Forceps delivery

2. Forceps Delivery

3. Operative vaginal delivery refers to any delivery
process which is assisted by vaginal operations.
Delivery by forceps, ventouse and destructive
operations are generally included.
FORCEPS DELIVERY: means extracting the fetus
with the aid of obstetric forceps when it is
inadvisable or impossible for the mother to
complete the delivery by her own efforts.
Forceps are also used to assist the delivery
after coming head in breech presentation and on
occasion to withdraw the head up and out of the
pelvis at cesarean section.

5. Obstetric forceps is a pair of instruments specially
designed to assist extraction of the fetal head and
thereby accomplishing delivery of the fetus.
VARIETIES OF OBSTETRIC FORCEPS: Ever since either
Peter I or Peter II of the Chamberlin family invented the
forceps around AD 1600, more than 700 varieties
were invented or modified. Most of them are of
historical interest only. But only three varieties are
commonly used in present day obstetric practice.

6. These are:-
1.Long-curved forceps with or without axis
traction device
2. Short-curved forceps
3. Kielland’s forceps
The basic construction of these forceps is the
same in that each consists of two halves (blades)
articulated by a lock.

9. Long-curved obstetric forceps is relatively heavy and is
about 37cm (15”) long. In India, Das’s variety (named after
Sir Kedar Nath Das) is commonly used with advantages. It
is comparatively lighter and slightly shorter than its
Western counterpart but is quite suited for the
comparatively small pelvis and small baby of Indian
women.
Measurements:-Length is 37cm (15”);distance in between
the tips is 2.5 cm and widest diameter between the blades
is 9 cm.
i. BLADES: There are two blades and are named right or
left in relation to maternal pelvis in which they lie when
applied.
ii. Shank
iii. Lock
iv. Handle with or without screw.

11. i. Blade: - The blade is fenestrated to facilitate a good
grip of the fetal head. There is usually a slot in the
lower part of the fenestrum of the blades to allow
the upper end of the axis traction rod to be fitted.
The toe of the blade refers to the tip and the heel to
the end of the blade that is attached to the shank.
The blade has got two curves: -
 Pelvic curve:-The curve on the edge is to fit more or
less the curve on the axis of the birth canal (curve of
Carus). The front of the forceps is the concave side
of the pelvic curve. Pelvic curve permits ease of
application along the maternal pelvic axis.
 Cephalic curve:-It is the curve on the flat surface
which when articulated grasps the fetal head without
compression.

12. ii. Shank:-It is the part between the blade and the lock
and usually measures 6.25 cm(2.5”).It increases the
length of the instrument and thereby, facilitates
locking of the blades outside the vulva.
iii. Lock: -The common method of articulation
consists of a socket system located on the shank at its
junction with the handle (English lock). Such type of
lock requires introduction of the left blade first.
iv. Handle: -The handles are apposed when the blades
are articulated. It measures 12.5 cm(5”). There is a
finger guard on which a finger can be placed during
traction. A screw may be attached usually at the end
(or at the base) of one blade (commonly left). It helps
to keep the blades in position.

15. 3.Kielland’s Forceps
It is a long almost straight (very slight pelvic
curve) obstetric forceps without any axis traction
device. It has got a sliding lock which facilitates
correction of the head. One small knob on each
blade is directed towards the occiput.

17. Type of procedure Criteria
Outlet Forceps Operation (1) Scalp is visible at the introitus without separating the labia
(2) Fetal skull has reached the level of the pelvic floor
(3) Sagittal suture is in direct anteroposterior diameter or in the right
or left occiput anterior or posterior position. ( Wrigley's forceps)
Low Forceps Operation Leading point of the fetal skull (station) is at +2 cm or more but has
not yet reached the pelvic floor. (Simpsons forceps)
Mid Forceps Operation Fetal head is engaged. Leading point of the fetal skull (station) is at
+2 cm or less above the spine.(Kielland's forceps)
High(Excluded) High Head is not engaged. This type is not included in classification

21. Cephalic application:-The blades are applied along
the sides of the head grasping the bi-parietal
diameter in between the widest part of the blades. The
long axis of the blades corresponds more or less to
the occipito – mental plane of the fetal head. It is the
ideal method of application as it has got a negligible
compression effect on the cranium.
Pelvic application:-When the blades of the forceps
are applied on the lateral pelvic walls ignoring the
position of the head, it is called pelvic application. If
the head remains un-rotated, this type of application
puts serious compression effect on the cranium and
thus must be avoided.

22.  Delay in the second stage.
 Maternal indications
 Maternal distress
 Pre-eclampsia, eclampsia
 Heart disease
 Failure to bear down.
 Fetal indications(fetal distress).
 Cord prolapsed
 After coming head of breech.
 Post maturity.

