Effect non-invasive low forceps delivery on pelvic floor muscle strength and postpartum depression in singleton full-term pregnant women

Abstract

BACKGROUND

Traditional low forceps midwifery requires lateral episiotomy, which affects the delivery experience of the parturient, impairs the recovery of postpartum pelvic floor muscle strength, and is associated with complications such as perineal pain and infection. These factors impose physical and psychological burdens and may increase postpartum depression. Non-invasive low forceps midwifery controls the delivery speed of the fetal head and applies traction during intervals between uterine contraction to assist gradual delivery without lateral episiotomy, thereby facilitating recovery of postpartum pelvic floor muscle strength.

AIM

To investigate the effect of non-invasive low forceps midwifery on postpartum pelvic floor muscle strength and postpartum depression in singleton full-term pregnant women.

METHODS

Clinical data from 70 parturients who underwent forceps-assisted delivery at Suzhou Ninth People’s Hospital (Affiliated with Soochow University) from January 2024 to June 2025 were retrospectively collected. According to the midwifery method, patients were divided into a control group (n = 35; traditional low forceps midwifery with episiotomy) and an observation group (n = 35; non-invasive low forceps midwifery). Baseline data, perioperative indicators, complications, delivery experience [Childbirth Experience Questionnaire (2.0)], pelvic floor muscle strength, and depression scores [Edinburgh Postpartum Depression Scale] were compared between groups.

RESULTS

There were no significant differences in baseline data, number of forceps tractions, or duration of the second stage of labor between groups (P > 0.05). However, the observation group had less intrapartum bleeding and lower bleeding at 24 hours postpartum than the control group (P < 0.05). Postpartum pain intensity was also lower in the observation group, with reduced Visual Analogue Scale scores at 12 hours and 24 hours (P < 0.05). Regarding complications, the severity of perineal tears was greater in the control group (Z = -2.368, P = 0.018) and the incidence of postpartum urinary retention was higher in the control group than in the observation group (χ² = 3.968, P = 0.046). Compared with the control group, the observation group reported better delivery experience scores (P < 0.05). Follow-up at six weeks, three months, and six months postpartum revealed higher pelvic floor muscle strength and lower Edinburgh Postpartum Depression Scale scores in the observation group than in the control group (P < 0.05).

CONCLUSION

Compared with traditional low forceps midwifery with episiotomy, non-invasive low forceps midwifery effectively reduces bleeding, postpartum pain, and complications, improves delivery experience, and promotes recovery of pelvic floor muscle strength while alleviating postpartum depression.

Key Words: Non-invasive forceps midwifery; Natural childbirth; Childbirth experience; Pelvic floor muscle strength; Postpartum depression

Core Tip: Traditional low forceps-assisted delivery requires episiotomy, which may negatively affect childbirth experience and recovery of postpartum pelvic floor muscle strength, potentially contributing to postpartum depressive symptoms. This study highlights that non-invasive low forceps-assisted delivery facilitates the recovery of postpartum pelvic floor muscle strength and helps alleviate postpartum depressive symptoms compared with traditional low forceps-assisted delivery with episiotomy.

INTRODUCTION

Vaginal delivery is a natural mode of childbirth, and its smooth progression depends on rhythmic and effective myometrial contractions[1]. However, fear of the severe labor pain, psychological tension, prolonged labor, reduced sleep, and excessive physical exertion may disrupt contraction rhythm, polarity, and symmetry, resulting in ineffective contractions or secondary uterine atony. Additionally, factors such as old age and poor health may reduce uterine contractility, hindering normal vaginal delivery progression and often leading to prolonged second stage or arrested fetal descent. When psychological counseling, uterotonic drugs, and guided cooperation fail, the use of forceps or suction devices may become necessary[2,3]. Forceps midwifery is a common method for managing dystocia and can effectively shorten labor. However, traditional forceps delivery requires lateral episiotomy, which can cause injury to the body and impair recovery of postpartum pelvic floor muscle strength[4]. It may also lead to complications such as perineal pain, infection, postpartum hemorrhage, scarring, defecation difficulty, urinary incontinence, and sexual pain[5], contributing to physical discomfort and psychological stress and increasing the risk of postpartum depression. Therefore, optimizing forceps techniques has become a focus of clinical attention. Non-invasive low forceps midwifery has emerged as an effective approach in recent years. It controls the delivery speed of the fetal head and applies traction during contraction intervals to facilitate gradual delivery, shorten labor duration, and improve the success rate of vaginal delivery. However, the current research mainly focuses on the effect of forceps midwifery on the amount of bleeding and delivery time[6,7], with limited research on pelvic floor muscle strength and postpartum depression. This study investigated the effects of non-invasive low forceps midwifery on these outcomes in singleton full-term pregnancies, aiming to provide reference for clinical practice.

