FORCEP DELIVERY.pptx

PRESENTED BY:
Ms. DEEPSHIKHA
ASSISTANT PROFESSOR
OBSTETRICS & GYNAECOLOGICAL
NURSING
MAHARISHI MARKANDESHWAR COLLEGE
OF NURSING, MULLANA, AMBALA

CASE SCENARIO
 A 23 years old primigravida with POG 35 weeks
admitted in labour room is having cardiac disease and
is exhausted, the FHR is 100 beats/min. What will be
the mode of delivery?
Programme: B.Sc. Nursing Course:OBG
Programme: B.Sc Nursing Course: OBG

LEARNING OBJECTIVES
 At the end of the teaching the students will be able to:-
1. Define forceps extraction
2. explain the obstetric forceps
3. Enlist and explain the classification of Forceps
4. explain the indication and contraindication for applying
forceps.
5. discuss the techniques of application.
6. enlist the complications of forceps extraction.
7. Discuss the nursing management for forceps extraction.

INTRODUCTION
Instrumental delivery refers to any delivery process
which is assisted by vaginal operations. It is an art,
which should be learnt by all obstetricians for
optimum maternal and perinatal outcome.

FORCEPS- ASSISTED
DELIVERY

FORCEPS
Obstetrics forceps is a pair of instruments specially
designed to assist extraction of the fetal head and
thereby accomplishing delivery of the fetus.

COMPONENTS
The blades:
 Two blades crossing each other
left or lower blade
right or upper blade,
 Depending on the side of the pelvis to which they are
applied.

CONT…
Each blade is made up of four parts
the fenestrated blade
the shank
the lock
the application handle.
 Each blade is fenestrated for better grip on the fetal
head.
 The lower part of fenestrated of blade has got a slot for
fitting the axis traction rod, if needed.

CURVES
 Pelvic curve: conforms to the axis of the birth canal
(curve of carus).
radius is 17.5 cm.
Concave shape
 Cephalic curve: conforms to the shape of the fetal head
when articulated graps the fetal head without
compression.
radius of the curve is 11.5 cm .

CONT….
The shank:
 The shank connects the blades and the handle and
gives the instrument its length
The lock:
 The two blades articulate at the lock. Most forceps
have the English lock which is simpler and more
efficient and allows the shank of one blade to slip
into the socket of the other.

CONT…
Handles:
 The two handles are apposed on articulation of the
two blades.
 Its length is 12.5cm.
 A screw may be attached usually at the end (or at the
base) of one blade (commonly left). It helps to keep
the blades in position

HOW TO IDENTIFY
BLADES?

IDENTIFICTION OF THE BLADES
ON ARTICULATION OF BLADES
 The articulated forceps are put before the pelvis with
the tips of the blades directing upwards and the
concavity of the pelvic curve being in front. The blade
which corresponds to the left side of the maternal
pelvis is the left blade, while the one corresponding to
the right side is the right blade.

CONT…
INDIVIDUAL BLADES
 The tip of the blade should direct upwards. The
cephalic curve directs inwards and the pelvic curve
direct forwards.

TYPES OF FORCEPS
Traction forceps
 Short – Wrigley’s outlet forceps, Simpson’s short
forceps
 Long – Simpson’s long forceps, Das forceps, Elliot long
forceps, Neville Barne’s forceps, Haig Ferguson forceps
 Axis traction- Tranier’s forceps, Milne Murray’s forceps

Rotational forceps
 Kielland forceps for deep transverse arrest
 Barton’s forceps for transverse arrest in flat pelvis

Special forceps
 Piper’s forceps for the after coming head of breech

CLASSIFICATION OF FORCEPS
 American College of Obstetrician and Gynaecologists
(ACOG-2007) has classified forceps into mid, low and
outlet forceps.

OUTLET FORCEPS
 Fetal scalp visible at introitus without separating the
labia
 Fetal skull has reached pelvic floor
 Sagittal suture is in anteroposterior diameter or right
or left occipito-anterior position (within 45°)
 Fetal head is at or on the perineum

WHICH FORCEPS?

LOW FORCEPS
 Leading point of the fetal skull (not caput) is at station
> +2cm and not on pelvic floor
 Rotation is 45° or less from occipito- anterior position
 Rotation is greater than 45°including occipito-
posterior position

MID FORCEPS
 Leading bony point of skull (station) is between 0 and
+2 cm. Rotation can be 45°or more.
HIGH FORCEPS
 Head not engaged. Station above ischial spines not
included in classification and not recommended.

TYPES OF APPLICATION OF
FORCEPS BLADES
Cephalic application-
 The blades are applied along the sides of the head
grasping the biparietal diameter in between the widest
part of the blades.
 The long axis of the blades corresponds more or less to
the occipito-mental plane of the fetal head.
 Ideal method of application as no compression on
crainum.

CONT…
Pelvic application-
 when the blades of the forceps are applied on the
lateral pelvic walls ignoring the position of the head
 If the head remains unrotated, this type of application
puts serious compression effect on the cranium and
thus must be avoided.

