Ep 86: Operative Vaginal Delivery: When & Why We Do It and What to Know

I was inspired to cover this episode's topic because I recently attended several births that ended up being operative vaginal deliveries. Also known as an assisted vaginal birth, an operative vaginal delivery means that the medical provider uses tools - either forceps or a vacuum cup - to help deliver the baby vaginally.

In this episode you'll learn a lot more about what operative vaginal delivery is, how often it's done, when it's necessary and what the procedure is like. Operative deliveries only happen about 3% of the time, but it's still good for you to have some knowledge about it so you're prepared in case that becomes the best option on the day your baby arrives.

I will walk you through the different tools we use for assisted deliveries, why your provider needs to use the tool they are most comfortable with, and why an epidural is often a good idea with this kind of delivery. I'll also dispel some myths about assisted delivery and share the potential risks to the birthing person & baby. 

In this Episode, You’ll Learn About:

  • What operative vaginal delivery is and how often it's done
  • Why assisted delivery is decreasing overall nationally and regionally among providers
  • Three big reasons why you may need an operative vaginal delivery and when a C-section might also be an option
  • When we do NOT perform an assisted delivery because of the risks to parent & baby
  • What the procedure is like and why it is so essential for your provider to get your informed consent first
  • When we will abandon the procedure if it's not working and trying something else
  • What the risks of operative vaginal delivery are and why serious complications are very rare

Links Mentioned in the Episode



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Transcript

Ep 86: Operative Vaginal Delivery: When & Why We Do It and What to Know

Nicole: In this episode of the podcast, you're going to learn all about operative vaginal delivery with a vacuum or forceps.

Nicole: Welcome to the All About Pregnancy & Birth Podcast. I'm Dr. Nicole Callaway Rankins a board certified OB GYN. Who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Well, hello there. Welcome to another episode of the podcast. This is episode number 86. Thank you for spending some of your time with me today. In today's episode of the podcast, I am talking about operative vaginal delivery and what that is, is a vaginal delivery with help from either forceps or a vacuum. And I'll of course, explain what all of that means. And I got inspired to do this episode because I recently had a run myself where I was doing several vacuum deliveries. It's not something that I do very commonly, but I had like three or four together. And I will say I'm actually pretty good at vacuum deliveries in the nurses that I, I worked with who are so lovely, they have jokingly called me the queen of vacuum deliveries. And I thought, you know, hey, let's talk about this on the podcast. And this topic falls into one of those things that is good for you to know in the sense of having a general idea about it.

Nicole: It's not likely to happen, but you have some understanding of it just in case. So in this episode, you're going to learn what an operative vaginal delivery is, how often operative vaginal deliveries are done, what are reasons why we might do an operative vaginal delivery, when is it okay, and when is it not okay to do an operative vaginal delivery, what the procedure itself is actually like, and then finally potential complications for both mom and baby from an operative vaginal delivery. Now, before we get into the episode, let me give a listener shot out. This is to K Winkie, and the title of the review is So Glad I Found This. And the review says, I am currently 17 weeks pregnant and decided to look up podcasts to decide my birth wishes and become more knowledgeable about the entire birthing experience. As a first time mom, this is the best, and best is in all caps, BEST podcast I could have asked for.

Nicole: I am glad I found it and will recommend to any new mommy too. It could be me, but after each episode, I feel like I was given a virtual hug because it's so informative, but comforting. Oh my goodness. Thank you so much for that review. That just truly, truly made my day. I cannot tell you how much I appreciate you taking the time to share that lovely review and also recommend the podcast to other mamas to be. And I love that you feel like I'm giving you a virtual hug. Love it, love it, love it. I'm definitely givin' lots and lots and lots of virtual hugs. Now you mentioned in the review that listening to the podcast, part of that was deciding about your birth wishes and speaking of birth wishes, I have an announcement to make about my free online class on making birth wishes.

