Forceps

FORCEPS DELIVERY
– An Overview

Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.

Introduction
• In the last several decades, obstetrics, as a science has
undergone phenomenal development with a proper
understanding of the entire process of pregnancy & childbirth.
• The present day labour management is basically influenced
by two factors:
– The availability of various modalities of antepartum & postpartum
foetal monitoring that gives the obstetrician precise knowledge of the
foetal condition, which enables him not only to terminate the
pregnancy & labour but also document his decision.
– The developments in the fields of anaesthesia, antibiotics, blood
transfusion, surgical aids & techniques have made a once dreaded
operation - "caesarean section ", very safe to-day.
12 October 2002 Forceps Delivery - Prof.S.N.Panda 2

Introduction
• In view of these developments, the expectations of all concerned -
patient, relatives, attending doctors & authorities including legal system
has undergone a sea change so that a small mishap will be viewed
seriously.
• In such a scenario, the practicing obstetrician of today is likely to have
reservations about using instrumental labour management methods of
unpredictable course & outcome. Hence today instrumental deliveries
are becoming rarer and rarer. In the last two decades, not only very few
developments have taken place in this field, many of the instrumental
deliveries have become obsolete.
• However in the present day concept of active management of labour ,
forceps still have their own place and should be considered in suitable
cases, particularly in developing countries like India.

History
• Earliest mention of instrumental delivery in Vedic era -
"Ankush."
• Albucasis described forceps with teeth on the inner surface for
dead foetus.
• WILLIAM CHAMBERLAIN –
– Fled from France in 1569 & practiced forceps delivery as a family
secret in Southampton. This was kept as a family secret for over
100yrs and four generations.
– He had two sons.
• Peter I - had greater distinction & attended notable women in society. Was
summoned by R.C.P. & Jailed in 1612. He had no sons.
• Peter II - who had several sons, died in 1626.


History
• Dr Peter III- the most prominent one studied in
Cambridge, Oxford, and Padua. Elected a fellow of
R.C.P. Died in 1683 in Woodham Mortimer Hall.It is
believed that the family treasure was kept buried here,
which was latter unearthed in 1813 by the then
occupant Mrs.Kembell.
• Hugh- had interest in politics, was forced to flee to
France, where in 1673 he sold the family secret to
Mauriceau. After few years he went to Holland & again
sold the secret (only one blade) to Roser
Roomhuysen.

History
• Hugh (son of Hugh)-who was highly educated and respected had
patients from best families including Duke of Buckingham
allowed the family secret to leak.
• The Chamberlain family used four pairs of forceps of different sizes with
only cephalic curve.
• Levret (1747)-introduced the pelvic curve
• Smellie (1751)- reinforced pelvic curve & introduced English lock
and used in aftercoming head.
• Tarnier (1877)-introduced axis traction.
• Barton and Kjielland - introduced the two specialized forceps.
• Since then very few and minor developments have taken place.
Moreover since the advent of Vacuum extractor, many of the earlier high
forceps applications have become obsolete.


Classification of forceps
application
• Classical (old) Classification : -
– Low/outlet forceps (no distinction): - forceps applied when
the foetal head/skull has reached the pelvic floor,
sagital suture has reached the A- P diameter of pelvis
and scalp is visible without separating the vulva.
– Mid forceps: - forceps applied when head is engaged
but criteria for low forceps not reached.
– High forceps: - forceps applied when head is not
engaged.


Classification of forceps
application
Newer classification as per A.C.O.G.1981(revised in 1991):-

Low forceps Foetal scalp is visible without separating the vulva
Foetal skull has reached the pelvic floor
Sagital suture is in the A.P.diameter or in the Lt./Rt. Occiputo
anterior/posterior position
Rotation does not exceed 45degrees

Outlet forceps The leading point of the skull is 2cm or more below the ischeal
spine but not on the pelvic floor
Sagital suture is in the A.P.diameter or in the Lt./Rt. Occiputo
anterior/posterior position

Mid forceps The leading point of the skull is 2cm or less above the spine but
head is engaged. Rotation not considered

High forceps EXCLUDED

Types of Forceps
Several hundred types of forceps have been designed which
can be classified into various types-.
• Classical instruments: -Originally designed by James Young
Simpson, Wrigley & George L.Elliot Jr in mid 19th century
commonly used for outlet & low pelvic rotational delivery.
• Modified classical instruments: -Overlapping solid blades
with extended shanks like Tucker-Melane forceps, Elliot type
commonly used as mid pelvic rotators or outlet blades. May be
occasionally pseudofenestrated like Luikart's modification.
• Specialized instruments : -Designed for specific indications like-
– Barton's for transverse arrest in platypeloid pelvis,
– Keilland's for mid pelvic rotation & correction of asynclitism and
– Piper's for delivery of Aftercoming head in breech.

