Forceps vs Cesarean in Second Stage: What the Evidence Says About Severe Maternal & Neonatal Outcomes

Dr. Reena Sherene
Jul 3
3 min read

Second-stage decision-making can be time-critical: proceed with operative vaginal birth (OVB) using forceps, or move to cesarean birth. Clinicians and trainees often ask a deceptively simple question—‘Which is safer?’—but the answer depends on outcomes chosen, case selection, operator skill, and the clinical context.

This essay summarizes and interprets the systematic review and meta-analysis: "Severe maternal and neonatal morbidity or mortality in forceps versus cesarean birth in the second stage of labor" (International Journal of Gynecology & Obstetrics).

Reference: https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.71152

Why this comparison matters

Second-stage cesarean is technically more challenging than first-stage cesarean and is associated with distinct risks (e.g., extensions, hemorrhage, infection, bladder/ureteric injury). Forceps-assisted birth, when feasible and performed by trained operators, can shorten time to delivery and avoid abdominal surgery—but carries risks such as obstetric anal sphincter injury (OASI) and neonatal trauma.

What the review asked

The authors compared severe maternal morbidity/mortality and severe neonatal morbidity/mortality between forceps birth and cesarean birth performed in the second stage of labor.

How to read the evidence

Most available studies are observational; confounding by indication is a major limitation (the reason a clinician chooses forceps vs cesarean is linked to risk).
‘Second stage’ is not a single scenario—station, position, fetal status, suspected CPD, and operator expertise change the risk profile.
Composite outcomes can hide important trade-offs (e.g., fewer severe maternal events overall but higher OASI).
Absolute risks matter as much as relative risks—especially for rare ‘severe’ outcomes.

Key takeaways (clinical interpretation)

While the exact pooled estimates and certainty depend on the included studies, the practical message for bedside decision-making is usually framed as follows:

When forceps birth is clinically appropriate (fully dilated, engaged head, known position, adequate pelvis, and an experienced operator), it may avoid the morbidity profile of second-stage cesarean—particularly surgical complications.
Forceps can increase the risk of perineal trauma, including OASI, compared with cesarean; prevention and repair expertise are essential.
Neonatal outcomes are strongly influenced by the indication (e.g., non-reassuring fetal status) and the speed of delivery; timely OVB may be advantageous when rapid birth is needed.
Failed OVB followed by cesarean can compound risk; careful case selection and a low threshold to abandon attempts are key safety behaviors.

Practical framework for choosing forceps vs second-stage cesarean

1) Confirm prerequisites

Full dilation, ruptured membranes, engaged head, and accurate assessment of position.
Adequate analgesia and maternal consent.
Empty bladder; readiness for shoulder dystocia and postpartum hemorrhage.
Immediate capability to proceed to cesarean if needed.

2) Define the indication

Fetal compromise: prioritize the fastest safe route.
Maternal exhaustion/prolonged second stage: consider station/rotation and likelihood of success.
Suspected CPD/high station/uncertain position: cesarean may be safer than a low-probability attempt.

3) Anticipate the dominant risk

If surgical risk is dominant (e.g., prior abdominal surgery, obesity, difficult access): successful forceps may reduce morbidity.
If perineal risk is dominant (e.g., high OASI concern, complex rotation): cesarean may reduce severe perineal trauma.
If time-to-delivery is critical: choose the option with the highest probability of rapid success in your hands and setting.

What this means for training and systems

The review reinforces a systems message: outcomes are not only about the instrument or incision—they are about competence, selection, and readiness. Maintaining forceps skills (including rotational techniques where appropriate), structured decision-making, and robust escalation pathways can improve safety.

Bottom line

Forceps birth and second-stage cesarean each carry distinct severe morbidity profiles. The safest choice is the one that is most likely to succeed quickly and safely for the specific clinical scenario, performed by a trained team with immediate backup.