Maternal and Neonatal Outcomes of
Successful Kielland’s Rotational
Forceps Delivery
Sarah J. Stock, PhD, Katherine Josephs, BSc, Sarah Farquharson, BSc, Corinne Love, MD,
Sarah E. Cooper, MD, Chris Kissack, MBChB, Ranjit Akolekar, PhD, Jane E. Norman, MD,
and Fiona C. Denison, MD
OBJECTIVE: To estimate the rates of early neonatal and
maternal complications in a consecutive series of suc-
cessful Kielland’s rotational forceps deliveries.
METHODS: This was a retrospective cohort study of
consecutive cases of successful rotational forceps deliv-
eries performed in singleton pregnancies at 36 weeks of
gestation or more in a tertiary referral center in Scotland,
UK, from 2001 to 2008 (n5873). We also compared out-
comes associated with successful rotational forceps
deliveries in 2008 (n5150) with those of nonrotational
forceps delivery (n5873), ventouse delivery (n5159),
spontaneous vertex delivery (n53,494), and emergency
cesarean delivery (n5947).
RESULTS: There was one stillbirth associated with a rota-
tional forceps delivery. This was diagnosed before
application of forceps. After rotational forceps deliveries,
58 of 872 (6.7%) of live-born neonates were admitted to
the neonatal unit. Twenty-seven of 872 (3.1%) neonates
had one or more complications that could be attribut-
able to traumatic delivery and seven neonates (0.8%) had
a diagnosis of neonatal encephalopathy. When com-
pared with alternative methods of delivery over a single
From the University of Edinburgh MRC Centre for Reproductive Health, Queen’s
Medical Royal, the Infirmary of Edinburgh, Little France, the Simpson Centre
for Reproductive Health, and the Neonatal Unit, Simpson Centre for Reproduc-
tive Health, Edinburgh, and Medway National Health Service Foundation
Trust, Gillingham, Kent, United Kingdom.
Corresponding author: Fiona C. Denison, MD, Senior Lecturer and Honorary
Consultant in Maternal and Fetal Health, University of Edinburgh MRC Centre
for Reproductive Health, Queen’s Medical Royal Infirmary of Edinburgh, Little
France, Edinburgh, EH16 4SA, UK; e-mail: Fiona.Denison@ed.ac.uk.
Financial Disclosure
Dr. Stock is supported by an Academy of Medical Sciences/Wellcome Trust
Clinical Lecturer Starter grant. Drs. Stock, Norman, and Denison are supported
by Tommy’s, the Baby Charity. The other authors did not report any potential
conflicts of interest.
© 2013 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/13
1032 VOL. 121, NO. 5, MAY 2013
year, neonatal admission rates after delivery by rotational
forceps deliveries (5 of 150 [3.3%]) were not significantly
different from spontaneous vertex delivery (128 of 3,494
[3.7%; P51.00]) or ventouse delivery (6 of 159 [3.8%;
P51.00]) and lower than emergency cesarean delivery
(106 of 947 [11.2%; P5.002). Postpartum hemorrhage
rates after rotational forceps deliveries (8 of 150 [5.3%;
P5.008]) were lower than those associated with emer-
gency cesarean delivery (142 of 947 [15.0%; P5.008]).
CONCLUSION: Rates of short-term neonatal and mater-
nal complications after successful rotational forceps deliv-
eries are low.
