New Assessment of Fetal Descent and Forceps Delivery

Satoru Takeda
Editor
New Assessment
of Fetal Descent and
Forceps Delivery
123
New Assessment of Fetal Descent
and Forceps Delivery
Satoru Takeda
Editor
New Assessment of Fetal

Descent and Forceps Delivery
Editor
Satoru Takeda, M.D., Ph.D.
Distinguished Professor Obstetric and Gynecology
Juntendo University
Tokyo, Japan
ISBN 978-981-10-4734-3 ISBN 978-981-10-4735-0 (eBook)

https://doi.org/10.1007/978-981-10-4735-0
Library of Congress Control Number: 2017955690
© Springer Science+Business Media Singapore 2018

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Preface
Forceps delivery and vacuum extraction delivery cases account for 5–15% of all deliveries.
Forceps and vacuum extraction are used to avoid maternal and fetal crises in the second stage
of labor, serving as essential tools for obstetricians. Although vacuum extraction delivery is the
major procedure, lawsuits over vacuum extraction delivery continue, and far more cases of
vacuum extraction delivery than forceps delivery are addressed by the Japan Obstetric
Compensation System Cause Analysis Committee. The reasons for this may include the fol-
lowing: multiple attempts at vacuum extraction despite poor fetal condition which prolongs
labor and results in deterioration and weak traction force necessitating combined use of the
Kristeller maneuver for expulsion of the fetus, resulting in deterioration of the fetal state. In
addition, in vacuum extraction delivery cases, trial traction may, unlike forceps delivery, be
performed even when the fetus is in a relatively high position, and traction may again be per-
formed if the fetal head descends. The forceps procedure involves no concept of carrying out
a trial; this procedure cannot be performed unless the fetal head is in the proper position for
forceps delivery. Therefore, the fetal head descent must be assessed accurately, and if the
proper position for forceps delivery is not achieved, there is no choice but to perform cesarean
section. Implementation of forceps delivery requires a good understanding of the processes of
normal labor, good pelvic examination skills for assessing the fetal head position, and acquisi-
tion of the proper technique.
Although we have consistently provided instruction on the forceps procedure alone, we
have attached the highest importance to the capability of the doctor to accurately perform pel-
vic examination, estimate the site of the largest fetal head circumference, explain these find-
ings, and share the information on cases with other doctors in case conferences, rather than
focusing on the forceps techniques themselves. Because the forceps procedure involves no
concept of a so-called trial run or practice attempts to assess the feasibility of delivery, the
forceps procedure cannot be performed without accurate pelvic examination. Therefore, the
goal of education is to master the site of the descending fetal head that allows safe and secure
forceps delivery. To this end, we provide education about accurate assessment of the fetal head
descent by means of important points of pelvic examination including the angle of the poste-
rior surface of the pubic symphysis and the palpable extent, using a new concept, the t-station,
based on the pelvic axis rather than the conventional concept of DeLee’s station, in order to
obtain more objective and practical pelvic examination findings.
This book describes new techniques for pelvic examination and the forceps procedure, but
we believe that this book is also useful for doctors who perform vacuum extraction delivery.
We would encourage readers to use this book as a reference and would appreciate any com-
ments from practitioners considering and applying the information provided.
Satoru Takeda, M.D., Ph.D.

Distinguished Professor
Juntendo University
Tokyo, Japan
v
Contents
New Concept of Fetal Station Based on the Trapezoidal Plane (T-Station) �� 1
Satoru Takeda
roperties and Characteristics of Forceps Delivery �� 9
P
Hiroyuki Seki and Satoru Takeda
Techniques for the Forceps Procedure�� 15
Jun Takeda and Satoru Takeda
Tokyo Kielland Forceps�� 29
U
Shintaro Makino, Jun Takeda, and Satoru Takeda
Education�� 37
Atsuo Itakura
vii
New Concept of Fetal Station Based
on the Trapezoidal Plane (T-Station)
Satoru Takeda
roper Positions for Vacuum Extraction

P In Japan, it seems that some operators of vacuum
and Forceps Delivery extraction delivery perform the vacuum extraction above
station −1 to ±0 as a trial and then switch to cesarean sec-
To perform vacuum extraction or forceps delivery, it is most tion, if extraction fails. However, in the case of forceps
important to estimate beforehand where in the pelvis the delivery, there is no concept of conducting a trial; there is
leading portion of the fetal head and the site of the largest only the choice between implementation of forceps deliv-
fetal head circumference are located. These are decisive fac- ery and implementation of cesarean section without for-
tors for judging whether the fetus is in the proper position for ceps delivery. The basic rule is that once the forceps
vacuum extraction or forceps delivery. If the position of the procedure is applied, the fetus should definitely be
fetal head is incorrectly estimated, forceps would be used on extracted, although there are some very rare cases in which
the fetus without proper positioning for forceps delivery, the forceps procedure is switched to cesarean section due
resulting in a failed forceps delivery or fetal injuries. If the to failure of the forceps delivery. The state in which the
fetus is correctly estimated to be not in the proper position fetal head is engaged is station −1 to ±0, as will be
for forceps delivery, cesarean section should be the proce- described later. Because this position is too high even for
dure of choice. It is important to ensure that this assessment forceps procedures with a strong traction force, vacuum
is performed objectively and the same assessment can be extraction of the fetal head in this position is necessarily
shared with other operators. Accurate assessment of fetal prolonged due to the time needed for expulsion of the
head descent and knowledge regarding the method, as well fetus, and the procedure carries risk when rapid extraction
as education and knowledge succession for the use of for- is necessary due to a non-reassuring fetal status. As pre-
ceps techniques, will assure successful, safe, and steady per- scribed in the American College of Obstetricians and
formance of forced delivery. Gynecologists (ACOG) guidelines, setting the requirement
When a worsening trend is observed through fetal heart rate for vacuum extraction and forceps delivery at station ≥ +2
monitoring and non-reassuring fetal status is thus suspected, is deemed appropriate [1].
the decision as to when the fetus reaches the proper position for
forceps delivery and whether the fetus can be extracted with
certainty largely depends on the extensive experience of the Largest Fetal Head Circumference
operator. Therefore, it is reasonable for the standards establish-
ing the proper position for forceps delivery to vary between Important diameters of the fetal head include the suboc-
experienced and inexperienced operators. The first priority is cipitobregmatic, anteroposterior, and mento-occipital
safe and secure implementation of the procedure. diameters, and their respective circumferences are also
important (Fig. 1). ACOG focuses on the distance
between the biparietal diameter and the lowest part of the
Electronic Supplementary Material The online version of this fetal head, because the cross section containing the bipa-
chapter (https://doi.org/10.1007/978-981-10-4735-0_1) contains sup- rietal diameter is consistent with the suboccipitobreg-
plementary material, which is available to authorized users.
matic circumference. On the other hand, the method of
S. Takeda, M.D., Ph.D. the University of Tokyo places importance on the dis-
Department of Obstetrics and Gynecology, Faculty of Medicine,
tance between the circumference and the lowest part of
Juntendo University, 2-1-1 Hongo, Bunkyo-ku,
Tokyo 113-8421, Japan the fetal head, taking into account its flexion and deflex-
e-mail: stakeda@juntendo.ac.jp ion status.
© Springer Science+Business Media Singapore 2018 1

S. Takeda (ed.), New Assessment of Fetal Descent and Forceps Delivery, https://doi.org/10.1007/978-981-10-4735-0_1
2 S. Takeda
a b c d
Fig. 1 Fetal attitude and the largest fetal head circumference plane. (d) Submentobregmatic plane (submentobregmatic circumference).
The lower figures (area and shape of the largest fetal head c ircumference The upper figures (fetal attitude and state of neck). (a) Occipital presen-
plane). (a) Suboccipitobregmatic plane (suboccipitobregmatic tation (flexion). (b) Bregmatic presentation (slight deflexion). (c) Brow
circumference). (b) Fronto-occipital plane (fronto-occipital circum- presentation (extension). (d) Face presentation (extreme extension)
ference). (c) Mento-occipital plane (mento-occipital circumference).
Occipitoanterior Position (Videos 1 and 2; Fig. 2) Frontoanterior Position (Videos 1 and 2; Fig. 2)
In normal delivery cases with the fetus in the occipitoanterior In the frontoanterior (FA) position (most frequent rotation
(OA) position, the fetal head is in flexion, and the suboccipi- abnormality), the fetal head is in a state of slight deflexion as
tobregmatic circumference is the largest fetal head circumfer- compared with the occipitoanterior (OA) position. Therefore,
ence (Fig. 1a). The passage of the greatest circumference in this case, the anteroposterior circumference becomes the
plane, not the lowest part, of the head through the pelvis largest head circumference (Fig. 1b). As labor progresses,
determines the stage of labor progression. Accordingly, when the fetal head becomes dolichocephalic, and the distance
the fetal head is engaged and descends into the pelvis, the site between the lowest part and the site of the largest head cir-
of the largest fetal head circumference in the pelvis is impor- cumference, i.e., the anteroposterior plane, becomes greater
tant for assessing “labor progression,” “fetal head descent,” than the distance between the lowest part and the suboccipi-
and “the potential difficulty level of forceps delivery.” tobregmatic plane (Fig. 2a). The cross-section area of the
In the OA position, the occipital region precedes, and anteroposterior plane in the FA position is wider than those
therefore, the largest fetal head circumference is estimated of the suboccipitobregmatic plane in OA position (Fig. 2b).
from this site of the leading portion. Of course, the distance Labor is often prolonged, and molding and caput succeda-
from the lowest part to the largest head circumference neum might be more substantial, causing a greater distance
expands if the fetal head is large, there is substantial molding between the lowest part and the largest fetal head circumfer-
of the fetal head, or severe caput succedaneum is present. ence. With this rotation abnormality, the FA position, the site
Therefore, the leading bony portion, rather than the leading of the largest fetal head circumference is actually higher than
skin portion, of the fetal head should be determined for accu- expected even if the lowest part appears to have descended
rate assessment of the station. The bone site is assessed after sufficiently (Fig. 2a). This makes vacuum extraction and for-
subtracting caput succedaneum. ceps delivery difficult.
New Concept of Fetal Station Based on the Trapezoidal Plane (T-Station) 3
a b
Published with kind permission of © Satoru Takeda 2017. All Rights Reserved
Fig. 2 Occipitoanterior (OA) position (left slide image) and frontoan- is the largest circumference in FA. Although the station is +3, the same
terior (FA) position (right slide image). (a) Site of the largest circumfer- as that of the occipitoanterior position, the site of fronto-occipital plane
ence plane in OA and FA position at station +3. The suboccipitobregmatic is far higher in FA position. (b) Area of the largest circumference plane
circumference (suboccipitobregmatic plane) is the largest circumfer- in OA and FA position at station +3. Area of fronto-occipital plane in
ence of OA. The fronto-occipital circumference (fronto-occipital plane) OA is far larger than those of suboccipitobregmatic plane in FA
a b
Fig. 3 Difference of frontoanterior (FA) position and occipitoposterior The fetal neck is in a state of extreme flexion. Forceps delivery for
(OP) position. (a) The leading portion is sinciput in FA position. The arrested OP position used to be more difficult from those for FA posi-
fetal neck is in slight deflexion. This FA position is one of the most tion. This OP position used to be hard to be delivered spontaneously
common malrotation. (b) The leading portion is occiput in OP position. without small baby, even by forceps delivery
Although ACOG does not distinguish between the term labor. The incidence of failed forceps in the OP position
frontoanterior (FA) and the occipitoposterior (OP) positions, cases is higher, compared with cases in the FA position.
we do, in fact, distinguish between these two (Fig. 3). The
former is a common rotation abnormality in which the sinciput
rotates anteriorly while it precedes with the fetal head in a Synclitism and Asynclitism
position of slight deflexion. The latter is an extreme flexion
with the presenting occiput rotating posteriorly. The latter is Synclitism is a condition in which the sagittal suture of the
common in premature infants having a small head that allows fetal head entering the pelvis is, for practical purposes, at the
the space between the pelvic wall and the fetal head. In this center of the plane of the pelvic inlet, with the right and left
condition, labor is relatively smooth in some cases while being parietal bones at the same level. Asynclitism is a condition in
usually arrested in term labor of the OP position. In both the which there is a substantial deviation of the sagittal suture of
FA and OP position cases, the largest head circumference is the entering fetal head anteriorly or posteriorly. Anterior
greater and thereby reduces the space to the pelvic wall, such asynclitism is a state in which the anterior parietal bone is
that labor progresses slowly, and is more likely to result in leading and lower, and posterior asynclitism is that in which
arrested or prolonged labor. Forceps deliveries of the OP posi- the posterior parietal bone is leading and lower. Asynclitism
tion are much more difficult than those of the FA position in of the fetal head is usually converted to synclitism when the
4 S. Takeda
fetal head is engaged in the pelvis. However, on rare occa- expressed with plus values, because these values are on a
sions, asynclitism continues to cause stagnation of labor. It virtual perpendicular line rather than being actual measure-
may occur in cases with prolonged or arrested labor in sta- ments. There are marked variations in individual values, and
tion +2 or +3 and is more common during painless labor with it is sometimes difficult to share an understanding of the
epidural anesthesia. conditions of clinical cases during rounds or at case confer-
ences, concerning the status of fetal head descent, imple-
mentation of forced delivery, and the circumstances of
Station (De Lee) difficult cases.
According to the parallel pelvic plane system (Hodge’s sys-

