By Dr Rosemary Listing, PhD (Product Liability), Of Counsel, Peter Evans & Associates | Birth trauma and obstetric negligence | Reading time: about 14 minutes
"The vacuum kept popping off, so they switched to forceps." "They tried forceps, then I was rushed to theatre." Mothers say versions of this in parenting forums, in birth trauma support groups and in submissions to the NSW Parliament's Birth Trauma Inquiry. They are usually followed by the same questions. Is that normal? Why did nobody ask me? Should they have done a caesarean sooner? Is my baby's head swelling something to worry about? Did someone do something wrong?
This article answers those questions. It explains what a failed instrumental delivery is, why clinicians sometimes move from one instrument to another (known as sequential instrument use), and what the guidelines say about when to stop. It sets out the risks to mother and baby. It also explains when a failed or sequential instrumental birth may give rise to a medical negligence claim in NSW.
If you want a general introduction to forceps and vacuum births first, read our companion guide, birth-related trauma after forceps or vacuum delivery.
Key points
- A failed instrumental delivery is when a vacuum (ventouse) or forceps attempt does not deliver the baby, and a different instrument or an emergency caesarean is then needed.
- Using vacuum then forceps (or the reverse) is recognised in guidelines, but it is linked to higher rates of injury to both mother and baby. It should be a deliberate, senior decision, not a default.
- Guidelines set limits on the number of pulls, cup detachments and minutes before an attempt should stop.
- Babies born after a difficult or sequential instrumental birth need close observation for subgaleal haemorrhage, a rare but dangerous scalp bleed.
- A poor outcome is not automatically negligence. The questions are whether the attempt should have been made, where it was made, whether limits were respected, whether you consented, and whether you and your baby were properly monitored afterwards.
Questions this guide answers
- What is a failed instrumental delivery?
- Why did the vacuum fail or keep popping off?
- Why use forceps after the vacuum?
- How many pulls is too many?
- Should I have had a caesarean sooner?
- Did they need my consent to switch?
- I could feel everything. Is that normal?
- Injuries to the mother
- Injuries to the baby
- When is it negligence?
- What happens in my next birth?
- Frequently asked questions
What is a failed instrumental delivery?
An instrumental (or "assisted") vaginal birth uses a vacuum cup or forceps to help deliver the baby in the second stage of labour. It is common. The Australian Institute of Health and Welfare reports that around one in four first-time mothers in its selected group had an instrumental birth in 2021.
An instrumental delivery "fails" when the chosen instrument does not deliver the baby. The clinician then has two options:
- Sequential instruments: switch to the other instrument, usually forceps after a failed vacuum.
- Caesarean section: move to an emergency caesarean, often called a "second-stage caesarean" because it happens when the cervix is fully dilated and the baby's head is low.
Some women experience both: a vacuum, then forceps, then a caesarean. Others have repeated attempts with the same instrument, such as several vacuum applications in the birth room followed by more in theatre.
Why did the vacuum fail or keep "popping off"?
The single most common question women ask is why the vacuum didn't work. A vacuum cup relies on suction. It can detach (a "pop-off") or fail to bring the head down for several reasons:
- The baby's position. Babies lying "back to back" (occiput posterior) or with the head tilted are harder to deliver. A large UK cohort found fetal malposition was strongly associated with needing sequential instruments.
- The baby's head was higher than thought. Assessing how far down the head is ("station") is a clinical skill. Swelling of the scalp (caput) can make the head seem lower than it is.
- The cup was placed in the wrong spot. A cup placed off-centre pulls the head at an awkward angle.
- A large baby or a tight fit. The same study linked a newborn head circumference above 37 cm with a five-fold higher chance of sequential instrument use.
- The type of cup. Soft cups cause less scalp trauma but fail more often than metal cups. A Cochrane review found the vacuum is overall more likely to fail than forceps.
The Royal College of Obstetricians and Gynaecologists (RCOG) patient information notes that an assisted birth is less likely to succeed if the mother's BMI is over 30, she is shorter than 161 cm, the baby is estimated at over 4 kg, the baby is back-to-back, or the head is not low in the birth canal. Several of these factors can be identified before an attempt begins. That matters, as explained below.
Why would they use forceps after the vacuum?
