Forceps delivery and vacuum extraction

7C
FORCEPS DELIVERY AND
VACUUM EXTRACTION

7C
INTRODUCTION
• Forceps delivery is an operative delivery
conducted with the help of obstetric forceps
• Obstetrics forceps is a pair of instruments
specially designed to assist extraction of fetal
head and thereby accomplishing delivery of
the fetus.

7C
HISTORY OF FORCEPS
• The credit for design and early use of
forceps goes to Chamberlen of England.
• The credit for using pelvic curve – Levert
(1747)
• Smellie gave us the English lock
• Tarnier -axis traction device.

7C
ANATOMY OF FORCEPS
FORCEPS- These instruments consist of two crossing
branches. Its components are-
 BLADE- fenestrated for good grip of fetal head
 SHANK
 LOCK
 HANDLE
 CEPHALIC CURVE- conforms to shape of fetal head.
 PELVIC CURVE-corresponds to axis of birth canal.
.

7C
ANATOMY OF FORCEPS contd..
• A sliding lock is used in Kielland forceps.
• Total length of long obstetric forceps is
37cm.
• The distance between two tips - 2.5cm
(when locked).
• The widest diameter between blade is
9cm.

7C
Components of forceps
Right and
left blade

7C
VARIETIES OF LOCKS
French lock
English lock
German lock
Gliding lock
Pivot lock

7C
VARIETIES OF OBSTETRIC FORCEPS
• CONVENTIONAL TRACTION
FORCEPS
• SHORT FORCEPS-
Wrigleys, Short Simpson
• LONG FORCEPS-Das
Simpson
• LONG FORCEPS with
AXIS TRACTION-
Milne Murray,
Haig Fergusen,
Nevelles Barnes

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ELLIOTS FORCEPS
• OVERLAPPING SHANKS
WITH SHORTER CEPHALIC
CURVE

7C
TARNIER FORCEPS (AXIS TRACTION DEVICE)

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ROTATION FORCEPS.
FORCEPS FOR SPECIAL
USE.
• Kielland, Moolgaokar,
Barton(for transverse
arrest in flat pelvis)
• AFTER COMING HEAD
OF BREECH-Pipers.
• AT CAESARIAN SECTION-
Hale

7C
PIPER FORCEPS(AFTER COMING HEAD OF BREECH)

7C
NAEGELE FORCEPS (FORCEPS WITH SEPARATE PARELEL
SHANKS AND SLIGHTELY LONGER BLADES)

7C
• Station is measured in cm -5 to 0 to +5.
Deliveries are categorized as outlet, low, and
mid-pelvic procedures.
• High forceps in which instruments are applied
above 0 station have no place in
contemporary obstetrics.

7C
CLASSIFICATION OF FORCEPS DELIVERY-
ACCORDING TO STATION AND ROTATION
OUTLET FORCEPS-
-Scalp is visible at the introitus without separating the labia.
-Fetal scalp has reached pelvic floor.
-Saggital suture is in antero-posterior diameter or right or left
occiput anterior or posterior position
-Fetal head is at or on perineum.
-Rotation does not exceed 45 degrees.

7C
LOW FORCEPS
• Leading point of fetal skull is at station greater
or equal to +2cm and not on pelvic floor and
• Rotation is 45 degrees or less.
• Rotation is greater than 45 degrees.
MIDFORCEPS- Station is between 0 and till 2cm.
HIGH FORCEPS- Not included in classification

7C
FUNCTIONS OF FORCEPS
• The most important function of forceps is
traction but can be used for rotation for
occiput transverse and posterior positions.
• To provide a protective cage for the head in
premature baby or to control delivery of after
coming head of breech to lessen dangers of
sudden decompression.
• One forceps blade may be used as a vectis to
assist delivery of head in caesarian section.

7C
IDENTIFICATION OF BLADE OF FORCEPS
• Take the blade of forceps
• Place it infront of maternal pelvis, tip of the
forceps directed towards maternal head,
concavity of pelvic curve directed toward the
midline of pelvis
• The blade which correspond to left side of
mother is left blade and right side right blade.