FUNCTION OF FORCEPS
Traction forceps
Rotation of the head
Acts as a protective cage
Controlled delivery of the
after-coming head
The compression effect
One forceps blade may be
used as a vestis

INDICATIONS FOR FORCEPS
DELIVERY
 MATERNAL
Inadequate expulsive
efforts
Maternal exhaustion
(distress)
Where expulsive efforts
(valsalva) are to be
avoided

CONT…
 FETAL
Non-
reassuring
fetal heart
rate-
After coming
head of
breech
Suspicion of
fetal
compression

CONT…
Others:
 Prolonged second stage of labor (nullipara > 2 hrs,
multipara>1 hr)
 To cut short the second stage of labor as in severe pre-
eclampsia, cardiac disease, post-caesarean pregnancy.

PREREQUISITES FOR FORCEPS
DELIVERY
 F: fully dilated cervix.
 O: occipito-anterior, occipito-posterior and other
suitable presentations (mento-anterior and after-
coming head of breech)
 R: ruptured membranes
 C: consent should be obtained. CPD should be ruled
out.

CONT…
 E: effective uterine contractions, empty bladder,
engaged head, episiotomy, epidural or regional
analgesia, experienced operator (obstetrician).
 P: position of head must be known. Paediatrician to be
present. Patient in lithotomy position.
 S: sagittal suture should be in antero-posterior
diameter (for outlet forceps) or within 45°(for low and
mid forceps).

TECHNIQUE ( LOW & OUTLET
FORCEPS APPLICATION )
 STEP-1: Identification of blades & their application
 STEP-2: Locking of blades
 STEP-3: Clinical checks for correct forceps application
Easy locking
The blades are equidistant from the lambdoid
suture
Firm gripping of the head on the biparietal
diameter

CONT…
 STEP-4: Traction and removal of blades
During contraction
Gripping of the articulated forceps during traction

CONT…
Direction of pull
Downwards & backwards until head comes to
the perineum
Horizontal straight(towards operator) till head
is crowned
Upwards and forwards (towards mother’s
abdomen) to deliver head by extension

CONT…
Removal of blades
 Remove right blade first followed by left blade.

DANGERS OF FORCEPS
OPERATION
Maternal:
 Immediate:-
Injury
Nerve
injury
Postpartum
hemorrhage
Anaesthetic
complication
Puerperal sepsis
and maternal
morbidity

CONT…
 Remote
Painful perineal scars
Gential prolapse
low backache
dyspareunia
Stress continence

FETAL COMPLICATIONS
 IMMEDIATE:
Asphyxia,
• intracranial hemorrhage
cephalhematoma,
• skull fractures
facial bruising,
facial palsy,

CONT…
Remote:-
 Cerebral or spastic palsy due to residual
cerebral injury (rare).

TRIAL OF FORCEPS
 Attempt to deliver fetus.
 Moderate traction is applied.
 Delivery is continued only if trial indicates that
delivery will be safely accomplished.
 Done in double-setup

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.

ADVANTAGES OF FORCEPS
OVER VENTOUSE
 In cases, where moderate traction is required, forceps
will be more effective
 Forceps operation can quickly expedite the delivery in
case of fetal distress where ventouse will be unsuitable
as it takes longer time
 It is safer in premature baby. The fetal head remains
inside the protective cage

CONT…
 Can be employed in anterior face or in after-coming head
of breech presentation
 Lesser neonatal scalp trauma, retinal haemorrhage,
jaundice or cephalhaematoma
 Higher success rate
 Cup detachment (“pop-off ”) occurs when the vacuum is
not maintained in ventouse. No such problem once forceps
blades are correctly applied
 Number of types of forceps are available for outlet, mid
cavity or rotational delivery.

NURSING RESPONSIBILITY
(1) Obtains forceps designated by the physician.
(2) Checks, reports, and records the fetal heart rate
before forceps are applied.
(3) Rechecks, reports, and records the fetal heart rate
again before traction is applied after application of the
forceps. Compression of the cord between the fetal
head and the forceps would cause a drop in fetal heart
rate. The physician would then remove and reapply the
forceps.

CONT…
(4) Give support to the patient.
(5) Observe for signs and symptoms of complications.
(6) Assess the newborn for indications of injury.

QUIZ

1) In current obstetrics, forceps deliveries are
categorized in one of the following three
groups:
a) High forceps, mid forceps, low forceps
b) Mid forceps, low forceps, outlet forceps
c) Inlet forceps, mid forceps, outlet forceps
d) Inlet forceps, low forceps, outlet forceps

B ( mid forceps, low forceps, outlet forceps)

2) Which of the following describes forceps that are
applied to the fetal head with the scalp visible at the
introitus without manual separation of the labia:
a) mid forceps
b) Low forceps
c) Inlet forceps
d) Outlet forceps

D ( OUTLET FORCEPS)

 Which of the following describes forceps that are
applied to the fetal head with the scalp visible at
the introitus without manual separation of the
labia:
a) mid forceps
b) Low forceps
c) Inlet forceps
d) Outlet forceps

 Outlet forcep

FORCEP DELIVERY.pptx

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