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Delivery using Forceps

Delivery using Forceps

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07/17/2015

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Charmaine G.

Abalos

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Forceps
y Two branches y 4 components y Blade y Shank y Lock y Handle

Components
y Blade - Fits according to the fetal head - Oval, elliptical, fenestrated, solid - Cephalic curve concavity of the articulated blade corresponds to the fetal head - Pelvic curve corresponds more or less the axis of the birth canal y Shank - Provides the length of the instrument - It connects the blade to the handle

Components
y Handle - Applies traction y Lock - Articulation between shanks - English lock is commonly used; consist of a socket located on the shank at the junction with the handle, into which it fits a socket similarly located on the opposite shank - Sliding lock used in some forceps (Kielland forceps) - French lock used in Barton forceps

Functions
y Traction y Direction must be along the pelvic curvature y Direction of pull should be perpendicular to the plane of the level of which it is being applied y Rotation y Carried out best in the midpelvis y Handles should be swung to a wide arc to reduce the arc of the blade y Easier and lowers the incidence and extent of vaginal lacerations

Different Types of Forceps
y Simpson forceps - Fenestrated blade - Wide and parallel shanks - Delivered fetus with molded head - Nulliparous women y Tucker-Mclane - Blade is solid - Crossing and narrow shank - Deliver fetus with rounded head - Multiparous women y Barton

for deep transverse arrest and POP

Different Types of Forceps
y Kielland - Sliding lock - Allows the shank to move forward and backward independently - Used in deep transverse arrest, or POP y Piper for the aftercoming head in breech deliveries y Elliot - cephalic curve is more curved and short - Used for less molded head y Bailey-Williamson long shanks

Selection of Proper Forceps
y Size of the fetal head y Degree of molding y Station y Position

Definition:
y Outlet forceps delivery fetal head must be on the

perineal floor with the sagittal suture no more than 45 degrees from AP diameter y Trial forceps delivery refers to application with the full knowledge that a certain degree of disproportion existing at the midplane may make delivery difficult, with unacceptable perinatal or maternal morbidity y Failed forceps delivery unexpected unsuccessful attempts at instrumental delivery

Classification of Forceps Deliveries
Procedure Outlet Criteria 1. 2. 3. 4. 5. Low Scalp is visible at the introitus without separating the labia Fetal skull has reached the pelvic floor Sagittal suture is in AP diameter or R or LOA or P position Fetal head is at or on the perineum Rotation does not exceed 45 degrees

Leading point of fetal skull is at station > +2 cm, and not on pelvic floor Rotation is 45 degrees or less (L or ROA to OA, or L or ROP to OP) Rotation is greater than 45 degrees Station above +2 cm but head is engaged Not included in classification

Midpelvic

High

Station above +2 cm but head is engaged

Leading point of fetal skull is at station > +2 cm, and not on pelvic floor Rotation is 45 degrees or less (L or ROA to OA, or L or ROP to OP) Rotation is greater than 45 degrees
1. Scalp is visible at the introitus without 2. 3. 4. 5.

separating the labia Fetal skull has reached the pelvic floor Sagittal suture is in AP diameter or R or LOA or P position Fetal head is at or on the perineum Rotation does not exceed 45 degrees

Forceps Delivery Classification and Instruments Used
y Outlet forceps y Low forceps

y Midforceps y Breech

Simpsons Elliot Elliot <45° rotation Kielland >45° rotation Tucker-Mclane Kielland or Mclane Pipers

Preparation for Forceps Delivery
‡ Regional analgesia or general anesthesia usually is

preferred for low-forceps or midforceps procedures ‡ Bladder must be emptied ‡ Experienced operator

Prerequisite
y Head must be engaged y Vertex presentation or mentum anterior y Position must be known y Cervix should be fully dilated y BOW ruptured y No CPD

Indications
y Prolong 2nd stage of labor - Nulli after 2 hours w/o or 3 hours w/ anesthesia - Multi after 1 hour w/o or 2 hours w/ anesthesia y Maternal - Heart disease - Maternal exhaustion - Previous CS y Fetal - Cord prolapse - Abruptio placenta - Fetal distress