tem of parallel pelvic planes, Fig. 4), the region from the rapezoidal Station (T-Station) Based
T
pelvic inlet to the tip of the coccyx is divided into three por- on the Pelvic Axis
tions by planes parallel to the pelvic inlet plane, and the third
plane that passes the ischial spine is the basis for the concept In view of the drawbacks of the concept of De Lee’s station,
of De Lee’s station (Fig. 4). The site of the lowest part of the we advocate a new station concept based on determining the
fetal head is expressed with a distance in cm from this base site of the lowest part of the fetal head descending along the
level, with upward set as minus and downward as plus. pelvic axis and expressing it in cm, using the plane connect-
However, in actuality, the lowest part of the fetal head ing the inferior margin of the pubic symphysis and the right
descends anteriorly along the pelvic axis when the fetal and left ischial spines as the base plane (Fig. 5) [2, 3]. The
head enters the pelvis (Fig. 2a). Therefore, this station lacks Center for Maternal, Fetal, and Neonatal Medicine of the
objectivity when the fetal head is engaged in the pelvis and Saitama Medical University Medical Center and the
Department of Obstetrics and Gynecology, Juntendo
University, use this base plane as the trapezoidal plane and
express descent from this plane as the trapezoidal station
(t-station). In comparison with the conventional De Lee’s sta-
tion, the obtained descent is theoretically greater, and there-
fore, plus values are slightly larger. However, differences in
relative clinical benefit, when put into practical use, are mini-
mal between these two methods of station expression.
In fact, fetal head descent can be palpated with the bent mid-
dle finger when the obstetrician touches the inferior margin of
the pubic bone with the superior margin of the root of the index
finger while applying the index finger to the ischial spine (Video
IP 3; Fig. 6a–d). If the “distance between the index finger and the
middle finger” and the width of the index finger are measured in
II P (Cp)
4
3
2
1
III P (Sp) 0
1
2
3
4
IV P
Fig. 4 De Lee’s station and Hodge’s system of parallel pelvic planes.

Station is defined according to the levels of the leading portion of the
fetal head in centimeters horizontally above or below the levels of the
maternal ischial spines (the third plane; IIIP). This fetal head is located
at station −2. First plane (the first parallel; I P) = plane consistent with
the pelvic inlet plane. Second plane (the second parallel; II P) = plane
parallel to the first plane and passes the inferior margin of the pubic
symphysis (also called the chief plane; CP). Third plane (the third Fig. 5 New fetal station (t-station) based on the trapezoidal plane (infe-
plane; III P) = plane that includes the end of the ischial spine (also rior oblique view). The concept of t-station along the pelvic axis is
called the interspinal; Sp). Fourth plane (the fourth plane; IV P) = plane based on the trapezoidal plane consisting of both ischial spines and the
that includes the tip of the coccyx lower edge of the pubic symphysis
Fig. 6 Actual measurement of

t-station. The distance between the a
extended second finger (index
finger) and the bent third finger
(middle finger) should be measured
in advance, with an image of
measuring the station while
touching the ischial spine. The
physician applies the index finger to
the ischial spine, palpates the
inferior margin of the pubic
symphysis with the superior margin
of the root of the index finger, and
bends the middle finger and palpates
the lowest part of the descending
fetal head with the third finger. At
this time, if the distance between the Published with kind permission of © Satoru Takeda 2017. All Rights Reserved
superior margin of the
metacarpophalangeal joint of the b
second finger and the distal
interphalangeal joint of the third
finger is known, the t-station can be
estimated. In the author’s experience
with his own fingers, however, the
t-station is about +3 when the ischial
spine is felt, and the fetal head is
palpated by the broadly expanded
third finger; in this situation, it is
determined that traction with the
forceps can be performed safely.
With the third finger expanded
lightly, the t-station can be regarded
as +2. The judgment is based on the
data of the width and rate of the
palpable posterior surface of the c
pubis. (a) The fetal head is
descending to t-station is +1, (b)
t-station +2, (c) t-station +3, (d)
t-station +4
6 S. Takeda
advance, the descent can be estimated as +1, +2, +3 cm, etc.,

using finger breadths, providing objective measurements asso-
ciated with fewer individual differences. Thus, this method
facilitates sharing of understanding of the situation and is useful
for the assessment of labor in the phase at which the fetal head
descends. Because the station represents the degree of fetal
descent, it should be assessed and recorded when the fetal head
is maximally descended during the uterine contraction phase.
When forceps are inserted, the fetal head will be elevated.
Therefore, traction with forceps should begin when the fetus has
sufficiently descended in response to bearing down efforts. To
avoid the influences of caput succedaneum, the station should
be expressed with the leading bony portion of the fetal head.
When the caput succedaneum is large or when there is
severe molding change due to prolonged labor, the largest fetal
head circumference is at an upper site. Even at the same sta-
tion, when the fetal head is large such as in an excessively
large infant, the largest head circumference is at a maximally
distant upper site; when the fetal head is small, the largest head
circumference is at a lower site. Rotation abnormalities such
as the frontoanterior position and the occipitoposterior posi-
tion, asynclitism, and the pelvic form also affect the station. Fig. 7 The pelvic segment divided by the four major planes and a site
of the fetal largest circumference plane. The plane of the inlet is
bounded by the promontorium and the inner border of the symphysis.
The plane of greater pelvis dimension ranges from the inner border of
elvic Segmentation and the Method
P the symphysis to the junction of the fused second and third sacral verte-
of Comprehensive Fetal Head Descent brae. The plane of least pelvic dimension is bounded by the inner bor-
der of the symphysis and the sacrococcygeal joint and laterally by the
Assessment ischial spines. The plane of the outlet is bounded by the inferior border
of the symphysis, the ischial tuberosities laterally, and the sacrococcy-
As shown in Fig. 7, the site of the largest fetal head circum- geal joint. Level of the pelvic segments is separated to high, mid, low,
ference in the pelvic segment is expressed as “high,” “mid,” and outlet levels. Types of forceps deliveries are classified into midfor-
ceps, low forceps, and outlet forceps by a site of the largest fetal head
“low,” and “outlet area.” The relation between t-station and
circumference plane
the largest fetal head circumference is shown by the accumu-
lation of the actual Guthmann pelvic radiogram (Video 1,
left; OA position; Fig. 8a–f). The largest circumference plane Palpation of the space between the posterior surface of the
is located above the inlet area at t-station −2, corresponding pubis and the fetal head and the situation of the space
to a “high” position, and in the vicinity of the inlet area at between the fetal head and the anterior surface of the sacrum
t-station −1, and the largest circumference plane is engaged enable more accurate assessment of fetal head descent, in
into the inlet area at t-station ±0 (Fig. 8a). addition to station, to be performed (Video 4; Fig. 8a–f).
The largest fetal head circumference plane is located in In general, in t-station +2, a 2/3–1/2 portion of the poste-
the higher-mid position at t-station +1 (Fig. 8b), whereas at rior surface of the pubis is palpable, and there is a wide space
t-station +2, it is in the lower-mid position to higher-low between the fetal head and the anterior surface of the sacrum
position (Fig. 8c). The corresponding site is in the low posi- (Video 4; Fig. 8c), although this is not entirely true due to
tion at t-station +3 (Fig. 8d), in the lower-low position to some variations reflecting the size of the fetal head and the
nearly outlet position at t-station +4 (Fig. 8e), and in the out- degree of rotation. In t-station +3, a 1/2–1/3 portion of the
let position at t-station +5 (Fig. 8f). The ACOG concepts of posterior surface of the pubis is palpable, and the space
low forceps and outlet forceps are nearly consistent with our between the fetal head and the anterior surface of the sacrum
classification by t-station (Table 1). is narrow (Video 4; Fig. 8d). In t-station +4 and more, a 1/3
However, in actual clinical practice, the largest head cir- or less portion, or even none, of the posterior surface of the
cumference varies greatly according to the size of the fetal pubis is palpable, and there is no space at the anterior surface
head, rotation abnormalities, and the grade of molding func- of the sacrum because the fetal head reaches the floor of the
tion, making it difficult to estimate based solely on the sta- pelvis (Video 4; Fig. 8e, f). Because the direction of traction
tion. Thus, if fetal head descent is assessed incorrectly, on the fetal head in forced delivery is consistent with the
traction begins from a high position, leading to the occur- angle of the posterior surface of the pubis, this angle should
rence of unexpected difficulties and potential complications. also be palpated during pelvic examination.
a b
Published with kind permission of © Satoru Takeda 2017. All Rights Reserved Published with kind permission of © Satoru Takeda 2017. All Rights Reserved
c d
e f
Fig. 8 Relation between t-station (0 to +5), the palpable range of the wide, empty space in front of the sacrum. (d) The fetal head at t-station
posterior surface of the symphysis, and the site for the largest fetal head +3. The corresponding site is descending into the low position at t-sta-
circumference. (a) The fetal head at t-station ±0. The site of the largest tion +3. A 1/2–1/3 portion of the posterior surface of the pubis is pal-
fetal head circumference usually descends through the true obstetric pable, and the space between the fetal head and the anterior surface of
conjugate at t-station ±0. All posterior surfaces of the pubic symphysis the sacrum is narrow. (e) The fetal head at t-station +4. The correspond-
are palpable. (b) The fetal head at t-station +1. The largest fetal head ing site is into the low position to nearly outlet position at t-station +4.
circumference plane is descending in the higher–mid position at t-sta- The posterior surface of the pubic symphysis can be barely palpated.
tion +1. (c) The fetal head at t-station +2. The site of the largest fetal There is no space between the fetal head and the sacrum. (f) The fetal
head circumference is usually located in the lower–mid position to near head at t-station +5. The corresponding site is into the outlet position,
the plane of greater pelvis dimension. At this point, two-thirds to half of and its level is nearly consistent with fetal head appearing
the posterior surface of the pubic symphysis are palpable. There is a
8 S. Takeda
Table 1 ACOG classification of forceps deliveries according to the De Lee’s station, compared with that according to T-station
ACOG, 2007 T-station
Rotation T-station The palpable range of The anterior space of
Types of forceps deliveries The De Lee station the symphysis the sacrum
Midforceps +1 +1 All
Low forceps +2 >45° +2 (higher level) 2/3–1/2 Wide
+3 (lower level) 1/2–1/3 Narrow
Outlet forceps Not exceeding 45° ≥ +4 (outlet) <1/3–none None
Difference from ACOG in descriptions of forceps is approximately consistent with outlet forceps
forceps procedures combined with a part of lower-low forceps of our
classification.As to the merits and appeal of forceps delivery
The levels of forceps application described by ACOG are as which are in clear contrast to vacuum extraction delivery, the
follows (Table 1): forceps procedure allows delivery of the fetus with a single
session of traction from the higher–low or lower–low posi-
1. Station +1 = midforceps tion, and it proves its worth in non-reassuring fetal status
2. Station ≥ +2 and the sagittal suture making an angle of cases, achieving expedient delivery.
45° or more (a state in which the sagittal suture makes
an angle of 45° or more, being approximately oblique
to the transverse, with 0 o’clock set as 0) = low forceps References
3. The sagittal suture making an angle of less than 45°
(approximating the longitudinal direction) = outlet forceps 1. Hale RW, editor. Dennen’s forceps deliveries. 4th ed. Washington,
DC: ACOG; 2001.
2. Takeda S, Takeda J, Koshiishi T, Makino S, Kinoshita K. Fetal station
Conventionally, the level of forceps application has been based on the trapezoidal plane and assessment of head descent dur-
expressed as higher-low, lower-low, and outlet forceps in ing instrumental delivery. Hypertens Res Pregnancy. 2014;2:65–71.
our classification. It seems that ACOG’s low forceps is 3. Seki H, Takeda S. A review of prerequisites for vacuum extrac-
tion: appropriate position of the fetal head for vacuum extraction
approximately consistent with our higher-low forceps and from a forceps delivery perspective. Med Clin Rev. 2016;2(2):22.
most part of lower-low forceps category, and ACOG’s outlet http://www.imedpub.com/
Properties and Characteristics
of Forceps Delivery
Hiroyuki Seki and Satoru Takeda
I ndications and Prerequisites before implementation. There are seven prerequisites for for-
for Forceps Deliveries ceps delivery, as below:
Indications 1. “The mother’s capacity to endure the burden imposed by