Types of Forceps
Several hundred types of forceps have been designed which
can be classified into various types-.

• Divergent or parallel blades instrument: -.
– Designed to limit foetal cranial compression. Examples
-Laufe, Shute & Moolgaoker.
• Axis traction instruments: -.
– As a separate handle like bill's handle to be attached to any
standard forceps.
– Axis traction as an integral part of the forceps like Howk-
Dennon's& de Wee's forceps.


Functions
• Traction: -This is the most important function. Pull required in a
primigravida is 18 kgs & in a multipara it is 13 kgs.
• Compression effect: -This is minimal when properly applied & should
not be more than necessary to grasp the head. However it has some
pressure effect on the well-ossified base of the skull.
• Rotation of head: -This occurs with the use of Kejilland's forceps and
also in low forceps cephalic application with the occiput in the 2 or 10 'o'
clock position.
• Protective cage: - When applied on a premature baby it protects from
the pressure of the birth canal. When applied on the aftercoming head it
lessens the sudden decompression effect.
• As a vectis: - By applying one blade to deliver the head in caesarean
section.

Indications for forceps
delivery
• Delay in second stage: -.
– Due to uterine inertia.
– Failure of progress of labour- if no progress occurs for more
than 20 to 30 minutes, with the head on the perineum.
Definition of prolonged second stage of labour redefined by A.C.O.G.
(1988/1991): -
– Nullipara-
• <3 hrs with regional anaesthesia
• <2 hrs without regional anaesthesia
– Multipara-
• <2 hrs with regional anaesthesia
• <1hr without regional anaesthesia


delivery
• Foetal indications: -
– Foetal distress in second stage when prospect of vaginal delivery is
safe: -
• Abnormal heart rate pattern
• Passage of meconium
• Abnormal scalp blood ph
– Cord prolapse in second stage
– Aftercoming head of breech
– Low birth wt. Baby
– Post maturity


delivery
• Maternal indication: -
– Maternal distress
– Pre-eclampsia
– Post caesarian pregnancy
– Heart diseases
– Intra partum infection
– Neurological disorders where voluntary efforts are
contraindicated or impossible


Prerequisites
(to be fulfilled before forceps application.)

• Suitable presentation & position: -.
– Vertex, anterior face or aftrcoming head are the ideal
positions.
• Cervix must be fully dilated.
• Membranes must be ruptured.
• Baby should be living.
• Uterus should be contracting & relaxing.
• Bladder must be empty.


Preliminaries
(before forceps application )
• Documentation: -
– All instrumental deliveries should be dictated in medical record as any surgical
procedure & it should include: Consent of the patient, indication for operation,
anaesthesia, personnel involved, type of instrument, difficulties & remedies,
resulting maternal & foetal complications or injuries and blood loss.
• Anaesthesia:-
– Pudendal block or Labio-perineal infiltration for outlet forceps.
– Regional or General anaesthesia for low & mid forceps.
• Catheterisation:-
• Internal examination: -
– To asses the state of cervix & membranes, presentation & position, pelvic outlet,
TDO & sub pubic angle.
• Episiotomy: -
– Should be done either before application of forceps or during traction when the
perineum bulges.


Types of application
(of forceps blades )

• Cephalic application -.
– Blades are applied along the sides of the head, grasping the biparietal
diameter in between the widest part of the blades and the long axis of
the blades correspond to the occiputo-mental plane.
• Pelvic application: -.
– Blades are applied on the lateral pelvic wall ignoring the position of
the head if the head is not rotated. Serious compression effect on the
cranium can occur, so it should be avoided.
– When the head is sufficiently rotated, pelvic & cephalic applications
naturally coincide and so pelvic application is only justified in low
forceps operations.


Technique
(of low & outlet forceps application )
1. Identification of blades & their application-
– The instrument should be placed in front of the pelvis
with the tip pointing upwards and pelvic curve forwards.
First the left blade should be applied guided by the right
hand & then the right blade with the left hand.
2. Locking of blades: -
– The blades should articulate with ease indicting correct
application.


Technique
3. Clinical checks for correct forceps application: -
– Sagital suture lies in the midline of the shanks.
– The operator is unable to place more than a fingertip
between the fenestration of the blade and the foetal head
on either side.
– Posterior frontanalle is not more than one finger breadth
above the plane of the shanks of the forceps.


Technique

4. Traction: -
– Steady & intermittent traction to be applied during
contraction, first downwards (horizontal), backwards,
forwards & lastly upwards.
– In outlet forceps - Only two fingers are to be introduced.
Traction is applied straight horizontal, upward & then
forwards.
– Removal of blades - Right blade should be removed
first.


