Table 2 Quantitative Summary of Findings and CERQual Assessment

Prevalence of assisted vaginal delivery Included studies indicate low levels of use of instrumental birth, and early default to CS. Lack of equipment and lack of trained staff contribute to this situation. Improved access to the Cochrane database was associated with an increased use of ventouse vs forceps over time in one UK study, but this was not explained by changes in individual staff knowledge attitudes, or access to Cochrane reviews.

Bailey 2017 [12] 40 LMIC countries [B]

vacuum, forceps, spontaneous

Two of the twelve surveys undertaken more than 30 years ago. Most studies of moderate or low quality. LMIC countries included and relatively recent. Most studies identify the instruments included

Moderate Downgraded for study quality

Crosby 2017 [39] Ireland Canada [C]

forceps

Fauveau 2006 [41] worldwide [C]

vacuum

Healy 1985 [45] US [B]

forceps

Hewson 1985 [46] Australia [B-]

forceps

Maaloe 2012 [66] Tanzania [A-]

vacuum, CS

Ramphul 2012 [50] UK [A]

AVD

Rowlands 2012 [54] UK [B]

forceps, spontaneous, elective and emergency CS

Ryding 1998 [55] Sweden [B]

AVD, spontaneous, elective and emergency CS

Schwappach 2004 [58] Switzerland [A]

AVD, spontaneous, emergency and elective CS

Uotila 2005 [61] Finland [B

vacuum

Wilson 2002 [64] UK [A]

vacuum, forceps

Skills (development) in assisted vaginal delivery Mixed findings about the self-reported skills of obstetricians in determining the need for, seeking a second opinion in, and accuracy of clinical stills for, instrumental delivery. Evidence from one study that more junior doctors report being more likely to default to a CS, and that senior doctors are more aware than junior doctors that they make errors in some relevant clinical judgements. Less than 15% of responding LMICs in one multi-country audit reported teaching in AVD, as reported in 2006. In another survey most trainees report correct techniques for assessment prior to instrumental vaginal birth, but that, in practice, this is more difficult where women have insufficient pain relief, or where there is significant fetal caput, or where the practitioner is relatively inexperienced. In one study, Irish trainees were more likely to use AVD than Candian trainees, but confidence in AVD usedid not differ between the two groups. Midwives who were trained in using ventouse in the UK seemed to be confident in its use. Actual skills and competence were not tested in any included studies.

Alexander 2002 [34] UK [A]

vacuum

One of the seven surveys undertaken more than 30 years ago. Mix of high and low quality studies. Varying results across studies. Four UK. All but one study identify the instruments included

Low Downgraded for study quality and coherence

Crosby 2017 [39] Ireland, Canada [C]

forceps

Fauveau 2006 [41] worldwide [C]

vacuum

Garcia 1985 [43] UK [C]

forceps

Ramphul 2012 [50] UK [A]

AVD

Sanchez del Hierro 2014 [57] Equador [A-]

forceps

Wilson 2002 [64] UK [A]

forceps

Professional attitudes to the use of assisted vaginal delivery In one US study undertaken in 1985, the attitude of the director of the obstetric training programme was not associated with the rate of forceps performed in their institution. One UK study showed that staff attitude was not a key determinant of a rise in use of ventouse over time. In an Egyptian study, nearly half of all obstetricians attending a conference rejected the use of instrumental birth (49%) with more experienced medical staff being more positive to AVD than more junior staff, and those working in the private sector less positive than those working in the public sector (check with full text. A survey of practitioners in 121 LMICs reported in 2006 indicated that practitioners in about half (48%) of the countries represented reported knowledge, positive attitude, teaching and countrywide use of the method,; 15% reported no knowledge and therefore no use in their country. Irish trainees were more likely to use AVD and were more comfortable with its use than Canadian trainees in one study.

Crosby 2017 [39] Ireland, Canada [C]

forceps

One of the six surveys undertaken more than 30 years ago. Most low or moderate quality. LMIC countries included and relatively recent. Varing results across the studies. All but one study identify the instruments used

Low Downgraded for study quality and coherence

Fauveau 2006 [41] worldwide [C]

vacuum

Healy 1985 [45] US [B]

forceps

Sanchez del Hierro 2014 [57] Equador [A-]

forceps

Shaaban 2012 [59] Egypt [B-]

AVD

Wilson 2002 [64] UK [A]

forceps

Personal attitudes to mode of birth for oneself/a partner (obstetricians) Preference for elective CS amongst UK obstetricians (for them/their partners) was around 16% (15–17%) in both 1997 and 2001. A majority in both time periods would be happy to have an instrumental birth as an alternative for mid-cavity arrest, especially if they could choose the operator. Junior staff in 1997 were more likely than senior staff to choose ventouse than forceps for arrested labour, for both OP and OA positions. Choices were not affected by gender, age, or hospital status.

Al-Mufti 1997 [35] UK [C]

forceps, spontaneous, elective CS

One of the two studies undertaken more than 20 years ag, but this is not a limitation in this case as one of the aims is historical comparison. Both studies from the UK, quality from high to low, instruments not identified in one.

Very low downgraded for relevance, quality and adequacy

Wright 2001 [65] UK [A-]

AVD, spontaneous, elective CS

Women’s experiences of assisted vaginal delivery. In all studies where spontaneous physiological birth is included, it scores the highest for a positive experience. In some, elective CS scores almost as highly. Having an unplanned mode of birth (emergency CS or instrumental, especially with an episiotomy, and especially where the intervention is done for delay in labour rather than for acute clinical risk) seems to be associated with less positive reports of childbirth experience for women. In some studies, emergency CS is rated as the least positive of all birth modes, followed by instrumental, with a better experience reported after ventouse than forceps in most, but not all comparisons. In others, instrumental birth with episiotomy is the most distressing, especially after a ToL following a previous CS. A few studies note that negative experience is associated with poor pain relief, but in one study women with AVD reported higher levels of pain relief than women with spontaneous birth Where longer term memories of birth experience are recorded, the differences reported immediately after birth persist (up to 3 years in one study).