the operation” is a basic prerequisite for an obstetrical or
Indications for forceps deliveries are classified into two fac- any other operative procedure.
tors such as maternal and fetal indications. Maternal indica- 2. “The fully dilated and effaced cervix” is required because
tions include in any condition threatening the mother or there is an increased risk of cervical laceration and uter-
fetus. The common are prolonged second-stage labor and ine rupture if forceps delivery is performed in cases with
arrested labor and exhaustion. The former is defined as >3 h full dilatation of the cervix.
with or >2 h without painless labor. Some indications are 3. “Absence of cephalopelvic disproportion (CPD)” is
maternal complications such as heart disease, preeclampsia, also an essential condition for implementation of vagi-
pulmonary disease, neurological disorders, and so on. Fetal nal delivery. The operator should know the type of
indications are nonreassuring fetal status due to cord com- pelvis. Outlet contraction is also an indication for for-
pression, placental dysfunction, and premature placental ceps delivery unless there is CPD. When forceps
separation. delivery is performed, if the fetus is pulled in a suit-
able direction, delivery can be achieved even with out-
let contraction, by a single session of traction so long
Prerequisites as there is no CPD.
4. “Existence of rupture of the membranes” is necessary
Prerequisites for forceps delivery are conditions under which because it is apparent that application of the forceps and
forceps delivery is feasible. More specifically, they are the traction of the fetus cannot be performed safely if the
absolutely necessary conditions for performing forceps membranes have not yet ruptured.
delivery safely, and forceps delivery should not be performed 5. “A proper position for forceps application” means the
unless these conditions are met. In forceps delivery cases, level of the fetal head at which the largest fetal head cir-
these prerequisites should be borne in mind and confirmed cumference is engaged in the small pelvic cavity, and
forceps delivery can be performed by a doctor who has
sufficiently mastered the technique and is able to diag-
nose the fetal head descent. More specifically, the proper
position is when the lowest part of the fetal head reaches
H. Seki, M.D., Ph.D.
Center for Maternal, Fetal and Neonatal Medicine, Saitama station +2 or a lower position. Therefore, forceps deliv-
Medical Center, Saitama Medical University, 1981 Kamoda, ery must not be performed in cases in which the fetal
Kawagoe, Saitama 350-8550, Japan head is located higher than station +2. The absolutely
e-mail: h_seki@saitama-med.ac.jp necessary conditions for safe forceps delivery are accu-
S. Takeda, M.D., Ph.D. (*) rate findings including the level of the fetal head and are
Department of Obstetrics and Gynecology, Faculty of Medicine, obtained from pelvic examination, and it is confirmed
Tokyo 113-8421, Japan that the fetal head has descended to station +2 or a lower
e-mail: stakeda@juntendo.ac.jp position.

10 H. Seki and S. Takeda
6. The fetal head is of nearly mature, normal size. To assure Certainty of Low Forceps
good forceps application, the fetal head should not be too
large or too small and should be sufficiently firm. It is Low forceps means the application of forceps for the fetal
necessary that the fetal head has grown to a certain size. head reaching station +2 or a lower position. Usually, the
In principle, forceps delivery is not performed on a hydro- sagittal suture is oblique. If vacuum extraction is used for
cephalic or an anencephalic fetus. the fetal head located in this position, it is difficult to pull
7. The fetus is alive. the fetus in a correct direction, and thus slippage is likely
to occur. In addition, as mentioned previously, slippage
Key points and precautions regarding forceps delivery are also occurs when the static friction force is equal to or
shown in Tables 1 and 2. greater than the suction force. Slippage is more likely to
occur when a rotation abnormality is present.
In contrast, if the prerequisites for forceps delivery are
Table 1 Key points for clinical application of forceps delivery
faithfully followed, and if the operator is skilled in perform-
1. Obtain accurate findings from pelvic examination and express ing the procedure, the low forceps approach allows steady
them properly (share the data of cases)
extraction of the fetus with a single traction even in the pres-
– T-station along the pelvic axis
ence of a rotation abnormality. Low forceps delivery repre-
– Set the inferior margin of the pubic bone and the line
between the ischial spines as the base lines sents the best example of forceps application as an excellent
2. Follow the indications and prerequisites procedure for achieving forced delivery.
– Fetal head descent at t-station +2 or a lower position
3. Take the operator’s forceps skills into account
– One-on-one instruction in the technique of forceps delivery Delivery Prospects
– Ascertain the level of the fetal head for safe implementation
of the forceps procedure with confidence Because there is no concept of a trial when performing for-
– T-station +3 or a lower position will suffice for beginners ceps delivery, the forceps procedure cannot be carried out
and residents
unless the fetus is in a proper position, i.e., station +2 or a
4. Delivery prospects
lower position. Depending on the level of skill mastery, the
– Abnormal fetal heart rate patterns and rough indications for
instrumental delivery operator may wait until the fetus is in a proper position for
– Prospect of fetal head descent forceps application and has reached a more assuring posi-
– Cesarean section is available anytime tion, i.e., station +3 or a lower position. It is also possible that
– Cesarean section should be performed, while contractions are the forceps procedure cannot be applied to cases with a
suppressed, and the fetal head is pushed up from the vagina transverse sagittal suture and must be switched to vacuum
– Forceps should be brought into the operating room because extraction or cesarean section. When abnormal fetal heart
the fetal head might descend while carring a patient from rate patterns appear on the monitor in cases with station +0
the ward
or +1, which are positions unsuitable for forceps delivery, it
is difficult to predict how long it will take until the fetus
Table 2 Educational precautions for forceps delivery
reaches a proper position for forceps application with efforts
to make the fetus descend. This is a difficult judgment to
1. Understanding of the properties of forceps and mastering of all
necessary skills
make, which requires experience, and also depends on
2. Judgment of the most proper position for forceps application and whether the mother is a primipara or a multipara. Even when
the delivery prospects the fetus is station +2, a proper position for forceps applica-
3. Mastery of low forceps delivery tion, the operator may wait until the fetus descends lower to
– In cases with NRFS a position that allows safer extraction.
4. Oblique or transverse presentation (pelvic application, fetal head The currently used fetal heart rate classification and the
application) concept of nonreassuring fetal status (NRFS) contain no
5. Direction of traction, handling of extraction difficulties temporal element, and the time limit for safe extraction of
6. Prevention and handling of soft birth canal injuries the fetus to avoid neonatal asphyxia and hypoxemia after the
– 2000 mL blood loss with the use of Kielland forceps or
onset of repetitive abnormal fetal heart rate waveforms
higher low forceps
remains unclear. The decision to use forced delivery requires
7. Cesarean section can be performed urgently
– The anesthesiology department and the operating room
management of the fetal heart rate waveform by monitoring
should be informed of the case including a rough temporal axis. In the event of forceps
– Uterine contractions should be suppressed by the delivery, the fetus can be extracted by a single traction if it is
administration of ritodorine hydrocloride or nitroglycerin, in a proper position for forceps application. In contrast, in
and forceps should be brought into the operating room vacuum extraction cases in which the traction force is
Properties and Characteristics of Forceps Delivery 11
weaker, multiple tractions or concomitant application of oil be applied to the outer side of the blades to facilitate
uterine fundal pressure maneuvers is often required. insertion of the forceps.
Prolonged delivery or mistaken predictions regarding the 2. Drip infusion
course of delivery can result in worsening of the fetal condi- It is essential to establish vascular access because the risk
tion, possibly leading to increased neonatal asphyxia. of soft birth canal laceration is high in forceps delivery
cases. Because blood transfusion may be required, it is
desirable to secure vascular access using an 18G or
Optimal Timing of Forceps Delivery greater indwelling needle. An infusion of 5% glucose or
lactated Ringer solution may also be administered.
Estimation of the time to reach a proper position for forceps 3. Anesthesia
application should be prompt and correct when a decision Local anesthesia at the time of episiotomy may be sufficient
as to whether or not to perform a cesarean section must be in some cases, but the pelvic floor muscles are often not
made. In this situation, a temporal index to estimate the relaxed in women undergoing forced delivery because the
time allowance is necessary. We predict the time of delivery maternal body is in a state of excessive tension. Therefore,
with reference to the data reported by Mukubo M., anesthetization is useful not only for pain control but also
Horiguchi S. and Makino S., et al. who examined the rela- for reducing tension in the pelvic floor muscles.
tionship between time from the appearance of abnormal Pudendal block is a useful and effective method of reducing
heart rate waveforms late in the first or in the second stage tension in the pelvic floor muscles that can be conducted
of labor until expulsion and a pH value of 7.20 or less for rapidly and easily. Epidural anesthesia is also a useful
umbilical arterial blood. Optimal timing of fetal extraction method that allows control of the intensity and duration of
after the appearance of abnormal fetal heart rate patterns at anesthesia, although it is more time-consuming than puden-
delivery as below [1, 2]: dal block to administer. The pudendal nerve is a set of
nerve fibers from the lower part of the vagina and perineum,
1 . “Continuous bradycardia” pattern is within 10–17 min. and it passes along the posteroinferior and medial side of
2. “Late deceleration” pattern is within 28 min. the ischial spine and is distributed after trifurcating to the
3. “Severe variable deceleration” pattern is within 30–33 min. inferior hemorrhoidal nerve, perineal nerve, and the dorsal
nerve of the clitoris. Pudendal nerve block is an anesthetic
Sustained bradycardia is roughly indicated by 15 min, method by which a local anesthetic infiltrates and spreads
considering an index of 17 min for uterine rupture. Severe into the area just above the trifurcation of these nerves:
variable or late deceleration is currently managed with an Apply fingers internally to the tip of the ischial spine, and
index of “30 min”. These indices are currently undergoing insert a Koback needle into a portion posteroinferior and
verification, and no particular complications of neonates medial to the site where the fingers are applied. Inject
have been recognized. about 5–10 mL of a local anesthetic (1% xylocaine) only
after confirming by suction test that there is no insertion
into the blood vessel.
Preparation for Forceps Delivery Inject the anesthetic bilaterally to reduce the tension of the
pelvic floor muscles. However, bilateral injection may
The most important thing to initiating forceps delivery is to decrease labor pain intensity and prolong the labor pain
obtain accurate pelvic examination findings. It is essential to interval. If urgent delivery is required because of nonreas-
perform an accurate pelvic examination to satisfy the prereq- suring fetal status (NRFS), anesthetic should be injected
uisites for forceps delivery. Therefore, after the decision to only on the perineotomy side. If the operator is suffi-
implement forceps delivery has been made, disinfection of ciently skilled, bilateral pudendal nerve block is complete
the vulva, urination, and setup of an infant warmer should be within 1 min.
completed. In principle, a neonatologist should be asked to Epidural anesthesia is usually used for painless delivery.
attend the delivery. Epidural anesthesia requires at least 30 min from insertion of
the epidural catheter to confirmation of insertion or no inser-
1. Devices tion into the dura mater (confirmation by infusion of a test
In routine forceps delivery cases, UTokyo Naegel forceps dose of the local anesthetic) and to the onset of the effect of
are used. However, UTokyo Kielland forceps may also be the local anesthetic even if a skilled anesthesiologist per-
used if there is any rotation abnormality. In the past, piper forms it. Therefore, epidural anesthesia can be chosen when
forceps were occasionally used for extracting the after- forceps delivery is performed for nonurgent cases with pro-
coming head in breach delivery cases, but UTokyo Naegel longed or arrested labor, but cannot be chosen when forceps
can be used as a substitution. It is recommended that the delivery is performed as a forced delivery procedure in cases
12 H. Seki and S. Takeda
with NRFS. Because the anesthesia is too deep, there is no Proper implementation of vacuum extraction ensures that
abdominal pressure. Therefore, the anesthetic depth should obstetricians perform an excellent forced delivery procedure,
be maintained at a level that just barely allows relaxation of making maximum use of the merits of vacuum extraction
the pelvic floor muscles, rather than aiming for complete and minimizing its demerits. In this regard, vacuum extrac-
elimination of labor pain. tion delivery should not be performed without careful con-
sideration, but should be implemented when the prerequisites
and indications are strictly met, the same as in forceps deliv-
ifferences Between Vacuum Extraction
D ery cases.
and Forceps Delivery
Vacuum Extraction Versus Forceps roblems of Vacuum Extraction