7C
INDICATION OF FORCEPS
MATERNAL INDICATIONS-
-Maternal exhaustion following prolonged labour.
-Prolonged second stage of labour.
-Maternal distress as shown by maternal
tachycardia,dehydration,mild pyrexia
-Maternal medical disorder( like cardiac disease, severe
anaemia,tuberculosis, pregnancy induced hypertension,
eclampsia ) To
shorten the second stage or obviate the need for prolonged
bearing down.
-Failure of decent or internal rotation for 2 hrs in primigravida
and 1hr in multigravida in second stage of labour.

7C
FETAL INDICATIONS
-Fetal distress in second stage of labour.
-After coming head of breech.
-Acute emergencies e.g. cord prolapse or cord
loops around the neck causing severe hypoxia.

7C
PROLONGED SECOND STAGE OF LABOUR
• IN NULLIPARA- more than three hour with or more
than two hour without regional analgesia.
• IN MULTIPARAS- more than two hours with or more
than one hour without regional anaesthesia.

7C
Indications for operative vaginal delivery
• Fetal - Presumed fetal compromise
• Maternal - To shorten and reduce the effects of the second stage of
labour on medical conditions-
• Cardiac disease -Class III or IV (N Y H Association Classification)
• Hypertensive crises,
• Myasthenia gravis,
• Spinal cord injury
• Patients at risk of autonomic dysreflexia,
• Proliferative retinopathy

7C
Indications for operative vaginal delivery
• Inadequate progress
• Nulliparous women – Lack of continuing progress for 3 hours
(total of active and passive second-stage labour) with regional
anaesthesia, or 2 hours without regional anaesthesia
• Multiparous women – lack of continuing progress for 2 hours
(total of active and passive second-stage labour)
• With regional anaesthesia, or 1 hour without regional
anaesthesia
• Maternal fatigue/exhaustion

7C
PREREQUISITES FOR FORCEPS APPLICATION
• The cervix must be completely dilated.
• The membranes must be ruptured.
• The head must be engaged.
• The fetus must be vertex, or present a face
with chin anterior.
• The position of the fetal head must be known.

7C
PREREQUISITES FOR FORCEPS APPLICATION
• There must be no cephalopelvic disproportion.
• Bladder must be emptied.
• Adequate analgesia
• Experienced operator
• Verbal or written consent.

7C
Prerequisites for operative vaginal delivery
• Head is ≤1/5th palpable per abdomen
• vaginal examination Vertex presentation.
• Cervix is fully dilated and the membranes ruptured.
• Exact position of the head can be determined so
proper placement of the instrument can be achieved.
• Assessment of caput and moulding.
• Pelvis is deemed adequate. Irreducible moulding may
indicate cephalo–pelvic disproportion.

7C
• Preparation of mother- Clear explanation should be
given and informed consent obtained.
• Appropriate analgesia is in place for mid-cavity rotational
deliveries. This will usually be a regional block.
• A pudendal block may be appropriate, particularly in the
context of urgent delivery.
• Maternal bladder has been emptied recently. In-dwelling
catheter should be removed or balloon deflated.
• Aseptic technique.

7C
• Preparation of staff- Operator must have the
knowledge, experience and skill necessary.
• Adequate facilities are available (appropriate
equipment, bed, lighting).
• Back-up plan in place in case of failure to deliver. When
conducting mid-cavity deliveries, theatre staff should be
immediately available to allow a caesarean section to
be performed without delay (less than 30 minutes).

7C
A senior obstetrician competent in performing mid-
cavity deliveries should be present if a junior trainee
is performing the delivery.
• Anticipation of complications that may arise (e.g.
shoulder dystocia, postpartum haemorrhage)
• Personnel present that are trained in neonatal
resuscitation.

7C
OUTLET FORCEPS DELIVERY
FORCEPS APPLICATIONS-
• For application of left blade-two or more fingers of right hand are
introduced inside the left posterior portion of vulva and into vagina beside
the fetal head.
• The handle of left branch is then grasped between the thumb and two
fingers of left hand and introduce under the guidance of right hand .
• For application of right blade-two or more fingers of left hand are
introduced into the right posterior position of vagina to serve as guide for
right blade.

7C
APPLICATIONS OF BLADES-
• The biparietal diameter corresponds to the greatest
distance between appropriately applied blades.
• The head of fetus is perfectly grasped only when long
axis of blades corresponds to occipitomental
diameter.
• If one blade is applied over brow and other on
occiput, instrument cannot be locked and if locked ,
blades will slip off when traction is applied.