MATERIALS AND METHODS

Research object

In this retrospective study, clinical data from 70 parturients assessed to require forceps-assisted delivery at Suzhou Ninth People’s Hospital (Affiliated with Soochow University) from January 2024 to June 2025 were collected. According to the midwifery method, patients were divided into a control group (n = 35) and an observation group (n = 35). The control group received traditional low forceps midwifery with episiotomy, whereas the observation group underwent non-invasive low forceps midwifery.

Inclusion criteria: (1) Age ≥ 20 years; (2) Singleton pregnancy; (3) Full-term pregnancy; (4) No obstetric complications; (5) Met indications for forceps midwifery: Viable fetus, fully dilated cervix, occipital or vertex presentation, the bony part of the fetal head is ≤ 3 cm below the spine, and ruptured fetal membrane; and (6) Receipt of routine standardized rehabilitation guidance after lochia clearance.

Exclusion criteria: (1) Pregnancy via assisted reproductive technology; (2) Scarred uterus; (3) Head basin disproportion; (4) Fetal malformation or death; (5) Abnormal birth canal; (6) Severe fetal head deformation; (7) Estimated fetal weight ≥ 4.0 kg; (8) Diagnosed mental illness before delivery; and (9) Inability to communicate normally.

Midwifery methods

The control group underwent traditional low forceps midwifery with episiotomy. During the first stage of labor, midwives guided correct breathing and closely monitored fetal heart rate and labor progress. During the second stage, episiotomy-assisted low forceps midwifery was performed. The parturient was placed in a semi-reclining position on a multifunctional delivery bed, followed by routine disinfection of the external genitalia and sterile draping. Cervical dilation and fetal head position (≤ 3 cm below the spinous process) were confirmed. Then, the parturient was positioned in the lithotomy position, and local anesthesia at the episiotomy site or bilateral perineal nerve block anesthesia was administered, followed by electrocardiogram monitoring and lateral episiotomy. The midwife carefully placed the left and right lobes of the forceps, ensuring no maternal soft tissue or umbilical cord was entrapped, and then locked. Traction was applied along the pelvic axis during uterine contraction. After exposure of the fetal forehead, the forceps were released and removed. In occiput posterior position, traction was adjusted laterally, and the forceps were removed when the nasal root or forehead reached the lower edge of the phalangeal joint (the right lobe forceps were removed first before the left lobe forceps). The fetus was then delivered with uterine contractions and abdominal pressure, followed by umbilical cord clamping (2 cm), placental delivery, and assessment of maternal and neonatal status.

The observation group underwent non-invasive low forceps midwifery. Management during the first stage was the same as in the control group. In the second stage, the parturient was positioned similarly, and standard routine disinfection and draping were performed. After confirming cervical dilation and fetal head position (3 cm below the spinous process), catheterization was performed, and the forceps were checked and lubricated. The left and right leaf forceps were placed sequentially and locked, ensuring no umbilical cord or soft tissue entrapment. Traction force and speed was adjusted according to perineal tension. Midwives controlled the speed of fetal head delivery (lightly holding the fetal head) while providing moderate perineal protection and verbal encouragement. Closely monitoring of contractions and labor progress was maintained. Once the fetal head crowned, the forceps were promptly removed and slowly slid out along the fetal head. Delivery was completed with uterine contractions and abdominal pressure, followed by umbilical cord clamping (2 cm), placental delivery, and assessment of maternal and neonatal status.

Observation indicators

Perioperative indicators: These included the number of forceps tractions, the amount of intrapartum bleeding, the duration of the second stage of labor, the amount of bleeding 24 hours postpartum, and postpartum perineal pain. Postpartum perineal pain was assessed using the Visual Analogue Scale (VAS) at 12 hours and 24 hours postpartum (0-10 points; higher scores indicate greater pain).

Complications: Maternal complications included cervical laceration and perineal tear (grade I: Vaginal mucosa and perineal skin tear with minimal bleeding; grade II: Involvement of perineal muscles and vaginal mucosa with increased bleeding; grade III: Deep perineal and external anal sphincter laceration), postpartum urinary retention, and postpartum perineal infection. Neonatal complications included skin abrasions, scalp hematoma, and neonatal asphyxia.