Avasarala 2009 [36] UK [C]

AVD, CS

Five of the 16 surveys undertaken more than 20 years ago. Most of low or moderate quality. Only one in a low income country. Instruments not identified in seven of the 16 studies

Low Downgraded for study quality and relevance

Garcia 1985 [43] UK [C]

forceps

Handelzalts 2017 [44] US [C]

spontaneous, emergency and elective CS

Hewson 1985 [46] Australia [B-]

forceps

Hildingsson 2013 [28] Sweden [B]

AVD, spontaneous

Kjerulff 2018 [47] USA A-

CS, AVD

Maclean 2000 [48] UK [C+]

spontaneous, forceps, emergency CS

Nolens 2019 [49] Uganda [B+]

CS

Ranta 1995 [51] Finland [C]

vacuum,‘, urgent’ and emergency CS

Rijnders 2008 [53] Netherlands [B]

AVD home, (spontaneous), emergency CS

Salmon 1992 [56] UK [C]

forceps, spontaneous, CS

Schwappach 2004 [58] Switzerland [A]

AVD, spontaneous, emergency and elective CS

Shorten 2012 [60] USA [B]

AVD, spontaneous, emergency and elective CS

Uotila 2005 [61] Finland [B]

vacuum

Waldenstrom 1999 [62] Sweden [A-]

spontaneous, vacuum, CS

Wiklund 2008 Sweden [C]

AVD, spontaneous, emergency and elective CS

Communication, information and consent Some evidence that many women do not have information about the risks and benefits of AVD (plus or minus episiotomy), either antenatally, intrapartum when the procedure is used, or postnatally to explain what happened.

Avasarala 2009 [36] UK [C]

AVD, CS

One of the six surveys undertaken more than 30 years ago. All of low or moderate quality. Instruments not identified in three studies

Moderate Downgraded for study quality

Fauveau 2006 [41] worldwide [C]

vacuum

Garcia 1985 [43] UK [C]

forceps

Ramphul 2012 [50] UK [A]

AVD

Renner 2007 [52] USA [C]

AVD, elective CS

Uotila 2005 [61] Finland [B]

vacuum

Impact of assisted vaginal delivery (women) Studies have variously measured postnatal mood, sexual function, desire to have more children, dyspareunia, urinary and bowel problems, postnatal fear of childbirth, pain, haemorrhoids, and backache, Having a spontaneous vaginal birth without instruments or episiotomy seems to result in the most positive outcomes in the short and longer term (though this is not the case for a few variables). Having an unplanned mode of birth may be the strongest predictor of negative outcomes. In some studies, emergency CS is associated with least positive impacts, followed by instrumental (negative outcomes reported for both forceps or ventouse in some studies – others show better outcomes for ventouse than CS in the short and longer term). In others, instrumental birth is the most distressing. Surveys that assessed preference for mode of birth next time indicate that spontaneous vaginal delivery is preferred by most, with some preferring a planned CS, and most preferring instrumental birth over emergency CS. If an instrumental birth is required, most seem to prefer ventouse over forceps.

Avasarala 2009 [36] UK [C]

AVD, CS

Three of the 14 papers report studies undertaken more than 20 years ago. Most of low or moderate quality. Two in the same LMIC setting, over the same time period. Instruments not identified in seven studies

Low Downgraded for study quality and relevance

Chan 2002 [38] UK [B]

AVD, spontaneous, CS

Declercq 2008 [40] USA [A]

AVD, spontaneous, CS

Fisher 1997 [42] Australia [B+]

forceps, spontaneous, CS

Garcia 1985 [43] UK [C]

forceps

Handelzalts 2017 US [C]

spontaneous, emergency and elective CS

Hildingsson 2013 [28] Sweden [B]

AVD, spontaneous

Nolens 2019 [2, 29] Uganda [B+]

vacuum, CS

Nolens 2018 [49] Uganda [B+]

vacuum, CS

Rowlands 2012 [54] UK [B]

forceps, spontaneous, elective and emergency CS

Ryding 1998 [55] Sweden [B]

AVD, spontaneous, elective and emergency CS

Schwappach 2004 [58] Switzerland [A]

AVD, spontaneous, emergency and elective CS

Uotila 2005 [61] Finland [B]

vacuum

Wiklund 2008 Sweden [C]

AVD spontaneous, emergency and elective CS

Experience of witnessing assisted vaginal delivery (partners) Witnessing an emergency CS or instrumental birth seems to be associated with less positive reports of childbirth for partners than a spontaneous vaginal birth. Emergency CS seems to be associated with marginally higher scores than instrumental birth, but only two studies measure this comparison. In one study, partners reported having panic attacks during the birth, and a few said they wouldn’t have more children. Some would prefer their partner chose an elective cs next time.

Belanger-Levesque 2014 [37] Canada [B]

AVD, spontaneous, elective and emergency CS

All three included studies relatively recent. All of moderate quality. None in an LMIC setting. Instruments not identified in any of the included studies

Low Downgraded for quality and relevance

Chan 2002 [38] UK [B]

AVD, spontaneous, CS

Hildingsson 2013 [28] Sweden [B]

AVD, spontaneous