When a vacuum attempt fails, the baby still needs to be born, and it may be in distress. Forceps grip the head rather than relying on suction, so they can sometimes succeed where a vacuum has not. The alternative, a caesarean with the baby's head deep in the pelvis, carries its own serious risks.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledges this dilemma in its statement on Instrumental Vaginal Birth (C-Obs 16). Because the vacuum is often the first instrument chosen and fails more often, sequential use may sometimes be hard to avoid. However, the statement is clear that a second instrument after a failed first attempt is associated with a higher risk of trauma to both mother and baby.
So switching instruments is not automatically wrong. It should, however, be a considered decision by an experienced clinician who has weighed the risks, not a reflex.
The numbers matter. In a US population study of more than 3,700 births where both vacuum and forceps were used, babies had markedly higher rates of intracranial haemorrhage, brachial plexus injury, facial nerve injury and seizures than babies born spontaneously. For several injuries, the combined risk was greater than the risks of the two instruments added together (Gardella et al, AJOG 2001). A UK cohort found anal sphincter tears in 17.4% of sequential deliveries compared with 8.4% of single-instrument deliveries.
How many pulls or pop-offs is too many?
This is one of the most searched questions after a difficult birth, and the answer matters legally. Guidelines set limits because the risk of injury rises sharply once an attempt stops making progress.
| Guideline | What it says about stopping |
|---|---|
| RANZCOG C-Obs 16 | Knowing when to abandon the procedure is vital. For vacuum, reassess if birth is not imminent after 15 minutes, with an upper limit of 20 minutes. Limit pulls without descent to about three. For rotational forceps, stop if application is difficult, the handles will not come together, rotation fails with gentle pressure, or there is no descent with moderate traction. |
| RCOG Green-top Guideline No. 26 (as applied in hospital protocols) | Stop if there is no progressive descent with each pull, or if birth is not imminent after three pulls by an experienced operator. Local protocols built on it commonly add abandoning a vacuum after two cup detachments, and require the reasons to be documented when instruments are used in sequence or more pulls are needed. |
| NSW hospital surveillance rules | The South Eastern Sydney LHD subgaleal haemorrhage procedure places babies on heightened monitoring if vacuum time exceeded 20 minutes, there were 3 pulls, or there were 2 cup detachments. |
These thresholds give your clinical records a concrete benchmark. If your notes show four, five or six pulls, multiple pop-offs, or a vacuum applied in the birth room and then again in theatre, an independent obstetric expert will want to know why the attempt continued.
"Should I have had a caesarean sooner?"
Many women look back and feel that a caesarean was always going to be the answer, and that the instruments only added injury. Sometimes that is hindsight. Sometimes it reflects a genuine problem with decision-making.
The key question is whether the risk of failure was foreseeable. Both RANZCOG and the RCOG advise that where failure is more likely, the attempt should be made as a "trial" in an operating theatre. That means a caesarean can begin immediately if the instrument does not work. RANZCOG identifies a BMI over 30, an estimated fetal weight over 4 kg, a back-to-back position and a mid-cavity head as features that increase the chance of failure.
A caesarean after a failed instrumental birth is not risk-free either. The baby's head may be wedged deep in the pelvis, a complication called impacted fetal head. The RCOG's Scientific Impact Paper No. 73 reports that it may complicate up to 1 in 10 unplanned caesareans. It can cause tears in the uterus, heavy bleeding, and head injury or oxygen deprivation in the baby. These risks are one more reason the decision about where and whether to attempt an instrumental birth matters. Our article on caesarean safety and your legal rights discusses how these choices should be explained to you.
"Nobody asked me." Did they need my consent to switch instruments?
Yes. Consent is required for an instrumental birth, and that includes moving to a second instrument. RANZCOG says verbal consent is the minimum in the birth room, that written consent is generally expected before a birth in theatre, and that the woman should understand a caesarean may be needed. Urgency can shorten the conversation, but it does not remove the need for it.
Under Australian law, the leading case is Rogers v Whitaker (1992) 175 CLR 479. Doctors must warn of material risks. Those are risks a reasonable person in your position would consider significant, or risks the doctor knows matter to you. The higher rate of serious tears and newborn injury with sequential instruments is the kind of information many women say they would have wanted before a second instrument was used. Some say they would have chosen a caesarean instead.