7C
TRACTION
 When it is certain that blades are applied
satisfactorily then gentle ,intermittent, horizontal
traction is exerted until perineum begins to bulge.
• With traction when vulva is distended by the
occiput, an episiotomy may be given if indicated.

7C
TRACTION contd…
• Additional horizontal traction is applied, and the handles
are elevated, pointing directly upwards as parietal bone
emerge.
• As handles are raised, head is extended. During birth of
head, spontaneous delivery should be simulated as
closely as possible.

7C
TRACTION contd..
• Traction should be intermittent ,and head should be
allowed to recede in intervals as in spontaneous
labour except in cases of fetal bradycardia.
• It is preferable to apply traction only with each
uterine contraction.
• Maximum permissible force is 45 lb(20kg) in the
nullipara or 30 lb(13kg)in multipara.

7C
Line of axis of traction(perpendicular to plane of pelvis)
1-high2-mid3-low4-outlet

7C
ROTATION FROM ANTERIOR AND TRANSVERSE
POSITION
• When occiput is obliquely anterior, it gradually rotates to
symphysis pubis as traction is exerted.
• However when it is directly transverse a rotary motion of
forceps is required.
• Rotation counter clockwise from left side to midline is
required when occiput is directed towards left, and in
reverse direction when it is directed towards right side of
pelvis.

7C
Rotation with simpson forceps from left occipitoanterior
position to occipitoanterior position prior to traction.

7C
FORCEPS DELIVERY OF OCCIPUT POSTERIOR POSITION
• When occiput is directly posterior, horizontal
traction should be applied until base of nose
is under symphysis pubis.
• The handle should then be gradually elevated
until occiput emerges from the perineum.
• Then forceps are directed in downwards
motion and the nose, face and chin emerge
from the vulva.

7C
SCANZONI MANEUVER IN OCCIPUT POSTERIOR POSITION.

7C
OCCIPUT POSTERIOR POSITION- COMPLICATION
• OCCIPUT POSTERIOR group had higher incidence of
perineal lacerations and extensive episiotomy as
compared to OCCIPUT ANTERIOR group.
• There is also high incidence of operative delivery in
OCCIPUT POSTERIOR group
• Infants delivered from OCCIPUT POSTERIOR group
had high incidence of ERBS and FACIAL NERVE PALSY.

7C
FACE PRESENTATION FORCEPS DELIVERY
• With mentum anterior face presentation, forceps can
be used to affect vaginal delivery.
• The blades are applied to the sides of head along the
occipitomental diameter with pelvic curve directed
towards neck.
• Downwards traction is applied until chin appears
under the symphysis. Then by upward movement the
face is slowly extracted with nose, eyes, brow and
occiput appearing in close succession over anterior
margin of perineum.

7C
FORCEPS SHOULD NEVER BE APPLIED TO MENTUM
POSTERIOR PRESENTATION BECOZ VAGINAL
DELIVERY IS IMPOSSIBLE.

7C
KIELLAND FORCEPS
 Named after Kielland of Norway(rotational forceps
1916), Specialised forceps with no pelvic curve. Used
in deep transverse arrest with asynclitism of fetal
head.
• Advantages over long curved forceps are- -It can
be used in unrotated vertex or face presentation.
-facilitating grasping and correction of asynclitic head
because of sliding lock.

7C
METHODS OF APPLICATION
1-Classical(obslete)
2-Wandering
3-Direct.

7C
Method of Application-(KIELLAND FORCEPS)
• Wandering method is popular-in this anterior blade is applied
first .Blade is inserted along side wall of pelvis and then
wandered by swinging it round the fetal face to its anterior
position.
• Posterior blade is inserted under guidance of right hand
,forceps handles are depressed down and handle tips are
brought in alignment to correct asynclitism.
• The occiput is rotated anteriorly, slight upward dislodgement
of head may facilitate rotation, traction is applied.
• DEEP MEDIOLATERAL EPISIOTOMY IS MANDATORY.

7C
MATERNAL MORBIDITY FROM FORCEPS
-The greater the rotation, greater will be the morbidity in
form of laceration and blood loss.
-Forceps deliveries are associated with higher episiotomy
rates and third and fourth degrees lacerations.
-Postpartum urinary retention and bladder dysfunction.
-Anal sphincter dysfunction
-Infection
-Pelvic haematoma.
-Traumatic post partum haemorrhage and shock.

