429141210-5-Forcepnnnnnnnnnns-delivery-ppt.ppt

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1. Forceps
delivery

2. Introduction
•The obstetric forceps operations is used in the
interest of the mother or the baby and when
properly performed can be a rewarding
experience and also lifesaving. The forceps has
inbuilt functions which permits traction,
rotation, dilatation, leverage, compression and
irritation of the uterus, stimulating it to
contract when traction is made.

3. Overview
•Forceps vaginal delivery
•Classifications of forceps
•Indications
•Contra-indications
•Pneumonic for forceps application

4. Learning objectives
•At the end of the class, the students will be
able to,
•Define forceps delivery
•Mention the indications
•List the criteria for applying forceps

5. Operative Vaginal Delivery

6. Forceps Delivery
Meaning
•ForcepsDeliveryisameansofextractingthe
fetuswithaidofobstetricforcepswhenitis
inadvisableorimpossibleforthemotherto
completethedeliverybyherownefforts.
•Forcepsarealsousedtoassistthedeliveryof
theafter-coming-headofthebreech&on
occasiontowithdrawtheheadup&outofthe
pelvisatcaesareansection.

7. CLASSIFICATION OF FORCEPS
DELIVERY
•Eversincetheinventionofobstetricforcepsaround
1,600ADbytheWILLIAMCHAMBERLAIN family,
manydesignswereinvented&modified.
•ForcepsDeliverieswereformerlyclassifiedbythelevel
oftheheadatthetimetheforcepswereapplied,i.e
•High-cavity,mid-cavity&low-cavity
•low-cavityforcepsisfrequentlyperformedasC.Sis
alternativeformoretraumatichigh&mid-cavity
operations.

8. CLASSIFICATION OF FORCEPS
DELIVERY
•Outlet Wrigley’s
•Outlet & low forceps Simpson /Elliot
•Mid forceps & outlet Tucker Mclane
•Mid forceps & rotation Kielland
•After coming head in breech Piper

9. Low
forceps
Foetalscalpisvisiblewithoutseparatingthevulva
Foetalskullhasreachedthepelvicfloor
SagitalsutureisintheA.P.diameterorintheLt./Rt.Occiputo
anterior/posteriorposition
Rotation does not exceed 45degrees
Outlet
forceps
Theleadingpointoftheskullis2cmormorebelowthe
ischealspinebutnotonthepelvicfloor
Sagitalsuture is in the A.P.diameteror in the Lt./Rt. Occiputo
anterior/posterior position
Mid
forceps
Theleadingpointoftheskullis2cmorlessabovethespine
butheadisengaged.Rotationnotconsidered
High
forceps
EXCLUDED
Newer classification as per
A.C.O.G.1981(revised in 1991)

10. Types of obstetric forceps
currently used
•Only three verities are commonly used in
present day obstetrics. They are
•Long-curved forceps with or without axis
traction device
•Short-curved forceps
•Kielland’s forceps

11. Long-curved forceps
•Long-curved forceps is heavy, 87 cm (15”)
long, suited for small pelvis & small baby of
Indian women.
•In India Das variety (named after Sir Kedar
Nath Das) is commonly used.
Measurements
Length –37 cm
Distance between the tips –2.5 cm
Widest diameter b/w the blades –9 cm

12. Each blade consists of
1.Blade
2.Shank
3.Lock
4.Handle with or without screw
The Blades are fenestrated which facilitate a
good grip of the fetal head.
A slot in the lower part of the fenestrumof the
Blades to allow the upper end of the axis
traction rod to be fitted.

13. Two curves in the Blade
•Pelvic curve-to fit the curve on the axis of the
birth canal
•Cephalic curve on the flat surface, which
when articulated, grasps the fetal head without
compression
The Shank –part b/w the blade & the lock,
measures 6.25 cm (2 ½ “), increases the length
of the instrument & thereby facilitates locking
of the blades outside the vulva.

14. When the blades are articulated, the shanks
are not apposed each other.
The Lock consists of a socket system located
on the shank at its junction with the handle
(English lock)
The Handles are apposed when the blades
are articulated, measures 12.5 cm (5”).
A screw is attached usually at the end (or at
the base) of one blade, commonly left, to
keep the blade in position.

