Incidence:  3.3% as of 2013  Indications:  Prolonged second stage  Risk of fetal compromise  Shortening 2nd stage for maternal benefit (ex: cardiac conditions) Consent:  Comparison is c-section typically  Failure rate of OVD is ~3-6%  Forceps has higher success rate over vacuum, but also higher risk 3rd/4th degree tear  Risks to both mom and baby Prep:  Fetus appropriate station/position  Anesthesia Empty bladder Assess Pelvis/Passenger sizes/fit OR Ready Peds available  Episiotomy – NO!  Contraindications Fetal conditions, known or supspected: bone disorders (OI), bleeding disorders  Maternal infections: Hep C, HIV, etc  Concern for shoulder dystocia/cephalo-pelvic dysproportion