Consent failures were a central theme of the NSW Legislative Council's Birth Trauma Inquiry report (2024). It recommended informed consent training for all maternity practitioners and formal debriefing clinics in public hospitals. In December 2025, NSW Health issued Safety Notice SN 027/25 on assisted vaginal birth. It reported that serious incident reviews had found problems with consent, the credentialling of junior doctors, senior obstetric involvement, escalation, and variation in setting abandonment criteria. If something similar happened to you, you are not alone. For a case study on consent in birth, see Emily's triumph after an unconsented episiotomy.
"I could feel everything." Is that normal?
It should not be. Women commonly describe an epidural that had worn off, being told they "can't feel that", and forceps applied as if they were numb. Adequate pain relief before an instrumental birth is a basic expectation. The RCOG describes the options as a local anaesthetic injection or a regional block (epidural or spinal). If you told staff you could feel pain and were not believed, that belongs in your account of what happened, both for any complaint and for any claim. Our article on being dismissed by doctors explains why this matters.
Was your birth a failed vacuum, forceps, or both?
Dr Rosemary Listing can review what happened, step by step, and tell you whether your care met the standard the law requires.
Or call Peter Evans & Associates on 02 4926 4788
Injuries to the mother after a failed or sequential instrumental birth
Severe perineal tears (OASI)
The RCOG estimates third- or fourth-degree tears in about 3% of all vaginal births, up to 4% after a vacuum and 8 to 12% after forceps. With sequential instruments, the UK cohort found a rate of 17.4%. These are obstetric anal sphincter injuries (OASI). They can cause loss of bowel or wind control, pain and sexual difficulties. A tear that is missed or under-classified at the time can mean an inadequate repair. Read more in "I can't control wind after birth": fourth-degree tears and your rights.
"They said it was a minor tear, but my physio disagrees"
This is a common experience. After a difficult forceps birth, the perineum and anal sphincter should be carefully examined, ideally including a rectal examination, so that the tear is correctly graded and repaired. RANZCOG's statement says the cervix, vagina and perineum should be examined after an instrumental birth. If a later assessment shows a more serious injury than you were told, that discrepancy can be significant.
Pelvic floor damage, prolapse and levator avulsion
Forceps in particular can tear the levator ani muscle from the pubic bone. This can lead to prolapse, bladder problems and a feeling of heaviness. See our guides on levator ani avulsion and severe pelvic floor damage and incontinence after childbirth.
Bleeding, uterine tears and bladder injury
A caesarean after a failed instrumental birth carries a higher risk of heavy bleeding and tears extending through the uterus. Rarely, injury to the bladder or bowel can lead to an obstetric fistula.
Psychological injury, for you and your partner
Women describe failed instrumental births as chaotic, frightening and, in some cases, like an assault. Partners describe watching a clinician brace against the bed to pull. Post-traumatic stress, anxiety, depression and fear of future birth (tokophobia) are recognised injuries. We discuss this in maternal birth injuries: what we must talk about.
Injuries to the baby
| Injury | What parents should know |
|---|---|
| Chignon and bruising | A raised, bruised "cone head" where the vacuum cup sat is common and usually settles within days. |
| Cephalhaematoma | Bleeding under the outer layer of a skull bone. It is limited by the suture lines and usually resolves without treatment, but can worsen jaundice. |
| Subgaleal haemorrhage | Bleeding into a large space between the scalp and skull. It is not limited by suture lines and a baby can lose a large proportion of their blood volume into it. RANZCOG estimates it occurs in about 1 in 300 vacuum births. It is an emergency. |
| Skull fracture and intracranial haemorrhage | Bleeding inside the skull. The risk is higher after sequential instruments. |
| Facial nerve palsy | Weakness on one side of the face, more common after forceps. Usually temporary. |
| Brachial plexus injury | Damage to the nerves of the shoulder and arm, often linked to shoulder dystocia after a difficult birth. |
| Oxygen deprivation (HIE) | Prolonged attempts while a baby is already distressed, or an impacted head at caesarean, can lead to hypoxic-ischaemic encephalopathy. |
"My baby's head was swollen and squishy." When to worry about subgaleal haemorrhage
Parents often describe a boggy, fluid-feeling swelling on the back of the head, a baby who is pale, floppy or unsettled when handled, puffy eyelids, or ears that seem pushed forward. These can be signs of a subgaleal haemorrhage. Hospital protocols in NSW require newborns to be regularly checked after an assisted birth, at birth and at intervals over the first 24 hours. Checks include palpating the scalp and measuring head circumference. Monitoring is heightened after prolonged vacuum use, three pulls or two cup detachments, and after an attempted assisted birth that ended in a caesarean. RANZCOG also says the doctor caring for the baby should be told when the birth involved sequential instruments.