P
Delivery in Japan
Vacuum extraction was associated with an obviously lower
frequency of soft birth canal laceration, less frequent anes- Because the forceps procedure carries a risk of causing com-
thesia at delivery, and milder pain during delivery and the plications in both the mother and the fetus if applied without
puerperal period, thereby causing less damage to the mater- sufficient prudence, meticulous efforts must be made to
nal body. Cephalohematoma and fundal hemorrhage were achieve safe implementation of the procedure, as described
clearly more frequent in cases undergoing vacuum extraction below:
delivery, while cranial and facial injuries were slightly more
frequent in forceps delivery cases, although the difference • Avoid high forceps delivery (the fetal head is above sta-
did not reach statistical significance. There was no signifi- tion +1).
cant difference in injuries to the fetus between the two types • Master the pelvic examination technique to accurately
of delivery [3, 4]. The probability of switching to cesarean assess the level of the fetal head.
section was lower with vacuum extraction delivery. This is • Learn the forceps delivery technique from one-on-one
probably explained by forceps delivery being performed in instruction and operative birth simulation training.
some cases in which an attempt at vacuum extraction deliv-
ery failed. It has also been shown that failure of the proce- The measures mentioned above are feasible and have
dure is more frequent with vacuum extraction delivery than been strictly undertaken. As a result, forceps delivery has
with forceps delivery. become a rather safe technique for forced delivery by mini-
The results of the aforementioned Cochrane review mizing the frequency of associated complications through
suggest that the following conclusions can be drawn [3, compliance with the prerequisites and proper indications for
4]. Namely, forceps delivery exerts a stronger traction forceps delivery, as well as ongoing learning and mastery of
force than vacuum extraction delivery and is thus also the necessary skills.
applicable to cases with abnormalities of rotation, achiev- But vacuum extraction delivery is technically easier than
ing vaginal delivery in cases with difficult expulsion with forceps delivery and therefore tends to be performed without
vacuum extractor so long as the prerequisites are faith- careful consideration. It is not rare to find that the main
fully met. It has also been suggested that the risk of inju- causes of complications in the mother and the child, such as
ries to the fetus during forceps delivery is comparable to cerebral palsy, were vacuum extraction procedures among
that associated with vacuum extraction delivery when the medical litigation cases or those receiving analysis from the
procedure is properly performed and the prerequisites and obstetric compensation benefits system. Analysis of these
indications are met, although the public tends to have the causes may facilitate our understanding of the easily missed
impression that the forceps procedure is dangerous to the drawbacks of vacuum extraction delivery and the advantages
fetus because the fetal head is held with metal forceps (in of forceps delivery.
fact, proper application of forceps does not cause com- In this regard, the author addresses and summarizes below
pression of the fetal head). These are the advantages of the problems identified in cases of medical litigation and
forceps delivery. those analyzed for the obstetric compensation benefits sys-
Vacuum extraction delivery, which involves the applica- tem in Japan [5]:
tion of a suction cup, is technically easier than forceps deliv-
ery, and the risk of maternal soft birth canal laceration is • The technique of vacuum extraction delivery is used with-
lower for vacuum extraction delivery than for forceps deliv- out careful consideration of the level of the fetal head.
ery, although the traction force is lower in the former. Thus, • Forceps delivery or cesarean section is not adopted even if
as in the USA, vacuum extraction delivery is more common slippage has occurred multiple times.
than forceps delivery in many institutions throughout Japan. • As a result, prolonged stress is imposed on the fetus.
Properties and Characteristics of Forceps Delivery 13
• Vacuum extraction fails to achieve delivery despite hav- is important to complete delivery rapidly. This is why rapid
ing been used as a technique of forced delivery, and a forced delivery is required. The Clinical Guidelines for
wait-and-see approach is consequently taken. (Once Obstetrical Practice in Japan recommend that traction be per-
forced delivery is attempted, delivery should be com- formed within five sessions and for not more than 20 min.
pleted by another more stable method such as forceps This does not mean that up to five sessions and 20 min are
delivery or cesarean section.) permitted. It would be best for the fetus to be extracted in a
single session of traction. If vacuum extraction fails to
achieve delivery, it is important to switch, early in the pro-
1. The technique of vacuum extraction delivery is used with- cess, to another forced delivery technique in order to com-
out careful consideration of the level of the fetal head. plete delivery. The duration of stress on the fetus should be
Theoretically, it is not rational to use vacuum extraction to as short as possible.
pull the fetal head located in a high position, which is a contra-
indication for forceps delivery, because the traction force of 4. Vacuum extraction fails to achieve delivery despite having
vacuum extraction is weaker than that of forceps delivery. A been used as a forced delivery technique, and a wait-and-see
successful vacuum extraction does not mean that the tech- approach is consequently taken.
nique is always performed safely and achieves the desired out- If a wait-and-see approach can be taken again, it is ques-
come. In other words, the success of vacuum extraction in a tionable whether there is an indication for forced delivery in
case in which the fetal head is located in a high position does the first place. If the waiting approach is actually possible,
not provide information about another case. It is important to the operator should not perform vacuum extraction delivery
perform vacuum extraction delivery after obtaining accurate hastily, but should wait for the fetal head to descend to a level
findings from pelvic examination to confirm the level of the that allows safe implementation of vacuum extraction
fetal head that allows steady traction (it should be station +2 or delivery.
a lower position, as in the case of forceps delivery). One of the reasons for cases like this frequently occurring
is that the advantage of vacuum extraction delivery, which is
2. Forceps delivery or cesarean section is not adopted not particularly difficult technically and has a lower risk of
immediately even if slippage has occurred multiple times. soft birth canal laceration in the mother as compared to for-
Multiple slippages in vacuum extraction delivery cases ceps delivery, may lead to the implementation of vacuum
might be attributable first to incorrect direction of traction. extraction without sufficient prudence. Vacuum extraction
However, the greatest weakness of vacuum extraction is the delivery is actually associated with fewer complications in
lack of guarantee that the fetus will be extracted even when the mother than forceps delivery, but complications in the
the direction of traction is correct (the fetus can surely be fetus are reportedly more frequent with vacuum extraction
extracted with forceps when the direction of traction is cor- delivery [6, 7]. Thus, vacuum extraction delivery should not
rect so long as the prerequisites for the procedure are met). be performed without careful consideration.
This fact is easier to understand from the viewpoint of the
“friction force” versus the “suction force.” For example,
when we attempt to pull a ball out of a cylinder with an aspi-
rator, slippage occurs repeatedly even with traction in the References
correct direction so long as the static friction force is greater
1. Makino S, Hirai C, Takeda J, Itakura A, Takeda S. Relationship
than the suction force. In an actual delivery, the same thing between fetal heart rate patterns and a time course for evaluation of
occurs when the fetus is large relative to the birth canal. fetal well-being: “the 30 minutes rule” for decision of mechanical
Furthermore, slippage is more likely to occur when there are delivery. TAOJ. 2017 (in press).
concomitant rotation abnormalities or tension in the soft 2. Seki H. Properties and characteristics of forceps delivery. In: Takeda
S, Seki H, editors. New assessment of fetal descend and forceps
birth canal. delivery. Tokyo: Medical View; 2015. p. 60–7. In Japanese.
Therefore, the procedure should be changed from vacuum 3. Chochrane Database Syst. Rev. 2010;11:CD000224.
extraction to forceps delivery or cesarean section if slippage 4. Chochrane Database Syst. Rev. 2010;11:CD005455.
has occurred twice or three times at most. Switching to 5. Seki H, Takeda S. A review of prerequisites for vacuum extraction:
appropriate position of the fetal head for vacuum extraction from
another forced delivery technique is usually recommended, a forceps delivery perspective. Med Clin Rev. 2016;2(2):22. http://
with prudence, if even a single slippage occurs. www.imedpub.com/
6. Bofill JA, Rust OA, Schorr SJ, et al. A randomized prospective trial
3. As a result, prolonged stress is imposed on the fetus. of the obstetric forceps versus the M-cup vacuum extractor. Am J
Obstet Gynecol. 1996;175:1325–30.
Forceps delivery and vacuum extraction delivery are 7. Johanson RB, Menon BK. Vacuum extraction versus forceps
themselves stressful for the fetus. Moreover, in many cases, for assisted vaginal delivery. Chochrane Database Syst Rev.
there is concomitant nonreassuring fetal status. Therefore, it 2000;2:CD000224.
Techniques for the Forceps Procedure
Jun Takeda and Satoru Takeda
The Structure of the Forceps
It is indispensable to understand the structure of forceps and

to remember the names of each part of the forceps before
performing the forceps procedure (Fig. 1). The blades denote
the upper half of the forceps that are to be inserted into the
birth canal to hold the fetal head. The blade has a long oval
shape with two types of curves. One is the pelvic curve that
is consistent with the pelvic axis and is concave upward dur-
ing traction. The other is the cephalic curve that is almost
entirely consistent with the contour of the fetal head and is
convex outward. The blade is fenestrated to decrease its
weight. The portion between the blade and the lock is called
the shank. The lock is located between the blade and the
handle, and this is the pivotal part where the right and left
blades cross each other. The mode and form of the lock vary
according to the type of forceps. Utokyo Naegele forceps
(modified small Naegele forceps) have a firm locking mech-
anism with a notch. The handles are the lowest portions of
forceps following the lock and are designed to be gripped by
the operator. In the upper part of the handle, there is a finger
guide which is useful for firmly holding the forceps during
traction.
Fig. 1 UTokyo Naegele forceps
rior to Implementation of the Forceps

P
Procedure: Importance of the Pelvic
Examination
Electronic Supplementary Material The online version of this As mentioned repeatedly, the most important prerequisite for the
chapter (https://doi.org/10.1007/978-981-10-4735-0_3) contains sup-
implementation of forceps delivery is obtaining accurate pelvic
examination findings. Accurate data on the extensibility of the
J. Takeda (*) • S. Takeda vagina and perineum as well as fetal head descent, hardness of
Department of Obstetrics and Gynecology, Faculty of Medicine,
the fetal head, and the location of the fontanel are very important
Tokyo 113-8421, Japan for the implementation of forceps procedure. In addition, data
e-mail: jtakeda@juntendo.ac.jp; stakeda@juntendo.ac.jp on dynamic elements such as fetal head descent, the direction of

