Gynaecological

1. Dr.Aklima Akter
Assistant Professor
( Gynae)
Sheikh Hasina Medical
College, Tangail

2. Forceps delivery
Obstetric forceps is a double-bladed metal instrument used for
extraction of the fetal head
Types:
• Long curved obstetric forceps
• Wrigley’s forceps
• Kielland's forceps
• Piper’s forceps
• Barton's forceps
Action of the Forceps
• Traction: is the main action.
• Rotation: in deep transverse arrest, persistent occipito- posterior and
mento-posterior.

3. Indications of Forceps Delivery
1.Prolonged 2nd stage: Prolongation for more
than 1 hour in primigravidae or 30 minutes in
multiparae. This may be due to:
(i)Inertia and poor voluntary bearing down
(ii)Rigid perineum.
(iii) Malpositions: persistent occipito-posterior
and deep transverse arrest.

4. 2. Maternal indication:
• Exhaustion.
• Pulse >100 beats / min.
• Temperature >38o
c .
• Signs of dehydration.
• Maternal diseases as: Heart disease, Asthma
• Pre-eclampsia and eclampsia.

5. Foetal indications
3.Fetal indication
• Fetal distress.
• Prolapsed pulsating cord.
• Preterm delivery.
• After-coming head in breech delivery.
• During caesarean section One (used as a
lever) or the two blades may be used to
extract the head through the uterine incision.

6. Pre-requisites for Forceps Application
Anaesthesia: general, epidural, spinal or pudendal block.
Adequate pelvic outlet.
Aseptic measures.
Bladder and Bowel evacuation.
Contractions of the uterus should be present.
Dilatation of the cervix should be fully.
Engaged head.
Forewater rupture.
Favourable position and presentation:
Occipito-anterior.
Occipito-posterior
Face presentation.
After-coming head in breech.

7. How to know Right and Left Blades
Putting in consideration that the mother is in the
lithotomy position, the blade will be applied
with the pelvic curve directed anteriorly and the
cephalic curve directed medially. If the blade will
be applied to the left maternal side it is a left
blade and vice versa.

8. Technique of Forceps Delivery
In occipito- anterior position
• The left blade is applied first. It is held by its handle
between the thumb and fingers of the left hand
almost parallel with the right inguinal ligament and
passed along the left side of the maternal pelvis
between the guiding palm of the right hand and
foetal head.
• As the blade passes into the birth canal the handle is
carried backwards and towards the midline. It is now
the lower blade.

9. • The fingers of the left hand are introduced
along the right side of the pelvis and the right
blade is held and passed in the same manner.
It is now the upper blade.
• The 2 blades should be locked easily, if not
this means that they were not correctly
applied and should be removed and re-assess
the position of the head.

10. Clinical checks for correct forceps application
• The sagittal suture lies in the midline of the
shanks.
• The operator cannot place more than a finger
tip between the fenestration of the blade and
the foetal head.
• The posterior fontanelle is not more than one
finger- breadth above the plane of the sha

11. Traction should be
• gentle by the force of the arm only,
• intermittent with uterine contractions only,
• in correct direction i.e. downwards and
backwards till the occiput appears at the
vulva, then downwards and forwards.
• The 2 blades are unlocked between
contractions to minimise the period of head
compression.

12. Complications of Forceps Delivery
Maternal complications:
Extension of the episiotomy.
Perineal tear.
Vaginal tears.
Cervical lacerations.
Bladder injury.
Rupture uterus

13. Bone injuries: to pelvic joints, coccyx or
symphysis pubis.
Pelvic nerve injuries.
Postpartum haemorrhage: due to lacerations or
atony.
Puerperal infections.
Remote effects: genital prolapse, stress
incontinence, cervical incompetence and genito-
urinary fistulas.

14. Foetal complications
• Fracture of the skull.
• Cephalohaematoma.
• Intracranialhaemorrhage.
• Facial nerve palsy.
• Trauma to the face, eyes or scalp.
• Asphyxia due to:
> intracranial haemorrhage or,
• > cord compression between the head and the
forceps.

15. FAILED FORCEPS
Failure to extract the foetus by the forceps which may be due to
failure to apply the forceps or to deliver the head with it .
Causes:
Cephalo-pelvic disproportion.
Contracted outlet.
Incomplete cervical dilatation.
Constriction ring.
Head is not engaged.
Malpositions as persistent occipito-posterior. Malpresentations as
brow.
Foetal congenital anomalies as hydrocephalus, ascitis and conjoined
twins.

16. Management after failed forceps
• Reassessment: The forceps is removed and the
patient is re-examined to detect the cause and
correct it if possible.
• Caesarean section: is indicated in
uncorrectable causes as cephalo-pelvic
disproportion, and contracted outlet.
• Exploration of the birth canal: for any injuries.

17. Vacuum Extraction (Ventouse)
Definition
It is traction of the foetal head by a created
negative pressure through a cup applied to the
head.

18. Description of the instrument
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.

19. Indications
• The same as forceps: but it is not recommended in preterm
babies and not used for the after-coming head in breech
delivery.
• During the 1st stage: The small cup 3 or 4 cm may be used in
a soft, stretchable cervix of not less than 7 cm dilatation.
• During caesarean section: It may be used to extract the
foetal head through the uterine incision.
• N.B. Vacuum is not an instrument for rotation of the head
but it rotates spontaneously when meets the pelvic floor.
Trial to rotate the head with the cup will cause it to slip.

20. Contraindications
• Moderate or severe cephalopelvic
disproportion.
• Other presentations than vertex.
• Premature infants.
• Intact membranes.

21. Procedure
• Lithotomy position.
• 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.

22. • Application of the cup: The largest cup that can easily
passed is introduced sideways into the vagina by
pressing it backwards against the perineum. It is then
applied as near as possible to the posterior fontanelle
over the mid sagittal line with its edge 3 cm from the
anterior fontanelle. This position will promote flexion of
the head and brings the smallest diameters of the foetal
skull into the maternal passages. 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.

23. • Creating the negative pressure: holding the
cup in place, the negative pressure is gradually
increased by 0.2 kg/cm2 every 1 minute until -
0.8 kg/cm2 is attained. This creates an artificial
caput within the cup.
• Traction on the handle is made perpendicular
to the cup and intermittently during uterine
contractions, the direction of pull is changing
as the head descends through the birth canal

24. • Release of the cup: 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 head must be completely or partially delivered
with no more than 3 pulls.
• The head is at least begin to move with the first pull.
• The cup must not be applied more than twice.
• Application of the cup must not exceed 20 minutes.

25. Advantages of Vacuum over Forceps
• 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.

26. Complications
Maternal:
• Vaginal and cervical lacerations.
• Annular detachment of the cervix, cervical
incompetence and may be future prolapse if used
with incompletely dilated cervix.
Foetal:
• Cephalohaematoma.
• Scalp lacerations.
• Rarely, intracranial haemorrhage.