Childbirth experience: One day before discharge, the Childbirth Experience Questionnaire (2.0)[8] was used to assess delivery experience. The questionnaire includes self-ability (6 items), professional support (6 items), safety perception (4 items), and participation (3 items), with scores ranging from 19 points to 76 points; higher scores indicate better childbirth experience.

Postpartum pelvic floor muscle strength: At six weeks, three months, and six months postpartum, pelvic floor muscle strength and electromyography were assessed by the same experienced obstetrician using standardized instruments. Type I pelvic muscle fiber endurance was graded from 0 (0 second) to 5 (≥ 5 seconds), and type II pelvic floor muscle fiber contractions were graded by repetition count. A level ≤ 3 indicated reduced muscle strength. Electromyography was measured using a vaginal electrode: Resting values were recorded under relaxation, and maximal values were obtained during rapid contractions (five repetitions at 10-seconds intervals). Normal values were 2-4 V (resting) and 35-45 V (maximum).

Postpartum depression: At six weeks, three months, and six months postpartum, depression was evaluated using the Edinburgh Postnatal Depression Scale (EPDS)[9]. The scale includes 10 items scored on four levels, namely: Never, 0 points; occasionally, 1 point; often, 2 points; and always, 3 points. The total score was 0-30 points; higher scores indicate more severe depression.

Statistical analysis

IBM SPSS Statistics version 25.0 was used for data analysis. Measurement data were analyzed to for normality using the Shapiro-Wilk test and expressed as mean ± SD. Between-group comparisons were performed using the independent samples t-test. Repeated measures within groups were analyzed using analysis of variance. Count data are presented as n (%) and were compared using the χ² test. Ranked data were analyzed using the rank-sum (Z) test. A significance level of α = 0.05 was applied, with P < 0.05 indicating statistical significance.

RESULTS

Comparison of baseline data between the two groups

No significant differences were observed between the two groups in age, body mass index, parity, education level, gestational age at delivery, indications for forceps-assisted delivery, or neonatal sex and birth weight (P > 0.05; Table 1).

Table 1 Comparison of baseline data between two groups, n (%)/mean ± SD.

Baseline data	Control group (n = 35)	Observation group (n = 35)	t/χ2 value	P value
Age (years)			0.324	0.569
< 35	28 (80.00)	26 (74.29)
≥ 35	7 (20.00)	9 (25.71)
Body mass index (kg/m2)	25.43 ± 1.65	25.63 ± 1.71	0.498	0.620
Type of maternity			0.357	0.550
Primipara	29 (82.86)	27 (77.14)
Multipara	6 (17.14)	8 (22.86)
Educational level			0.651	0.722
Junior high school and below	11 (31.43)	8 (22.86)
Secondary/high school	15 (42.86)	17 (48.57)
College degree or above	9 (25.71)	10 (28.57)
Delivery gestational week (weeks)	38.72 ± 1.03	38.95 ± 1.26	0.836	0.406
Types of forceps delivery required			0.253	0.969
Fetal distress	13 (37.14)	14 (40.00)
Uterine atony	8 (22.86)	9 (25.71)
Abnormal position of the fetal head	6 (17.14)	5 (14.29)
Prolonged second stage of labor	8 (22.86)	7 (20.00)
Gender of newborn			0.233	0.629
Baby boy	19 (54.29)	21 (60.00)
Baby girl	16 (45.71)	14 (40.00)
Newborn birth weight (kg)	3.55 ± 0.42	3.43 ± 0.39	1.239	0.219

Comparison of perioperative indicators between the two groups

There were no significant differences in the number of forceps tractions or the duration of the second stage of labor between the two groups (P > 0.05). However, the amount of bleeding intrapartum and 24 hours postpartum were lesser in the observation group than in the control group (P < 0.05). Postpartum pain intensity was also lower in the observation group, with reduced VAS scores at 12 hours and 24 hours postpartum (P < 0.05; Table 2).

Table 2 Comparison of perioperative indicators between two groups, mean ± SD.

