatal composite morbidity(includ-ing NICU admission, hypoxic-ischemic encephalopathy, sepsis, Apgar score<4 at 5min, perinal death, and birth injury) was not different among groups(12.1% forceps vs. 14.6% vacuum; 14.8% repeat CS).

Similarly, Son et al.77 conducted a retrospective secondary analysis of data from the Cesarean Registry of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, to determine the safety of attempting AVB among women undergoing VBAC. Their analysis included women who were at least 36 weeks of pregnancy, with a live, singleton, non-anomalous gestation in cephalic presentation,and station of the fetal head of+2 or greater. Of the 1230 women included in their analysis, 438 had a vacuum birth, 507 had a forceps birth, and 285 had second-stage repeat CB. The success rate of vag-inal birth in the AVB group was 96.7%. Compared with women who had repeat CB, those who underwent AVB had a lower mean BMI(30.4±6.0 vs.31.8±5.9;P=0.001) and gestational age(GA) at birth(39.5±1.3 weeks vs. 39.8±1.2 weeks; P=0.012), were more likely to have had a history of a previous vaginal birth(34.9% vs. 20.4%;P<0.001) or VBAC(23.0% vs. 14.0%; P=0.001), and fetal station greater than+2(55.6% vs. 16.8%; P<0.001). There were no sig-nificant differences in maternal outcomes except for endometriitis,which was more frequent in women who underwent second-stage repeat CB. There were also no significant differences in neonatal outcomes. Smaller observational and retrospective studies have also reported successful low-forcesp and vacuum births in women

undergoing VBAC, with no significant adverse maternal and neona-tal effects compared with repeat CB.78-83

7.4| AVB versus second-stage CS

A systematic review by Thierens et al. in 2023 compared maternal and perinatal morbidity,mortality,and other adverse outcomes after vacuum extraction versus second-stage CB.84 They reviewed 15 ar-ticles, providing outcomes for a total of 20051 births by second-stage CB and 32823 births by vacuum extraction. All five maternal deaths documented in their review occurred due to anesthetic com-plications during second-stage CB. More perinatal deaths occurred in the second-stage CB group than the vacuum extraction group(92/20051, 0.45% vs. 41/32823, 0.12%), with more of the perinatal deaths occurring during the decision-to-birth interval in the second-stage CB group than in the vacuum extraction group.

Another systematic review and meta-analysis of 10 studies including 23104 pregnant women, among whom 18106 had CB during the first stage of labor while the remaining 4998 underwent a second-stage CB, compared the maternal and neonatal morbid-ity of first- and second-stage CB.85 Maternal ICU admission rates(OR: 7.41, 95% CI: 2.47-22.5), transfusion rates(OR: 2.60, 95% CI:1.49-2.54), and maternal deaths(OR:7.96,95% CI:1.61-39.39) were higher among women who underwent a second-stage CB. Neonatal death rates were also increased(OR: 5.20, 95% CI: 2.49-10.85),along with NICU admissions(OR: 1.63, 95% CI: 0.91-2.91) and rates of Apgar score below 7 in 5min(OR: 2.77, 95% CI: 1.02-7.50).

A retrospective cohort study of 189 021 paired first and second births found that CB in the second stage of labor was associated with a two-fold increase in the risk of subsequent spontaneous PTB(sPTB) both below 37 weeks(RR: 1.57, 95% CI: 1.43-1.73) and below 32 weeks(RR:2.12,95% CI:1.67-2.68), as well as an increased rate of subsequent perinatal death(RR: 1.44, 95% CI: 1.05-1.96).86 Second-stage CB has also been linked with an increased risk of recurrent sPTB below 30 weeks(RR: 3.06, 95% CI: 1.22-7.71).87 A plausible explanation for the link between second-stage CB and subsequent PTB may be due to iatrogenic extension of the uterine incision to the cervix, which often occurs during second-stage CB.

Given the increased maternal and neonatal morbidity associ-ated with second-stage CB, in addition to the increased risks of pla-centa accreta spectrum disorders and uterine rupture in subsequent pregnancies seen with CB,88 obstetricians should counsel and offer women with fetal distress or poor progress in the second stage of labor ABV rather than a second-stage CB(Figure 1), except in situa-tions where a second-stage CS is judged to be safer. ${}^{37}$

7.5| Recommendations on AVB in special/high-risk situations

1. Fetal macrosomia(weight>4kg) is not an absolute contraindication to AVB(conditional, low). However, when fetal macrosomia is

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 FIGURE 1 Algorithm on how to choose between assisted vaginal birth(AVB) versus second stage cesarean section(CS) in the second stage of labor.AVB,assisted vaginal birth;CS,cesarean birth;CTG,cardiotocography.

identified,AVB should be conducted cautiously, bearing in mind the higher risk of shoulder dystacci and increased likelihood of failure, necessitating obstetric maneuvers to relieve the shoulder dystocia or an immediate recourse to CB(strong, low).

2. Maternal HIV, hepatitis B and C, and HSV infections are not ab-solute contraindications to AVB, provided the women have been adequately treated for these infections prior(conditional, low).However, in women with HIV, hepatitis B and C, and HSV,difficult AVB should be avoided, as this may increase the risk of fetal skin abrasion or/and scalp injury, facilitating viral transmission from mother to child(strong, low). When indicated, vacuum with soft or silastic cups should be used in these situations(strong, low).

3. In carefully selected patients, a low or outlet forceps or vacuum birth for the usual indications may be cautiously attempted in women undergoing VBAC(conditional, low). Candidates for such trial of AVB include women with one previous lower segment CS,with a history of a previous vaginal birth or VBAC, BMI less than 30, and a single, non-macrosomic(<4kg), term fetus in cephalic presentation(conditional, low).