Safer Care Victoria's good practice point on subgaleal haemorrhage (2025) notes that babies still die each year from this condition, and that deficiencies in care were found in most of those deaths. It is usually treatable when detected early. Missed or delayed monitoring after a sequential instrumental birth is therefore a recurring issue in claims.
If your baby is at home and you notice these signs, seek emergency care immediately.
When does a failed or sequential instrumental birth become negligence?
Instrumental births sometimes fail despite excellent care, and a sequential approach can be reasonable. The law does not expect a perfect outcome. It asks whether the clinicians acted as a reasonably competent practitioner would have, and whether any failure caused harm that would otherwise have been avoided.
In our experience, harm in these cases is rarely one bad pull. It is usually a series of decisions, each narrowing the margin for safety. The issues we examine include:
Before the first instrument
- Was an instrumental birth actually indicated, or was there pressure to "get the baby out"?
- Was the baby's position and station properly assessed and recorded? Was an ultrasound used if the position was unclear?
- Were risk factors for failure (back-to-back position, large baby, high head) recognised, and should the attempt have been made in theatre?
- Was the operator suitably experienced and credentialled, and was a senior obstetrician involved?
- Was effective pain relief in place, and was informed consent obtained?
During the attempt
- Were the limits on pulls, cup detachments and time respected?
- Was the attempt abandoned when there was no descent?
- Was a second instrument a deliberate, senior decision, with the risks explained, rather than a default?
- Was the baby's heart rate monitored and acted on?
After the birth
- Were the perineum and anal sphincter properly examined, the tear correctly graded and repaired by an appropriately skilled clinician?
- Was the paediatric team told that sequential instruments were used, and was the baby observed according to protocol?
- Were signs of subgaleal haemorrhage, bleeding or infection recognised and escalated promptly?
- Were the reasons for sequential use, the number of pulls and the cup detachments properly documented?
Instruments themselves can also be a factor. Cup design and device failures are discussed in birth injuries and medical devices in Australia.
The legal framework in NSW
The standard of care
Claims in NSW are governed by the Civil Liability Act 2002 (NSW). Under section 5O, a professional is not liable if they acted in a way widely accepted in Australia by peer professional opinion as competent practice, unless the court finds that opinion irrational. Guidelines such as RANZCOG C-Obs 16 and hospital procedures are not law, but they are strong evidence of what competent practice looks like. Independent obstetric, midwifery, neonatal and colorectal or urogynaecology experts are usually needed.
Time limits
Under section 50C of the Limitation Act 1969 (NSW), a personal injury claim generally must be brought within three years of the date the claim became "discoverable", and no later than 12 years after the event. The NSW Judicial Commission's bench book on limitation periods explains how this works. Many women only realise months later, often after a physiotherapy or colorectal assessment, that their injury was more serious than they were told. Different rules can apply to a baby's claim. See NSW medical negligence time limits and can you still sue years later?
What compensation may cover
Depending on the injury, compensation may cover pain and suffering, treatment such as pelvic floor physiotherapy and surgery, lost income, care provided by family, and future needs. For a child with a brain or nerve injury, those future needs can be lifelong. Many families also take on debt while they recover. We discuss this in medical negligence and financial debt in NSW.
What to do now
- Ask for a debrief or open disclosure meeting. Health services must have an open disclosure process consistent with the Australian Open Disclosure Framework. Ask specifically how many pulls were made, how many times the cup detached, why the instrument was changed, and who made the decision.
- Request the complete records. Ask for the birth notes, the "operative vaginal birth" form, CTG traces, cord gases, the perineal repair notes, theatre and anaesthetic records, and your baby's neonatal observation charts.
- Write your account and your partner's account now, while memories are clear.
- Get an independent assessment of your injuries, for example by a pelvic floor physiotherapist or colorectal surgeon.