(Obstet Gynecol 2013;121:1032–9)
DOI: 10.1097/AOG.0b013e31828b72cb
LEVEL OF EVIDENCE: II
K
ielland’s rotational forceps are specifically
designed for rotation and delivery of the fetal
head, ie, in either a transverse or occipitoposterior
position.1 There is regional variation in their use
nationally and internationally,2–5 but generally there
has been a decline in the use of rotational forceps over
the past 30 years and there is an increasing preference
among obstetricians to use cesarean delivery for this
type of midcavity delivery.2–5 Although reasons for
this decline are complex, the perception that rota-
tional forceps are associated with increased complica-
tions and litigation is likely a strong influence.6,7
Concerns about litigation have also been cited as a rea-
son for the increasing use of cesarean delivery as
opposed to instrumental delivery for nonrotational
midcavity deliveries.8,9
Modern obstetric guidelines10 reiterate the poten-
tial risks of rotational forceps, but the data that these
recommendations are based on are more than 25 years
old and originate from uncontrolled observational
OBSTETRICS & GYNECOLOGY
studies examining neonatal morbidity and mortality.11
Subsequent small studies have not supported the find-
ing that rotational forceps are associated with increased
neonatal morbidity and provide conflicting data on
associations with maternal morbidity.3,12–21 There is
therefore a need for contemporary data from large
series to inform current obstetric practice.
The aim of this study was to estimate the rates of
early neonatal and maternal complications in a series
of consecutive Kielland’s rotational forceps deliveries
in a single center. Secondary aims were to compare
the rates of complications of rotational forceps re-
corded in a maternity database with those of other
types of delivery (spontaneous vertex delivery, non-
rotational forceps delivery, ventouse delivery, and
cesarean delivery) and to explore factors associated
with complications of rotational delivery including
the grade of operator.
MATERIALS AND METHODS
Ethical approval for the study was obtained from
Lothian Research Ethics Committee (REC reference
09/S1102/28). The study was performed in the Simp-
son Centre for Reproductive Health. This is a tertiary
referral obstetric center in the United Kingdom where
Kielland’s rotational forceps are regularly used for mid-
cavity rotational operative deliveries.
To estimate the rates of early neonatal and
maternal complications, we performed a retrospective
cohort study of women with singleton pregnancies
with cephalic presentation who were delivered suc-
cessfully by Kielland’s rotational forceps at 36 weeks
of gestation or greater between January 2001 and
December 2008. Data were not collected on deliveries
subsequent to December 2008 because the hospital
database system changed and there were difficulties
with case ascertainment with the new system. There
were 47,501 deliveries over the study period, 905 of
which were Kielland’s rotational forceps (1.90% deliv-
eries). Records of all cases were requested for review.
Five cases were misclassified and were actually non-
rotational forceps deliveries (misclassification rate
0.55%), 10 Kielland’s rotational forceps deliveries
were performed at less than 36 weeks of gestation,
and 17 were performed in one or more neonates of
multiple pregnancies. These cases were excluded
from analysis leaving a final cohort of 873 cases.
A secondary aim of the study was to compare
complications of Kielland’s forceps with other modes
of delivery. Outcomes after Kielland’s rotational deliv-
eries were compared with a contemporaneous cohort
of women with a singleton pregnancy at 36 weeks of
gestation or more delivered in the same hospital
VOL. 121, NO. 5, MAY 2013
between January 1, 2008 and December 31, 2008, by
spontaneous vertex delivery (n53,494), ventouse
(n5159), nonrotational midcavity forceps (n5873), or
emergency cesarean delivery (at any dilation; n5947).
We restricted comparisons to this single year as a result
of the large number of comparator deliveries over this
time period. We examined the neonatal unit electronic
patient records database (Badger) to estimate the pro-
portion of neonates admitted after each mode of deliv-
ery during this period and the number diagnosed with
neonatal encephalopathy. We also used data routinely
recorded in the maternity database to compare the
rates of postpartum hemorrhage and (vaginal deliveries
only) obstetric anal sphincter injury associated with
each mode of delivery.