Perioperative observation indicators	Control group (n = 35)	Observation group (n = 35)	t value	P value
Number of forceps traction (times)	1.26 ± 0.18	1.34 ± 0.21	1.711	0.092
Amount of bleeding during delivery (mL)	267.19 ± 19.76	221.47 ± 17.28	10.301	< 0.001
Second stage of labor duration (minute)	87.04 ± 7.55	88.59 ± 8.85	0.788	0.433
Postpartum 24-hour bleeding volume (mL)	314.87 ± 25.48	268.92 ± 23.51	7.881	< 0.001
VAS score at 12 hours postpartum (points)	7.24 ± 0.73	5.38 ± 0.51	5.713	< 0.001
VAS score at 24 hours postpartum (points)	5.19 ± 0.45	3.56 ± 0.37	6.398	< 0.001

VAS: Visual Analogue Scale.

Comparison of complications between the two groups

The severity of perineal tears was greater in the control group than in the observation group (Z = -2.368, P = 0.018), and the incidence of postpartum urinary retention was higher in the control group than in the observation group (χ² = 3.968, P = 0.046). There were no significant differences in cervical laceration, postpartum perineal infection, or neonatal complications between the two groups (P > 0.05; Table 3).

Table 3 Comparison of complications between two groups, n (%).

Complications situation	Control group (n = 35)	Observation group (n = 35)	χ2/Z value	P value
Cervical laceration	2 (5.71)	1 (2.86)	0.348	0.555
Perineal tear			-2.368	0.018
I degree	14 (40.00)	9 (25.71)
II degree	11 (31.43)	5 (14.29)
III degree	1 (2.86)	0 (0.00)
Postpartum uroschesis	6 (20.00)	1 (2.86)	3.968	0.046
Postpartum perineal infection	1 (2.86)	0 (0.00)	1.014	0.314
Skin abrasions in newborns	3 (8.57)	2 (5.71)	0.215	0.643
Neonatal scalp hematoma	3 (8.57)	1 (2.86)	1.061	0.303
Neonatal asphyxia	4 (11.43)	2 (5.71)	0.729	0.393

Comparison of delivery experience scores between the two groups

Compared with the control group, the observation group had higher scores across all dimensions of the delivery experience (self-ability, professional support, security awareness, and participation), as well as a higher total score (P < 0.05; Table 4).

Table 4 Comparison of delivery experience scores between two groups, mean ± SD.

Group	n	Self-ability	Professional support	Security awareness	Participatory nature	Total score
Control group	35	15.48 ± 2.19	11.56 ± 1.49	12.47 ± 1.72	6.97 ± 1.09	46.48 ± 5.25
Observation group	35	16.79 ± 2.47	12.35 ± 1.06	13.48 ± 1.94	8.15 ± 1.26	50.77 ± 5.79
t value		2.348	2.556	2.305	4.190	3.247
P value		0.021	0.013	0.024	< 0.001	0.002

Comparison of postpartum pelvic floor muscle strength and pelvic floor electromyography between the two groups

Pelvic floor muscle strength (type I and type II muscle fibers) increased gradually at six weeks, three months, and six months postpartum (P < 0.05). At each time point, pelvic floor muscle strength levels were significantly higher in the observation group than in the control group (P < 0.05; Table 5). The pelvic floor electromyographic values (resting average and maximum fast muscle values) also increased in both groups (P < 0.05). These parameters were significantly higher in the observation group at all follow-up time points than in the control group (P < 0.05; Table 6).

Table 5 Comparison of pelvic floor muscle strength between two groups after delivery (mean ± SD, grade).

Group	n	Type I muscle fibers					Type II muscle fiber
		6 weeks postpartum	3 months postpartum	6 months postpartum	F value	P value	6 weeks postpartum	3 months postpartum	6 months postpartum	F value	P value
Control group	35	2.97 ± 1.32	3.23 ± 1.36	3.95 ± 1.42	4.825	0.011	3.02 ± 1.18	3.39 ± 1.41	4.07 ± 1.51	5.261	0.007
Observation group	35	3.60 ± 1.12	3.98 ± 1.17	4.63 ± 1.28	6.684	0.002	3.72 ± 1.29	4.13 ± 1.35	4.84 ± 1.32	6.448	0.002
t value		2.153	2.473	2.104			2.369	2.243	2.271
P value		0.035	0.016	0.039			0.021	0.028	0.026

Table 6 Comparison of postpartum pelvic floor electromyography between the two groups (mean ± SD, V).

