2. FORCEPS IN CHILDBIRTH
Forceps are a surgical instrument that resembles
a pair of tongs and can be used in surgery for
grabbing, or removing various things within or
from the body. They can be used to assist
the delivery of a baby as an alternative to
the ventouse (vacuum extraction) method.
3.
4. STRUCTURE
Obstetric forceps consist of two branches that are
positioned around the fetal head.
These branches are defined as left and right
depending on which side of the mother's pelvis they
will be applied.
The branches usually, but not always, cross at a
midpoint which is called the articulation.
Most forceps have a locking mechanism at the
articulation, but a few have a sliding mechanism
instead, allowing the two branches to slide along each
other.
5. Forceps with a fixed lock mechanism are used for
deliveries where little or no rotation is required, as
when the fetal head is in line with the mother's pelvis.
Forceps with a sliding lock mechanism are used for
deliveries requiring more rotation.
The blade of each forceps branch is the curved
portion that is used to grasp the fetal head. The
forceps should surround the fetal head firmly, but not
tightly.
The blade characteristically has two curves, the
cephalic and the pelvic curves.
The cephalic curve is shaped to conform to the fetal
head. The cephalic curve can be rounded or rather
elongated depending on the shape of the fetal head.
6. The pelvic curve is shaped to conform to the
birth canal and helps direct the force of the
traction under the pubic bone.
Forceps used for rotation of the fetal head
should have almost no pelvic curve.
The handles are connected to the blades by
shanks of variable lengths. Forceps with longer
shanks are used if rotation is being considered.
7.
8. TECHNIQUE
The cervix must be fully dilated and retracted and the
membranes ruptured. The urinary bladder should be
empty, perhaps with the use of a catheter.
The station of the head must be at least +2 in the
lower birth canal.
The woman is placed on her back, usually with the
aid of stirrups or assistants to support her legs.
9. A mild local or general anesthetic is administered
(unless an epidural anesthesia has been given) for
adequate pain control.
Ascertaining the precise position of the fetal head
with ultrasound , the two blades of the forceps are
individually inserted, the left blade first for the
commonest occipito-anterior position; posterior
blade first if a transverse position, then locked.
The position on the baby's head is checked. The
fetal head is then rotated to the occiputo anterior
position if it is not already in that position
10. An episiotomy may be performed if necessary. The
baby is then delivered with gentle (maximum
30 lb or 130 Newton traction in the axis of the pelvis.
The accepted clinical standard classification system
for forceps deliveries according to station and
rotation was developed by ACOG and consists of:
<American College of Obstetricians and
Gynecologists.
11. Outlet forceps delivery:
where the forceps are applied when the fetal
head has reached the perineal floor and its
scalp is visible between contractions .
This type of assisted delivery is performed only
when the fetal head is in a straight forward or
backward vertex position or in slight rotation
(less than 45 degrees to the right or left) from
one of these positions.
12. Low forceps delivery: when the baby's head is
at +2 station or lower. There is no restriction on
rotation for this type of delivery
Mid forceps delivery: when the baby's head is
above +2 station. There must be head
engagement before it can be carried out.
High forceps delivery: is not performed in
modern obstetrics practice. It would be a forceps-
assisted vaginal delivery performed when the
baby's head is not yet engaged.
13. INDICATIONS FOR USE
Maternal factors
Maternal exhaustion
Prolonged second stage
Maternal illness; such as heart disease,
hypertension, glaucoma, aneurysm, or other
things which make pushing difficult or
dangerous
14. Haemorrhage
Analgesic drug-related inhibition of maternal
effort (especially with epidural/spinal
anaesthesia )
Fetal Factors
Non-reassuring fetal heart tracing
After-coming head in breech delivery
15. COMPLICATIONS
Fetal
Cuts and bruises
Occasionally, (usually temporary) facial
nerve injury can occur
rarely, clavicle fracture
Intracranial hemorrhage sometimes leading to
death
Improper twisting of the neck can cause damage
to cranial nerve VI, resulting in strabismus.
16. Mother
Increased risk of perineal lacerations,
pelvic organ prolapse and incontinence
Increased postnatal recovery time and pain
Increased difficulty evacuating during the
recovery time
17. CONTRAIDICATIONS
The following are contraindications to forceps-assisted
vaginal deliveries:
Any contraindication to vaginal delivery
Refusal of the patient to verbally consent to the procedure
Cervix not fully dilated or retracted
Inability to determine the presentation and fetal head
position
18. Inadequate pelvic size
Confirmed cephalopelvic disproportion
Unsuccessful trial of vacuum extraction
Absence of adequate anesthesia/analgesia
Inadequate facilities and support staff
Inexperienced operator
19. NURSING MANAGEMENT
PREOPERATIVE DETAILS
Reviewing the indications for operative vaginal
delivery and confirming the presence of all the
prerequisites for forceps application are crucial steps.
In particular, the presentation, position, and station of
the presenting part must be reconfirmed just before
the procedure.
20. Maternal verbal consent should be obtained
prior to the forceps attempt, although the
procedure may need to be performed
emergently or after the mother has been
medicated.
If a planned forceps delivery is to be
performed (i.e, for maternal medical
indications), counseling and consent may be
completed prior to the onset of active labor.
21. INTRAOPERATIVE DETAILS
The most crucial point of forceps delivery is
knowledge of the presentation position of the fetus.
The term pelvic application is used when the left
blade is applied on the left side of the pelvis and the
right blade is applied on the right side of the pelvis,
regardless of the fetal position.
Pelvic application is never to be used as a substitute
for knowledge of the fetal position; inappropriate
pelvic application may cause maternal harm.
22. Once again, emphasizing that forceps delivery
is skill- and training-dependent is important.
The operator must have a clear
understanding of his or her own capabilities, as
well as the safe limits of the procedure, and
must not exceed either of these.
23. POSTOPERATIVE DETAILS
After a forceps delivery, thorough examination of
both the mother and the newborn is advisable.
Maternal cervical, vaginal, and perineal lacerations
must be excluded.
In addition, maternal vulvar edema may be
significant. Most operators institute measures such as
perineal ice to ameliorate this.
Pain medication is also advisable. These patients are
at increased risk for hemorrhage, and a postoperative
hemogram should be obtained and the condition
corrected as needed.
24. Before discharge, pelvic and rectal
examinations may help confirm the integrity of
pelvic organs and may exclude such entities as
pelvic hematoma, rectal tears, and misplaced
sutures.
Diagnostic studies should be obtained as
needed.
The newborn must be examined for
lacerations, bruising, and other injuries. The
pediatric service should be made aware of the
circumstances of delivery
25. FOLLOW UP
In the absence of specific forceps-
related complications, a follow-up
postpartum examination within 4-6
weeks, according to the usual protocol for
postpartum care, with a thorough pelvic
examination, is usually sufficient.
26. Today I discussed with you
Structure of forceps.
Types of forcep deliveries.
Indications for forcep delivery.
Complications of forcep delivery.
Contraindications of forcep delivery and
Nursing management of forcep delivery.