15. Axis traction device consists of rods & traction
handle.
can be applied in the mid forceps operation,
especially following manual rotation of the
head.
It provides traction in the correct axis of the
pelvic curve & less force is needed.

16. Short-curved forceps (Wrigley’s forceps)
•It is lighter, shorter & stubby handled
•Short d/t reduction in the length of the shanks
& handles
•Has a marked cephalic curve with a single
pelvic curve
•Used for very low forceps deliveries for the
after-coming head of a breech delivery or at
C/S

17. Kielland’s forceps
•Long, almost straight (very slight pelvic curve),
without any axis traction device
•Has sliding lock
•Used when the head is in an occipito lateral or
occipito-posterior position (un-rotated vertex or
face presentation)

18. 18
Functionsof forceps
•Traction:-Thisisthemostimportant
function.Pullrequiredinaprimigravidais
18kgs&inamultiparaitis13kgs.
•Compressioneffect:-Thisisminimalwhen
properlyapplied&shouldnotbemorethan
necessarytograspthehead.Howeverithas
somepressureeffectonthewell-ossified
baseoftheskull.

19. •Rotationofhead:-Thisoccurswiththeuseof
Kejilland'sforcepsandalsoinlowforceps
cephalicapplicationwiththeocciputinthe2
or10'o'clockposition.
•Protectivecage:-Whenappliedona
prematurebabyitprotectsfromthepressure
ofthebirthcanal.Whenappliedonthe
aftercomingheaditlessensthesudden
decompressioneffect.
•Asavectis:-Byapplyingonebladetodeliver
theheadincaesareansection.

20. Indications for forceps delivery
•Delay in second stage: -.
–Due to uterine inertia.
–Failure of progress of labour-if no progress occurs
for > 20 to 30 mts, with the head on the perineum.
Maternal indications
•Maternal distress
•Pre-eclampsia, eclampsia
•VABC (Post caesarian pregnancy)
•Heart disease
•Failure to bear down during the II stage of labour d/t
regional blocks, paraplegia or psychiatric illness

21. •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

22. 22
Prerequisites
(to be fulfilled before forceps application.)
•Suitable presentation & position: -.
–Vertex, anterior face or after-coming head are the
ideal positions.
–Fetal head engaged (head is ≤⅕ palpable per
abdomen)
–Fetal head position is exactly known
•Cervix must be fully dilated.

23. •Membranes must be ruptured.
•Baby should be living.
•Uterus should be contracting & relaxing.
•Bladder must be empty.
•F-fetal position & presentation (vertex, engaged,
position is exactly known)
•O-os fully dilated cervix
•R-ruptured membranes
•C-cephalic presentation
•E-empty bladder
•P-pelvis adequate
•S-stir up position (lithotomy position)

24. 24
Preliminaries (before forceps application)
•Informedconsentwithpriorclearexplanation
•Documentation:-include:
–Consentofthepatient,
–indicationforoperation,
–anaesthesia,
–personnelinvolved,
–typeofinstrument,
–difficulties&remedies,
–resultingmaternal&foetalcomplicationsor
injuriesandbloodloss.

25. •Anaesthesia:-
–PudendalblockorLabio-perinealinfiltration
foroutletforceps.
–RegionalorGeneralanaesthesiaforlow&
midforceps.
•Catheterisation:-
•Internalexamination:Toassesthestateof
cervix&membranes,presentation&position,
pelvicoutlet,TDO&subpubicangle.
•Episiotomy:-
–Shouldbedoneeitherbeforeapplicationofforceps
orduringtractionwhentheperineumbulges.

26. 26
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.

27. 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.

28. 28
Technique
(of low & outlet forceps application)
1.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.
2.Lockingofblades:-
Thebladesshouldarticulatewithease
indicatingcorrectapplication.

