Table 4.

CERQual Summary of findings (SoFs)

Review finding	Studies contributing to review finding	CERQual Assessment	Explanation of confidence in the evidence assessment
Coming to know AVD by experience
Expectations and preparedness for AVD - a birth you couldn’t plan for Women and men reported views of assisted vaginal deliveries as a birth experience that you couldn’t plan for. In some cases, this was because an assisted vaginal delivery had simply not been contemplated, with women’s birth preparations focused elsewhere. While women perceived an absence of information about forceps or ventouse, compared to spontaneous vaginal birth or caesarean section, there was an appreciation of the difficulties surrounding information about assisted vaginal delivery, which not everyone needs to know, and not everyone desires to know. Although assisted vaginal delivery was reported to be a missing component of antenatal preparation, other parents described their own self-imposed limitations on preparation.	Murphy 2003 [23]	Low confidence	Major concerns regarding adequacy (two studies from one country). Moderate concerns regarding coherence.
	Hurrell 2006 [26]
Beliefs about need/indications for AVD Some parents described an acceptance of assisted vaginal delivery based on their perception of necessity. In some cases, there was a lack of understanding about what happened, when and why. Some women understood that there had been a problem with either themselves or their baby, which some women viewed as a failure on their part to deliver vaginally. Some women could not remember any explanation from a health professional as to what happened, others could remember being spoken to, but not what it was about.	Murphy 2003 [23]	Low confidence	Major concerns regarding adequacy (two studies from one country). Moderate concerns regarding coherence.
	Hurrell 2006 [26]
Reconciling/coping with experience - Women described finding a context for their birth experience that allowed them to come to terms with it. Conversely some women had difficulties with moving on, describing feels of low mood and low self-worth.	Hurrell 2006 [26]	Low confidence	Major concerns regarding adequacy (only one study). Moderate concerns regarding coherence.
Turbulent feelings about the actual experience
Pain- For some women, effective pain relief allowed an absence of major concerns about the procedure, and for other women who did experience pain, compassionate support enabled them to work with it. However, some women experienced pain as traumatic (self-reported), and men expressed concerns that their partners would be traumatized too (as witnessed by partner).	Hurrell 2006 [26]	Moderate confidence	Major concerns about adequacy (studies from only two countries).
	Nystedt 2006 [32]
	Zwedberg 2015 [31] Sjödin 2018 [30]
Frightening and violent experience - Some women and men experience AVD as frightening, distressing or violent. Participants use vivid language to describe the sights and sounds of their experience - seeing blood, perceptions of force or violence (words like tearing, ripping, dragging), the baby’s appearance afterward. Participants described the emotional impact of the experience in terms of fear or distress and a few participants relate experiences of dissociation or trying to avoid perceiving/experiencing anything.	Hurrell 2006 [26]	Moderate confidence	Moderate concerns about adequacy (studies from three countries).
	Nystedt 2006 [32]
	Goldbort 2009 [33]
	Zwedberg 2015 [31]
	Sjödin 2018 [30]
Beneficial or positive reactions - Women and men reported a range of positive reactions after experiencing an AVD. These included feeling unperturbed by having an AVD, to feeling relief that labour is over, to feelings of joy at the birth of the baby. Men described finding strength to cope with a difficult situation to support their partners.	Hurrell 2006 [26]	Moderate confidence	Major concerns about adequacy (studies from only two countries).
	Zwedberg 2015 [31]
	Nystedt 2006 [32]
Barriers and facilitators
Trust, control and relationships
Active participation through collaboration and involvement - Both women and men wished to feel part of a team with care providers and to be involved in decision making. Men expressed feelings of being excluded, but wishing to be involved.	Hurrell 2006 [26]	Moderate confidence	Major concerns about adequacy (studies from only two countries).
	Sjödin 2018 [30] Zwedberg 2015 [31]
Balancing control and trust - The amount of trust that women and men have in their care givers at the time of an assisted vaginal delivery is linked both to their perceptions of control and to their acceptance of the intervention.	Hurrell 2006 [26]	Moderate confidence	Moderate concerns about adequacy (studies from three countries).
	Nystedt 2006 [32]
	Goldbort 2009 [33]
	Zwedberg 2015 [31]
	Sjödin 2018 [30]
The need to understand and to be understood - The quality of communication between caregivers, women and men at the time of an assisted vaginal delivery was key. Women appreciated care in what was said and how it was said. They wanted information and to be listened to as a means to retaining some degree of involvement in something they had little control over.	Hurrell 2006 [26]	Moderate confidence	Major concerns about adequacy (studies from only two countries).
	Zwedberg 2015 [31]
	Sjödin 2018 [30]
Implications for future reproductive choices
Mixed views about any future pregnancy and delivery - AVD impacts on women and men views about future pregnancies - In some cases, the experience of an assisted vaginal delivery put women off planning another pregnancy, while for other women and some men, it meant that they had stronger views about a particular birth mode. Some women, and men, described preferring a caesarean for any future birth. Other women, and men, felt better prepared for labour and a future vaginal delivery.	Murphy 2003 [23]	Moderate confidence	Major concerns about adequacy (studies from only two countries).
	Hurrell 2006 [26]
	Zwedberg 2015 [31]