forceps delivery

Forceps delivery

1. Name=Nelofar Farooq SAIMA HABEEB Ph.D (N) SCHOLAR

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. OPERATIVE VAGINAL DELIVERY

4. Forceps

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. Forceps

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.

7. 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. 1.Long-Curved Obstetric Forceps

8. 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.

9. 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.

10. 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.

11. 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 CLASSIFICATION FOR OPERATIVE VAGINAL (FORCEPS/VENTOUSE) DELIVERY (ACOG–2000)

12. 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. TYPES OF APPLICATION OF FORCEPS BLADES

13. 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. Indications of forceps delivery

14. 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. Pre-requisites of forceps delivery

15. 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. Procedure of low forceps operation:

16. 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.

17. 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.

18. 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. Preparation of the women

19. 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.

20. 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. Complications of forceps operation

21. 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.

22. 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.

23. 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.

24. T H A N K Y O U