Maternal outcomes after Kielland’s rotational for-
ceps delivery were collected by hand-searching mater-
nity case records. Maternal outcomes were episiotomy,
obstetric anal sphincter injury (third- or fourth-degree
tear), cervical tears, bladder injury, postpartum hemor-
rhage of 1,000 mL or greater, postpartum pyrexia
greater than 38°C, urinary retention (defined as recathe-
terization after removal of the catheter as a result of
incomplete bladder emptying), urinary incontinence,
fecal incontinence, and length of hospital stay. We also
explored factors associated with complications. The fol-
lowing data were collected: birth weight, maternal age,
body mass index (calculated as weight (kg)/[height
(m)]2), presence of antenatal complication (preeclampsia
or hypertensive disorder [defined as per International
Society for Hypertension in Pregnancy Guidelines]),22
pregestational or gestational diabetes (diagnosed by the
Scottish Intercollegiate Guideline Network, 200123), an-
tepartum hemorrhage and other medical condition
(including cardiac), onset of labor (spontaneous or
induced), previous vaginal delivery, epidural anesthesia,
fetal position (occipitotransverse or occipitoposterior),
indication for Kielland’s rotational forceps delivery
(delay in second stage, nonreassuring cardiotocograph,
or both, maternal medical indication for elective short
second stage), and grade of operator (consultant, senior
trainee [more than 5 years’ postgraduate experience and
postgraduate qualification obtained], junior trainee).
In 26 cases, maternity case records were missing
or incomplete. For these records, missing maternal
data were imputed from the hospital maternity
database, which holds more limited data. The follow-
ing data only were therefore available for these
women: obstetric anal sphincter injury, postpartum
hemorrhage of 1,000 mL or greater, maternal age,
maternal body mass index, onset of labor, previous
vaginal delivery, and indication for Kielland’s rota-
tional forceps delivery.
Stock et al Kielland’s Rotational Forceps Delivery 1033
 Neonatal outcomes after Kielland’s rotational for- Table 1. Details of Kielland’s Rotational Forceps
ceps were collected from the maternity records and Deliveries Cohort
neonatal case records if a neonate was admitted to the
neonatal unit. To ensure full case ascertainment of Variable n (%) or Mean6SD
neonatal complications, the neonatal unit admission Age (y) 29.466.01
database was interrogated to identify admitted neo- BMI (kg/m2) 25.264.53*
nates and case notes were reviewed. This was to Medical or obstetric condition
ensure that no neonatal admissions were missed. Sim- Preeclampsia or hypertension 57 (6.5)†
Diabetes 14 (1.6)†
ilarly, local and national perinatal mortality databases
Cardiac condition 3 (0.3)
were searched for every case of Kielland’s rotational Other‡ 32 (3.7)
forceps delivery to identify whether any of the 873 None identified 745 (85.3)
neonates delivered by Kielland’s rotational forceps Missing 23 (2.6)
delivery had died. No additional cases were found. Onset of labor
Spontaneous onset of labor 651 (74.6)
The neonatal outcomes collected were perinatal mor-
Induction of labor 219 (25.1)
tality (stillbirth or death within first 28 days), admis- Missing 3 (0.3)
sion to a neonatal unit for special or intensive care, Parity
duration of neonatal unit admission, indication for Primiparous 714 (81.8)
neonatal unit admission, arterial cord pH of less than No previous vaginal birth 769 (88.1)
Missing 1 (0.1)
7.00, 5-minute Apgar score of less than 7, seizures,
Epidural anesthesia during the first
nerve palsy (including facial nerve and Erb’s palsy), stage of labor
cephalohematoma, and any other significant trauma. Yes 546 (62.5)
Although transient bruising and forceps marks did No 320 (36.6)
occur and were sometimes described in the medical Missing 7 (0.8)
Indication for Kielland’s delivery
notes, these were not recorded as a result of variation
Delay in second stage 544 (62.3)
in reporting. Suspected fetal compromise 224 (25.7)
No formal sample size calculation was calculated. Both delay in second stage and 94 (10.8)
We aimed to collect data on all cases through the suspected fetal compromise
specified time period to maximize power for detection Maternal medical condition 3 (0.3)
Missing 8 (0.9)
of outcomes. Data were analyzed using SPSS 19.
