Instrumental Vaginal Delivery in Abuja, Northcentral Nigeria: A 5-Year Review

Alu Francis E.1, Mai Aminu M.2, Nwachukwu Chiemezie N.D.3, Igbinovia Imuentinyan4, Anate Abdullahi5,

Dennis Mary Clement6.

1.Consultant Obstetrician & Gynaecologist/Associate Professor, Department of Obstetrics and Gynaecology, Asokoro

District Hospital, Abuja and Nile University of Nigeria, Abuja; Email: drfrankalu@yahoo.com;

francis.alu@nileuniversity.edu.ng. 2. Consultant Obstetrician & Gynaecologist/Associate Professor, Department of

Obstetrics and Gynaecology, Asokoro District Hospital, Abuja and Nile University of Nigeria, Abuja; Email:

aminu.mai@nileuniversity.edu.ng. 3. Consultant Obstetrician & Gynaecologist, Department of Obstetrics and

Gynaecology, Maitama District Hospital, Abuja; Email: nduum@yahoo.co.uk. 4. Consultant Obstetrician &

Gynaecologist/Lecturer 1, Department of Obstetrics & Gynaecology, Maitama District Hospital, Abuja and Baze

University, Abuja; Email: tinyano@yahoo.com. 5. Consultant Obstetrician & Gynaecologist, Department of Obstetrics

& Gynaecology, Maitama District Hospital Abuja. Email: abdullahianate@gmail.com. 6. Department of Obstetrics &

Gynaecology Maitama District Hospital, Abuja. Email: mardenclem@yahoo.com

ABSTRACT

Correspondence:

Dr. Francis E. Alu

Department of Obstetrics &

Gynaecology,

Asokoro District Hospital/Nile

University of Nigeria Abuja

Phone number: +2348037206243

E-mail address:

drfrankalu@yahoo.com;

francis.alu@nileuniversity.edu.ng

Background: Instrumental vaginal delivery (IVD) is an important

intervention in obstetrics practice. Its main goal is to expedite vaginal delivery

with minimal feto-maternal morbidity while obviating the need for caesarean

section (CS). There has been a steady decline in the art of IVD worldwide for

a number of reasons including over reliance on CS and lack of training of

practitioners in the art. Regular audit of this important intrapartum intervention

in health institutions is key to improving its practice and outcome. Aim: The

aim of the study was to evaluate the practice and outcome of IVD in a

secondary healthcare facility in Abuja. Materials and Method: This was a

retrospective analysis of cases of IVD conducted in Maitama District Hospital

Abuja, over a 5-year period, between January 1st 2018 to December 31st 2022.

Results: The IVD rate in this study was 0.65%. Vacuum delivery was the

commonest type of IVD accounting for 96.2 % of cases. Majority, (65.4%),

were primigravidae. Delayed second stage of labour (76.9%) and fetal distress

in the second stage (11.3%) were the commonest indications for IVD. Maternal

and perinatal complications were rare and overall feto-maternal outcome was

good. Conclusion: IVD rate is low in our facility with a preponderance of

vacuum delivery. Periodic training, with facilitative supervision by

Obstetricians experienced in the art, is key to ensuring sustenance of the

practice of IVD and is therefore recommended.