4. A trial of AVB in women undergoing VBAC should be conducted by a senior/skilled/experienced obstetrician in an operating theater, where immediate recourse to CB can be undertaken in case of any complication(conditional, low).

5. The fetus should be on continuous electronic monitoring while at-tempting a trial of AVB in women undergoing VBAC(strong, low).

6. For women undergoing a trial of AVB in the setting of VBAC, the risks and benefits in the context of her individual circumstances should be discussed with the woman herself, and her family, as appropriate(strong, low).

7. Women with fetal distress or poor progress in the second stage of labor should be counseled and where appropriate, offered AVB rather than second-stage CB, given the maternal and neonatal morbidity as-sociated with the latter, except in situations where second-stage CB is judged by the operator to be the safer opi option(conditional, low).

8| CONCLUSIONS

Although CB rates are increasing exponentially worldwide, rates of AVB are declining rapidly. Increasing the use of AVB globally has the

potential to mitigate the increase in CB rates, and in particular, avoid-ing the most unsafe cesarean sections at full dilatation. We there-fore recommend that obstetricians, obstetric trainees/residents, and interns (and midwives in some local contexts) should be trained and achieve competency in performing AVB.

In carefully selected patients, mid-cavity and rotational births can be conducted when conditions are safe. Even for macrosomic babies, in women with HIV, hepatitis B and C, HSV infection, as well as those with one previous lower segment CB, AVB can be at-tempted with appropriate precautions.

Correct application of the instrument and knowing when to abandon the procedure are crucial in minimizing complications of AVB. Sequential application of forceps and vacuum can be asso-ciated with significant maternal and neonatal morbidity and is not routinely recommended.

Women with suspected fetal hypoxia or poor progress in the second stage of labor should be counselled, and where appropriate,offered AVB rather than second-stage CB, as the latter is associated with significantly higher maternal and neonatal morbidity. Second-stage CB should only be performed if it is judged by the operator to be a safer option than AVB.

AUTHOR CONTRIBUTIONS

AEB,ERB,ND,and MM conceptualized the paper.AEB carried out the literature review, synthesis of evidence, grading of recommen-dations and evidence, and wrote the first manuscript draft, which was reviewed and revised by ERB, ND, and MM, to produce a sec-ond manuscript draft. The second manuscript draft was critically re-viewed and revised by JB-K,IN,AJN-C,EGT,ZJM,BO,and AW for sound intellectual and current best evidence content. The second round of reviews and revisions was coordinated by AW, with AEB implementing the reviews and revisions, to produce a third manu-script draft, which was reviewed by all the authors. All the authors read and approved the final manuscript draft.

AFFILIATIONS

1Department of Obstetrics and Gynecology, PAMO University of Medical Sciences, Port Harcourt, Nigeria

${}^{2}$ World Association of Trainees in Obstetrics & Gynecology (WATOG), Paris,France

3Society for the Investigation of Early Pregnancy(SIEP), New York, New York, USA

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NOB ECOLOGY\n㈩

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${}^{4}$ Department of Obstetrics, Gynecology& Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA

$^{5}$ Department of Biomedical Sciences, Humanitas University, Milan, Italy

6Humanasan San Pio X,Milan,Italy

${}^{7}$ IRCS Humanitas Clinical and Research Hospital, Milan, Italy

8Department of Obstetrics and Gynecology, Lindenhofruppe, Bern,Switzerland

${}^{9}$ Department of Pediatrics, Maastricht University Medical Centre (MUMC),Maastricht, The Netherlands

${}^{10}$ Mulago Specialized Women and Neonatal Hospital, Kampala, Uganda

${}^{11}$ Department of Obstetrics and Gynecology, Gaia/Espinoh Local Health Unit, Porto, Portugal

12CINTESIS-Center for Health Technology and Services Research,University of Porto, Porto, Portugal

${}^{13}$ Department of Medical Sciences, University of Aveiro, Aveciro, Portugal

${}^{14}$ Departmentato de Ginecologia y Obstetricia, Fundacion Valle del Lili,Cali,Colombia

15Faculty of Health Sciences, Universidad ICESI, Cali, Colombia

<BeginOfPara>16Department of Obstetrics and Gynaecology, Assisted Reproductive Technologies Unit,Acidemas Masiak Hospital, Istanbul, Turkey

17Department of Obstetrics and Gynecology, School of Medicine, University of Juba, Juba, South Sudan

${}^{18}$ Association of Gynecologists and Obstetrics of South Sudan(AGOSS),Juba, South Sudan

${}^{12}$ Department of Obstetrics and Gynecology, Sahlgrenski Academy.

University of Gothenburg, Gothenburg, Sweden

${}^{20}$ Department of Obstetrics and Gynecology, Zherns Water Health Care Region,

${}^{21}$ Department of Genetics and Bioinformatics, Division of Health Data and Digitalisation, Institute of Public Health, Oslo, Norway

22 Royal Free London NHS Foundation Trust, London, UK

23University College London, London, UK

FUNDING INFORMATION

The authors received no funding for this paper.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were cre-ated or analyzed in this study.

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SUPPORTING INFORMATION

Additional supporting information can be found online in the Supporting Information section at the end of this article.

How to cite this article: Ubom AE, Barnea ER, DiSimone N,et al.FIGO good practice recommendations: Assisted vaginal birth and the second stage of labor. Int J Gynecol Obstet.

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