Fetal head position
Fisher’s exact test was used to compare rates of neo- Occipitotransverse 458 (52.5)
natal unit admission, maternal trauma, and rate of Occipitoposterior 388 (44.4)
postpartum hemorrhage between different modes of Missing 27 (3.1)
delivery. Logistic regression was performed to exam- Grade of operator
Consultant 106 (12.1)
ine the influences of factors on complication rates.
Senior trainee 626 (71.7)
The following factors were included as dichotomous Junior trainee 135 (15.5)
events in the model: age older than 35 years, previous Days postnatal inpatient 2.9661.12
vaginal delivery, presence of any antenatal complica- Birth weight (g) 3,553.916462.29
tion, occipitotransverse position of the head, position, Birth weight more than 4,000 g 146 (16.7)
birth weight greater than 4 kg, and grade of operator SD, standard deviation; BMI, body mass index.
performing the procedure. Factors found to be signif- * In 141 women, BMI was not recorded.
†
One participant had both diabetes and preeclampsia.
icantly associated with risk of maternal complications ‡
Poor obstetric history, obstetric cholestasis, antepartum hemor-
after univariable analysis were entered as independent rhage.
variables in multivariable analysis using multiple
logistic regression. Results were expressed as adjusted
odds ratio (OR, 95% confidence intervals [CIs]). Miss- accounted for 81.8% of the group, 62.5% had epidural
ing fields were excluded from analysis. The number of anesthesia, and 85.3% were free from medical or
missing fields for each outcome stated in the results obstetric complications. The indication for Kielland’s
were relevant. Significance was defined as P,.05. rotational forceps delivery was delay in second stage
in 62.3%.
RESULTS Neonatal outcomes are summarized in Table 2.
Details of cases of Kielland’s rotational forceps deliv- There was one intrapartum stillbirth. This was diag-
eries are provided in Table 1. The cohort had a mean nosed before Kielland’s forceps were applied and was
age of 29.4 years (standard deviation 6.01). Primiparas associated with a congenital anomaly. This case was

1034 Stock et al Kielland’s Rotational Forceps Delivery OBSTETRICS & GYNECOLOGY

Table 2. Neonatal and Maternal Complications nerve palsies (seven Erb’s, four facial nerve, one with
After Kielland’s Rotational Forceps both Erb’s and facial nerve palsies, one vocal cord
Delivery paralysis). One neonate had a corneal abrasion, one
neonate had a fractured clavicle, and one neonate had
Missing a subdural hematoma. One neonate had both cepha-
Complications n (%) Data
lohematoma and facial nerve palsy. All Erb’s and
Neonatal complications (n5872*) facial palsies were transient.
Admission to neonatal unit 58 (6.7) 4 In total 58 neonates (6.7%) were admitted for
Admission to neonatal unit 41 (4.7) 4 neonatal special or intensive care. Fifteen of these
unrelated to delivery
5-min Apgar score 7 or less 33 (3.8)
were otherwise well neonates admitted from the
Arterial pH less than 7 17 (1.9) 27 postnatal ward or readmitted from home with transi-
Neonatal encephalopathy 7 (0.8) tional feeding difficulties (with or without jaundice or
Congenital injury 27 (3.1) dehydration); one neonate was admitted for social
Cephalohematoma† 12 (1.4) reasons and one neonate for assessment of dysmor-
Corneal abrasion 1 (0.1)
Transient nerve palsy† 13 (1.5)
phism. If these cases, which are unlikely to relate to
Fractured clavicle 1 (0.1) delivery, are excluded, the neonatal admission rate
Subdural hemorrhage 1 (0.1) was 41 of 872 (4.7%). The most common primary
1 or more early neonatal 45 (5.2) reason for neonatal unit admission was respiratory
complications‡ problems (20 neonates), low cord pH (five neonates),
Maternal complications (n5873)
Obstetric anal sphincter injury 53 (6.1) 19
and suspected sepsis (three neonates). In seven neo-
Vaginal laceration (in addition to 121 (13.9) 19 nates (0.8%), a diagnosis of neonatal encephalopathy
any episiotomy) was recorded.