Group	n	Resting average electromyographic value					Maximum electromyographic value of fast muscle
		6 weeks postpartum	3 months postpartum	6 months postpartum	F value	P value	6 weeks postpartum	3 months postpartum	6 months postpartum	F value	P value
Control group	35	2.42 ± 0.51	2.97 ± 0.64	3.25 ± 0.62	17.760	< 0.001	25.02 ± 2.71	27.45 ± 3.08	32.07 ± 4.12	39.840	< 0.001
Observation group	35	2.79 ± 0.38	3.34 ± 0.48	3.63 ± 0.53	29.150	< 0.001	30.25 ± 2.25	32.64 ± 3.32	35.13 ± 4.32	17.990	< 0.001
t value		3.442	2.736	2.756			8.784	6.780	3.033
P value		0.001	0.008	0.008			< 0.001	< 0.001	0.003

Comparison of postpartum depression scores between the two groups

The EPDS scores in both groups increased slightly at six weeks, three months, and six months postpartum, but the differences were not statistically significant (P > 0.05). At each time point, the EPDS scores were lower in the observation group than in the control group (P < 0.05; Table 7).

Table 7 Comparison of postpartum depression scores between the two groups (mean ± SD, points).

Group	n	EPDS rating
		6 weeks postpartum	3 months postpartum	6 months postpartum	F value	P value
Control group	35	7.06 ± 2.54	8.12 ± 2.68	8.26 ± 2.62	2.205	0.115
Observation group	35	5.37 ± 1.73	6.13 ± 1.65	6.39 ± 2.13	2.877	0.061
t value		3.253	3.741	3.276
P value		0.018	< 0.001	0.002

EPDS: Edinburgh Postnatal Depression Scale.

DISCUSSION

Low forceps delivery has clear advantages in managing difficult deliveries, such as cephalic dystocia and fetal distress, as it can shorten the second stage of labor and effectively solve cephalic dystocia. It is therefore widely used in clinical practice[10]. However, traditional low forceps delivery typically requires lateral episiotomy to expand the vaginal outlet, which may cause physical injury[11]. Moreover, perineal protection during traction increases operational difficulty and may be associated with greater intraoperative blood loss[12]. Therefore, it is necessary to optimize forceps delivery techniques in clinical practice to reduce maternal trauma.

Forceps-assisted delivery refers to a situation in which the bony part of the fetal head has descended below the ischial spine, allowing quick delivery and improved maternal and neonatal outcomes. However, traditional low forceps delivery involves episiotomy, and forceps are typically removed after exposure of the fetal forehead. Expansion of the operative space may increase the risk of perineal laceration, leading to significant postpartum perineal pain[13], while episiotomy is also associated with puerperal infection[14]. Kudish et al[15] noted that the combination of forceps delivery and episiotomy is unfavorable for the perineum. In this study, non-invasive (i.e., no episiotomy) low forceps midwifery was adopted (observation group) and compared with traditional episiotomy-assisted low forceps midwifery (control group). The results showed that the observation group had lesser amount of intrapartum and 24-hours postpartum bleeding than the control group. Postpartum pain intensity, assessed using the VAS scores at 12 hours and 24 hours postpartum, were also significantly lower. Additionally, the severity of perineal laceration and the incidence of postpartum urinary retention were lower in the observation group than in the control group. Reason analysis: Clinically, it is believed that after performing lateral episiotomy, fetal delivery becomes smoother and faster due to the expansion of the perineal opening. However, it has been overlooked that this procedure is invasive, increasing bleeding and tissue pain. Okeahialam et al[16] also reported that episiotomy during vaginal delivery is associated with complications such as perineal and sexual pain in the later stage. Additionally, in traditional low forceps midwifery, forceps removal after fetal forehead exposure may result in excessive perineal traction, increasing the risk of further perineal injury and significant postpartum pain[17]. Both episiotomy and perineal laceration are traumatic and may lead to increased bleeding and a higher risk of puerperal infection. However, non-invasive low forceps midwifery avoids lateral episiotomy and reduces excessive perineal traction. By controlling the delivery speed of the fetal head and applying gentle traction, unnecessary intervention is minimized, reducing the risk of perineal tear and bleeding. Timely removal of the forceps after fetal head crowning further protects the perineum and helps reduce the amount of bleeding and postpartum pain intensity. Additionally, episiotomy may damage the nerves innervating the bladder and pelvic floor muscles (e.g., perineal nerve branches), which are involved in urinary signaling and regulation of detrusor and urethral sphincter muscles. Such nerve damage may impair bladder contractility or sphincter relaxation, thereby affecting normal urination reflexes and increasing the risk of urinary retention.