Nicole: It's called How To Make A Birth Plan That Works. And I have recently updated the class to make it even better. This is a one hour on demand class that teaches you how to make a birth plan that works to help you have the beautiful birth you want, the beautiful birth you deserve. You can sign up for that class at drnicolerankins.com/register. And if you have been following me for a while, you may have noticed something else new in what I just said, and that is my website. I have a brand new gorgeous website, drnicolerankins.com. Shout out to my amazing web designer, Claire from Claire Concept, she did a phenomenal job. Check it out. Everything of course, is there: the podcast, the free online class on how to make a birth plan, all of the details about my signature online childbirth education class: The Birth Preparation Course, and there's also a brand new resources page where you can download all of the free guides that I've created.

Nicole: It's like six or seven of them. So head to the website, drnicolerankins.com, check it out, let me know what you think. Okay. So let's get into today's episode operative vaginal delivery. So an operative vaginal delivery is when we use forceps or a vacuum. And again, I'll tell you what those are in a minute. They're used to help facilitate a vaginal delivery. Sometimes it's also called an assisted vaginal delivery. It doesn't happen very often. In 2017, for, that's when we have the most recent information, about 3% of all deliveries were operative vaginal deliveries, and of those 0.5% were forceps, and 2.6% were vacuum deliveries. And I'll talk a little bit later about why we tend to favor vacuum or why, I should say, vacuum is favored in general, but there also some regional differences in the United States in terms of how often vacuum deliveries are done, and between forceps vacuum deliveries in the Midwest, they have the highest rates of both forceps and vacuum deliveries.

Nicole: The Northeast has the lowest forceps rate and the South has the lowest vacuum rate. Overall, the operative delivery rate has been decreasing nationally and regionally in the United States. And I think part of that is because, to be honest with you, it's just fewer and fewer people have this skill to do it. And people are kind of jumping a bit more to Cesarean birth. And then, I believe, that the reason that vacuum is used more is that honestly, it's just a little bit easier. It doesn't require as much technical skill and ability to use the vacuum. Now, as far as what they are, so forceps are metal instruments. They kind of look like giant metal salad tongs for lack of a better way to put it. And they grasp the baby's head. And there are a bunch of different types. I'm not going to go into the different types.

Nicole: They can be used for different circumstances, but in general they're metal instruments that kind of grasp the baby's head. And the operator uses the handles to pull the baby out. They were supposedly invented by the Chamberlain family back in like the 1500's-1600's in order to help facilitate difficult deliveries. And they were kept secret for quite some time, actually. And a vacuum is just that it's a vacuum, it's a soft cup, or it could be a rigid cup, but most often it's a soft cup that's placed on the baby's head. And then that cup is attached to a vacuum pump and you use it to apply pressure and pull the baby out like that. And there's several different types of vacuum cups. I'm not going to go into all of those either. Now, overwhelmingly physicians are the ones who do operative vaginal deliveries. I have never met a midwife who does an operative vaginal delivery.

Nicole: I know very few will do vacuum deliveries, but overwhelmingly it's going to be a physician who does an operative vaginal delivery. Now, as far as when we may do an operative vaginal delivery, there are few reasons. One of the most common reasons is if a baby is in distress and needs to be delivered quickly. So, if baby is, you know, you're pushing babies, calming babies is close and the heart rate drops and it's faster to deliver the baby vaginally. Then going back for a cesarean, because remember us, a cesarean takes time. You have to get back to the operating room. You have to get the anesthesiologist there. You have to get comfortable with the anesthesiology medicine. You have to get the operating room set up. All of those things take time. So if a baby is in distress and is close to coming out of the vagina and just needs that little bit of extra help, then an operative vaginal delivery is very appropriate then.