Cervical tear 2 (0.2) 19 Maternal outcomes are also summarized in
Bladder injury 0 25 Table 2. Fifty-three women (6.1%) had obstetric anal
Postpartum hemorrhage more 57 (6.5) 5
than 1,000 mL
sphincter injury, 121 (13.9%) a vaginal laceration, and
Postpartum pyrexia greater 15 (2.0) 25 two women (0.2%) had a cervical tear. All women had
than 38˚C episiotomies performed. There were no cases of blad-
Perineal wound infection/ 12 (1.4) 25 der injury recorded. Fifty-seven women (6.5%) had
breakdown a postpartum hemorrhage greater than 1,000 mL.
Urinary retention 29 (3.3) 24
Urinary incontinence 7 (0.8) 25
Overall 15 women (2.0%) had postpartum pyrexia,
Bowel symptoms 4 (0.5) 25 and 12 women (1.4%) had perineal infection or wound
Nerve damage 3 (0.3) 25 breakdown. Twenty-nine (3.3%) women had urinary
Postnatal hospitalization more 64 (7.3) 24 retention, seven women (0.8%) had urinary inconti-
than 4 d nence, and four women (0.5%) had bowel symptoms
1 or more early maternal 276 (31.6) 26
complications
(one woman with fecal urgency, one woman with pain
on defecation, and two women with fecal inconti-
* One stillbirth associated with congenital abnormality diagnosed
before application of Kielland’s forceps excluded. nence). The median length of stay postnatally was 3
†
One neonate had both cephalohematoma and transient nerve days (range 1–9 days) with 64 women (7.3%) staying
palsy. more than 4 days. Overall, 276 women (31.6%) had
‡
Defined as neonatal unit admission (excluding admissions
unrelated to delivery), neonatal encephalopathy, and congen- one or more complication (defined as obstetric anal
ital injury. sphincter injury, genital tract trauma, postpartum
hemorrhage, other early postnatal complication, or
postnatal hospitalization of more than 4 days).
excluded from subsequent analysis of neonatal out- Table 3 compares outcomes for women delivered
comes. There were no other perinatal deaths in the by Kielland’s rotational forceps compared with other
cohort. modes of delivery in the Simpson Centre for Repro-
In the 872 live-born neonates delivered by ductive Health during 2008. The maternal demograph-
Kielland’s rotational forceps, 17 neonates (1.9%) had ics of women delivered by Kielland’s rotational forceps
Apgar scores less than 7 at 5 minutes. Arterial cord delivery in 2008 were not significantly different from
pH results were available in 845 neonates (96.9%) and those of overall cohort (data not shown).
were below 7.00 in 17 neonates (1.9%). The rate of admission to the neonatal unit after
Congenital injury was recorded in 27 neonates Kielland’s rotational forceps was not significantly dif-
(3.1%). Twelve neonates had cephalohematoma, 13 had ferent from rates after other modes of vaginal birth

VOL. 121, NO. 5, MAY 2013 Stock et al Kielland’s Rotational Forceps Delivery 1035
Table 3. Complications After Kielland’s Rotational Forceps Delivery Compared With Other Modes of
Delivery*†

Kielland’s Nonrotational Spontaneous Emergency

Rotational Forceps Ventouse Vertex Cesarean
Forceps Delivery Delivery Delivery Delivery
(n5150) (n5873) P (n5159) P (n53,494) P (n5947) P

Neonatal unit 5 (3.3) 53 (6.1) .25 6 (3.8) ..99 128 (3.7) ..99 106 (11.2) .002
admission
Neonatal 1 (0.7) 2 (0.2) .38 1 (0.6) ..99 3 (0.1) .15 6 (0.6) ..99
encephalopathy
Postpartum 8 (5.3) 63 (7.2) .49 4 (2.5) .25 80 (2.3) .027 142 (15.0) .008
hemorrhage
3rd-degree or 14 (9.3) 74 (8.5) .64 3 (1.9) .005 102 (2.9) ,.001 — —
4th-degree tear
* Outcomes from deliveries in 2008 only.
