• Prolonged second stage of labor (lack of progress despite adequate pushing efforts)
• Maternal exhaustion or failure of voluntary expulsive efforts
• Medical need to shorten the second stage (e.g., severe maternal cardiac disease, severe hypertension, aneurysmal disease)
• Non-reassuring fetal heart rate (FHR) pattern requiring expedited delivery when vaginal birth is imminent

• Cervix is 10 cm (fully) dilated and membranes are ruptured
• Fetal head is engaged in the pelvis (station ≥ +2 is optimal)
• Exact fetal lie, presentation, and position are known
• Clinically adequate maternal pelvis
• Empty maternal bladder
• Adequate anesthesia in place
• Operator is experienced and capable of performing an immediate cesarean section if the procedure fails

• Can rapidly resolve non-reassuring fetal status, often faster than preparing for a cesarean section when the head is low
• Avoids the severe maternal surgical morbidity and future uterine scarring associated with cesarean delivery

• Maternal: Markedly increased risk of severe perineal lacerations (3rd and 4th degree), anal sphincter injury, and pelvic floor dysfunction, particularly with forceps
• Fetal: Risk of scalp lacerations, cephalohematoma, subgaleal hematoma, facial nerve palsy, and retinal hemorrhage
• Sequential use of both instruments (failing with vacuum, then applying forceps) exponentially increases the risk of severe neonatal intracranial injury and is explicitly discouraged

• Thoroughly inspect the vaginal vault and perineum for severe lacerations or cervical tears
• Repair anal sphincter injuries systematically via skilled operator
• Alert pediatrics to observe the neonate for signs of subgaleal hemorrhage or pathological jaundice (due to resolving hematomas)
• Provide aggressive maternal postpartum analgesia

• Abandon the vaginal approach immediately if progress is not made with appropriate traction
• Do NOT sequentially switch from vacuum to forceps (or vice versa)
• Proceed immediately to an operative delivery (cesarean section) recognizing the high likelihood of an impacted fetal head

The obstetric forceps were famously invented by the Chamberlen family in the 17th century, kept as a secret family trademark for over a century. The vacuum extractor (Ventouse) was later popularized in the 1950s by Tage Malmström as an alternative attempting to reduce maternal perineal trauma.