Forceps delivery injuries

How does this happen?

Forceps blades are designed to cradle the sides of the baby's head, spreading pressure over the cheekbones and the sides of the skull rather than squeezing.

Injury happens through two routes.

Pressure where the blade sits. If a blade lies over the path of the facial nerve, just in front of and below the ear, it can compress the nerve. That produces a facial palsy, which usually recovers because the nerve is stunned rather than torn. ³ Pressure can also bruise, abrade or, rarely, fracture bone.

Traction and rotation. Pulling transmits force to the skull and its contents and to the neck. That can cause skull fracture, bleeding inside the skull, and rarely injury to the neck or spinal cord. Rotational deliveries involve additional force and are classified separately in guidance. ¹

For the mother, forceps widen what has to pass through the vaginal opening, which is why the rate of severe tearing is higher than with spontaneous birth. ²

Guidance sets out the prerequisites, classifies the procedure by how far down the head is and how much rotation is needed, and addresses when to stop. ¹

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• A forceps delivery that was genuinely indicated, where the baby needed to be born quickly and the alternative carried greater risk. ¹
• A difficult head position requiring rotation.
• A prolonged second stage. ⁴
• A large baby. ⁵
• Facial marks and bruising, which are expected and not an injury in any meaningful sense.
• Facial nerve palsy from pressure of the maternal pelvis, which also occurs with no instrument at all. ³

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Prerequisites not met, including full dilatation, known head position, adequate anesthesia, an empty bladder, and consent. ¹
• Head position not confirmed before application, which matters for blade placement.
• Blades placed over the path of the facial nerve. ³
• Repeated attempts, or continuing without descent, rather than abandoning the procedure. ¹
• Sequential vacuum and forceps. ¹
• Rotational delivery attempted without the necessary skill or setting. ¹
• A severe perineal tear not recognized or not repaired properly, where guidance addresses classification and repair. ²
• The baby not examined afterward for facial movement and for scalp and skull injury. ⁶
• The eye not protected where facial palsy prevents eye closure. ³

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record. Forceps are used to prevent harm, and injuries occur after correctly performed deliveries.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• Red marks, bruises or grazes on the cheeks and sides of the head where the blades sat. These are expected and fade over days.
• One side of the face not moving when the baby cries, which is facial nerve palsy. ³
• An eye that does not close on that side.
• Swelling or a dent over the skull.
• Low Apgar score scores if the delivery was difficult. ⁷

The first week

• Bruising fading.
• jaundice from bruised blood breaking down. ⁸
• Feeding difficulty where facial palsy affects the seal.
• Seizures if there was bleeding inside the skull. ⁹
• Eye redness if an unclosing eye is not being protected.

Around 3 months

• Most facial palsy from pressure has recovered. ³
• Marks gone.
• Developmental follow-up where there was bleeding or a period of low oxygen. ⁶

Around 6 months

• Usually nothing.
• Persistent facial asymmetry in a minority, which should be re-evaluated.

Around 12 months

• No expected effects from an uncomplicated forceps birth.

Toddler years

• No expected effects in the great majority.
• Persistent facial palsy affects the smile and some speech sounds.

School age

• No expected effects in the great majority.

How is it diagnosed?

Examination of the baby. Facial movement during a cry, eye closure, forehead movement, the scalp and skull, and general neurological status. ³

Imaging where a skull fracture or bleeding inside the skull is suspected. CT scan shows both quickly. ³

bilirubin monitoring where bruising is significant. ⁸

Examination of the mother for perineal tearing, which should be classified and documented, because the degree determines the repair and the follow-up. ²

What the operative note should record

Ask for it. It should state the indication, the station and position of the head, the classification of the procedure, whether rotation was performed, the number of attempts, and whether any other instrument was used. ¹

If your baby has facial palsy, ask whether the forehead moves on the affected side. That distinguishes a nerve injury from a brain cause, and it is a question a doctor can answer in seconds. ³

What is the treatment?

For marks and bruises: nothing. They fade.

For facial nerve palsy: protect the eye with lubricating drops and ointment, and taping at night if advised. Most recover within weeks. Re-evaluate if there is no improvement by around 3 months. See facial nerve palsy. ³

For feeding difficulty: feeding support, since a weak seal on one side makes feeding slow.

For skull fracture: usually observation, sometimes surgical elevation.

For bleeding inside the skull: observation or surgical drainage depending on size, with seizure treatment as needed. ⁹

For bilirubin: monitoring and phototherapy if the level crosses the threshold. ⁸

For the mother: proper classification and repair of any perineal tear, pain relief, and follow-up including pelvic floor physiotherapy where indicated. ² See obstetric tears and pelvic floor injury.

What is the long-term outlook?

The great majority of babies born by forceps have no lasting effects. Marks and bruises fade within days. ³

Facial nerve palsy from pressure usually recovers completely within weeks. The complication to avoid is corneal damage from an unprotected eye. ³

Where there was a skull fracture or bleeding inside the skull, the outlook follows that injury.

For mothers, severe perineal tearing has real long-term consequences for continence and comfort, and it is under-discussed. It is worth following up properly rather than accepting symptoms as normal after childbirth. ^{2 10}

What does daily life look like?

For most families, marks fade and life is ordinary.

Where there is facial palsy, eye drops and ointment several times a day, and adjusting feeding.

For mothers with significant tearing, recovery takes weeks to months, and pelvic floor physiotherapy is worth asking for rather than waiting to be offered. ²

What does care cost over a lifetime?

For an uncomplicated forceps birth, no additional cost.

Where there is facial palsy, the cost of eye lubricants and follow-up.

Where there is brain injury, the published anchor for cerebral palsy is CDC's estimate of about $921,000 in 2003 dollars. ¹¹ See the cost of care estimator.

What can you do this week?

1. Ask whether your baby's face moves symmetrically when crying, and whether the forehead moves on both sides.
2. If the eye does not close, get drops and instructions before discharge.
3. Ask for the operative note, including the indication, the classification, whether rotation was performed, and the number of attempts.
4. Ask whether both vacuum and forceps were used.
5. Ask whether bilirubin is being followed.
6. Ask about your own tearing: what degree, how it was repaired, and what follow-up you need.
7. Request the complete records with the records request builder.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the pediatrician

• Does the whole side of the face move, including the forehead?
• Does the eye close, and how do I protect it?
• Has the skull been examined, and is imaging needed?
• Is bilirubin being followed?
• When should the marks and any weakness be gone?

For the obstetric team

• What was the indication for forceps?
• What was the station and position of the head?
• Was rotation performed?
• How many attempts, and was another instrument used?
• What degree of tearing did I have, and how was it repaired?

You can also build a printable list with the question generator.