Nicole: And then the second common reason for an operative vaginal delivery is mom gets exhausted from pushing and needs a little bit of help, or wants a little bit of help to deliver. Pushing a baby out can be hard work. And some women may push for three hours or four hours or sometimes longer. And that can be exhausting. Most of the time in the cases where moms are exhausted from pushing, they are happy to have an option of a vacuum or forceps delivery. And it's just a little bit of help, right at the end. It's sort of a, it's not that we're like completely doing everything. It was just giving a little bit of extra oomph to help mom get across the finish line. If she's really, really tired from pushing. Now, a more uncommon reason that a vacuum may be done is if a mom has a medical condition where vaginal delivery is safe, but actually pushing should be minimal.

Nicole: And this is like a few rare heart conditions or brain conditions where you don't want to increase the pressure in the head from pushing where it's better to do an operative vaginal delivery. And in that case, we literally let the baby come almost all the way completely out. You know, labor takes a little bit longer in those instances. And then at the very end, we do that operative vaginal delivery. So mom doesn't have to push at all, but that doesn't happen very commonly. Now, keep in mind that cesarean is also an option. And all of these circumstances, you don't have to have an operative vaginal delivery if you're exhausted, or if you have a medical condition or if the baby is in distress, but it can certainly be a great option to facilitate a faster delivery and achieve a vaginal delivery. If that's what you want.

Nicole: Now, there are some circumstances when operative vaginal delivery should not be used in general. We typically don't do it before 34 weeks, especially for a vacuum delivery. Some people may do a forceps delivery a little bit earlier, earlier than 34 weeks. So before 34 weeks we don't do an operative vaginal delivery, just because their little bodies are a bit more fragile. And there's a little bit of trauma. I hate to say trauma. I don't know. I don't want to seem like it's like this big major event, but it is something to have forceps put on or vacuum put on your head. You gotta be a little bit sturdy to take that. And preemie babies are a little bit more fragile in that regard. We also cannot use operative vaginal delivery if the baby has a bone disorder where there issues with the bones, that's rare, or the baby has a bleeding disorder where they're at increased risk of bleeding.

Nicole: That is also rare. We can't do it if the baby is not low enough in the pelvis, we shouldn't really be pulling babies from really high up in the pelvis. So they have to be low enough in the vagina and in the pelvis in order to do the delivery. And then they also have to be coming down a certain way. So most babies come down in the Vertex presentation. Vertex is the top part of the head. And most babies come down where that is the first part that is coming down into the vagina. But very rarely a baby will come down with its face as the first part that's really rare, or the brow, the eyebrow area is the first part. That's also really rare, but you can't do an operative vaginal delivery in those circumstances because you can't get the instruments on properly.

Nicole: And then we also shouldn't do it if we don't think that it's going to be successful. So if we don't think the baby will fit, if we think that there's a reason, like, hey, something doesn't look right, this baby, you know, you've been pushing for a long time. The baby's not making much progress. Maybe the baby's suspected to be big. If we don't think that the baby will fit, or if the baby's large and we end up pulling what we call to a shoulder dystocia, so the head comes out, but then the shoulders get stuck. That can be bad. So if we don't think it'll be successful or we'll think there'll be some risks, we should not do it. So as far as what an operative vaginal delivery is like and how the procedure goes, it's actually not, you know, operative. You think it's like a fancy sort of thing or like surgery sort of thing, but it's actually not that complicated, so to speak. Now, the first thing that of course should happen before an operative vaginal delivery, the first thing that should happen before we do anything, is informed consent. Now, many hospitals have you, when you come in, you sign a blanket like general sort of consent form that covers everything. Vaginal deliveries, the cesarean birth, operative vaginal delivery, that is written consent. That is not informed consent. Informed consent means that there should be a discussion at the time of thinking about doing the operative vaginal delivery, where we talk about the risks, why we want to do it, or why it's being suggested, the risks, the benefits, the alternatives, so that is what informed consent is. So there needs to be that discussion before it happens. And it's not just, I'm going to put forceps on the baby because the baby's heart rate is low, or I'm going to put a vacuum on the baby because the baby's heart rate is low.

