Delivery Room Decisions: New Study Links Assisted Birthing Techniques to Long-Term Neurodevelopmental Risks

February 21, 2026

Decisions made in the final, critical moments of labor can have lifelong implications. A massive new study of more than 500,000 births has found that using instruments like vacuums or forceps during difficult deliveries—particularly when both are used sequentially—is associated with a slightly higher risk of children developing attention-deficit/hyperactivity disorder (ADHD) and intellectual disabilities.

The research, published in JAMA Network Open, provides a rare look at the long-term neurodevelopmental outcomes of “operative vaginal deliveries” compared to second-stage cesarean sections (C-sections). While the findings add a new layer of complexity to obstetric care, medical experts caution that the absolute risk to individual children remains very low and should not overshadow the immediate safety of the mother and baby during birth.

The Search for Answers in the Second Stage

The “second stage” of labor is the period between full cervical dilation and the birth of the baby. When this stage stalls—often due to maternal exhaustion, fetal positioning, or signs of fetal distress—doctors must choose between an operative vaginal delivery (using a vacuum or forceps) or a surgical C-section.

Canadian researchers analyzed a staggering dataset from British Columbia, tracking 507,724 full-term births occurring between 2000 and 2019. With a follow-up period of up to 22 years, the study is one of the most comprehensive of its kind, aiming to determine if these high-pressure delivery choices change a child’s long-term brain health.

The Findings: A Nuanced Risk Profile

The majority of births in the study were spontaneous vaginal deliveries (80.9%). However, for the roughly 19% that required intervention, the researchers noted specific associations:

• Sequential Instrument Use: When a vacuum was attempted first and failed, followed by the use of forceps, children had a 13% higher risk of developing ADHD compared to those born via second-stage C-section.

• Vacuum Delivery: Births involving only a vacuum extractor were associated with a 53% higher risk of the child being diagnosed with an intellectual disability.

• Forceps Alone: Interestingly, the use of forceps alone did not show a statistically significant increase in the risk of ADHD or intellectual disability.

• Autism: The study found no significant link between any delivery method and the risk of autism spectrum disorder (ASD).

Putting the Numbers in Perspective

While percentages like “53% higher risk” can sound alarming, health journalists and medical professionals emphasize looking at the absolute risk—the actual number of cases per 1,000 children.

In this study, the differences were marginal. ADHD occurred at a rate of 7.9 per 1,000 person-years for sequential instrument delivery, compared to 6.6 for C-sections. For intellectual disabilities, the rate was 0.3 per 1,000 for vacuum births versus 0.2 for C-sections.

“These are small absolute differences,” notes Dr. Andrea Edlow, a maternal-fetal medicine specialist at Massachusetts General Hospital, who was not involved in the study. “While the association exists, it doesn’t mean the delivery method caused the condition. Often, the reason the instrument was needed in the first place—such as fetal distress or a lack of oxygen—may be the more significant factor.”

Why Doctors Use Forceps and Vacuums

Despite the rise in C-section rates globally, operative vaginal delivery remains a vital tool in the obstetrician’s kit.

• Speed: A vacuum or forceps delivery can often be performed faster than a surgical C-section, which is critical if the baby’s heart rate is dropping dangerously.

• Maternal Health: C-sections are major abdominal surgeries with risks of infection, hemorrhage, and longer recovery times.

• Future Pregnancies: Having a C-section can complicate future births, increasing the risk of uterine rupture or placental issues.

However, the practice of “sequential use”—switching from a vacuum to forceps—has long been discouraged by organizations like the American College of Obstetricians and Gynecologists (ACOG). Since the early 2000s, ACOG has warned that using multiple instruments significantly increases the risk of intracranial hemorrhage (bleeding inside the skull).

“It is well known that obstetricians should avoid sequential operative delivery, and this is not standard practice in the U.S.,” says Dr. Edlow.

The “Chicken or the Egg” Dilemma

A primary limitation of this study, and many others like it, is the difficulty of separating the procedure from the indication.

If a baby is stuck in the birth canal for a prolonged period, they may experience subtle brain inflammation or oxygen deprivation. If a doctor then uses a vacuum to deliver that baby, is the subsequent ADHD linked to the vacuum itself, or to the hours of stress the baby experienced before the vacuum was applied?

Dr. Edlow emphasizes that “immediate maternal and neonatal risks take priority over long-term associations when a patient is in labor.” The goal of the medical team is a healthy mother and a healthy baby, and the choice of tool is often dictated by the mother’s anatomy and the baby’s position.

What This Means for Expectant Parents

For parents-to-be, these findings are a prompt for conversation rather than a cause for panic.

1. Discuss “Plan B” with Your Provider: During prenatal visits, ask your doctor or midwife about their approach to assisted delivery. What are their criteria for using a vacuum versus a C-section?

2. Trust the Training: Most obstetricians choose instruments based on their specific training and the immediate clinical factors (like fetal size and maternal effort).

3. Focus on the Big Picture: The vast majority of children born via vacuum or forceps go on to lead healthy, typical lives. The slight statistical increase in ADHD or intellectual disability risk is one of hundreds of environmental and genetic factors that influence neurodevelopment.

Conclusion

The JAMA Network Open study provides valuable data for public health researchers, but it is unlikely to change the “heat of the moment” decisions made in delivery rooms. As medical science evolves, the focus remains on refining techniques to ensure that the transition into the world is as safe as possible—both for the first minutes of life and the decades that follow.

References

• https://www.medscape.com/viewarticle/birthing-techniques-linked-adhd-risk-2026a10005gn

Medical Disclaimer: This article is for informational purposes only and should not be considered medical advice. Always consult with qualified healthcare professionals before making any health-related decisions or changes to your treatment plan. The information presented here is based on current research and expert opinions, which may evolve as new evidence emerges.