FIGO good practice recommendations: Assisted vaginal birth and the second stage of labor

Cesarean birth (CB) rates are increasing globally, with a current prevalence of 21.1% and a projected prevalence of 28.5% by 2030. Conversely, assisted vaginal birth (AVB) rates are declining, with reported rates of less than 10% in low- and middle-income countries (LMICs) and 10%-15% in high-income countries (HICs). In some African countries, AVB rates are as low as <1%. Declining AVB rates are attributable to lack of appropriate skills, equipment, and trained personnel, especially in LMICs, fear of litigation, and misconceptions that CB is safer, paucity of local guidelines and policies encouraging AVB, and increasingly accessible, acceptable, and safer CB techniques, amongst others. Optimizing appropriate care and decision making around CB and mode of birth is now a public health priority, especially given the significantly higher morbidity and mortality associated with CB compared to vaginal birth. Increasing AVB rates can potentially reduce CB rates, therefore improving maternity safety. This paper reviews the current best evidence on AVB and makes recommendations for good practice, including indications and prerequisites for AVB, who to determine who is suitable for AVB, choice of instrument, sequential application of instrument, when to abandon AVB, analgesia, antibiotic prophylaxis and episiotomy for AVB, special situations such as fetal macrosomia, maternal viral infections, previous CB, and risks and benefits of AVB versus second stage CB. An AVB safety checklist is included to reduce the risk of complications. We conclude by recommending that all maternity care providers and skilled birth attendants, including obstetricians, obstetric trainees/residents, interns, and midwives, should be trained and competent to perform AVB, to potentially reduce the current CB epidemic and its associated higher mortality and morbidity.