Nicole: Sometimes that conversation needs to happen quickly, especially if the baby's heart rate is low, but it can definitely still happen. So first thing that needs to happen is informed consent. And again, we're not to try forceps or a vacuum, unless we think it's going to be successful. Most of the time it is successful. It's actually successful 85 to 90% of the time. So it's most likely that it's going to work. You're not going to have complications. And I'll talk about the complications later and you're able to avoid a cesarean birth. So we're not going to have this discussion or bring it up unless we think that it's going to be successful. Now, in terms of choosing which instrument to use the most important consideration is which one your physician feels most comfortable using. You cannot go into your birth saying, oh, I only want to have a vacuum.

Nicole: Oh, I only want to have forceps. Okay. It really needs to be the one that your physician feels most comfortable using. I would say in general, that forceps in particular really need to be used by a skilled and practiced physician because they have a little bit of a higher risk of complications. And fewer physicians have training using forceps. I personally don't do forceps. I don't use forceps. I did a few forceps deliveries during my residency training at Duke. And when I did those, of course, I had like an attending physician, an experienced physician right there with me, but I didn't do enough that I feel comfortable doing them now. So I only use the vacuum. I'm very good at the vacuum, but I only use the vacuum. I don't use forceps. So you really want to that's the most important thing is that it's whatever the physician feels comfortable with.

Nicole: Okay. Now, as far as preparing for the procedure or preparing for an operative vaginal delivery, there's not much to it. So you definitely need to have effective anesthesia, especially for forceps. For forceps really an epidural is the only thing that's going to really decrease the sensation of pain when you're putting those instruments inside the vagina, and you can Google obstetric, forceps and see what they look like. If you're interested. And I'll try to have a picture in the show notes as well, but that's going to cause some discomfort having those instruments in your vagina. So really an epidural is going to be your best bet. Nitrous oxide may help to reduce the sensation of pain, but it doesn't like take away the pain. So that might be a nice sort of thing you can do. In addition, if your epidural isn't working great, but epidural and nitrous oxide, you're going to need some sort of pain medication, particularly for forceps. For a vacuum the vacuum itself does not touch your vagina. The vacuum cup is only on the baby's head, so it's not as painful as forceps. You're not gonna necessarily feel it there, but, um, it's still a baby coming out. So if you can have anesthesia, then that is great. The other thing we need to do is empty your bladder. The bladder sits right in front of the uterus and when the bladder is full, it kinda takes up space in the pelvis. And if we can empty your bladder, then it may help create extra space for the baby to come on down. Sometimes we can't empty your bladder right at the end because the baby's so low in the pelvis that you can't actually get the catheter around the baby's head into the bladder, but we at least try to empty the bladder. Uh, your water needs to be broken, your cervix needs to be fully dilated as well. Before we attempt to do any sort of operative vaginal delivery. Now in many places, the NICU, if there's a NICU, the NICU will be present at the delivery just to be able to evaluate the baby right away. And that's because they are present at any sort of potentially, um, any potential things that can slightly increase the risk of issues for the baby. 99% of the time they look at the baby, they say the baby's okay. And they leave. So the NICU may be present. If you're delivering at a hospital that doesn't have a NICU, it may be a pediatrician that's present, or it may not necessarily be anybody there from the baby side, but sometimes there will be. Sometimes there will be. Some other things that may be done, but that are not routinely done, some people will do an ultrasound to confirm the baby's position, confirm which way the head is facing.

Nicole: Sometimes it can be difficult to feel just with your fingers, which way a baby is facing, um, or like the, you know, the exact position of the baby. So some people will do an ultrasound in order to really know that because it may affect, especially the choice of forceps that you use. So some people will do an ultrasound, definitely episiotomy is not routinely necessary. People used to do episiotomies almost routinely with forceps to make some extra room because you're putting these instruments in, but really episiotomy is not routinely necessary. And when you do an operative vaginal delivery, also antibiotics are not routinely necessary. When you do an operative vaginal delivery. There was recently a study that came out that evaluated this in the UK, but the conditions of the study are not really very applicable to the way that we practice obstetrics here.