Contraindications
y Any contraindications to vaginal delivery y Refusal of patient to the procedure y Cervix not fully dilated y Inability to determine station, position, or inadequate

pelvis y Possible CPD y Unsuccessful trial of vacuum extraction y Absence of adequate anesthesia y Inadequate facilities and support staff y Inexperienced operator

Forceps Application
y Cephalic curve is closely adapted to the sides of the

fetal head y The fetal head is perfectly grasped when the long axis of the blade corresponds to the OMD y The major portion of the blade is lying over the face y The concave margins of the blade directed toward either the sagittal suture (OA) or the face (OP) y Forceps should not slip and traction may be applied

Types of Application
y Cephalic application the blade lie against the side of

the head covering space between orbit and eye
y Pelvic application

L blade applied to the L side of the mother, and the R blade applied to the R side of the mother regardless of the position of the fetal head

y NOTE:
Cephalic curve ± conforms to the shape of the fetal head Pelvic curve ± corresponds more or less the axis of the birth canal

Types of Grip
y Pencil grip

most favorable, more easier than

y Hand-shaking grip an

alternate to pencil grip
y

y

Long forceps grips the mandible of the fetus Short forceps grips the maxilla of the fetus

Insertion of the Blade
y L blade

held by the L hand of the examiner, applied to the L side of the mother, and to the L side of the fetus; is guided by the fingers of the R hand held by the R hand of the examiner, applied to the R side of the mother, and to the R side of the fetus; is guided by the fingers of the L hand

y R blade

How to note that the Blade is locked?
y Sagittal suture is perpendicular to the plane of the

shank
y Posterior fontanel is one fingerbreadth distance from

the plane
y Fenestrations of the planes are equally felt bilaterally

Outlet Forceps Delivery
y The small fontanel (posterior) is directed toward the

symphysis pubis y The forceps are applied as follows:
y

y

Two or more fingers of the R hand are introduced inside the L posterior portion of the vulva and into the vagina beside the fetal head The handle of the left branch is then grasped between the thumb and two fingers of the L hand and the tip of the blade is gently passed into the vagina between the fetal head and the palmar surface of the fingers of the R hand.

Outlet Forceps Delivery
y For application of the R blade, two or more fingers of

the L hand are introduce into the R, posterior portion of the vagina to serve as a guide for the R blade, which is held in the R hand and introduce into the vagina.

Outlet Forceps Delivery: Traction
y Gentle, intermittent, horizontal traction y The handles are gradually elevated, and eventually

pointing almost directly upward as the parietal bones emerge. y As the handles are raised the head is extended y Upward traction: four fingers should grasp the upper surface of the handle and shanks, the thumb exerts force on their lower surface

Outlet Forceps Delivery: Traction
y Spontaneous delivery: intermittent, head is allowed to

recede in intervals y Severe fetal bradycardia: delivery is sufficiently slow, deliberate, and gentle to prevent undue head compression
y Traction is applied only with each uterine contraction

Outlet Forceps Delivery
y Delivery is completed: y 1. forceps in place to control the advance of the head y 2. forceps is removed and delivery is completed by the Modified Ritgens Maneuver
Modified-Ritgens Maneuver head distends the vulva and perineum enough to open the vaginal introitus to a diameter of 5 cm or more, a towel draped, gloved hand is used to exert forward pressure on the chin of the fetus through the perineum just in front of the coccyx, the other hand exerts pressure superiorly against the occiput

Low and Midforceps Operation
y Head lies above the perineum y Sagittal suture usually occupies an oblique or

transverse diameter of the pelvis y Forceps should always be applied to the sides of the head

Low and Midforceps Operation: LOA

position

y R hand is introduced into the LP segment of the

vagina (L ear posteriorly) y R hand guides the introduction of the L branch of the forceps (held by the L hand and applied over the L ear)
y L hand guides the R branch of the forcep y Then applied over the anterior ear of the fetus by

gently sweeping the blade anteriorly until it lies opposite the blade that was introduce first.