Keywords: Instrumental vaginal delivery, vacuum delivery, forceps delivery,

fetal outcome, maternal complications, Abuja

Alu, et al. Instrumental Vaginal Delivery

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

273

INTRODUCTION

Instrumental vaginal delivery (IVD) is an important

intrapartum intervention in obstetric practice. The term

IVD is used interchangeably with operative vaginal

delivery (OVD) and assisted vaginal delivery (AVD). It

is defined as vaginal delivery accomplished with the aid

of instruments which can be vacuum or forceps.1,2 It is

performed when certain criteria have been met and

when the benefits outweigh the risks. The goal is to

expedite vaginal delivery with minimal feto-maternal

morbidity.1,3 If successful, it obviates the need for

emergency caesarean section (CS) with its attendant

complications. The incidence of IVD varies widely

between regions and within countries and depends on

the availability of trained personnel to perform the

procedure.4,5

An incidence of 10-15% of deliveries has been

reported in the UK and 4.5% in the USA, with rates in

primigravid women as high as 30%.6,7 In Nigeria,

reported IVD rates range from 0.4% to 6% of all

deliveries.2,8-14

Indications for IVD can be maternal or fetal, or

both, and include fetal compromise in the second stage

of labour, delayed second stage of labour due to

inadequate uterine activity, malposition, and poor

maternal efforts, maternal exhaustion as well as

maternal medical conditions where prolonged pushing

or Valsalva manoeuvre should be discouraged. These

maternal conditions include cardiac disease, respiratory

disease, hypertensive crises, cerebral vascular disease,

myasthenia gravis, and spinal cord injury.1

The prerequisites for IVD include maternal

informed consent, skilled operator, fully dilated cervix,

empty urinary bladder, ruptured fetal membranes,

cephalic presentation with the head engaged, the

position must be well known, the pelvis must be

adjudged adequate, adequate anaesthesia/analgesia,

availability of resources for emergency caesarean

section and neonatal resuscitation.1,3,15

IVD is not without risks. Complications

associated with the procedure include maternal genital

tract laceration, primary postpartum haemorrhage

(PPH), increased risk of anaemia and blood transfusion,

pelvic floor and anal sphincter injury. Fetal

complications include cephalhaematoma, retinal

haemorrhage, scalp laceration, facial palsy especially

with forceps and need for special care baby unit

(SCBU) admission.16,17 Routine antibiotics prophylaxis

has been shown to effectively reduce infectious

morbidity in IVD.18

Generally, most Obstetricians prefer vacuum to

forceps delivery due to the former’s simplicity of use

and the relative ease of acquiring the skill, although

vacuum delivery has a higher failure rate than

forceps.19,20 The RCOG recommends that IVD should

be conducted only by skilled operators in the chosen

procedure or by trainees under direct supervision of an

experienced trainer to ensure a favourable outcome.6

There has been a steady decline in the rate of

IVD with a corresponding disproportionate increase in

caesarean section rate (CSR) with its associated

increased maternal and neonatal morbidity and

mortality. The decline in IVD rate is thought to be

mainly due to medico-legal concerns and decline in

practice of IVD, especially forceps application, in most

obstetric units. Other reasons attributed to this decline

include lack of training and supervision of trainees on

the art, lack of relevant guidelines and policies for IVD,

and restriction of use of IVD in HIV positive patients

among others.5 Vacuum delivery has become more

common than forceps with reported vacuum delivery to

forceps delivery ratio of 4:1.14,21 Regular audit of this

important intrapartum intervention in health

institutions is key to improving its practice and

outcome.

This study aimed to retrospectively review the

practice and outcome of IVD in our centre, a secondary

healthcare institution in Abuja, Northcentral Nigeria.

MATERIALS AND METHOD

This was a retrospective review of all cases of IVD

performed at the Maitama District Hospital (MDH)

Abuja over a 5-year period, between 1st January 2018

to 31st December 2022. MDH is a public secondary

healthcare facility in Abuja. It is located in the Abuja

Municipal Area Council of the Federal Capital

Territory. It is accredited for Residency training in

Obstetrics and Gynaecology and provides specialized

obstetric care and serves as a referral centre for patients

from both public and private health institutions in the

Federal Capital Territory Abuja and its environs. The

Hospital operates an electronic medical records system

with secure database for easy data retrieval.

For the study, data were collected from the

patients’ records on the electronic medical records

database and also from the labour ward, postnatal ward

and theatre records. The relevant socio‑demographic

and obstetric characteristics of the patients obtained

included the age, booking status, parity, indication for

the IVD, and maternal and neonatal outcomes. The data

extracted were entered into a computer and analysed

using Statistical Package for Social Sciences (SPSS)

version 26.0 (IBM, Chicago IL, USA) with results

presented in tables and simple percentages. Ethical

approval was obtained from the Institution’s Research

Ethics Committee.

Alu, et al. Instrumental Vaginal Delivery

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

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RESULTS

During the period of study, a total of 8,046 deliveries

was recorded. Of these, 52 were IVD, giving an IVD

rate of 0.65% (Vacuum 0.62%; Forceps 0.03%).

Vacuum delivery accounted for the majority 50(96.2%)

of IVD, with forceps contributing only 2(3.8%). The

trends in IVD rate remained consistently lower than 1%

of all deliveries between 2018 and 2022 (0.31% in

2018; 0,89% in 2019; 0.76% in 2020; 0.70% in 2021,

and 0.55% in 2022). The lowest rate of IVD (0.31%)

recorded in 2018 coincided with the migration to E-

Medical Records system in the hospital with possible

loss of data.