7C
FETAL MORBIDITY
-Cephalhaematoma, skull fracture and intracranial
haemorrhage.
-Brain damage
-Marked depression of respiration and asphyxia.
-Facial palsy, brachial palsy.
-soft tissue injury to face, bruising and laceration, Cord
compression, convulsions.

7C
CONTRAINDICATIONS FOR FORCEPS
-Absence of full dilatation of cervix.
-In case of cephalopelvic disproportion.
-High station of fetal head.
-If uterine contraction cease.
-Lack of experience of operator.
-Mentum posterior face presentation.
-Hydrocephalic infant.
-Brow presentation.

7C
TRIAL OF FORCEPS
It is a tentative attempt of forceps delivery in case of suspected
midpelvic contraction with a declaration of abandoning it in
favor of caesarean section if moderate traction fails to
overcome the resistance.
Such an operation must be undertaken on a operating table in
properly equipped operating theatre with an anaesthetist
present.
If there is difficulty at any stage from introduction of blades,
locking of device or resistance to gentle traction then undue
force is not used forceps withdrawn and caesarian section
done.

7C
FAILED FORCEPS
When a deliberate attempt in vaginal delivery with
forceps has failed to expedite the process, it is called
failed forceps.
FORCEPS FAILED IF-
Fetal head does not advance with each pull.
Fetus is undelivered after three pulls with no descent
or after 30minutes
If forceps fails caesarian section is performed.

7C
Higher rates of failure are associated with:
• maternal body mass index over 30
• estimated fetal weight over 4000 g or clinically big baby
• occipito-posterior position
• mid-cavity delivery or when 1/5th of the head palpable per
abdomen
• African American race, increased maternal age.
• Diabetes, polyhydramnios,
• Dysfuctional labour, induction of labour

7C
PROPHYLACTIC FORCEPS(ELECTIVE)
• Named after DeLee. It refers to forceps delivery only to
shorten the second stage of labour when maternal and or
fetal complications are anticipated.
• INDICATIONS –Eclampsia, heart disease ,previous history of
caesarean section,postmaturity, lowbirth weight baby, to
curtail the painful second stage, patient under epidural
analgesia.
• Prophylactic forceps should not be applied until the criteria of
low forceps are fulfilled.

7C
Vacuum Extraction
(Ventouse)

7C
Vacuum Extraction (Ventouse)
• It is an instrumental device designed to assist
delivery by creating a vacuum between it and the
fetal scalp
• In the United states the device is referred to as
the vacuum extractor whereas in Europe it is
called as Ventouse- from the french word literally
meaning soft cup.

7C
Historical background
• In 1705, Yonge described an attempted vaginal
delivery using a cupping glass
• In 1848 Simpson devised a bell shaped device called
an “air tractor vacuum extractor”
• In 1953 a metal cup extractor was developed by
Malmstrom .

7C
Description
• Vacuum extractor is composed of:
• A specially designed cup with a diameter of 3, 4, 5 or 6 cm.
• A rubber tube attaching the cup to a glass bottle with a screw
in between to release the negative pressure.
• A manometer fitted in the mouth of the glass bottle to declare
the negative pressure.
• Another rubber tube connecting the bottle to a suction piece
which may be manual or electronic creating a negative
pressure that should not exceed - 0.8 kg per cm2.

7C
Types of vacuum extractors
Vacuum extractors are divided on the
basis of the type of cup-
-metal or plastic
1.Metal cup vacuum extractors
2.Soft cup vacuum extractors

7C
Metal cup
• The metal-cup vacuum extractor is a mushroom-shaped
metal cup varying from 40 to 60 mm in diameter.
• Metal-cup vacuum extractors have a higher success rate
and easier cup placement in the occipitoposterior (OP)
position,
• The rigidity of metal cups can make application difficult
and uncomfortable, and their use is associated with an
increased risk of fetal scalp injuries.

7C
Soft cup
• Traditionally soft cups are bell or funnel shaped.
• Soft-cup instruments can be used with a manual vacuum
pump or an electrical suction device. Soft-cup vacuum
extractors may be disposable or reusable.
• Compared with metal-cup devices, soft-cup vacuum
extractors cause fewer neonatal scalp injuries. However, these
instruments have a higher failure rate.