Low and Midforceps Operation: ROA

position

y Blades are introduced similarly but in opposite

direction y Blades are applied at the sides of the head, the left handle and shank lie above the right y Forceps do not immediately articulate y Locking the branches is affected, however, rotating the left around the right branch brings the lock into its proper position

Low and Midforceps Operation: OT position
y First blade applied over the posterior ear y The second blade is rotated anteriorly to a position

opposite to the first y One blade lies in front of the sacrum y And the other behind the symphysis y Simpson, Mclane, Keilland forceps

Low and Midforceps Operation: Anterior and

Transverse position
y Occiput is obliquely anterior, it gradually rotate

spontaneously to the symphysis as traction is exerted y When it is in transverse, a rotary motion is required y Rotation CCW from the left side towards the midline is required when the occiput is directed towards the left, and the reverse if directed towards the right side of the pelvis y Flattened pelvis , rotation is not attempted until the head has reached or approached the pelvic floor y Traction is exerted downward until the occiput appears at the vulva

OP Position: Manual Rotation
y A hand with the palm upward is inserted into the

vagina and the fingers are brought in contact with the side of the fetal head that is to be rotated toward the anterior position, while the thumb is placed over the opposite side of the head y Occiput in the RP position, the left hand is used to rotate the occiput anteriorly in a CW direction y The right hand is used for the LOP position y The head must not be disengaged during the procedure y Occiput has reached the anterior position labor is allowed to continue or assisted by forceps

OP Position: Forceps delivery
y If manual rotation is not accomplished y Blade is applied to the head in the posterior position

and is delivered in the OP position y MC of POP position is anthropoid pelvis y Occiput is directly posterior, horizontal traction is applied until the base of the nose is under the symphysis y Handles are slowly elevated until the occiput gradually emerges over the anterior margin of the perineum y Forcep is directed in a downward motion and the nose, face and chin , emerges out from the vulva

y Large episiotomy y Severe perineal lacerations y Severe vaginal lacerations y Erb and Facial nerve

palsies

OP Position: Forceps rotation on

Occiput Oblique Posterior
y Tucker-Mclane, Keilland, and Simpson forceps y Rotated 45 degrees to posterior position or 135 degrees

to anterior position y With Simpson and Mclane forceps head must be flexed
y Pelvic curvature which is originally directed upward, is

inverted and directed posteriorly y Causes vaginal sulcus tears and sidewall lacerations

y Keilland forceps

flexed head is not necessary for they have a more straightened pelvic curve

Forceps Rotation of OT
y Difficult operative vaginal delivery y Special skills and training are important y Either Simpson or Keilland forceps y The station of the fetal head must be accurately at or

below or below the level of the ischial spines

Forceps Rotation of OT: Keilland
y Wandering or gliding method y Anterior blade is introduced over the side of the pelvis over the brow or face y Blade is arched to an anterior position with the handle held close to the opposite maternal buttock y The second blade is introduced posteriorly and the branches are locked y Direct or classical application y Anterior blade is introduced with the cephalic curved directed upward curving under the symphysis y After it has entered far into the uterine cavity, it is turned on its axis into 180 degrees to adapt the cephalic curvature to the head

Forceps Delivery of Face Presentation
y With the chin directed toward the symphysis

mentum anterior forceps are occasionally used to effect vaginal delivery y Blades are applied to the sides of the head along the OM diameter, with the pelvic curve directed toward the neck y Downward traction is exerted until the chin appears under the symphysis y By an upward movement, face is slowly extracted with the nose, eyes, brow, and occiput appearing in succession over the anterior margin of the perineum

Morbidity from Forceps Operations
y Elective outlet forceps with rotations not exceeding 45

degrees are associated with little, if any, increase in maternal morbidity y Maternal injury increases significantly with rotations greater than 45 degrees and at higher stations y The need for blood transfusions is increased with operative vaginal delivery
y y y