16 J. Takeda and S. Takeda
Table 1 Points to be checked prior to the application of forceps tion. In such cases, the fetal position is diagnosed as the occip-
1. Direction of the sagittal suture and the sites of anterior and itoposterior rather than the frontoanterior position. To perform
posterior fontanels correct traction of the forceps, it is necessary to distinguish
2. Status of rotation (palpation of the fetal ears, sagittal suture) and between the frontoanterior position in deflexion and the occip-
the lowest part of the fetal head itoposterior position in flexion. The fetus in the frontoanterior
3. Assessment of the level of the fetal head
position can be extracted by the forceps procedure. However,
4. Whether or not the operator’s fingers can be inserted between the
posterior surface of the pubic symphysis and the fetal head
in the occipitoposterior position, the fetus is already in flexion
when it enters the third rotation, thereby making it difficult to
complete the third rotation, often resulting in arrested labor
rotation, and extensibility of the vaginal wall and perineum dur- and usually a failure to descend into the low position. The US
ing uterine contractions and under abdominal pressure should classification of presentation of the fetus refers to a category of
also be obtained. Fetal head descent is expressed in terms of left (right) occiput posterior alone, with no distinction between
station. DeLee’s station is expressed as a numeric value (cm) of the frontoanterior and occipitoposterior positions. However, it
the distance of the lowest part of the fetal head from the base is necessary to distinguish the frontoanterior position from
plane, which is the third plane (line between the ischial spines) occipitoposterior position because the distinction between
in the parallel pelvic plane system. If the lowest part of the fetal flexion and deflexion is important for safely extracting the
head is located on the line between the ischial spines, the station fetus by applying traction in a correct direction with forceps.
is ±0; if it is above the base line, the station is −1 to −5; and if it
is below the base line, the station is expressed as +1 to +5. In the
negative value stations, the fetal head descends vertically along Occipitoanterior Presentation
with the pelvic axis, such that it is not difficult to assess the level
of the fetal head. However, in the positive value stations, i.e., Application of UTokyo Naegele Forceps
those exceeding ±0, it is difficult to spatially determine the site
of the leading part of the fetal head because it does not descend The forceps procedure consists of the following basic pro-
vertically to DeLee’s third plane but rather in an oblique anterior cesses [3]:
direction. Therefore, a certain level of training with skill mastery
is necessary to accurately assess the level of the fetal head for 1. Simulated holding of the forceps (Fig. 2)
steady traction, i.e., the most proper position for forceps applica- –– Before performing forceps procedure, always simulate
tion. By learning the trapezoidal station (T-station) for assessing the holding of the forceps, confirm that the blades join
fetal head descent described in another section, the position of and match correctly, and confirm the direction of traction
the fetal head can be correctly assessed as upper inlet, high, mid, by imaging the traction applied to the fetal head with the
low, or outlet [1, 2]. forceps in place. In principle, the left blade is held with
Furthermore, the following points should be confirmed the left hand and the right blade with the right hand.
(Table 1).
Confirmation of these points allows the level of the fetal head
and the presence/absence of rotation abnormality to be objec-
tively assessed, facilitating confirmation of the requirements for
forceps delivery and appropriate application of the forceps.
When the operator moves the inserted fingers along the sagittal
suture, the anterior and posterior fontanels can be palpated. The
anterior fontanel is felt as the crossover site of four sutures and
the posterior fontanel as the crossover site of three sutures.
Even if the sagittal suture is difficult to touch because of
caput succedaneum, a reasonable speculation as to the direc-
tion of the sagittal suture can be made by touching the fetal
ears. If the posterior or anterior fontanel can be touched, flex-
ion or deflexion of the fetus can be diagnosed (if the poste-
rior fontanel is palpated frontward, showing precedence of
the posterior fontanel, the fetus is in flexion in the “occipito-
anterior position”; if the anterior fontanel is palpated front-
ward, showing precedence of the anterior fontanel, the fetus
is in deflexion in the “frontoanterior position”).
In extremely rare cases, the posterior fontanel is palpated
Fig. 2 Simulated holding of the forceps (Apprication in right occipito-
backward, though the posterior fontanel is in a preceding posi- anterior presentation)
Techniques for the Forceps Procedure 17
2. Insertion of the forceps (Figs. 3 and 4) intrusion and torsion. Do not perform these maneuvers
–– Insert the forceps, first the left blade and then the right in a forceful manner. If these maneuvers fail to achieve
blade (Fig. 3a). joining of the blades together, remove the forceps and
–– Insert four fingers, all but the thumb, of the right hand try insertion again.
between the left vaginal wall and the fetal head. –– In general, the handles should be gripped with the right
–– Press the left vaginal wall outward with the four hand with the second and third fingers hooked from
inserted fingers to make a space between the fetal head above at the finger guides and the other three fingers
and the vaginal wall. lightly gripping the handles (Fig. 5). It is often the case
–– Push the lower portion of the blade inward with the that the second finger or the second and third fingers of
right thumb along the cephalic curve (Fig. 3b, c). the left hand are inserted from beneath the forceps to
–– At the same time, hold the handle with the left hand in a the crossover site of the blades, and the lock and the
vertically hanging manner. Insert the left blade in concert finger guide are held with the other four or with three
with the right hand, while inclining the handle toward the fingers. The left second finger inserted to the crossover
anterior area of the right inguinal region, making use of site of the blades plays a role in preventing excessive
its weight. At this time, do not push the handle forcibly pressure on the fetal head during traction. This maneu-
with the left hand. Push the blade f orward with the right ver may be performed by reversing left and right.
thumb in a nonresisting direction along the fetal head, –– In a different manner of gripping, the handles may be
while using the left hand only adjunctively. held with the right hand from beneath with the fingers
–– Once the blade is inserted to a sufficient depth, hold hooked at the finger guides, essentially as described
the handle almost horizontally in the midline (Fig. 3d). above, and the left hand may be applied from above to
At this time, the tip of the blade passes between the hold the lock and the finger guide in a manner similar
anterior area of the fetal auricle and the outside of the to the above description.
orbit and reaches the mandible. –– After confirming that the blades are joined, be sure to
–– After insertion of the left blade has been completed, let perform trial traction. Draw out the forceps lightly and
the assistant hold the handle. If there is no assistant, slowly during the interval of the labor pains to confirm
hold the handle with the left little finger or release the that the fetal head descends, forceps slippage does not
handle, and begin to insert the right blade. If the han- occur, and there are no abrupt changes in the fetal heart
dle is released, be careful not to let the blade drop. rate. Then, loosen the lock and wait until the next onset
–– When inserting the right blade, follow the same pro- of labor pains. If there are abrupt changes in the fetal
cess as insertion of the left blade only by reversing left heart rate, compression of the umbilical cord due to the
and right (Fig. 4). However, because the left blade has forceps might be present. In such an event, remove the
already been inserted, the space between the fetal head forceps immediately and try insertion again.
and the right vaginal wall is insufficient. Therefore, 4 . Traction applied to the fetal head (Figs. 6 and 7)
insertion of the right blade is often slightly more dif- –– Join the blades together in time with labor pains, and
ficult than insertion of the left blade. begin traction (Fig. 6). Pull the fetus slowly and con-
–– If the fetal head is located in a high position, the blades tinuously with a constant force in a correct direction
are inserted more deeply, and the handles will there- while observing the fetal head descent and rotation.
fore be positioned below the horizontal plane. Never perform forcible or intermittent traction or trac-
3. Joining of the forceps (Fig. 5) tion while moving the forceps back and forth, and/or
–– After insertion of the blades has been completed, con- around.
firm the matching of the blades at the lock. If the –– Pull the fetal head in the direction of the tangent line
blades are correctly applied, it is relatively easy to join along the posteror surface of the pubic bone (Fig. 7a)
the blades together at the lock. The direction of traction should be changed from posi-
–– On occasion, there is a slight difference in the levels of tion 1 (downward traction) to position 2 (outward or
the left and right blades, or the locking parts of the horizontal traction) and to position 3 (upward traction)
blades are not present in the same plane, making it according to the level of the fetal head (Fig. 7b, c; see
difficult to join the blades together. Such cases should the animation on video 1 and 2).
be dealt with in the following manner. –– In principle, position 1 means pulling out-downward
–– First, it may be possible to join the blades when the (horizontal and inferior direction), position 2 means
handles are pushed down toward the perineum. If this pulling almost horizontally (outward or horizontal
fails, twist the blades slightly using the finger guides direction), and position 3 means pulling out-upward
during intrusion to adjust the locking parts to the same (horizontal and superior direction).
plane. If this is also unsuccessful, insert the forceps –– In low forceps cases, the direction of traction is posi-
slightly further into the pelvis at the same time as tion 1 → position 2 → position 3 (the direction of
Fig. 3 Application of the left

blade. (a) Whole aspect. (b) a
Front view. (c, d) Side view
Fig. 3 (continued)
d
Fig. 4 Application of the right

blade. (a) Front view. (b, c) Published with kind permission of © Satoru Takeda 2017. All Rights Reserved
Side view
Fig. 4 (continued)
c
tively large perineal incision may be made prior to

traction (Table 2).
5 . Removal of the forceps (Fig. 8)
–– In principle, the forceps should be removed at the time
of expression of the fetal head (at delivery of the exter-
nal occipital protuberance) or, at the latest, when the
fetal forehead is delivered. If forceps removal is
delayed, vaginal laceration is likely to occur under the
blades; this is a particularly common cause of grade
IV laceration.
–– Removal of the forceps should be carried out in the
reverse order of insertion, the right blade first and then
the left blade, along the pelvic curve and the cephalic
curve. The blades are never to be drawn out linearly. If
possible, protect the perineal area while removing the
forceps.
–– The forceps should not be removed before delivery of
the external occipital protuberance of the fetal head
Fig. 5 Joining of the forceps
because removal that is too early may result in prob-
lematic and time-consuming delivery of the fetal head.
position 1 in higher low forceps should begin with a 6. Examinations for both maternal and fetal complications
more downward direction than in lower low forceps),
whereas the direction of traction should be position When forceps delivery has been completed, the possible
2 → position 3 in outlet forceps cases. presence/absence of uterine rupture and soft birth canal
–– With forceps delivery, the fetus should basically be laceration in the mother and any injury and/or impression of
extracted by a single traction maneuver. However, if the blade in the infant should be assessed. With regard to
labor pains end during traction, loosening the lock impression of the blade, the presence/absence and the location,
and waiting until the next onset of labor pains is a if any, of blade impressions should be recorded in the chart.
feasible option. Usually, extraction of the fetus by a When high forceps delivery was an approved procedure,
single traction maneuver is attempted. Therefore, the serious complications such as skull fracture, intracranial hem-
uterine fundal pressure maneuver may be combined orrhage, cephalohematoma, cervicobrachial paralysis, and
with this traction attempt, but excessive force should corneal injury occurred. In contrast, these complications usu-
be avoided. ally do not occur in low or outlet forceps delivery cases, if the
–– Perineotomy is performed during the period from prerequisites and indications are followed faithfully.
crowning to expression of the fetal head. However, if Stated unequivocally, forceps delivery is an operation that
there is insufficient extension of the perineum, a rela- sacrifices the mother’s birth canal to achieve steady delivery
Fig. 6 Holding the forceps.

(a) Front view. (b) Side view a
Fig. 7 Traction. (a) Whole

aspect. (b) Position 1 and 2
(downward and outward). (c) Published with kind permission of © Satoru Takeda 2017. All Rights Reserved
Position 3 (upward)
Fig. 7 (continued)
b
Table 2 Tips for achieving optimal traction of the fetal head in low or
outlet forceps
1. Traction should be performed with slight addition of force.
Large lacerations can be prevented if traction is performed by
stopping whenever movement begins
2. The direction of traction is along the vector formed from the
intensity and direction of outward force and the intensity and
direction of downward force. The resultant vector, consistent
with the angle of the posterior surface of the pubic bone, should
be produced (Fig. 9d)
3. The fetal head often does not move because the outward force
without downward force is too strong
4. The initial movement should be made to pass through the pubic
bone
5. In cases with a higher position, it is recommended that the
operator remain highly conscious of position 1 during traction Fig. 8 Removal of the forceps. Remove the right blade first and then
the left blade
of the fetus. Therefore, even careful and gentle traction may When examining for soft birth canal laceration, the author
cause soft birth canal laceration (perineal, vaginal, cervical, begins observation from the upper part and proceeds to the
and vaginal fornix lacerations are possible), uterine rupture, lower part. More specifically, the state of uterine contraction
bladder injury, and rectal injury. Postoperative examination and the presence/absence of uterine rupture are determined.
should be performed with due caution, to avoid overlooking Subsequently, palpation and inspection to examine for cervi-
any of the above complications. cal or vaginal laceration and inspection to examine for
perineal laceration are performed. It is indispensable to have fingers are inserted, the fetal head is slightly elevated, to
an assistant expose the vaginal wall for accurate inspection. assure that rotation of the fetus can be attempted with ongo-
The hand (to the wrist) can be inserted into the uterine ing efforts by the mother to bear down, during the uterine
cavity immediately after delivery because the uterine os is contraction phase (Fig. 9b). If the fetus is rotated success-
sufficiently dilated. It is necessary to examine by inserting fully to make the angle of the sagittal suture less than 45°,
the hand into the uterine cavity for the presence/absence of the left blade and the right blade should be inserted to begin
retained placenta or injuries such as uterine rupture. forceps delivery. In a left occiput oblique presentation
cases, the fingers of the right hand should be inserted to
rotate the fetus in the same manner. The important point is
Oblique Presentation to elevate the fetal head slightly before making it rotate. If
rotation is not successful, vacuum extraction delivery
The forceps may be inserted in accordance with the pelvis should be performed, or UTokyo Kielland forceps should
regardless of the orientation of the fetal head (pelvic applica- be used to achieve rotation and traction.
tion) or in accordance with the orientation of the fetal head
(cephalic application). Pelvic application is used for UTokyo
Naegele forceps and Piper forceps, which are forceps blique Presentation with the Sagittal Suture
O
designed for aftercoming head, whereas cephalic application Making an Angle of Less Than 45°
is used for Kielland forceps, which are rotational forceps.
The most commonly used Naegele forceps are basically The forceps should be routinely inserted by pelvic appli-
inserted by pelvic application because of their structure. This cation for traction, or UTokyo Naegele forceps should be
chapter describes how UTokyo Naegele forceps should be inserted in a manner similar to that used for fetal head
applied to the fetal head when the sagittal suture is oblique. application to achieve traction. If the blades cannot be
Because pelvic application is used for UTokyo Naegele
forceps, the blades are designed to make a certain angle with
the handle which produces an upward curve according to the a
sacral curve. Therefore, the left and right blades cannot catch
the bilateral cheek bones unless the sagittal suture of the fetal
head is longitudinal or oblique, making an angle of less than
45°; thus, this type of forceps cannot be used for transverse
diameter cases or those with a transverse presentation.
Unless Kielland forceps are used, certain measures are
required in oblique presentation cases with an angle of 45° or
more or in a transverse presentation.
Manual Rotation (Fig. 9)

