Maternal and neonatal outcomes of forceps delivery in women undergoing trial of labor after cesarean

Introduction Cesarean delivery during the second stage of labor is increasing, while the use of forceps is declining. Evidence on forceps in trial of labor after cesarean (TOLAC) is limited. We compared maternal and neonatal outcomes between attempted forceps delivery and second-stage repeat cesarean (ssRCD) among TOLAC women, and compared forceps outcomes between TOLAC women and those with no prior cesarean (NPC).Methods This retrospective cohort study (2015–2022) included singleton, term, vertex pregnancies requiring immediate second-stage delivery due to fetal distress, prolonged second stage, or maternal compromise. Three groups were defined: fd-TOLAC (forceps delivery in TOLAC), ssRCD (second-stage repeat cesarean without attempted forceps), and fd-NPC (forceps delivery in women with NPC). Outcomes were compared between fd-TOLAC and ssRCD, and between fd-TOLAC and fd-NPC.Results A total of 176, 30, and 769 women were included in the fd-TOLAC, ssRCD, and fd-NPC groups, respectively. Compared to ssRCD, fd-TOLAC had lower postpartum hemorrhage (1.1% vs 20.0%; aOR 0.05, 95% CI 0.01–0.33), blood transfusion (4.0% vs 23.3%; aOR 0.15, 95% CI 0.04–0.57), and postpartum infection (1.7% vs 10.0%; aOR 0.06, 95% CI 0.01–0.58). One hysterectomy occurred in ssRCD (3.3%), compared with none in fd-TOLAC (p = 0.234). No significant differences were observed in neonatal outcomes between the groups. Maternal and neonatal outcomes did not differ between fd-TOLAC and fd-NPC (p > 0.05).Conclusion In TOLAC women requiring second-stage delivery, clinically feasible low forceps was associated with lower maternal morbidity than ssRCD without increased neonatal risk. Forceps outcomes in TOLAC were comparable to NPC. Findings suggest the safety of attempted forceps in selected TOLAC patients.