†
Data analyzed by Fisher’s exact test.

(3.3% [5 of 150] compared with 6.1% [53 of 873] for
nonrotational midcavity forceps delivery, 3.8% [6 of
159] for ventouse, and 3.7% [128 of 3,494] for spon-
taneous vertex delivery; P..05). The rate of neonatal
admission after emergency cesarean delivery was sig-
nificantly higher than for other modes of delivery
(11.2% [106 of 947], P5.002). There was no significant
difference in rates of neonatal unit admission with
neonatal encephalopathy after Kielland’s rotational
forceps delivery compared with other modes of deliv-
ery, but the overall number of cases of neonatal
encephalopathy was small.
The incidence of postpartum hemorrhage was not
significantly different after Kielland’s rotational for-
ceps delivery than after nonrotational forceps delivery
(5.3% compared with 7.2%; P5.49) or ventouse deliv-
ery (2.5%; P5.25) and was significantly lower than
after emergency cesarean delivery (15.0%; P5.008).
It was however higher than that associated with spon-
taneous vertex delivery (2.3%, P5.027). The inci-
dence of obstetric anal sphincter injury after
Kielland’s rotational forceps was also similar to that
of nonrotational forceps (9.3% compared with 8.5%;
P5.64) but higher than after ventouse delivery or
spontaneous vertex delivery (1.9% and 2.9%, respec-
tively; P5.005 and,.001).
Because numbers of cases with neonatal compli-
cations was low, we did not undertake further analysis
of associated factors.
The contribution of factors that might be associ-
ated with maternal complications after Kielland’s rota-
tional forceps delivery was assessed using univariable
analysis. Results are presented in Table 4 as ORs with
95% CI. The primary outcome of maternal complica-
tion was defined as a dichotomous event. Induction of
labor and epidural were associated with increased
odds of maternal complications (OR 1.42 [95% CI
1.03–1.96] and 1.67 [95% CI 1.23–2.28], respectively),
whereas previous vaginal delivery was associated with
a reduction in odds of maternal complication (OR
0.38 [95% CI 0.22–0.66]). No other factor was associ-
ated with a significant change in risk of maternal com-
plication. The three significant factors were entered as
independent variables in multivariable analysis with
multiple logistic regression. Adjusted ORs with 95%
CI were calculated and shown in Table 5. After adjust-
ment, induction of labor was no longer associated
with increased odds of maternal complications after
Kielland’s rotational forceps delivery, whereas previ-
ous vaginal delivery remained protective (adjusted
OR 0.39 [0.23–0.67]) and epidural remained associ-
ated with increased odds of maternal complications
(adjusted OR 1.60 [1.17–2.19]).
DISCUSSION
The findings of this large consecutive series of
Kielland’s forceps deliveries suggest a low neonatal
complication rate after Kielland’s forceps delivery.