7C
Indications of vacuum extraction
• Generally vacuum extraction is reserved for
fetuses who have attained a gestational age of
34 weeks.
• Otherwise, the indications and pre-requisites
for its use are the same as for forceps
delivery(American College of obstetricians and
Gynecologists

7C
Contraindications
• Operator inexperience
• Inability to assess fetal position
• High station(above 0 station)
• Suspicion of cephalopelvic disproportion
• Other presentations than vertex.
• Premature fetus(<34 weeks).
• Intact membranes.

7C
Pre-requisites of the Procedure
• Procedure should be explained to the patient and consent
should be taken
• Emotional support and encouragement
• Lithotomy position.
• Bladder should be emptied.
• Antiseptic measures for the vagina, vulva and perineum.
• Vaginal examination to check pelvic capacity, cervical
dilatation, presentation, position, station and degree of flexion
of the head and that the membranes are ruptured.

7C
Application of the cup
• Identification of the flexion point-
-It is situated 3 cm in front of the posterior fontanelle.
-Centre of the cup should be overlying the flexion
point. This placement promotes flexion ,descent and
autorotation.
• If traction is directed from this point the fetal head is
flexed to the narrowest sub-occipitobregmatic
diameter(9.5 cm).

7C
Precautions-
• The largest cup that can be easily passed is
introduced sideways into the vagina by
pressing it backwards against the perineum.
• Be sure that there is no cervical or vaginal
tissues nor the umbilical cord or a limb in
complex presentation is included in the cup.

7C
Creating the negative pressure
• When using the rigid cups, the negative pressure is
gradually increased by 0.2 kg/cm2 every 2 minutes
until - 0.8 kg/cm2 is attained. This creates an
artificial caput within the cup.
• With soft cups negative pressure can be increased
to 0.8 kg/cm2 over as little as 1 minute

7C
Episiotomy
• An episiotomy may be needed for proper
placement of the cup
• If not, then delay the episiotomy till the head
stretches the perineum or perineum interferes
with the axis of traction
• This will minimize unnecessary blood loss.

7C
Traction
• Traction should be intermittent and co-
ordinated with maternal expulsive efforts and
with uterine contractions.
• Traction should be in line of the pelvic axis and
perpendicular to the plane of the cup

7C
Traction contd..
• Traction may be initiated by using a two
handed technique
• Fingers of one hand are placed against the
suction cup while the other hand grasps the
handle of the instrument
• This allows one to detect negative traction.
• Manual torque to the cup should be avoided
as it may cause cephalhaematoma and scalp
lacerations.

7C
Traction contd..
• Between contractions, check for fetal heart
rate and proper application of the cup
• Check for sacral hand wedge if the head has
descended to the perineum with traction but
further progress is slow.

7C
Release
• When the head is delivered the vacuum is
reduced as slowly as it was created using
the screw as this diminishes the risk of
scalp damage.
• The chignon should be explained to the
patient and the relatives.

7C
Reapplication of the cup
If the cup detaches for the first time, reassess the
situation.
If favorable ,then reapply.
If cup detaches for the second time, reassess if
vaginal delivery is safe or move to caesarean
section
Caesarean section is necessary if there is inadequate
descent and rotation

7C
Failure of vacuum
• Vacuum extraction is considered failed if-
-fetal head does not advance with each pull
-fetus is undelivered after 3 pulls with no
descent or after 30 minutes
-cup slips off the head twice at the proper
direction of pull with the maximum negative
pressure.

7C
Advantages of Vacuum over Forceps
Regional Anaesthesia is not required so it is preferred in cardiac and pulmonary
patient.
The ventouse is not occupying a space beside the head as forceps.
Less compression force (0.77 kg/cm2) compared to forceps (1.3 kg/cm2) so
injuries to the head is less common.
Less genital tract lacerations.
Can be applied before full cervical dilatation.
It can be applied on non-engaged head.

7C
Complications
Maternal
Perineal, vaginal ,labial, periurethral and cervical
lacerations.
Annular detachment of the cervix when applied
with incompletely dilated cervix.
Cervical incompetence and future prolapse if used
with incompletely dilated cervix.

7C
Complications
Fetal
• Cephalohaematoma.
• Scalp lacerations and bruising
• Subgaleal hematomas
• Intracranial haemorrhage.
• Neonatal jaundice
• Subconjunctival haemorrhage
• Injury of sixth and seventh cranial nerves
• Retinal hemorrhage
• Fetal death

Forceps delivery and vacuum extraction

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