FORCEPS DELIVERY An Overview

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FORCEPS DELIVERY An Overview

• Prof.S.N.Panda, M.S.
• Department of Obstetrics and Gynecology
• M.K.C.G.Medical College, Berhampur

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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.

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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.

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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.

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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.

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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.

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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.

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

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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.

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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.

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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-
• Multipara-

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Indications for forceps 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

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Indications for forceps delivery

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

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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.

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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.

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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.

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Technique (of low outlet forceps application )

• 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.
• Locking of blades -
• The blades should articulate with ease indicting
  correct application.

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Technique (of low outlet forceps application )

• 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.

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Technique (of low outlet forceps application )

• 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.

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Technique (of low outlet forceps application )

• 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.

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Technique (of low outlet forceps application )

• 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.

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Technique (of mid forceps application )

• Forceps used are - long curved with or without
  axis traction device Keillands.
• 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.

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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.

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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.

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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.

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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.

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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.

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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

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Trial forceps
Failed forceps

• Knowing that a certain degree of disproportion at
  mid pelvis may make the procedure incompatible,
  low/mid forceps delivery is attempted, abandoning
  it at the earliest in favour of Caesarean
  section.
• So it should be done only in the O.T., keeping
  everything ready for C.S.

• When a vigorous but unsuccessful attempt is made
  with the forceps, anticipating a successful
  forceps delivery.
• Mostly it is due to lack of obstetric skill and
  poor clinical judgment
• Factors responsible are- Disproportion,
  Incomplete cervical dilatation malposition of
  foetal head

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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

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Towards a safe motherhood
Thank you