Nicole: So our specialty society ACOG, the American College of Obstetricians and Gynecologists has not changed the recommendation regarding antibiotics. So, um, that study did show that one dose of antibiotics may reduce the risk of infection, but antibiotics do not need to be routinely used in order to help reduce the risk of infection just because of an operative vaginal delivery. Okay. So did we come in, we had the discussion, here's why we think we should do it, the risk, the benefits. And again, I'll go over the risk in a minute. We empty your bladder, make sure your anesthesia is okay, I get the team present and then go for the delivery. And basically that just means applying the instrument and forceps have to be applied really carefully and in the right way so that they, they have to articulate together. They have to click together in order to make sure that the instruments are on correctly and the vacuum has to be placed on at a certain point on the baby's head to make sure you're you have the right angle in order to bring the baby out.

Nicole: So as far as how long the procedure takes, in general, we abandon the procedure if delivery hasn't occurred with three pulls, okay. And that's not necessarily three contractions because sometimes we'll do one pull. Cool. And then like maybe take it off, do a few contractions to push or do like two pulls and the baby's really close and then push for a couple more contractions and do one last pull in order to get the baby out. So in general, over three pules or roughly 20 minutes or so. So if delivery has not occurred after three attempts with pulling or 20 minutes, then in general, we abandon the procedure. It should also be abandoned if we're not seeing progress over that time. Okay. So if we are making pulls and we're not seeing any, you know, traction, we're not seeing that the baby is coming, then we should stop because the risk of complications, it's gonna start to go up.

Nicole: Now, there are exceptions to these where we may do one more pull or even two more pulls. You feel like the baby's so close and it's better to, or I should say the risk is less from doing one additional pull than trying to go do a cesarean. Because at that point, your only other option for delivery is a cesarean, and it's either get this baby out right now, or we gotta go back for a cesarean. And so you may do one additional pull more than three. If you think that it's warranted and the risk is lower than the cesarean birth. But most often we do three attempts and if it's not coming or close, then, then we abandoned the procedure. And sometimes the three attempts may be that the baby gets to like crowning. And then you have to push for a few more contractions yourself.

Nicole: So there's a little bit of wiggle room and flexibility in that regard. Now, one thing we pretty much never do is we don't switch between instruments. So by that, I mean, we don't try a vacuum first. And then if the vacuum doesn't work, try forceps or the other way around, we don't try forceps first. And then if the forceps don't work, try the vacuum, uh, that can increase the risk of injury. Again, there is a little bit of an exception to that. Maybe if you have a less experienced person doing a vacuum and then you have a more experienced person who feels better with forceps to come in for another attempt and feel like they can successfully do it, then maybe. But that is really rare that that is going to happen. So most often we don't go in between instruments. Now, one thing I will say is that there's a perception that when forceps or a vacuum are used, the physician does all the work and then just like, just pull the baby out.

Nicole: And that is not true. Most of the time, the only instance where that is true is in those medical conditions where it's not safe for mom to push. And that is not frequent, that that happens. Most often, you are still pushing even with the forceps and the vacuum, it makes it go so much faster. I kind of liken it to like mom is doing 95% and the vacuum or the forceps is just that last 5% to get across the finish line. So we just add that to your own effort, to facilitate a quicker delivery. It is a team effort between you and the physician in order to achieve that vaginal delivery. So you're still pushing, the vacuum and forceps just give you that little extra oomph to get across the finish line. All right. So let's finish up by talking about some of the risk of using forceps or vacuums for operative vaginal delivery.