Table 1: Demographic Characteristics of the Study

Participants

Variable Frequency (n=52) (%)

Age (years)

≤20 2 3.8

21-30 30 57.7

31-40 19 36.5

≥40 1 1.9

Booking status

Booked 42 80.8

Unbooked 10 19.2

Parity

0 34 65.4

1-4 17 32.7

≥5 1 1.9

Table 1 shows the age distribution, booking status and

parity of the study participants. Majority, 30(57.7%),

were in the 21-30 age group. Most of them, 42(80.8%),

were booked, and 34(65.4%) were primigravidae.

Table 2: Indications For Instrumental Vaginal

Delivery

Indication

Frequency

(n=52)

Percentage

(%)

Delayed

second stage

of labour

Maternal

exhaustion

Severe

Preeclampsia

Fetal distress

76.9

9.6

1.9

11.5

Table 2 shows the various indications for IVD.

Delayed second stage of labour, mainly due to

occipito-posterior position and poor maternal effort,

was the main indication (76.9%), followed by fetal

distress in the second stage of labour (11.5%), and

Table 3: Perinatal Outcome Following Instrumental

Vaginal Delivery

Perinatal outcome

Frequency

(n=52)

Percent

age (%)

Live births

Alive with Apgar

score ≥7 at 1 min

Alive with Apgar

score <7 at 1 min

Total

Alive with Apgar

score ≥7 at 5 min

Alive with Apgar

score <7 at 5 min

Total

Perinatal death

94.2

53.1

46.9

100.0

81.6

18.4

100.0

5.8

maternal exhaustion (9.6%). Maternal exhaustion and

fetal distress were more common in the unbooked cases

most of whom were referred from primary health care

centres in late second stage of labour. Severe

preeclampsia was an indication in 1.9% of cases.

Thirteen cases of maternal complications were

recorded. Of these, primary PPH occurred in 4(7.7%)

of all cases. Two of the PPH cases were due to genital

tract laceration. Two resulted from both genital tract

trauma and uterine atony. All the cases of PPH had

blood transfusion. Genital tract laceration, including

two cases of cervical laceration and one case of vaginal

laceration occurred in 3(5.8%) of IVD. There was one

case of third-degree perineal tear due to extension of an

episiotomy during forceps delivery for a failed vacuum

delivery. Another case of a failed vacuum delivery

resulted in an emergency caesarean section. Some of

the women had more than one complication.

There were 49 live births and three perinatal

deaths. Of the 49 live births, 26 (53.1%) neonates had

Apgar scores ≥7 in the first minute. This number

increased to 40(81.6%) at 5 minutes. Nine neonates

whose Apgar scores failed to improve at 5 minutes were

admitted in the special care baby unit (SCBU). Out of

these, one neonate, who had fetal distress and

cephalhaematoma, died after 48 hours on admission.

The rest were discharged in good condition. There were

two fresh stillborn babies (FSB). One followed a failed

vacuum delivery completed via forceps delivery. The

other was due to severe birth asphyxia following

vacuum delivery. One neonate developed neonatal

jaundice.

Alu, et al. Instrumental Vaginal Delivery

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

275

DISCUSSION

This study shows an IVD rate of 0.65% in our facility.

This rate is low compared to the rates reported in

developed countries.6,7 It is, however, comparable with

the less than 1% rates reported in some studies in

Nigeria and other West African countries2,8,11,21 In

contrast, our rate is much lower than the rates of 1-6%

reported in some centres in Nigeria.13-14,25-26 The low

rate of IVD in our facility is in tandem with the global

trend in decline of the practice of IVD. This might be

attributed to the decline in training in the art of IVD,

especially with the forceps, and the overall preference

for caesarean section as an alternative to IVD. Other

factors that could have contributed to the low rate of

IVD in our facility include concerns for fetal

complications and restriction on conduct of IVD in HIV

positive parturients.