Pelvic application of UTokyo Naegele forceps causes virtu-
ally no problems in cases with an almost longitudinal sagittal b
suture making an angle of less than 45°, whereas it is prob-
lematic in cases with an angle of 45° or more because one of
the blades may catch the face. In nonurgent cases, guiding
the fetal head while the mother bears down may cause the
fetal head to descend and facilitate the second rotation, lead-
ing to a longitudinal sagittal suture.
In urgent cases, rotation should be attempted manually.
In cases with a right occiput oblique position, four fingers
of the left hand, from the index finger to the fifth finger,
should be inserted between the temporal region of the fetal
head and the posterior vaginal wall from the 6 o’clock
direction of the vagina during an interval of labor pains
(Fig. 9a). While placing the thumb on the occipital bone or Published with kind permission of © Satoru Takeda 2017. All Rights Reserved
on the anterior temporal bone near the lambdoid suture, the

Fig. 9 Manual rotation. (a) Manual rotation for right occiput transverse
fetal head should be anteflexed and rotated using the four position. (b) Manual rotation from right occipitotransverse to right occ-
fingers to obtain a longitudinal sagittal suture. When the cipitoanterior position
joined together, it is important to remove and insert the seen at the pubic arch, the fetus should be pulled toward posi-
blades again, in order to make another attempt. The fetal tion 3 (slightly upward) (Fig. 10b), which is higher than posi-
head is elevated when the forceps are inserted, but traction tion 2 (outward), and then the posterior fontanel and the
with the forceps in pelvic application causes no problems occipital region emerge in this order. Unlike traction in the
so long as it is started after the fetus has sufficiently direction of position 1 (downward again) in the occipitoante-
descended in response to bearing down efforts. If the sag- rior position, the fetus would not move unless pulled in a
ittal suture making an angle of 45° or more, UTokyo lower direction toward position 1. If a beginner fails to make
Kielland forceps should be used [4]. the fetus move by applying traction in the frontoanterior posi-
tion, this is due to the fetus not being pulled properly in an
attempted direction toward position 1 (downward).
Frontoanterior Presentation After the external occipital protuberance has been deliv-
ered, another traction toward position 1 yields delivery of the
In the occipitoanterior presentaion, the cross section of the forehead, face, and chin of the fetus in this order (Fig. 10c).
fetal head passing through the birth canal contains the suboc- It is recommended that the fetus be pulled, imaging a wave-
cipitobregmatic circumference. In contrast, the correspond- form. Soft birth canal laceration is likely to be caused by
ing cross section containing the frontooccipital circumference passing of the cross section containing the suboccipitobreg-
in the frontoanterior position is larger than those in the occip- matic diameter through the perineum.
itoanterior presentation. Therefore, regardless of fetal size, it
is more difficult for the fetus in the frontoanterior position to
come out, often leading to prolonged or arrested labor, and Difficult Cases
frequently necessitating forceps delivery because of a resul-
tant high incidence of non-reassuring fetal status [1]. Failed Forceps
Simulated holding, insertion, joining, and removal of the
forceps should also be conducted for fetuses in the frontoan- The frequency of forceps failure was 2/1109 (0.2%) in the
terior position in the same manner as those in the occipitoan- Center for Maternal, Fetal, and Neonatal Medicine of the
terior position, using UTokyo Naegele forceps. However, the Saitama Medical University Medical Center (1985–2005) and
direction of traction on the fetal head is different from that 4/547 (0.7%) in the Department of Obstetrics and Gynecology,
applied in occipitoanterior position cases. Juntendo University (January 2009 to December 2013).
In the same manner as in the occipitoanterior position case, The forceps procedures in two cases were performed by
the fetus should first be pulled strongly in the direction of experienced operators. Both fetuses were small and had a
position 1 (downward) (Fig. 10a). When the anterior fontanel rotation abnormality in the frontoanterior position. The first
is seen at the perineum, and the area between the eyebrows is fetus was at station +3 in the anterior forehead position, and
Fig. 10 Forceps delivery for

frontoanterior position. (a) a
Pulling downward, usually
more strongly (b) Pulling
outward and slightly upward
(c) Pulling downward again
Fig. 10 (continued)
b
the decision to use the forceps procedure was based on non- Table 3 Precautions for switching to cesarean section
reassuring fetal status (NRFS). When traction was per- 1. In NRFS cases, perform postural change and elevation of the
formed, deflexion was enhanced to promote movement into fetal head and endeavor to stop uterine contractions by tocolytic
the mentoanterior position. Because the fetal head did not a gents
descend, cesarean section was performed. The second case 2. If the mother is on oxytocic medication, it should be
was a second twin at station +3 in the frontoanterior position. changed to an electrolyte fluid or a colloid solution. Perform
super emergency cesarean section while relaxing the uterine
The decision to use the forceps procedure was based on muscle with ritodrine hydrochloride or nitroglycerin, if
NRFS. Traction enhanced deflexion, leading to the mentoan- necessary
terior position. Because the fetal head did not descend, cesar- 3. Be sure to bring forceps into the operating room because the
ean section was performed. Both infants were light-for-dates, fetal head may descend to a position that allows easier traction
during transport
weighing 2200 g and 2100 g, respectively. The other four
infants were actually high station cases in which pelvic
examinations had not been sufficiently accurate.
When the forceps procedure has failed, cesarean section
should be performed immediately. It is ideal to perform be possible, depending on the facility. Therefore, precautions
cesarean section on the delivery table or in the operating for switching forceps delivery to cesarean section are sum-
room adjacent to the delivery room. However, this may not marized below (Table 3).
Difficulty with Forceps Insertion In addition, there were a few cases in which traction of the
fetal head in the frontoanterior position caused severe vagi-
Insertion of forceps is often difficult in cases in which the nal laceration, with suturing and hemostasis being
fetal head has descended to the outlet area and in cases of time-consuming. In these cases, cesarean section might have
arrested labor or abnormal rotation, because the fetal head yielded better results.
cannot be elevated during an interval of labor pains. In such It should be noted that the site of the largest fetal head
cases, there is not enough room between the fetal head and circumference at station +3 in the frontoanterior position is
the vaginal wall, making it difficult to insert the guiding hand superior to the corresponding site in the occipitoanterior
adequately to allow forceps insertion. The key points in position, being comparable to station +1 to +2 in the occipital
addressing cases in which inserting the forceps is difficult presentation. In particular, this tendency is prominent when
are outlined below (Table 4). there is substantial molding of the fetal head in the frontoan-
If the blades are not joined together, the inserted blades terior position in cases of arrested or prolonged labor.
are often oriented properly in the 3 o’clock and 9 o’clock Traction may fail due to being applied in the wrong
directions while being deviated downward, such as in the 4 direction. In particular, inexperienced practitioners tend to
o’clock and 8 o’clock directions. If the fetal head is in a high excessively pull the forceps forward (in the direction of
position such as at t-station +2, the direction of the blade position 2), which makes the fetal head strike the pubic
tends to deviate downward during insertion. Incorrect orien- bone, interfering with descending of the fetal head. It is
tation of the blades is also likely to occur in cases managed important to perform traction at position 1 (downward trac-
with forceps application to the fetal head. In any case, the tion) along the inclination of the posterior surface of the
following actions should be undertaken when the blades do pubis. If the traction is performed while k eeping an image
not join together (Table 5). of the angle of this inclination in mind, the fetal head will
descend smoothly.
Blade slippage usually occurs when the blades are inserted
Difficulty with Traction and Slippage shallowly or in an incorrect manner, leading to a risk of inju-
ries to the fetus. Although it is rare, blade slippage may also
No more than two traction attempts should be made, in prin- occur when the forceps are pulled in the wrong direction,
ciple, because achieving concordance with labor pains may resulting in the application of excessive force.
be difficult. More frequent traction is prohibited. Efforts In any case, particularly when the forceps are applied to
made to perform the forceps procedure will be fruitless if they a high level such as station +2, attention should be paid to
are excessive and result in deterioration of the fetal condition. insert the blades sufficiently deeply regardless of the rota-
If the operator who has failed is inexperienced, a skilled oper- tion status. When the blades are applied at a high level, the
ator should immediately take over, and one additional traction lock is, of course, located in the vicinity of the vaginal
attempt can thus be performed by this skilled operator. ostium, and the handles may be positioned horizontal or
In general, cases with difficult traction requiring major force slightly upward. Traction should not be performed simulta-
include macrosomia, arrest of labor, weak labor pains, and neously with bearing down efforts. Instead, descent of the
rotation abnormalities (frontoanterior position, asynclitism). fetal head should be facilitated under sufficient bearing
down efforts in advance of traction. In this manner, rotation
Table 4 Key points in addressing cases in which forceps insertion is progresses in such a manner as to allow sufficiently safe
difficult traction (Table 6).
1. Perform pudendal anesthesia, instruct the mother to avoid
bearing down efforts, and insert the guiding right hand
adequately Complications
2. When the guiding hand is inserted, it can be inserted deep enough
in the manner of slightly pushing up the fetal head. The blades
should be inserted quickly, by the time of the next labor pains
Lacerations
3. The blades cannot be inserted during labor pains or under
bearing down efforts. Wait until the next interval of labor pains In comparison with normal vaginal delivery, forceps delivery
is associated with high incidence rates of severe birth canal
lacerations. In particular, laceration tends to be more severe
Table 5 Actions to be undertaken when the blades do not join together
when traction is performed for cases with a high position or
1. In principle, remove the blades and attempt insertion again arrested labor, macrosomia, or rotation abnormalities. The
2. If the gap between the blades is small, it might be possible to join increased frequency of laceration and the increased volume
the blades when the handles are pushed downward. At this time,
confirm that there is no tissue or other material tucked between of blood loss might essentially be unavoidable in cases
the fetal head and the blade, the blades are applied properly to the undergoing forceps delivery causing the labor process to end
fetal head, and trial traction does not cause slippage in short bursts in contrast to the normal labor process which
Table 6 Summary of precautions for difficult traction cases Table 8 Key points in addressing bleeding
1. Traction should be limited to two attempts, in principle. More 1. It is important to ascertain the characteristics of forceps,
frequent traction attempts should be avoided accurately assess the location of the fetal head, and have a good
2. Understand in advance the situation of difficult traction cases understanding of engagement of the fetal head, as well as the
such as macrosomia, arrest of labor, weak labor pains, and process, physiology, and pathology of rotation
rotation abnormalities 2. It is necessary to be skilled in rapid and steady hemostasis and
3. Note that the largest fetal head circumference is located at a suturing because vaginal wall and perineal lacerations may be
higher level in the frontoanterior position than in the associated with cervical laceration or crush injury, deep cervical
occipitoanterior position laceration, or atonic bleeding. It is also important to understand and
4. Perform traction along the inclination of the posterior surface of practice the actions to be carried out in case of maternal
the pubis. The fetal head descends smoothly if traction is emergencies, such as those prescribed in guidelines for obstetric
performed while keeping an image of the angle of this critical bleeding, to respond quickly to increased bleeding by
inclination in mind means of whole-body control, fluid infusion, and blood transfusion
5. Blade slippage usually occurs when the blades are inserted 3. Learn the direction and adjustment of the force of traction with
shallowly or in an incorrect manner. Exercise caution to avoid forceps, thoroughly review every case, and acquire experience.
slippage These pathways merge to form the royal road to reduction and
control of complications
Table 7 Techniques of the forceps procedure to avoid soft birth canal with normal vaginal delivery. The incidence rate of blood
laceration loss of 1000 mL or more during labor also increases.
1. It is recommended to pull the fetus in the direction of position 1 Precautions for management of bleeding during forceps
(downward), and traction should be performed in such a manner as delivery are summarized as follows (Table 8).
to simulate a slow halting as soon as the initial movement is obtained
2. When the external occipital protuberance has passed through the
inferior margin of the pubic bone, traction in the direction of
position 2 (outward) should be stopped, and instead the fetus Fetal Complications
should be induced to move in the direction of position 3
(upward). The forceps should be removed after appearing of the Among 1109 forceps delivery cases at the Center for
fetal head
Maternal, Fetal, and Neonatal Medicine of the Saitama
3. Traction in the direction of position 1 should not be continued after
the initial movement. When the fetus begins to move, traction in
Medical University Medical Center, cephalohematoma, sub-
the direction of position 1 and then position 2 should be performed galeal hematoma, conjunctival hemorrhage, three (0.3%)
in a suppressive manner. Traction in the direction of position 3 cases with Erb’s palsy (injuries to the upper nerves of the
should only be applied in the manner of guiding the fetus brachial plexus), and two (0.2%) cases with clavicle frac-
tures were found in relation to macrosomia and arrested or
prolonged labor, although no direct relationship with the use
progresses slowly through the formation of caput succeda- of forceps was revealed. One (0.1%) case with linear fracture
neum and molding of the skull. Hematoma formation is seen of the skull and 2 (0.2%) with subarachnoid hemorrhage as
in the vaginal wall or the vulva on rare occasions. It is indis- serious complications were found to be related to forceps
pensable to pursue technical efforts and to gain practice in delivery. Fortunately, none of these infants suffered sequelae.
rapid suturing in order to reduce complications. These complications may also occur in normal delivery
When removal of the forceps is delayed, rail mark-like cases, but seem to be related to the status of rotation and level
lacerations may occur in the portion of the posterior vaginal of the fetal head and the operator’s mastery of forceps
wall. Rapid and forceful traction, abrupt expulsion of the techniques.
fetal head, or prolonged pulling in the direction of position 2 Although skin abrasion and subcutaneous hemorrhage
(outward traction) may result in grade IV laceration. involving the fetal face due to application of the blades
As a rare complication, caution is necessary regarding the occurred in some cases, none suffered problematic sequelae.
possible occurrence of isolated rectal laceration in the poste- There were no injuries to the cornea or conjunctiva, nor were
rior vaginal wall and bladder injury, which are different from fundal hemorrhages detected.
a grade IV laceration which would be continuous from a Congenital cataract may be unilateral and may later
perineal laceration (Table 7). raise suspicion of being a complication of forceps deliv-
ery. Therefore, when there is an impression of the blade
on the eyelid or when conjunctival hemorrhage is present,
Increased Bleeding an ophthalmologist should be consulted, and the absence
of any abnormalities should be documented in the medi-
In forceps delivery cases, soft birth canal lacerations may be cal record. Although the occurrence of facial palsy has
larger, deeper, and more complicated at higher frequencies, been described in the literature, we have not experienced
resulting in an increased volume of blood loss as compared such a case.
References 2. Seki H, Takeda S. A review of prerequisites for vacuum extraction:

