Instrumental Delivery

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Instrumental Delivery
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Forceps Deliveryindications

• Indicated
• Anesthesia
• Heart disease
• Pulmonary disease
• Fetal distress
• After coming head
• In cesarean section

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• Selected
• Poor cintractions
• Fatigue
• Op position
• Prevention of cystocele and rectocele ?
• Prevention of hemorrohid?

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Contraindications

• Extreme prematurity (lt 34 weeks)
• Suspected bleeding disorder
• Macrosomia, suspected or USG established

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Prerequisitions for forceps

1. Full dilatation
2. Engagement
3. Empty bladder
4. Known position (of the fetal head)
5. Ruptured membranes
6. Adequate anesthesia
7. Episiotomy
8. R/O C.P.D
9. Skilled operator

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Parts of Equipment

• Cup size 40, 50, 60 mm.
• Types of cup
• Malestorm
• Bird
• Siliastic (Mety-vac)
• M-cup.
• Vacuum tubing.
• Traction chain.
• Suction apparatuswhich has capacity to produce
  0.8 kg/cm2 negative suction _at_ 550-600 mm Hg.

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1. Traction force max _at_ 22.7 kg required before
   detachment or pop-off takes place. This is the
   safetyend point.
2. Application distance is 3 cm from post edge of
   anterior fontanelle of fetal sclap till the
   anterior outer edge of traction cup.

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• Site of applications
• a- Flexing median
• b. Hexing paramedian Result in
• c. Deflexing median Asyncilitism
• d. Deflexing paramedian
• Failure
  for
• correct
  
• traction

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Parts of Forcep's

• Has two crossing blade branches
• Each branch blade has four components
• 1. The blade
• 2. Shank
• 3. LockEnglish and/or sliding type
• 4. Handle
• Each blade has two curves
• a. Cephalic-coniorms to shape of fetal
  head
• b. Pelvic-confoims to pelvic curvature

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Common Types of Forceps in Use

• 1. Wringly's outlet forceps
• 2. Simpson's
• 3. Tucker-McIane
• 4. Kielland forceps
• 5. Piper's forceps
• 6. Hay's forceps

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Classification of Forceps Delivery(Instrumental
Delivery) (ACOG 2000)

• Procedure Criteria
• Outlet forceps
• 1. Sclap visible and at
• interoitus without
• separating labia
• 2. Fetal skull at pelvic floor
• 3. Sagittal suture in AF dia or
• LOA or ROA position
• 4. Fetal head is or at pelvic
• perineum (leading pole)
• 5. Rotation needed does not
• exceed 45

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• Low forceps
• Leading point 2 station and
• not on pelvic floor
• Rotation is 45 or less. LOA/
• ROA to occiput ant and/or
• LOP/POP with occiput pos-
• terior
• Rotation is gt 45
• Mid forceps
• Station above 2 cm but head
• is Engaged (Abdomen palpable
• vertex is I/5th only)
• High forceps
• Not included in this classification

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Function of Forceps

• Used as traction, rotation or both,
• by and large used as a tractor
• Possible Max Force Used
• Upto 60 kg max after which fetal skull damage
  is assured. Generally with forceps at elbow along
  side body leads to force of 22-27 kgs per tractor
  pull.

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Preparation of Forcep Application

1. Pudendal block or regional anesthesia
2. Lithotomy position
3. Bladder assured empty
4. Perineum cleaned and draped
5. Forceps are constructed outside as to be applied
6. Precise knowledge of exact position of fetal head
   either by suture direction or by locating
   posterior ear
7. Application as for biparital or bi malar
   position, is only safe application of forceps.

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Indications

• A. Maternal
• Exhausation
• Poor/absent maternal expulsive efforts
• Need to avoid maternal expensive effort,
• cardiac disease/CVA
• Lack of effort

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• B. Fetal
• Nonreassuring fetal CTG test
• C. Prolonged 2nd stage
• Primi gt 2 hr without regional anesthesia
• Multi gt 1 hr anesthesia (for with RA addl
  hr)
• Desired selective shortening of 2nd stage

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Prerequisites

• A. Maternal
• Lithotomy position
• Reassurance
• Consent
• Adequate analgesia
• Empty bladder
• Adequate assessed pelvis.

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• B. Fetal
• Cephalic presentation
• Membranes ruptured
• Engaged fetal head
• Position of head-known
• Station 2
• Flexed attitude
• Moulding of head 1 only.

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• C. Others
• Cervix fully dilated
• No placenta praevia
• Experienced operator
• Ability to do less, with facilities
• existing prtoi to attempting.

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Indications

• Maternal
• Heart disease
• Pulmonary injury or severe COFD
• Severe intrapartum infection
• Neurological conditions such as cord injury or
  neuromuscular diseases
• Prolonged 2nd stage.

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• Fetal Indications
• Prolapse of umbilical cord
• Premature separation of placenta
• Non-assuring CTG tracing, persistant.
• Others
• Lack of maternal expulsive effort
• Elective shortening of 2nd stage
• (prophylactive) or social need.

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Prerequisites

1. Vertex presentation or face with chin out
   (mento-anterior)
2. Head must be engaged
3. Position of fetal head well known
4. Cervix fully dilated
5. Bladder completely empty
6. Membranes ruptured
7. No CPD assessed
8. Informed mother's consent.