29. Technique (of low & outlet forceps
application)
1.Identify & apply blades
Place instrument in
front of pelvis with tip
pointing up & pelvic
curve forward
Apply left blade, guided
by right hand, then
right blade with left
hand
2.Lock blades
Should articulate with ease

30. 30
3.Clinical checks for correct forceps
application:
–Sagittal suture in midline of shanks
–Cannot place more than one fingertip
between blade and fetal head
–Posterior frontanalle is not more than one
finger breadth above the plane of the shanks
of the forceps.

31. 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.

32. 32
–Remove blades as fetus crowns
–Removal of blades -Right blade
should be removed first.

33. 33
Technique
(of low & outlet forceps application)
5.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.

34. 34
Technique
(of low & outlet forceps application)
6.In face presentation-
–Blades are to be introduced along
the Occipito-mental diameter.
–Traction is applied downwards till
the chin appears under the
symphysis pubis & then upwards
delivering the nose, eyes, brow &
occiput.

35. 35
Technique (of mid forceps application
)
•Forceps used-long curved with or without
axis traction device & Keilland’s.
•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.

36. 36
Forceps for After-coming 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.

37. Keilland's forceps application
•Indication: Can be applied in unrotated
vertex / face presentation and for
correction of asynclitism (deflection of the
head in relation to the pelvis).
•Application: -
–Anterior blade is applied first followed
by the posterior blade. After the blades
are applied, the head is rotated to an
occipito-anterior position & the sliding
lock allows correction of asynclitism

38. –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.
–Rotation of the head can be achieved at the
same level or the lower level after pulling the
head down
–Direct method-Blades also can be applied
directly over the parietal bones.

39. 39
Keilland's forceps application
Epidural anesthesia generally preferred in
this application
Limitations
•Complexity in the technique of application
•Chances of injury to the vagina or
perineum
•Needs deep medio-lateral episiotomy

40. 40
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.

41. –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.

42. 42
•Fetal Complications / Dangers
–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%.

43. 43
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

44. 44
Trial forceps
•It is a tentative attempt of forceps delivery in a
case of certain degree of disproportion at mid
pelvis with the preamble declaration of
abandoning it at the earliest in favour of
Caesarean section, if moderate traction fails to
overcome the resistance.
•So it should be done only in the O.T., keeping
everything ready for C.S.
•If moderate traction leads to progressive
descend of the fetal head, the delivery is
completed vaginally, if not C.S is done
immediately

45. Failed forceps
•When a delibrate attempt in vaginal delivery
with forceps has failed to expedite the
process, it is called failed forceps
•Mostly it is due to lack of obstetric skill and
poor clinical judgment
•Failure may be d/t improper application or
failure of descend of the head even with
forcible contraction
•Factors responsible are-Disproportion,
Incomplete cervical dilatation & malposition
of foetal head

46. Management of failed forceps
•Asses the effect on mother & fetus
•Start I.v infusion with 5% dextrose if not
started already
•Administer parental antibiotic
•Exclude rupture of uterus & plan for other
modes of delivery
•Shift the woman to an equipped hospital

47. 47
Summary
•Consideringallaspects,forcepsdeliveryhas
stillgotaplaceinmodernobstetricpractice
andshouldbeconsideredincertaincases.
•Ifperformedjudiciouslybyproperselectionof
casesandcareful&timelyapplication,forceps
deliverycanbeusefulinreducingnotonly
unnecessarycaesareansectionsbutalsofoetal
&maternalcomplicationsduetoprolonged
labour

48. Evaluation
•Define forceps delivery
•Tell the pneumonic for forceps application
•What are the pre-requisities for forceps
application
•Indications fro kelland’s forceps

49. Activities
•Draw different types of forceps and label the
parts
•Methods of teaching
Lecture cum discussion

50. References
•Shirish N Daftary, “ Manual of obstetrics”, 3
rd
edition ( 2011), elsevier publications, london.
•DCDutta,“Textbookofobstetrics”,6
th
edition(2004),publishedbynewcentralbook
agency(P)ltd,calcutta
•Myles,“Textbookformidwives”,14
th
edition
(2006),publishedbychurchilllivingstone,
philadelphia.

51. 51
Towards a safe motherhood