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\begin{document}

\title{Authors' reply re: Assisted Vaginal Birth: Green-top Guideline No. 26.
(Response to BJOG-20-1243)}



\author[1]{Deirdre Murphy}%
\author[2]{Rachna Bahl}%
\author[2]{Bryony Strachan}%
\affil[1]{Trinity College Dublin and Coombe Women and Infants University Hospital}%
\affil[2]{St Michael's Hospital, Bristol}%


\vspace{-1em}



  
  \date{May 15, 2024}


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Letter to the Editor, BJOG Exchange

\textbf{Authors' reply re: Assisted Vaginal Birth: Green-top Guideline
No. 26.}

Dear Editor

The challenge when counselling a woman about Assisted Vaginal Birth
(AVB), and which instrument to use, encompasses a range of potential
outcomes including early and late maternal and neonatal morbidity, and
the implications for future births. Pelvic floor trauma is one important
factor to consider and for those with a specialist interest in levator
ani muscle avulsion it would seem obvious that assisted vaginal birth
should be avoided whenever possible, and that vacuum should be preferred
to forceps. \textsuperscript{1} However, for circumstances where
clinicians are attempting to avoid failed vacuum, subgaleal haemorrhage
and second stage caesarean section, forceps may be preferred. In
response to Dietz \& Esegbona's assertion that the guideline conveys a
pro-forceps bias that does little to help clinicians make informed
choices, exposing the RCOG to substantial medicolegal liability, we
believe the guideline has provided balanced guidance for clinicians
advising women on AVB. \textsuperscript{2}

Dietz and Esegbona find it ``astounding'' that the guideline and
associated patient information leaflet ``channel the state of the
literature as it was over 10 years ago, especially since some of the
most relevant literature was published in this journal.'' Dietz cites
three of his own publications including a BJOG publication from 2008 (12
years ago), and two systematic reviews of observational studies (many
published over 10 years ago).

In preparation for the RCOG Guideline, a literature search was conducted
by the college and included publications up to May 2019. A total of 149
publications were cited based on relevance and methodological quality,
and at least 35 reported data on pelvic floor morbidity. A publication
from 2015, addressing levator ani muscle injury, co-authored by Dietz,
was included. \textsuperscript{3}

When comparing vacuum and forceps assisted delivery, the most reliable
data are from randomised controlled trials and we cited the original
Cochrane systematic review. \textsuperscript{4} This review reported
that vacuum assisted delivery was significantly less likely to be
associated with significant maternal perineal and vaginal trauma than
forceps (OR 0.4; 95\% CI 0.3--0.5). We cited a further Cochrane review
from 2010 that addressed choice of instrument and included additional
RCTs that compared different types of vacuum device.
\textsuperscript{5}The conclusion of this review was entirely consistent
with the guideline.

\emph{``The results showed that the forceps was the better instrument in
terms of achieving a successful delivery. However, it was also
associated with higher rates of complications for the mother. These were
perineal trauma, tears, requirements for pain relief and incontinence.
``}

The relevant RCOG Assisted Vaginal Birth Guideline recommendation is as
follows:

\emph{``Operators should be aware that forceps and vacuum extraction are
associated with different}

\emph{benefits and risks; failure to complete the birth with a single
instrument is more likely with}

\emph{vacuum extraction, but maternal perineal trauma is more likely
with forceps. {[}New 2020{]}''}

We leave it to the readers of the guideline and those responsible for
local implementation to determine if this represents a pro-forceps bias.
Where we agree with Dietz \& Esegbona is that much of the published
literature is dated, and that further high quality longitudinal research
is required. We would highlight for those conducting research in this
field that they should differentiate between intended forceps-assisted
delivery and sequential delivery (forceps following failed vacuum
delivery) when reporting instrument specific pelvic floor morbidity, as
the two are not the same.

Deirdre J Murphy,\textsuperscript{1} Rachna
Bahl,\textsuperscript{2}Bryony Strachan\textsuperscript{2}

1) Coombe Women \& Infants University Hospital

Cork St, Dublin 8, Republic of Ireland

2) St Michael's Hospital, Bristol

\textbf{References}

1. Dietz HP, Esegbona G. Letter to the Editor, BJOG Exchange. (ref to be
added by BJOG)

2. Murphy DJ, Strachan BK, Bahl R, on behalf of the Royal College of
Obstetricians Gynaecologists.

Assisted Vaginal Birth. BJOG 2020;
https://doi.org/10.1111/1471-0528.16092

3. Memon HU, Blomquist JL, Dietz HP, Pierce CB, Weinstein MM, Handa VL.
Comparison of levator ani muscle avulsion injury after forceps-assisted
and vacuum-assisted vaginal childbirth. Obstet Gynecol 2015;125:1080--7.

4. Johanson RB, Menon BK. Vacuum extraction versus forceps for assisted
vaginal delivery. Cochrane Database Syst Rev 2000;2:CD000224.

5. O'Mahony F, Hofmeyr GJ. Menon V. Choice of instruments for assisted
vaginal delivery. Cochrane Database of Syst Rev 2010;11:CD005455.

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