Vacuum extraction 6.1 % Forceps 4.2 % CS 1.4 %

Febrile Morbidity
y Postpartum metritis is more frequent and severe in CS

deliveries compared to operative vaginal deliveries

Perinatal Morbidity
y In midpelvic level

increases neonatal morbidity y Higher incidence of intracranial hemorrhage y Increase the risk for brachial plexus injury

Complications
y Maternal - Pulmonary embolism - Increase blood loss - Febrile morbidity - Cervical and vaginal lacerations y Fetal - Facial and abducens nerve palsies resolve by 6 weeks - Increase risk of brachial nerve injury - Cephalhematoma midforceps - Transient forceps marks

Trial of Forceps and Failed Forceps
y Attempt for operative vaginal delivery is anticipated to

be difficult y OR and the staff are equipped for immediate cesarean delivery y If unsatisfactory - abandoned and proceeds to vacuum or CS delivery y If satisfactory gentle downward pulls are made on the forceps; if no descent abandoned y Fails to effect vaginal delivery CS delivery

Vacuum Delivery
y First used in 1829 by Seemann and Arnott y 1957 Malmston developed the modified instrument

using a metal cup

y Metal cup y Soft cup y Low incidence of scalp injury y Higher failure rate

y Silastic cup y Reusable device y Soft y 65mm diameter y CMI tender touch uses 62mm cup

Advantage
y Avoidance of insertion of space occupying steel blades

within the vagina y Avoidance of the requirement for precise positioning over the fetal head y Ability to rotate the fetal head without impinging on maternal tissues y Decreased ICP during traction

Recommendations
The classification of vacuum deliveries should be the same as that utilized for forceps deliveries (including station) 2. The same indications and contraindications utilized for forceps deliveries should be applied to vacuum-assisted deliveries 3. The vacuum should not be applied to an unengaged vertex, that is, above O station 4. The individual performing or supervising the procedure should an experienced operator 5. The operator should be willing to abandon the procedure if it does not proceed easily or if the cup pops off more than 3 times
1.

Indications
y Cervix must be completely dilated y Membranes must be ruptured y Fetal head must be engaged y Capability of quick CS is available

Maternal Indications
y Inadequate voluntary effort y Soft tissue obstruction y Elective avoidance of valsalva effort in the second stage y Malpresentation of the vertex

Fetal Indications
y Anticipated or evident fetal intolerance of continued

labor

Contraindications
y Inexperienced operator y Application to the aftercoming head, brow or face

presentation

Relative Contraindications
y Fetal prematurity y Prior fetal scalp trauma y Active bleeding or suspected fetal coagulation defects y Macrosomia y Nonvertex presentations

Procedure
y Note: y Proper cup placement is the most important determinant of success y Center of cup should be over the sagittal suture about

3 cm in front of posterior fontanelle towards the face y Full circumference of the cup should be palpated before and after vacuum has been created and prior to traction y Rigid cup gradually increases suction by o.2 kg/cm² every 2 min until a negative pressure of o.8 kg/cm² is reached

Procedure
y Soft cup

negative pressure can be increased to 0.8 kg/cm² over as little as 1 min y Traction is intermittent and coordinated with maternal expulsive efforts y 2 handed technique fingers of 1 hand are placed against the suction cup, while the other hand grasp the handle of the instrument y Progress of descent should accompany each traction attempt y Willingness to abandon attempts if satisfactory progress is not made

Guidelines for Abandonment
y Repeated detachments y Prolonged vacuum and traction efforts w/o significant

progress of delivery y Total extraction time takes up to 15 minutes or y 5-10 tractions during uterine contractions

Complications
y Maternal
y

Fewer vaginal and perineal lacerations

y Fetal
y y y y y

Large caput Cephalhematoma Subaponeurotic hemorrhage Retinal hemorrhage Occasional intracranial hemorrhage

Comparison of Vacuum Extraction with Forceps
Forceps Higher frequency of maternal trauma and blood loss More 3rd and 4th degree laceration Infants delivered have more marks and bruising Vacuum Increase in the incidence of neonatal jaundice Incidence of shoulder dystocia and cephalhematoma is doubled Increased fetal trauma Decreased maternal trauma and neonatal morbidity

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