Operative Vaginal Delivery Compared to Cesarean After Failed Labor: A Population-Based Analysis of Neonatal and Maternal Outcomes

Objective: We sought to compare common neonatal and maternal morbidity outcomes amongst operative vaginal delivery (OVD) versus cesarean delivery performed in the setting of failed attempt at labor. We planned to stratify outcomes by type of OVD (vacuum-assisted vaginal delivery (VAVD) and forceps-assisted vaginal delivery (FAVD)). Methods: This was a retrospective cohort study of singleton live births in the United States, using the 2023 National Vital Statistics birth certificate dataset. The primary outcome of interest was the risk of neonatal morbidity, as listed on the birth certificate. The secondary outcome of interest was the risk of maternal morbidity. Neonatal morbidities were planned to be analyzed independently (i.e., risk of NICU admission, need for antibiotics) as well as in aggregate (i.e., the risk of any morbidity occurring). Three groups were planned: FAVD, VAVD, and cesarean in the setting of attempted labor or attempted induction of labor (referent group). Differences in demographic and clinical characteristics were compared and subsequently adjusted for, and odds ratios (aOR) were calculated using multivariable logistic regression. Results: Of the 3,605,081 births from 2023, there were 15,384 FAVDs; 83,134 VAVDs; and 325,310 cesareans after failed labor. Neonatal morbidity was lower in FAVD (aOR 0.71, 95% CI 0.66–0.76) and VAVD (aOR 0.57, 95% CI 0.55–0.59) compared to cesarean delivery, with VAVD showing the lowest rates, in particular, the need for assisted ventilation (aOR 0.52 95% CI 0.48–0.57 with VAVD and aOR 0.74 95% CI 0.68–0.81 with FAVD) and NICU admissions aOR 0.66, 95% CI 0.60–0.71 with FAVD and aOR 0.48, 95% CI 0.46–0.51 with VAVD) were reduced with operative vaginal delivery. Antibiotic usage was only reduced in VAVD, not FAVD. Maternal morbidity was highest FAVD; however, this was driven by perineal lacerations. ICU admission, hysterectomy, and ruptured uterus were all higher in cesarean delivery than FAVD or VAVD. Conclusions: Operative vaginal delivery, particularly VAVD, is associated with reduced neonatal morbidity compared to cesarean delivery in the setting of labor.