This supports smaller earlier studies12,17,24 and pro-
vides evidence that the perception that rotational for-
ceps are dangerous may be unfounded. This study
was primarily designed as a descriptive study of out-
comes of Kielland’s rotational forceps. To put these
findings in context, we compared complication rates
associated with Kielland’s rotational forceps with
those occurring after other types of deliveries. In this
secondary analysis we made no attempt to match the
different delivery groups or adjust for potential con-
founding factors between the groups. The mode of
delivery reflects, among other things, maternal and

1036 Stock et al Kielland’s Rotational Forceps Delivery OBSTETRICS & GYNECOLOGY

Table 4. Results of Univariable Analysis for Factors Associated With Maternal Complications After
Kielland’s Rotational Forceps Delivery

Total
Variable n n (%) Maternal Complication P

Age (y)
Younger than 20 97 31 (32.0) 1.14 (0.68–1.89) .622
20–24 116 36 (31.0) 1.09 (0.67–1.77) .346
25–29 236 69 (29.2) 1.00*
30–34 281 101 (35.9) 1.36 (0.94–1.97) .106
35–39 114 33 (28.9) 0.99 (0.60–1.61) .955
40 or older 15 6 (40.0) 1.61 (0.55–4.71) .381
BMI (kg/m2)
19.99 or less 71 21 (29.6) 0.92 (0.53–1.60) .767
20–24.99 386 121 (31.3) 1.00*
25–29.99 189 62 (32.8) 1.06 (0.74–1.55) .725
30 or more 86 33 (38.4) 1.36 (0.84–2.22) .210
Antenatal risk factor†
No 738 226 (30.6) 1.00*
Yes 112 42 (37.5) 1.36 (0.90–2.01) .146
Induction of labor
No 640 193 (30.2) 1.00*
Yes 218 83 (38.1) 1.42 (1.03–1.96) .031
Previous vaginal delivery
No 757 259 (34.2) 1.00*
Yes 102 17 (16.7) 0.38 (0.22–0.66) ,.001
Epidural
No 314 80 (25.5) 1.00*
Yes 539 196 (36.4) 1.67 (1.23–2.28) ,.001
Position
Occiput posterior 388 120 (30.9) 1.00*
Occiput transverse 458 148 (32.3) 1.07 (0.80–1.43) .666
Grade of operator
Consultant 103 33 (32.0) 1.00*
Senior trainee 618 194 (31.4) 0.97 (0.62–1.52) .896
Junior trainee 134 48 (35.8) 1.18 (0.69–2.04) .543
Birth weight (kg)
Less than 3 97 31 (32.0) 1.06 (0.67–1.67) .818
3–3.99 617 190 (30.8) 1.00*
4or more 143 55 (38.5) 1.41 (0.96–2.05) .078
BMI, body mass index.
Data are odds ratio (95% confidence interval) unless otherwise specified.
* Reference category is represented by an OR of 1.0.
†
Antenatal risk factor defined as preeclampsia, hypertension, diabetes, cardiac condition, or other (poor obstetric history, obstetric
cholestasis, antepartum hemorrhage).

fetal well-being, the anticipated difficulty of delivery,
and maternal and operator preference for mode of
delivery. This means that different delivery groups
are fundamentally different with regard to case com-
plexity. Furthermore, it is impossible to accurately
determine such factors retrospectively from maternity
records, yet they are likely to influence both the mode
of delivery and outcomes and thus confound attempts
to demonstrate superiority of one method over another
retrospectively. We therefore decided to simply pres-
ent descriptive outcomes, believing that this approach
will be useful in informing the operator of the likely
outcomes for women and their neonates delivered by
Kielland’s rotational forceps. The limitations of this
approach to draw conclusions regarding the superiority
of one mode of delivery over another in individual
women should be recognized.
Like with any retrospective study, this study was
dependent on the quality of the data recorded. We
performed careful and systematic review of medical
records collecting predefined data in an attempt to
maximize accuracy. We used multiple sources of data
to collect neonatal outcome data so as to increase
confidence that no cases of perinatal mortality or

VOL. 121, NO. 5, MAY 2013 Stock et al Kielland’s Rotational Forceps Delivery 1037
Table 5. Results of Multivariable Analysis for
Factors Associated With Maternal
Complications After Kielland’s Rotational
Forceps Delivery
Variable Maternal Complication P
Induction of labor
No 1.00*
Yes 1.31 (0.94–1.82) .106
Previous vaginal delivery
No 1.00*
Yes 0.39 (0.23–0.67) .001
Epidural
No 1.00*
Yes 1.60 (1.17–2.19) .003
Data are adjusted odds ratio (95% confidence interval) unless
otherwise specified.