Nicole: Now keep in mind before I go into the risk that all of these things can actually occur in a spontaneous vaginal delivery without the use of a vacuum or forceps. Okay? All of these things can occur on a regular delivery. It's just that when using vacuum or forceps, the risk of some things goes up. So first let's talk about the risk of injury for mom. Some possible risk that can happen from mom when using a forceps or vacuum include injuring the vagina. Again, you're putting these instruments inside the vaginas, and you can have vaginal tears. You can also have blood clots. Those are called hematomas that form inside of the vagina, or on the labia and the vulva area, you can have an injury to the anal sphincter. The anal sphincter is the collection of muscles that allows us to control our gas and control our bowel movements.

Nicole: And you can have injury to those muscles, particularly higher with forceps. You can also have urinary tract injuries because the urinary system is very close to the vagina as well. So the urethra or the bladder. Um, but again, that's, that's rare. And as I said, because forceps are in direct contact with your tissues or with a mom's tissues, whereas the vacuum is not. Forceps carry that higher risk of injury for mom, then a vacuum, definitely a higher risk of those more severe tears like third and fourth degree laceration. So vaginal lacerations, we classify them as first is the most minor. Fourth is the most severe. And for third and fourth degree lacerations in a spontaneous vaginal delivery without a vacuum or forceps, it's 2%. with a vacuum it's 10%, and with forceps it's 20%. So forceps will definitely increase the risk of those severe tears from mom.

Nicole: And that makes sense again, because you have these instruments inside the vagina. All right. So what are the risks for baby with a vacuum or forceps? So the risk for a baby include cuts to the baby scalp, potentially nerve injury, and then also bleeding around the brain, particularly where those, the suction cup is that can in rare cases, cause life threatening bleeding around the brain. It can also increase bleeding around the skull or retinal hemorrhage, which is bleeding in the eyes. Forceps can cause skin marks or cuts on the baby. I myself was delivered by forceps and my mom was always concerned. She thought I was going to have something wrong with me because I had marks around my temples after I was born. And for a few days afterwards. So forceps can cause skin marks cuts on the baby. Also injury to the eyes.

Nicole: Um, I know of one severe case, just kinda by story, where a baby was injured, a baby's eye was severely injured by forceps. Bleeding in the brain nerve injury, skull fracture, and an extremely rare cases. Death has been associated with forceps. The other issue with forceps is that facial injury is more likely with forceps because of the way forceps fit around the baby's face. Whereas the vacuum does not. The vacuum cup is just on the top of the baby's head. Now I know all of that sounds crazy scary. Okay. And understandably so. But fortunately serious complications from using either the forceps or vacuum are very, very rare. Okay. They're not very common that they happen. Knock on wood. I have been in practice for, um, you know, almost 15 years. I personally have not had any serious complications from a vacuum delivery.

Nicole: I don't know any of my colleagues who have, but of course it's certainly possible, but I'm just saying that to say that it's rare. And even when complications do happen, most of them are not serious and most resolve without long term problems. Okay. So again, we believe that when we do it, the benefits outweigh the risk. Also, there's also some concern kind of getting back to the story of my mom and me being born by forceps. And she thought that I was going to have some sort of, um, like neurodevelopment problems growing up because of that. And there's no evidence that forceps or vacuum affects the baby's brain development or putting those things on the baby's head does anything to affect their development as they grow into school-age children.

Nicole: Now, it would be lovely to tell you that, you know, if you have these factors, this will increase your risk of complications from an operative vaginal delivery. But it's not that straightforward. Complications can come up and it's based on a number of factors and some of them are related. So it depends on like what type of instrument is used. It depends on the position of the baby. It depends on why we're doing the operative vaginal delivery. It depends on the length of labor. It depends on the physician's experience. So some of those are related. So it's not very easy to say like, oh, if you're this type of person and your labor has been going on for this many hours, or if you're a certain weight or height or whatever, anything that it'll increase your risk because the things are all related. So it's not easy to tell if you're at risk for experiencing complications from an operative vaginal delivery. And I know that when you hear those risks again, you may be thinking, well forget that I'm going to just do a C-section.

