FORCEPS DELIVERY

DEFINITION

Forceps delivery is defined as vaginal childbirth with the aid of obstetric forceps

Obstetric forceps is a double-bladed metal instrument used for extraction of the foetal
head.

DESIGN OF OBSTETRICS FORCEPS

It consists of 2 blades each of them is 15 inches (37.5 cm) long, crossing each other
and lock at the site of crossing. Each is composed of:

 The blade proper (7.5 inches): has 2 curves;

o pelvic curve adapted with the maternal pelvic axis,
o cephalic curve adapted to the foetal head.
o The blade is fenestrated to;
 prevent compression of the head,
 prevent its slippage as the parietal eminences are protruding
through the fenestration.
 make its weight lighter.
o The 2 blades are separated by one inch at the tip and 3.5 inches at the
centre.
 The shank (2.5 inches):
o It is the part between the blade proper and the handle giving a length
for the forceps sufficient to be locked easily outside the vagina.
 Lock: there are 4 types of lock;
o English type: double slot lock.
o French type: screw lock.
o German type: combination of both .
o Sliding lock: present in Kielland’s and Barton's forceps.
 Handle (5 inches): It may be serrated or smooth. A projecting shoulder may be
present to facilitate traction.
 Axis traction piece: In mid forceps delivery, a separate piece is attached to the
forceps to direct the traction in the direction of pelvic axis i.e. downwards and
backwards till the perineum.
o There are 2 common types of axis traction piece:
 Neville- Simpson- Barnes: is the commoner one composed of
a single bar attached to the handle just behind the lock.
 Milne-Murray’s: It is composed of 2 bars and a handle to be
attached to the blade proper.
o Pajot’s manoeuvre: is an alternative to the use of axis traction piece.
Traction on the handle is made by the right hand while the left hand
pulls downward on the shank or pushes on the shank from above
(Modified Pajot’s manoeuvre).
 Fig. 4. Locks of obstetric
forceps: French lock (top left ),
English lock (top right ),
German lock (middle left ),
Sliding rock (middle right ), and
Pivot lock (bottom ). (Laufe LE:
Obstetric Forceps. New York,
Harper & Row, 1968)

TYPES OF FORCEPS

Classical Forceps (all-purpose)

- Simpson Forceps
o Has English locks, which allow locking only at one point and only when
the shank of the right branch overlies the left
o have parallel shanks, fenestrated blades, and a long, tapered cephalic
curve designed to fit the molded fetal head
- Elliot Forceps
o Also Has English locks,
 o have overlapping shanks and short, fenestrated blades with a shorter
and more rounded cephalic curve that is somewhat better suited for
application to the unmolded fetal head
o A wheel-and-screw device is built into the handle of the instrument to
avoid compression of the fetal head if the handles are squeezed (see
image below)

A close-up view of the handle of the Elliot forceps

demonstrating the set screw between the handles, which is
designed to reduce cephalic compression.

- The Tucker-McLane forceps,

o a variant of the Elliot type, have short, solid blades. The overlapping
shanks and solid blades make this a popular instrument for rotations
- Wrigley’s forceps
o It is a short curved forceps of 11 inches length and used for low and
outlet forceps delivery.
-

Specialized Forceps - have been developed to effect delivery in situations not

amenable to solution with the classical instruments.

- The Kielland forceps,

o Characterized by:
 Minimal pelvic curve which is again nullified by a slight bend
between the blade proper and the shank so it is nearly a
straight forceps allowing rotation and extraction of the head by
a single application.
 A sliding lock: to allow application on asynclitic head, to
correct asynclitism, a common problem in transverse arrest
 Knobs on the handle: on the side of the minimal pelvic curve
and should be directed toward the foetal occiput during
application
 Bevelled inner surface of the blades: to minimise foetal head
injury
o Kielland forceps also are occasionally used to effect delivery of the face
presentation.
- Piper forceps
o have long shanks with a reverse pelvic curve for ease of application to
the after-coming fetal head in a breech delivery
o The forceps stabilize and protect the fetal head and neck during
delivery.
o When difficulty is encountered in spontaneous delivery of the fetal
head, use of Piper forceps may produce lower morbidity than manual
maneuvers.