Technique

5. In Occiputo-posterior position –
– Blades are to be applied as usual but they should be
equidistant from sinciput & occiput
– Traction - Horizontal till the root of the nose is under the
pubic symphysis, then upward till the occiput emerges
over the perineum & finally downwards.


Technique

6. In face presentation-
– Blades are to be introduced along the Occiputo-mental
diameter.
– Traction is applied downwards till the chin appears
under the symphysis pubis & then upwards delivering
the nose, eyes, brow & occiput.


Technique
(of mid forceps application )
• Forceps used are - long curved with or without axis traction
device & Keilland’s.
• Indication - following manual rotation in occiputo posterior
position.
• General anaesthesia is preferable.
• Blades are to be introduced only after manual correction of
malposition of occiput.
• Traction - same as low forceps without axis traction. With axis
traction, the traction rods should remain parallel with the
shanks and should be removed when the base of the occiput
comes under the symphysis.


Forceps for Aftercoming head

• Piper's forceps are specially designed for this purpose.
• Forceps to be applied when the occiput lies against the
back of the symphysis
• Blades to be applied from below after raising the legs.
• Traction to be maintained in an arc, which follows the
axis of the birth canal.


Keilland's forceps application
• Indication: -
– Can be applied in unrotated vertex / face presentation and
for correction of asynclitism.
• Application: -
– Anterior blade is applied first followed by the posterior
blade.
– In Wondering method in deep transverse arrest:- The
anterior blade is applied over the face and then moved over
to the anterior parietal bone. The posterior blade is applied
between the head and the sacrum.
– Blades also can be applied directly over the parietal bones.

Keilland's forceps application
• Complication: -
– Disengagement of the head may occur leading to cord prolapse.
• Scanzoni-Smellie maneuver: -
– Twice application. First the posterior blade is applied posteriorly over
the posterior ear and then the anterior blade is applied over the
anterior ear and head is rotated for 45o towards sacrum or 135 o
towards symphysis. Then blades are removed and reapplied.
• Traction is applied as per Pajot's maneuver: -
– Traction is applied horizontally with the right hand while pressing
downward with the left hand.
• General anaesthesia is necessary.

Complications / Dangers
Complications/dangers of forceps delivery: - are mostly due to faulty
technique rather than the instrument.
• Maternal-
– Injury-.
• Extension of the episiotomy involving anus & rectum or vaginal vault.
• Vaginal lacerations and cervical tear if cervix was not fully dilated.
– Post partum haemorrhage –.
• Due to trauma, Atonic uterus or Anaesthetisia.
– Shock –.
• Due to blood loss, dehydration or prolonged labour.
– Sepsis –.
• Due to improper asepsis or devitalisation of local tissues.
– Anaesthetic hazards.
– Delayed or long-term sequel –.
• Chronic low backache, genital prolapse & stress incontinence.


Complications / Dangers
Complications/dangers of forceps delivery: - are mostly due to
faulty technique rather than the instrument.
• Fetal-
– Asphyxia.
– Trauma-
• Intracranial haemorrhage.
• Cephalic haematoma.
• Facial / Brachial palsy.
• Injury to the soft tissues of face & forehead.
• Skull fracture
– Remote-cerebral palsy.
– Foetal death-around 2%.


Prophylactic/Elective forceps
Introduced by Dee Lee (1920), refers to outlet forceps delivery,
only to shorten the second stage of labour to prevent
anticipated maternal or foetal complications in -

• Eclampsia
• Heart disease
• Previous c.s.
• Post maturity
• Low birth wt babies
• During epidural anaesthesia


Trial Failed
forceps forceps
• Knowing that a certain • When a vigorous but
degree of disproportion at unsuccessful attempt is
mid pelvis may make the made with the forceps,
procedure incompatible, anticipating a successful
forceps delivery.
low/mid forceps delivery is
• Mostly it is due to lack of
attempted, abandoning it at
obstetric skill and poor
the earliest in favour of clinical judgment
Caesarean section.
• Factors responsible are-
• So it should be done only in Disproportion, Incomplete
the O.T., keeping everything cervical dilatation &
ready for C.S. malposition of foetal head

Conclusion

• Considering all aspects, forceps delivery has still got a
place in modern obstetric practice and should be
considered in certain cases.
• If performed judiciously by proper selection of cases
and careful & timely application, forceps delivery can
be useful in reducing not only unnecessary caesarean
sections but also foetal & maternal complications due
to prolonged labour


Towards a safe motherhood


Forceps

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