Severe maternal and neonatal morbidity or mortality in forceps versus cesarean birth in the second stage of labor: A systematic review and meta‐analysis

BACKGROUND: Approximately one in four first-time mothers reach the second stage of labor but cannot have a spontaneous vaginal birth, necessitating an intervention such as forceps to facilitate birth. OBJECTIVE: This study synthesizes evidence comparing severe maternal morbidity (SMM) and neonatal morbidity or mortality (SNMM) following forceps and cesarean birth (CB) in the second stage of labor. METHOD: Four databases were searched from database inception to May 30, 2023. Original studies comparing SMM or SNMM among individuals with an attempted forceps birth versus second stage CB were included. Meta-analyses were conducted using the Mantel-Haenszel random-effects model and the risk ratio (RR) was used as an effect measure with 95% confidence intervals (CIs). RESULTS: After screening 945 articles, a total of 13 cohort studies encompassing 52 192 individuals were included. Four studies with 34 131 total individuals provided data on SMM. The incidence of SMM was 2.6% with attempted forceps versus 3.7% with second-stage CB (pooled RR of 0.83, 95% CI 0.64, 1.07). Six studies with a total of 36 135 individuals provided data on SNMM. The incidence of SNMM was 4.5% with forceps versus 2.1% with second stage CB (pooled RR of 1.34, 95% CI 0.90, 2.00). The evidence is very uncertain about the effect of attempted forceps on SMM and SNMM due to moderate or serious risk of bias, inconsistency, and heterogeneity. CONCLUSION: Risks of SMM and SNMM are unclear after forceps and second stage CB and the choice between operative interventions should depend on the clinical scenario. Our study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42023387112) on January 2, 2023.