- Consider a complaint to the NSW Health Care Complaints Commission. A complaint does not replace a compensation claim.
- Get legal advice early, before time limits become an issue.
"Will this happen again?" Planning your next birth
Many women who have had a failed or sequential instrumental birth wait years before another pregnancy. Some ask for an elective caesarean next time. The RCOG confirms that a woman who does not want an assisted birth can choose a planned caesarean before labour begins. If you had a severe tear or ongoing pelvic floor symptoms, your next birth plan should be discussed with a specialist well before your due date. You are entitled to a full explanation of your options and their risks. A request for a caesarean based on a previous traumatic birth deserves to be taken seriously.
How we can help
Dr Rosemary Listing acts only for injured patients and families, with a focus on birth trauma and obstetric negligence. Her method maps every decision point in your labour, from the decision to use an instrument to the observation of your baby on the postnatal ward. This identifies where care fell short. She also trains maternity clinicians in informed consent through birth trauma training with the Maternity Consumer Network.
Learn more about Dr Listing, browse the resource hub, or read Ms Jones' story of justice and healing after birth trauma.
You deserve to understand what happened in that room.
Your first conversation is free and confidential. You do not need your records to start.
Frequently asked questions about failed instrumental delivery
Is it normal to use vacuum and then forceps?
It happens and is recognised in guidelines, but it is not routine. Using a second instrument after a failed first attempt is associated with more injuries to mother and baby, so it should be a careful decision by an experienced clinician, with the risks weighed against a caesarean.
How many times can a doctor try the vacuum?
Guidelines generally advise stopping if there is no descent with each pull or the baby is not about to be born after about three pulls. Many hospital protocols also advise stopping after two cup detachments, and RANZCOG sets an upper limit of around 20 minutes.
Why did my baby go to NICU after a vacuum and forceps birth?
Babies born after sequential instruments or a failed instrumental birth have a higher risk of scalp bleeding, intracranial bleeding and breathing problems. They are often observed more closely, sometimes in a special care nursery. Ask the paediatric team for a written explanation of why your baby was admitted.
Can I refuse forceps or a vacuum during labour?
Yes. You can decline any procedure. In labour, declining usually means waiting for the baby to be born without assistance or having a caesarean. Your care team should explain the risks of each option so you can make the choice.
Should they have done a caesarean instead?
Sometimes. Where failure was foreseeable, for example a large baby, a back-to-back position or a high head, guidelines recommend attempting the instrumental birth in theatre so a caesarean can start straight away. Whether a caesarean should have been chosen first depends on the facts and needs an independent expert review.
Can I sue for a failed instrumental delivery in NSW?
You may have a claim if the care fell below the accepted standard and that caused injury to you or your baby. Examples include continuing past safe limits, failing to obtain consent, not recognising a severe tear, or not monitoring your baby properly. Claims are generally subject to a three-year time limit from when the claim became discoverable.
Sources
- RANZCOG, Instrumental Vaginal Birth (C-Obs 16)
- RCOG, Assisted Vaginal Birth, Green-top Guideline No. 26 and patient information
- RCOG, Management of Impacted Fetal Head at Caesarean Birth, Scientific Impact Paper No. 73
- NSW Health, Safety Notice SN 027/25: Assisted Vaginal Birth (December 2025)
- NSW Legislative Council, Birth Trauma Inquiry final report (2024)
- South Eastern Sydney LHD, Subgaleal haemorrhage following assisted vaginal birth or second stage caesarean section (2025)
- Safer Care Victoria, Subgaleal haemorrhage good practice point (2025)
- Murphy DJ et al, A cohort study of maternal and neonatal morbidity in relation to use of sequential instruments at operative vaginal delivery, EJOGRB 2011
- Gardella C et al, The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes, AJOG 2001
- O'Mahony F et al, Choice of instruments for assisted vaginal delivery, Cochrane Database of Systematic Reviews
- Australian Institute of Health and Welfare, National Core Maternity Indicators: instrumental vaginal birth
This article provides general information only. It is not medical or legal advice and should not be relied on as a substitute for advice about your circumstances. Reframe Legal is a thought leadership website by Dr Rosemary Listing. Legal services are provided by Peter Evans & Associates. Liability limited by a scheme approved under Professional Standards Legislation.