Vacuum delivery was the commonest type of

IVD, accounting for 50(96.2%). This is not surprising

as most Obstetricians prefer the Vacuum because its

learning curve is relatively easier, and it is simple to use

compared with forceps. These advantages over forceps

have also made Vacuum use more popular among other

healthcare professionals such Nurses/Midwives and

Community Health Extension Workers (CHEW) as part

of task-sharing in the health sector. The two cases of

forceps delivery recorded in this study were performed

for failed vacuum. One resulted in a fresh stillborn

while the other was a live birth. The latter was

associated with extension of the episiotomy resulting in

a third-degree perineal tear. The low incidence of

forceps delivery and the indication for their use clearly

demonstrate that forceps use has fallen into disrepute in

our facility and is only employed in desperate situations

to avoid late emergency caesarean section as an

alternative. The difficult learning curve for forceps

application, and the perception that forceps delivery is

associated with more maternal and neonatal

complications, are contributory factors for their limited

use in our facility. This view has also been expressed

by other authors.2,8,11,23,24

In this study, IVD was most commonly

performed in primigravidae. This is consistent with

findings in other studies.10-14 Primigravidae are more

prone to dysfunctional labour leading to prolonged

labour and maternal exhaustion in the second stage.1

Surprisingly, some studies recorded higher rates of IVD

in multiparous women compared with

primigravidae.2,8,26

The commonest indication for IVD in our study

was delayed second stage of labour (76.9%), followed

by fetal distress (11.5%). Concerns about possible

adverse fetal outcome in the presence of fetal distress

are usually taken more seriously than delays in the

second stage of labour due to poor maternal efforts,

hence cases of fetal distress are most often treated by

EMCS. This might explain the lower rate of fetal

distress as an indication in this study. Maternal medical

conditions were not a common indication in our study.

Again, this is because CS is generally performed for

most of our patients with pregnancies complicated by

severe maternal medical conditions such as

preeclampsia/eclampsia, unless they present in second

stage of labour, like the only case recorded in this study.

Maternal complications were few. Primary PPH was

the commonest maternal complication, occurring in

4(7.7%) of all IVD. Two of the PPH cases were due to

genital tract laceration; two resulted from both genital

tract laceration and uterine atony.

All four cases of PPH had blood transfusion.

Genital tract laceration occurred in 3(5.8%) of IVD.

This included two cases of cervical laceration both of

which occurred with vacuum delivery. Vacuum

delivery, unlike forceps, have often been employed in

the late first stage of labour at cervical dilatation of 8cm

and above in cases of severe fetal compromise, and this

may result in cervical lacerations.1,22 However, forceps

deliveries are reported to cause more genital tract

injuries, including pelvic floor and anal sphincter

injury, than vacuum.16,23,27 This study recorded one case

of a third-degree perineal tear resulting from extension

of an episiotomy during forceps delivery for a failed

vacuum delivery. There were two cases of failed

vacuum delivery; one was completed by forceps

delivery and the other by EMCS. This underscores the

need to ensure that resources are available for both

EMCS and advanced neonatal resuscitation as part of

the prerequisites for performing IVD. In our facility,

prophylactic antibiotics is routinely given following all

IVD.18 This might explain the lack of any infectious

morbidity recorded in the study.

Perinatal outcome was generally good with a

live birth rate of 94.2% and good Apgar scores. Nine

neonates, however, required SCBU admission on

account of persistent low Apgar scores at 5 minutes.

Eight of them were discharged in good condition while

one neonate who had fetal distress and

cephalhaematoma died after 48 hours in the SCBU. It

is pertinent to note that the low Apgar scores recorded

in most of the cases were as a result of the conditions

that necessitated the IVD (severe fetal distress) rather

than from the intervention itself.

Perinatal complications recorded included three

cases of cephalhaematoma, one case of neonatal

jaundice and three perinatal deaths. Two of the

perinatal deaths were fresh stillborn babies. One

occurred following forceps delivery for a failed vacuum

delivery, and the other due to severe birth asphyxia

following vacuum delivery for fetal distress; the third

case was an early neonatal death in the SCBU. Two of

the perinatal deaths occurred in unbooked patients

Alu, et al. Instrumental Vaginal Delivery

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

276

apparently due to late referral to our facility and the

poor condition of the fetuses on arrival. Studies have

shown that serious neonatal complications are

uncommon with both instruments in well selected

cases, although vacuum delivery is generally reported

to be safer for the mother while forceps is generally

safer for the fetus.20,21 When compared with EMCS,

maternal and perinatal morbidity and mortality are

considerably lower with IVD.27 However, EMCS

following failed IVD, is associated with more adverse

maternal and perinatal outcome.23

CONCLUSION

IVD rate is low in our facility with a preponderance of

vacuum delivery, and favourable maternal and perinatal

outcomes. We recommend periodic training on IVD

with facilitative supervision of trainees to improve

uptake and outcome of IVD. This will reduce the need

for EMCS with its associated complications.

Limitation of the Study

The limitation of the study lies in its retrospective

design. In addition, the study did not compare maternal

and perinatal outcomes with that of emergency

caesarean section which is the immediate alternative to

IVD.

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