Bercovich et al[18] reported that forceps-assisted delivery with lateral episiotomy can enlarge the perineal opening, accelerate fetal delivery, shorten the second stage of labor, and reduce the risk of fetal hypoxia, brain damage, or even suffocation due to vaginal compression. This differs from our findings, as we no significant differences were observed between the observation and control groups in the duration of the second stage of labor or neonatal complications. This discrepancy may be explained by several factors. The duration of the second stage of labor is often influenced by maternal pelvic shape, uterine contraction intensity, and fetal head position; thus, even with lateral episiotomy, unfavorable conditions may still prolong the second stage of labor. Furthermore, lateral episiotomy during low forceps delivery may require greater perineal protection, which can increase resistance to traction and delay delivery speed. Maternal fear about expansion of the incision may also reduce effective pushing, further delaying delivery. Non-invasive low forceps-assisted delivery avoids additional procedures and is relatively simple to perform. When the fetal head crowns (i.e., the biparietal diameter of the fetal head crosses the pelvic outlet), the forceps are removed promptly, allowing the fetus to slide out naturally and reducing the risk of fetal skin abrasion from transitional traction. Encouraging maternal abdominal pressure facilitates delivery while preserving perineal integrity and does not increase the risk of neonatal asphyxia. Therefore, compared with traditional forceps midwifery, non-invasive forceps midwifery is associated with less trauma, reduced pain, a lower risk of perineal tear, and faster postoperative recovery. In cases with better perineal conditions and smaller fetuses, this approach may be particularly suitable; however, episiotomy remains necessary in situations such as fetal distress requiring emergency delivery.

Given these advantages, non-invasive low forceps-assisted delivery may also improve maternal childbirth experience. In this study, delivery experience scores were higher in the observation group than in the control group. This may be attributed to reduced blood loss and fewer perineal injuries, and the absence of increased fetal risk, as well as fewer maternal complications and less postpartum pain, resulting in greater comfort and safety during delivery. Additionally, during delivery, prolonged compression of pelvic floor tissues can lead to stretching and injury of muscles, fascia, and nerves, significantly reducing pelvic floor muscle strength[19]. Without effective postpartum rehabilitation, stress urinary incontinence may occur[20]. Previous studies have shown that more severe perineal tears during childbirth are associated with a higher incidence of pelvic floor dysfunction[21,22]. In this study, follow-up at six weeks, three months, and six months postpartum demonstrated higher pelvic floor muscle strength and electromyographic parameters in the observation group than in the control group. This may be because lateral episiotomy during traditional forceps delivery causes direct injury to pelvic floor muscles and nerves, impairing nerve signal transduction of pelvic floor muscles. In addition, traction and compression from forceps on the pelvic floor muscles may further exacerbate pelvic floor damage, reducing overall function and muscle strength. In contrast, non-invasive forceps delivery minimizes tissue damage by reducing excessive traction and preserving perineal integrity, thereby exerting minimal impact on postpartum pelvic floor muscle strength. VanWiel et al[23] reported a close association between pelvic floor health and postpartum psychological health, while Zhao and Zhang[24] found that negative childbirth experiences increase the risk of postpartum depression. These findings indirectly support our results, in which EPDS scores at six weeks, three months, and six months postpartum were significantly lower in the observation group than in the control group. This may be related to reduced childbirth-related trauma and fewer functional impairments, leading to improved body image and psychological status. Additionally, decreased pelvic floor muscle strength and urinary dysfunction associated with forceps use may contribute to urinary incontinence, which can negatively affect self-esteem and increase postpartum depression. Furthermore, episiotomy in traditional forceps-assisted delivery increases pain and complications, contributing to physical and psychological discomfort and a poorer childbirth experience. This may promote stress responses, causing the maternal hypothalamus-pituitary-adrenal axis hyperactivity, affecting neuroendocrine function, thereby increasing the risk of postpartum depression.

This study has several limitations. This study is a single-center retrospective cohort with a small sample size and short follow-up duration, which limits generalizability. Therefore, future studies should include prospective, multicenter designs with larger sample sizes and longer follow-up to further evaluate the benefits of non-invasive low forceps-assisted vaginal delivery.

CONCLUSION

Compared with traditional low forceps delivery with episiotomy, non-invasive low forceps delivery - characterized by timely removal of forceps after fetal head crowning and manual perineal protection - effectively reduces the amount of maternal bleeding, postpartum pain, and complications without increasing neonatal complications. It also improves childbirth experience, preserves postpartum pelvic floor muscle strength, and contributes to the alleviation of postpartum depressive symptoms.