Appropriate position of the fetal head for vacuum extraction from a
forceps delivery perspective. Med Clin Rev. 2016;2:22.
1. Takeda S, Takeda J, Koshiishi T, Makino S, Kinoshita K. Fetal
3. Takeda J, Makino S, Itakura A, Takeda S. Technique of forceps
station based on the trapezoidal plane and assessment of head
delivery using UTokyoNaegele forceps Hypertens Res Pregnancy
descent during instrumental delivery Hypertens Res Pregnancy
2017;5:24–25.
2014;2:65–71.
4. Takeda J, Makino S, Itakura A, Takeda S. Technique of rotational
forceps delivery using UTokyo kielland forceps Hypertens Res
Pregnancy 2017;5:26–27.
UTokyo Kielland Forceps
Shintaro Makino, Jun Takeda, and Satoru Takeda
If the blades of UTokyo Naegele forceps are inserted in par-

allel with the pelvic longitudinal diameter in cases with rota-
tion abnormalities, such as deep transverse arrest, in which
the sagittal suture is oblique, making an angle of more than
45° with the pelvic longitudinal diameter, the blade is often
placed on the fetal face, particularly the anterior surface of
the palpebral fissure, producing the risk of eyeball injury
during traction. If Naegele forceps are inserted to correct a
rotation abnormality without regard for the pelvic curve,
there is major movement of the blades in the bony birth canal
and the soft birth canal (Fig. 1).
To avoid such risks, UToyko Kielland forceps (modified
small Kielland forceps) can be applied to the fetal head in
parallel with the sagittal suture (cephalic adaptation).
UToyko Kielland forceps have the following structural fea-
tures: (1) the blades do not have the curve characteristic of
Naegele forceps (Fig. 2) and (2) the lock has a sliding func-
tion to make joining of the blades relatively simple and to
facilitate traction.
Fig. 1 Rotation of UToyko Naegele forceps used for deep transverse

arrest without regard for the pelvic curve. There is major movement of
Electronic Supplementary Material The online version of this
the blades in the bony birth canal and the soft birth canal
chapter (https://doi.org/10.1007/978-981-10-4735-0_4) contains sup-
S. Makino (*) • J. Takeda • S. Takeda
Department of Obstetrics and Gynecology,
Faculty of Medicine, Juntendo University
Tokyo, Japan
e-mail: shintaro@juntendo.ac.jp

30 S. Makino et al.
direction of the sagittal suture and the fontanels, the examiner

should insert fingers deep into the vagina to confirm the loca-
tion and direction of the fetal auricle. Transabdominal or
perineal sonography is also desirable, as a means of confirm-
ing the sites of the eyeballs and the direction of the sagittal
suture.
Simulated Holding of the Forceps
Before inserting the forceps, the operator should stand in

front of the vulva and imagine the state in which the blades
are properly applied to the fetal head based on the detailed
findings from the preceding pelvic examination.
It should also be confirmed in advance that the blades join
and match correctly, and this can be achieved by running a
simulation.
Insertion of the Forceps
In the case of using Kielland forceps, the anterior blade that

is to be inserted anteriorly to the maternal body should
always be inserted first, regardless of whether it is the right
or the left blade. The blade inserted anteriorly to the maternal
body is called the anterior blade, and that inserted posteriorly
is called the posterior blade.
The insertion procedure differs between the first and sec-
ond transverse presentations.
Left occiput transverse position
Fig. 2 Rotation of UTokyo Kielland forceps used for deep transverse
arrest. Kielland forceps smoothly rotate according to the pelvic curve –– Insert the anterior blade, which is the right blade in this
case, in the 9 o’clock direction in the same manner as with
Naegele forceps (Fig. 3a, b).
–– Hold the handle with the right hand, attach the second and
Techniques of UTokyo Kielland Forceps third fingers of the left hand to the inferior border of the
blade (Fig. 3c), and shift the blade clockwise to the
There are several technical differences in rotation and traction 12 o’clock site in the manner of pushing the entire blade
of the fetal head with UTokyo Kielland forceps (modified slightly, deep and internally (Fig. 3d). This maneuver
small Kielland forceps) in oblique sagittal suture cases [1]. requires no substantial force.
–– Thereafter, insert the posterior blade (which is the left blade
in this case) directly in the 6 o’clock direction (Fig. 4a).
Pelvic Examination
Right occiput transverse position
It is indispensable before the implementation of forceps
delivery to accurately understand fetal head descent, the –– Insert the anterior blade, which is the left blade in this
direction of the sagittal suture, and the locations of the ante- case, in the same manner as that used for Naegele forceps
rior and posterior fontanels. insertion.
In particular, when there is a rotation abnormality of the –– Hold the handle with the left hand, attach the second and
fetal head, the second stage of labor is prolonged, often third fingers of the right hand to the inferior border of the
resulting in arrest of labor. In this case, there is marked caput blade, and shift the blade counterclockwise to the
succedaneum or overlapping of bones, which makes it diffi- 12 o’clock site in the manner of pushing the entire blade
cult to identify the fontanels. To accurately confirm the slightly, deep and internally.
UTokyo Kielland Forceps 31
a-1 a-2
b-1 b-2
Fig. 3 Insertion and rotation of the anterior blade of Kielland forceps. and push the blade into the vagina by applying only the force of this
(a) Insertion of the anterior blade (right blade) in the 9 o’clock direc- thumb. Continue inserting the blade until the handle held with the right
tion in the same manner as that used for Naegele forceps. First, insert hand gradually inclines midline frontward and reaches the 9 o’clock
the four fingers other than the thumb of the left hand between the fetal site. (c) Next, hold the handle with the right hand, attach the second
head and the right vaginal wall of the mother, and confirm that there is and third fingers of the left hand to the inferior border of the blade, and
no tissue or other matter between the left hand and the fetal head. (b) shift the blade clockwise to the 12 o’clock site in the manner of push-
Then, hold the right handle lightly with the right hand such that the ing the entire blade slightly into the deep internal portion. (d) When
handle is essentially in a vertical position. Place the tip of the blade shifting of the blade has been completed, the handle should be
between the fetal head and the left hand, attach the thumb to the blade, vertical
32 S. Makino et al.
c-1 c-2
d-1 d-2
Fig. 3 (continued)
–– Then, insert the posterior blade (which is the right blade blades come into agreement spontaneously during the
in this case) in the 6 o’clock direction. course of rotation and traction.
–– When insertion of both blades has been completed, the –– When the blades are locked, and their depths are
applied blades should be in parallel with the sagittal allowed to agree, pelvic examination should always be
suture of the fetal head. performed to confirm that the direction of the sagittal
suture is the same as that before insertion of the
forceps.
Locking of the Forceps
–– When the handles are pushed down after joining the two Trial Traction
blades together, the anterior blade gradually descends at
the locking part, thereby decreasing the depth difference –– Try to draw the forceps lightly and slowly during an inter-
between the two blades (Fig. 5). It is unusual for the val of labor pains to confirm that the fetal head is held
depths of the two blades to completely match up with steadily and descends slightly with traction and that there
each other before rotation and traction. The depths of the are no abrupt changes in the fetal heart rate.
a-1 a-2
Fig. 4 Insertion of the posterior blade of Kielland forceps. (a) Start blades; the site of the posterior blade is unavoidably shallower, showing
insertion of the posterior blade (which is the left blade in this case) a difference from the other blade. When the handles are pushed down
directly in the 6 o’clock direction. The blade can be inserted relatively after joining the two blades together, the anterior blade gradually
easily at the beginning but cannot be inserted deeply because its tip descends at the locking part, thereby diminishing the depth difference
opposes the sacrum or sacral promontory. When insertion of both between the two blades. It is unusual for the depths of the two blades to
blades has been completed, there should be a gap between the depths of completely match up with each other before rotation and traction. The
the blades, and the applied blades should also be in parallel with the depths of the blades come into agreement spontaneously during the
sagittal suture of the fetal head. (b) When the blades of Kielland forceps course of rotation and traction
are joined together initially, there is a gap between the depths of the two
a-1 a-2
Fig. 5 Locking of the forceps. When the handles are pushed down after joining the two blades together, the anterior blade gradually descends at
the locking part, thereby decreasing the depth difference between the two blades
34 S. Makino et al.
–– If the blades alone descend at this time, there is a high • The key point of this maneuver is to confirm by pelvic
risk of slippage, necessitating deeper reinsertion of the examination that not only the forceps but also the
blades. fetal head is rotated during rotation of the forceps.
–– If trial traction is appropriately performed, loosen the This is because, on occasion, the forceps alone are
lock and release the pressure on the fetal head until the rotated without accompanying rotation of the fetal
next onset of labor pains. head. To confirm rotation of the fetal head, the second
and third fingers of the left hand are placed near the
posterior fontanel during rotation of the forceps
Rotation and Traction (Fig. 6a, b).
• As many textbooks recommend completing rotation
• In principle, rotation is performed to facilitate the second before performing traction, the process starts with rota-
rotation of the fetal head, i.e., rotation of the occipital tion. Interestingly, the fetal head gradually descends just
region toward the pubic side (Fig. 6a, b). after rotation. At the same time, the aforementioned gap
a-1 a-2
b-1 b-2
Fig. 6 Rotation of the fetal head using Kielland forceps. In principle, tion before performing traction” is not an appropriate strategy. At the
rotation is performed to facilitate the second rotation of the fetal head, same time, the gap between the depths of the two blades is eliminated
i.e., rotation of the occipital region toward the pubic side. Because the spontaneously during traction of the fetal head
fetal head gradually descends during traction, aiming “to complete rota-
c-1 c-2
d-1 d-2
Fig. 6 (continued)
between the depths of the two blades is spontaneously Removal of the Forceps