Nicole: I'm not, I'm not going through all that. Well, keep in mind. Yes, C-section is an option. You certainly don't have to do a vacuum or forceps if you feel uncomfortable, but on balance vaginal delivery is safer than cesarean birth. And even when forceps or vacuum are used, because when a baby is verry low in the vagina, a cesarean birth is more difficult to perform because think about it. You're pulling a baby from way down in the vagina. You have to pull the baby up and out of an incision in the abdomen. And that increases the risk of bleeding and injury to the mom. And also the baby when a cesarean birth is done at that point. Now don't get me wrong. It can happen and we can do it if we need to. But if we can do an operative vaginal delivery on balance, it's almost always safer for mom and for baby.

Nicole: And also remember I said, it takes time to get prepared for a cesarean. Uh, you have to get to the operating room. You have to get the anesthesia ready. So if we can do a quick vacuum or forceps birth, it can be great. In certain circumstances, it really is a tool that we as obstetricians need to keep in our toolbox in order to help reduce this cesarean birth rate. And then finally, some folks may wonder, oh, if I have one operative vaginal delivery, does that mean all of them are going to be like that? And no, that's not the case. Only approximately 5% of women who have an operative vaginal delivery will necessarily have a second operative vaginal delivery. All right. So that is it for this episode of the podcast, just to recap operative vaginal delivery is a vaginal delivery by forceps or by vacuum.

Nicole: It's done in about 3% of births and it's mostly vacuums that are done. The two most common reasons that we do a operative vaginal delivery are fetal distress, so baby is in distress and we need baby to be born quickly and it's quicker to do a vaginal birth than to do a cesarean birth, or maternal exhaustion, where mom is just tired and needs a little help to get across the finish line. We only do an app, an operative vaginal delivery. When we think it's going to be successful, it's almost always only done in term babies, definitely thirty four weeks or more. There's some circumstances when we shouldn't do it. If there's some issues that baby has, or if we suspect that baby is too big or won't fit, there's a reason why baby's not coming out. It's not a terribly long procedure. We typically abandon it after three pulls or three attempts, roughly 20 minutes or so.

Nicole: And finally there are complications potentially for mom and baby, that varies slightly between vacuum and forceps, but they are rare and they are not likely to be serious. However, in rare instances, things could be serious. Oh, and then the final thing to say is that the choice of instrument? Cause I think this is really important, depends most on the skill of the provider and what that physician feels doing. All right. So that's it, don't forget to subscribe to the podcast in Apple podcast or wherever you're listening to me right now, whether it's Spotify or Google play. And if you feel so inclined, please leave me a review in Apple podcasts. It helps other folks to find the show and helps the show to grow. And I do shout outs from those reviews on future episodes. Oh, and did you notice, you have to see, I got new podcast cover art also, please, please do shoot me a note about what you think about the new podcast cover art.

Nicole: I so, so love it. If you can't tell it's a silhouette of a pregnant person on the podcast cover art. It was done by a designer whose wife is pregnant or is it was pregnant at the time that he did the design. And he used that as inspiration. You have to tell me what you think about the new podcast cover art. Also do check out my new website, drnicolerankins.com. There you can sign up for my free online class on how to make a birth plan that works. You can check out all the details of the birth preparation course and grab all of those free resources that I have for you on that resources tab. Now, next week on the podcast, the episode will actually fall on my birthday. I am turning 46 and this birthday has a special meaning for me.

Nicole: So you will hear all about that next week. So do come on back next week. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the All About Pregnancy & Birth Podcast. Head to my website, drrnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class, on how to make a birth plan that works as well as everything you need to know about my signature online childbirth education class, the birth preparation course. Again, that's drnicolerankins.com and I will see you next week.

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