- Laufe-outlet forceps
o incorporate the unique design of a pivot lock and finger grips.
o Divergent blades diminish the compressive force on the fetal head, and
traction on the finger grips applies no additional force at the toes of the
blades.
o The short length of the instrument makes it easy to apply at cesarean
section.
o The Laufe forceps may also be useful for delivery of the after-
coming head of the preterm breech fetus.

- Barton forceps,
o which consist of a hinged anterior blade, a posterior blade with an acute
curvature, and a sliding lock,
o were developed for high-transverse arrest, especially in a
platypelloid pelvis with a flat sacrum
o Although not recommended by most obstetricians, there has been
renewed interest in their use for delivery at cesarean section
(Megison, 1993).
ACTION OF THE FORCEPS

 Traction: is the main action.

 Rotation: in deep transverse arrest, persistent occipito-posterior and mento-
posterior.
o E.g. of rotational forceps - - Kielland’s, Barton’s

CLASSIFICATION OF FORCEPS DELIVERY

ACOG (1991) Classification:

PROCEDURE INSTRUMENTS DESCRIPTION

Outlet The foetal head is at the perineum.
Forceps
Delivery The scalp is visible at the introitus
without separating the labia.

Sagital suture is in
anteroposterior diameter, right or
left occipito-anterior or posterior.

Rotation does not exceed 45°

The leading point of the skull is at
station +2 or more and divided
into: i-Rotation ≤45°. ii- Rotation
>45°
The head is engaged, but the
leading point is above station +2
Not included in the classification.
It is abandoned in favour of
caesarean section.
INDICATIONS OF FORCEPS DELIVERY

Prolonged 2nd stage

It is prolongation for more than 1 hour in primigravidae or 30 minutes in multiparae. This

may be due to:

 Inertia and poor voluntary bearing down.

 Large foetus.
 Rigid perineum.
 Malpositions: persistent occipito-posterior and deep transverse arrest.

Maternal indications

 Maternal distress manifested by:

o Exhaustion.
o Pulse >100 beats / min.
o Temperature >38oC .
o Signs of dehydration.
 Maternal medical conditions that mean active pushing or prolonged exertion
e.g:
o Heart disease.
o Pulmonary T.B.
o Pre-eclampsia and eclampsia.

Foetal indications

 Foetal 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.

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:
o Occipito-anterior.
o Occipito-posterior.
o Face presentation.
o After-coming head in breech.

Types of Forceps Application

 Cephalic application: the forceps is applied on the sides of the foetal head in the
mento-vertical diameter so injury of the foetal face, eyes and facial nerve is
avoided .
  Pelvic application: The forceps is applied along the maternal pelvic wall
irrespective to the position of the head. It is easier for application but carries a
great risk of foetal injuries.
 Cephalo-pelvic application: It is the ideal application and possible when the
occiput is directly anterior or posterior or in direct mento-anterior position.

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.

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.
 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.

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 shanks.

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.

Kielland forceps in deep transverse arrest

 The forceps is locked outside with the knobs towards the occiput to know the
anterior blade.
 The anterior blade is applied first by one of the following methods:
o The wandering method: The anterior blade is guided into the lateral
side of the pelvis with the cephalic curve facing the foetal head. It is
then slid over the forehead to fit against the anterior parietal eminence.
o The direct method: when the head is low down in the pelvis, the
anterior blade is slid between the head and symphysis pubis with the
cephalic curve facing the foetal head.
o The old (classical) method: The anterior blade is applied with the
cephalic curve towards the symphysis pubis then it is rotated 1800 to fit
with the head. This method is not recommended as the lower uterine
segment and bladder may be injured.
 The posterior blade is applied along the concavity of the sacrum.
  The 2 blades are locked, head is rotated and extracted as occipito-anterior.

Complications of Forceps Delivery

Maternal complications

 Complications of anaesthesia.
 Lacerations:
o Extension of the episiotomy.
o Perineal tear.
o Vaginal tears.
o Cervical lacerations.
o Bladder injury.
o Ureteric injury.
o Rupture uterus.
 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.

Foetal complications

 Fracture of the skull.

 Cephalohaematoma.
 Intracranial haemorrhage.
 Facial nerve palsy.
 Trauma to the face, eyes or scalp.
 Asphyxia due to:
o intracranial haemorrhage or,
o cord compression between the head and the forceps.

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.

Management

 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.

Links

 Obstetrical forceps, vacuum extraction : Guidelines, reviews