eliminated (Fig. 6c, d).
• If rotation is complete, and the sagittal suture corresponds to –– The optimal timing of traction cessation is the expression
the pelvic longitudinal diameter, the final traction should be of the fetal head or when the fetal forehead is seen.
performed. Although the Kielland forceps may be replaced –– Subsequent removal of the forceps should be performed
by Naegele forceps at the end of rotation, the following pro- slowly, first from the right blade and then the left blade.
cedures are performed to prevent the fetal head from rotat- At this time, caution is necessary to sufficiently protect
ing in the reverse direction during forceps replacement: the perineal area, in order to prevent the fetus from being
–– Remove only the left blade of the Kielland forceps, expelled too quickly. If this protection of the perineal area
and insert the left blade of the Naegele forceps. is insufficient, the fetal head is extracted together with the
–– Then, remove the right blade of the Kielland forceps, forceps due to the quick descent of the fetal head, and
and insert the right blade of the Naegele forceps. severe perineal laceration may result videos 1 and 2.
36 S. Makino et al.
Reference
1. Takeda J, Makino S, Itakura A, Takeda S. Technique of rotational
forceps delivery using UTokyo Kielland forceps. Hypertens Res
Pregnancy 2017;5:26–27.
Education
Atsuo Itakura
he History of the Instrumental
T ing the indication and adoption of obstetric forceps, the
Vaginal Delivery principles that are passed on from the master teacher to resi-
dents had been hard to obtain. As cesarean delivery can
Obstetric forceps have a long history. Ancient Egyptian avoid several complications arising during instrumental
writings pictures refer to forceps. It is presumed that these vaginal delivery, the complications associated with forceps
instruments were used for the extraction of a dead fetus. delivery especially of neonates have a high risk for being
They already knew that the retention of dead fetus in utero blamed in spite of the avoidance of abdominal delivery. In
may induce critical situation of the mother. After the seven- company with heightened awareness of medical malpractice
teenth century, several precursors of the modern instru- claims, innate human mentality may also decrease the
ments for use on live fetus had been developed. In 1845, occurrence of forceps. Consequently, the use of forceps had
Professor James Simpson designed a new forceps that was declined significantly by the 1980s. These trends bear strik-
calculated to the appropriate fetal cephalic and maternal ing similarities to observations regarding the decline and
pelvic curvatures [1]. This forceps modified by DeLee after ultimate extinction of biologic species and portend the inev-
several years has been widely spread, and the further modi- itable disappearance.
fied instruments are now used in the modern obstetric prac- On the contrary, no matter how much the perioperative
tice. Although vaginal delivery was mandatory prior to the management of cesarean operation has improved, cesarean
advances in the perioperative management of cesarean delivery confers substantially higher maternal morbidity and
operation, the situation changed drastically by improving mortality than vaginal delivery. Vaginal instrumental deliver-
of cesarean delivery techniques. The establishment of safe ies also have some advantages in medical economy.
management made it a better alternative than a difficult for- Additionally, the success rate of vacuum extraction is unable
ceps delivery. to overcome that of forceps. Therefore, obstetric forceps
James Simpson also introduced Simpson’s “suction trac- should be inherited of skills to the trainee at this time. As
tor” that was a bell-shaped metal instrument equipped with “trial-and-error” method for skill up in a habitual and long-
a suction piston. Over the following decades, vacuum standing manner has become obsolete, a novel educational
extraction underwent a number of modifications and could system is necessary to establish for the skill up of forceps
compete with forceps in some indication and situation. techniques.
Technique of vacuum extraction can be achieved without
high skill compared with that of forceps delivery. Recent US
surveys indicate that 95% of residency programs in obstet- raining Curriculum for Forceps-Assisted
T
rics and gynecology were providing instruction in vacuum Vaginal Delivery
extraction [2]. In addition, other forceps along with narrow-
Physicians and surgeons must acquire some procedural
skills during their training period. These skills and tech-
niques are conventionally passed down orally and atten-
A. Itakura tively from mentors to the trainees according to the
Department of Obstetrics and Gynecology, Faculty of Medicine, apprentice system. Trainees learn through observing men-
Juntendo University, 2-1-1 Hongo, Bunkyo-ku, tors performing the procedures and imitating those skills
Tokyo 113-8421, Japan while received coaching from them. With the progress of
e-mail: a-itakur@juntendo.ac.jp

38 A. Itakura
the times, their training programs are required systemati- practice. As simulation training has been developed in
cally to inculcate these skills. Now a training tradition of obstetric practice originally, the birthing simulator is actually
“see one, do one, teach one” is considered insufficient to an excellent midwifery teaching tool. Now prior to the expo-
ensure patient safety, and new training methods must be sure to actual patients, simulation training for forceps deliv-
introduced. Other than the evaluation for the skills of train- ery may contribute to the reduction of the rate of maternal
ees by mentors objectively, it is important to provide struc- perineal trauma. The use of standardized teaching methods
tured teaching, assessment, and feedback for trainees in with objective assessment of simulated skills before the per-
performing procedures now. Most of such training has been formance of forceps in actual patients may improve patient
done while working under their masters who help the safety [5].
apprentices learn their skills. This transactional training However, standardized simulation curriculum for forceps
has been called “on-the-job training.” In addition to the vaginal delivery has not been established. What trainees have
training during working, “off-the-job training” is required learnt from the simulation must be measured and can be
to evaluate their skills objectively and to satisfy the mini- accomplished by using pre- and post-testing, and observa-
mal knowledge and skills concerning the procedure for tion by simulator- and non-simulator-trained trainers,
training curriculum. Simulation is a technique for practice through debriefing tools. Our simulation program is
and learning that can be applied to many fields including described in Tables 1 and 2.
military flight operations and emergency control measures Recently, RCOG sets high standards in training as RCOG
against disaster. However, despite this lack of solid evi- Operative Birth Simulation Training (ROBuST), in order to
dence, multiple institutions and organizations have been ensure that the future specialists acquire both technical and
pushing for this type of training. Various simulation appli- non-technical skills, which together are essential to correctly
cations involve artificial “patients” that can show symp- manage patients.
toms and respond to simulated treatment, allowing trainees These training programs contain techniques for nonrota-
to hone their clinical skills without putting patients at risk. tional forceps and rotational forceps.It is reported that the
Before performing forceps delivery to actual patients under rate of forceps delivery to assist vaginal birth has been grad-
assist by mentors, trainees are now recommended taking ually increased in England, and the rates of forceps delivery
procedural training using simulator. now becomes higher than those of vacuum extraction on
How many number of procedures to actual patients are 2013 in England and Scotland.
required for trainees to obtain technical skills to performing
forceps deliveries in independent clinical practice? Andrews
et al [3]. demonstrated that exceeding 13 forceps deliveries Table 1 Content and time table of simulation program for forceps-
made it highly likely that obstetricians would use them in assisted vaginal delivery in Juntendo University Hospital
practice. At least 13 forceps deliveries in residency are Title Times (min)
allowed to set reasonable thresholds for procedures by 1 Lecture-style lesson 10
obstetrics and gynecology residents by the time of 2 Using simulator 1 20
graduation. Identify ischial spine
Identify the fetal station
Identify the fetal position
imulation Training for Assisted
S Deliver the neonate
Vaginal Delivery 3 Hands-on tutorial for forceps procedure 5
4 Using simulator 2 30
In the eighteenth century, Madame du Coudray was an estab- Place blades
lished midwife who had been teaching her skills in Paris [4]. Traction in the appropriate vector
She already taught her skills using anatomical model of the Disarticulate blades atraumatically
female abdomen and fetus called “obstetric phantom,” which 5 Posttest (forceps skills checklist) 5
is considered as the oldest simulation model for medical Total 70
Education 39
Table 2 Checklist for performance of simulated forceps-assisted vagi- References

nal delivery
Forceps Skills Checklist: POSTTEST 1. Sheikh S, Ganesaratnam I, Jan H. The birth of forceps. JRSM Short
ID# ____________________ Rep. 2013;4:1–4.
Date ______________ Evaluator ____________________ 2. Bofill JA, Rust OA, Perry KG, et al. Forceps and vacuum delivery:
Forceps-Assisted Vaginal Delivery a survey of north American residency programs. Obstet Gynecol.
Skill 1996;88:622–4.
3. Andrews SE, Alston MJ, Allshouse AA, et al. Does the number of
Identify the fetal station A B
forceps deliveries performed in residency predict use in practice?
Identify the fetal position A B Am J Obstet Gynecol. 2015;213:93.e1–4.
Estimate EFW A B 4. Museum of Applied Arts & Sciences. Inside the collection https://
Assess adequacy of pelvis A B maas.museum/inside-the-collection/2012/07/23/midwifery-train-
Informed consent obtained: benefits, risks, permission given A B ing-simulator. Accessed 14 Oct 2017.
5. Gossett DR, Gilchrist-Scott D, Wayne DB, Gerber SE. Simulation
Time out A B
training for forceps-assisted vaginal delivery and rates of maternal
Assess adequacy of analgesia A B trauma. Obstet Gynecol. 2016;128:429–35.
Drain the bladder sterilely A B
Select instrument A B
Select which blade should be placed first depending on A B
fetal position
Phantom application based on position A B
First blade hand position: vaginal hand in vagina, A B
external hand with “pencil grip” on handle
Place first blade: arc of handle A B
Assess position of first blade A B
Second blade hand position: vaginal hand in vagina, A B
external hand with “pencil grip” on handle
Place second blade: arc of handle A B
Assess position of second blade A B
Check sagittal suture before articulation A B
Lock shanks (articulate) A B
Assess position of posterior fontanel A B
Traction in the appropriate vector A B
Use appropriate velocity of traction A B
Continuous adjustment of vector based on extension of A B
fetal vertex
Decide whether to disarticulate blades before delivery A B
Disarticulate blades atraumatically (or not) A B
Deliver the neonate A B
A done correctly, B done incorrectly or not done, EFW estimated fetal
weight
(From: Gossett DR, Gilchrist-Scott D, Wayne DB, Gerber SE6). Simulation
training for forceps-assisted vaginal delivery and rates of maternal
trauma. Obstet Gynecol 2016;128:429–35 with permission)

New Assessment of Fetal Descent and Forceps Delivery

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Satoru Takeda

New Assessment of Fetal

ISBN 978-981-10-4734-3 ISBN 978-981-10-4735-0 (eBook)

Library of Congress Control Number: 2017955690

© Springer Science+Business Media Singapore 2018

Printed on acid-free paper

This Springer imprint is published by Springer Nature

 Satoru Takeda, M.D., Ph.D.

 roper Positions for Vacuum Extraction

© Springer Science+Business Media Singapore 2018 1

According to the parallel pelvic plane system (Hodge’s sys-

Fig. 4 De Lee’s station and Hodge’s system of parallel pelvic planes.

Fig. 6 Actual measurement of

advance, the descent can be estimated as +1, +2, +3 cm, etc.,

Indications 1. “The mother’s capacity to endure the burden imposed by

© Springer Science+Business Media Singapore 2018 9

Vacuum Extraction Versus Forceps  roblems of Vacuum Extraction

Jun Takeda and Satoru Takeda

The Structure of the Forceps

It is indispensable to understand the structure of forceps and

Fig. 1 UTokyo Naegele forceps

 rior to Implementation of the Forceps

© Springer Science+Business Media Singapore 2018 15

Fig. 3 Application of the left

Fig. 4 Application of the right

tively large perineal incision may be made prior to

Fig. 6 Holding the forceps.

Fig. 7 Traction. (a) Whole

Manual Rotation (Fig. 9)

on the anterior temporal bone near the lambdoid suture, the

Fig. 10 Forceps delivery for

References 2. Seki H, Takeda S. A review of prerequisites for vacuum extraction:

Shintaro Makino, Jun Takeda, and Satoru Takeda

If the blades of UTokyo Naegele forceps are inserted in par-

Fig. 1 Rotation of UToyko Naegele forceps used for deep transverse

© Springer Science+Business Media Singapore 2018 29

direction of the sagittal suture and the fontanels, the ­examiner

Simulated Holding of the Forceps

Before inserting the forceps, the operator should stand in

In the case of using Kielland forceps, the anterior blade that

between the depths of the two blades is spontaneously Removal of the Forceps

© Springer Science+Business Media Singapore 2018 37

Table 2 Checklist for performance of simulated forceps-assisted vagi- References

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Satoru Takeda, M.D., Ph.D.

roper Positions for Vacuum Extraction

Vacuum Extraction Versus Forceps roblems of Vacuum Extraction

The Structure of the Forceps

rior to Implementation of the Forceps

Manual Rotation (Fig. 9)

direction of the sagittal suture and the fontanels, the examiner

Simulated Holding of the Forceps

between the depths of the two blades is spontaneously Removal of the Forceps