2. 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.
3. 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.
4. 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.
.
5. 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.
8. 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
9. 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
12. • The current classification of ACOG(2000,
2002) emphasizes the two most important
discriminators of risk for both mother and
infant are station and rotation.
• 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.
13. 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.
14. 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
15. 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.
16. 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.
17. 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.
18. 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.
19. PROLONGED SECOND STAGE OF LABOUR-(ACCORDING TO
ACOG 2002)
• 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.
20. Indications for operative vaginal delivery (RCOG
Guideline)
• 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
21. Indications for operative vaginal delivery (RCOG
Guideline) contd..
• 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
22. 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.
23. PREREQUISITES FOR FORCEPS APPLICATION
contd..
• There must be no cephalopelvic disproportion.
• Bladder must be emptied.
• Adequate analgesia
• Experienced operator
• Verbal or written consent.
24. Prerequisites for operative vaginal delivery
(RCOG Green top guidelines)
• 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.
25. Prerequisites for operative vaginal delivery (RCOG
Green top guidelines)contd..
• 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.
26. Prerequisites for operative vaginal delivery (RCOG
Green top guidelines)contd..
• 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).
28. 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.
31. 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.
32. 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.
33. 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.
34. 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.
35. Line of axis of traction(perpendicular to plane of pelvis)
1-high2-mid3-low4-outlet
36.
37. 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.
39. 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.
41. 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.
42. 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 .
43. 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.
46. 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
47. 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.
48. 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.
49. 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
50. 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.
51. 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.
52. 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).
53.
54. 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.
55.
56. 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
57.
58. 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.
59. 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
60. 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.
62. 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.
63. 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.
64. 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
65. 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. (POP OFFS)
66. 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.
67. 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.
68. 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