* Reference category is represented by an odds ratio of 1.0.
significant morbidity were missed. In 26 cases, some
or all of the maternal outcome data were obtained
from the maternity database, which may be less accu-
rate than data obtained from review of the maternity
case records because the maternity case records are the
primary source of outcome data. Nevertheless, we
found that the database fields included were concor-
dant with maternity case records in more than 98% of
cases in which both sources of data were available.
A limitation of our study is the inclusion of all
emergency cesarean deliveries rather than only those
performed at full dilatation. Many emergency cesar-
ean deliveries are performed for suspected fetal
compromise, and the higher neonatal unit admission
rate seen in association with cesarean delivery may
reflect this. A prospective study of operative delivery
in the second stage of labor found that both maternal
and neonatal morbidity was lower after operative
vaginal delivery than after full dilation cesarean deliv-
ery, supporting our findings.25 Another limitation is that
we were unable to identify patients undergoing manual
rotation before instrumental delivery and compare out-
comes of neonates who underwent manual rotation
with those of Kielland’s rotational forceps. Finally, our
maternity database only records the final mode of deliv-
ery. Thus, for women whose final mode of delivery was
by cesarean delivery, we were unable to identify those
women in whom delivery was initially attempted by
Kielland’s rotational forceps, ventouse, or nonrotational
forceps. We were therefore unable to report the failure
rate after Kielland’s rotational forceps delivery for our
cohort and compare maternal and neonatal outcomes
between successful and unsuccessful Kielland’s rota-
tional forceps deliveries. The incomplete ascertainment
of unsuccessful attempts of operative vaginal delivery
1038 Stock et al Kielland’s Rotational Forceps Delivery
and reporting of outcomes of only successful deliver-
ies means that our study is representative of outcomes
only in women who were ultimately delivered by
Kielland’s forceps. However, it is possible that out-
comes in all women in whom Kielland’s forceps were
attempted are better or worse than those reported
here.
We have only examined immediate complication
rates associated with delivery. Qualitative work has
shown that women frequently feel inadequately pre-
pared for forceps delivery and that it affects their
views about future deliveries.26 Nevertheless, a pro-
spective cohort study found that women were more
likely to prefer a future vaginal delivery after a success-
ful forceps delivery than after a cesarean delivery.27
Further research is needed on longer-term outcomes
of Kielland’s rotational forceps, maternal satisfaction,
and preference for future deliveries.
This study is not powered to estimate the inci-
dence of rare events such as neonatal mortality. In
2009, a Kielland’s rotational forceps delivery was
associated with a neonatal death in the Simpson Cen-
tre for Reproductive Health.28 However, this neonatal
death fell outside our prespecified study period and as
a result of changes in our hospital database system, we
were unable to collect data on deliveries subsequent to
December 2008. We were therefore unable to deter-
mine whether there were any neonatal deaths associ-
ated with other modes of delivery as a comparator for
the neonatal death associated with the Kielland’s rota-
tional forceps delivery. Despite this, the low incidence
of neonatal complications after Kielland’s rotational
forceps delivery in the present study is reassuring.
This study was performed in a single center where
the majority of obstetric consultants have expertise in
rotational forceps delivery and trainees are taught and
supported in performing rotational forceps deliveries.
This is an increasingly unusual situation,2 and in many
centers rates of operative vaginal delivery are low and
skills for performing rotational deliveries have been
lost. Widespread reintroduction of rotational forceps
delivery would be challenging and would depend on
a program of training and support by obstetricians
experienced in rotational delivery. This may be par-
ticularly difficult in the United States where those with
recent experience in Kielland’s forceps deliveries are
in short supply. However, we believe that there is
a place for Kielland’s rotational forceps delivery of neo-
nates with malposition of the head. Increasing the avail-
ability of this form of delivery may have potential to
reduce maternal complications associated with cesar-
ean delivery, both in the short term and in subsequent
pregnancies.
OBSTETRICS & GYNECOLOGY
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