23.  There are certain conditions which must exist
before delivery can be performed.
 The cervix must be fully dilated and effaced.
 Membranes must be ruptured.
 The head must be engaged with no parts of
head palpable abdominally.
 No appreciable Cephalopelvic disproportion.
 The bladder must be emptied.
 Presence of good uterine contractions as a
safeguard to postpartum hemorrhage.

24.  The women’s vulval area is thoroughly cleaned and
draped with sterile towels using aseptic technique.
The bladder is emptied using a straight catheter.
 A vaginal examination is performed by the
obstetrician to confirm the station and exact
position of the fetal head.
 A pudental block, supplemented by perineal and
labial infiltration with 1 % lignocaine hydrochloride,
is given to produce effective local anesthesia.
 An episiotomy may be done prior to introduction of
the blades or during traction when the perineum
becomes bulged and thinned out by the advanced
head.
 The forceps are identified as left or right by
assembling them briefly before proceeding.

25. The left blade is passed gently between the perineum
and fetal head with the first two figures of the
operator’s hand lying alongside the fetal head
protecting the maternal tissue. The tip of the forceps
blade slides lightly over the head, in to the hollow of
the sacrum and is then ‘wandered’ to the left side of
the pelvis where it should sit alongside the head.
The procedure is repeated with the right blade until
it sits on the right of the pelvis.
It should then be easy to lock the two blades and
there should be little or no gap between the handles.
A significant gap suggests that the forceps are
wrongly positioned and they should be reapplied after
carefully checking the position of head.

26. As soon as the operator is ready and the uterus
contracts, the woman is encouraged to push. To
supplement her efforts the obstetrician exerts steady,
downwards traction on the forceps. Traction is released
between contractions. Intermittent traction is continued in
a downward and backward direction until the head comes
to the perineum. The pull is then directed horizontally
straight towards the operator until the head is almost
crowned. The direction of pull is gradually changed
towards the mother’s abdomen to deliver the head by
extension.
The blades are removed one after the other, the right one
first.
Following the birth of the head, usual procedures are to
be followed as in normal delivery. Intravenous methergine
0.2mg is to be administered with the delivery of the
anterior should. Episiotomy is repaired as quickly as
possible and the woman made comfortable.

28.  The women should be prepared in advances for the
possibility of a forceps delivery.
 Full explanation of the procedure and the need for it
must be given to the woman.
 Once the decision has been made, adequate and
appropriate analgesia must be offered.
 The women should be placed in lithotomy position.
 Both legs must be placed simultaneously to avoid
strain on the woman’s back and hips.

29. During the application of the forceps, the
woman should be given full support and
attention.
The fetal heart rate is to be monitored
throughout.
Preparations must also be done for the baby
including equipment for resuscitation. In some
hospitals a pediatrician will also be present.

30. The hazards of the forceps operation are mostly
related to the faulty technique and to the
indication for which the forceps are applied.
In the mother
 Immediate
 Injury
 Extension of the episiotomy towards rectum or
upwards up to the vault of vagina
 Vaginal lacerations
 Cervical tear especially when applied through an
incompletely dilated cervix.
 Bruising and trauma to the urethra.

31.  Postpartum hemorrhage due to trauma, or
atonic uterus related to prolonged labor or
effects of anesthesia.
 Shock due to blood loss, prolonged labor and
dehydration.
 Sepsis due to devitalization of local tissues and
improper asepsis.
 Late complications
 Chronic low backache due to tension imposed
on softened ligaments of lumbosacral or
sacroiliac joints during lithotomy position.
 Genital prolapse or stress incontinence.

32. In the infant
 Immediate
 Asphyxia due to intracranial stress out of
prolonged compression.
 Intracranial hemorrhage due to misapplication
of the blades.
 Cephalhematoma
 Facial palsy due to damage to facial nerve.
 Abrasions on the soft tissues of the face and
forehead by the forceps blade, severe bruising
will cause marked jaundice.
 Tentorial fear from compression of the fetal
head by the forceps.

35. Prevention: It is a preventable condition. Only
through skill and judgment, proper selection of the
case ideal for forceps can be identified. Even if
applied in wrong cases, one should resist the
temptation to give forcible traction in an attempt to
hide the mistake.
Management:
(1)To assess the effect on the mother and the fetus.
(2)To start a Ringer’s solution drip and to arrange
for blood transfusion, if required.
(3)To administer parenteral antibiotic.
(4)To exclude rupture of the uterus.
(5) The procedure is abandoned and delivery is done
by cesarean section
(6) Laparotomy should be done in a case with rupture
of uterus.

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