Characteristics of the obstetric forceps 

Table of Contents
 Characteristics of the obstetric forceps 
 Classification of obstetric forceps ( Forceps Delivery)
 Types of obstetric forceps 
o Wrigley’s forceps
o Neville–Barnes or Simpson’s forceps
o Kielland’s forceps
 Procedure of Forceps Delivery
 Maternal Complications of Forceps Delivery
 Neonatal Complications Forceps Delivery
o With the ventouse
o With any instrument

Forceps Delivery:

All obstetric forceps are composed of two separate blades (determined as right
and left by reference to their insertion around the fetal head within the maternal
vagina), two shanks (shafts) of varying length, and two handles. Forceps are
often described as non-rotational or rotational. Nonrotational forceps are ‘held’
together by either an English (non-sliding) lock on the shank or, in the case of
rotational forceps, by a sliding lock on the shank. The blades have a cephalic
curve to accommodate the form of the baby’s head and are fenestrated (and
not solid) to minimize the trauma to the baby’s head during both placement and
birth. They also have a pelvic curve to reduce the risks of trauma to the
maternal tissues during the birth process.

When the blades are correctly positioned around the fetal skull, the handles will
be neatly aligned in the hands of the doctor who applies them and will be noted
to ‘lock with ease’. Forceps that do not lock are most commonly incorrectly
placed.

Classification of obstetric forceps ( Forceps

Delivery)
Forceps operations fall into two categories: mid-and low cavity. Mid-cavity
forceps are used when the leading part of the fetal head has reached below the
level of the ischial spines; low-cavity forceps are used when the head has
descended to the level of the pelvic floor. High-cavity forceps (with the leading
part of the fetal head above the level of the ischial spines) are now considered
unsafe and a CS will be the preferred method of birth in nearly all cases.

Image credited Myles Text Book of Midwives

Types of obstetric forceps 

Wrigley’s forceps
These are designed for use in outlet lift-out when the head is on the perineum
or to assist the birth of the fetal head at cesarean section. They have a short
shank, fenestrated blades with both pelvic and cephalic curves, and an English
lock.

Neville–Barnes or Simpson’s forceps

These are generally used for a low- or mid-cavity forceps birth when the sagittal
suture is in the anteroposterior diameter of the cavity of the pelvis. Whilst they
have cephalic and pelvic curves to the fenestrated blades, the handles are
longer and heavier than those of the Wrigley’s. Anderson’s and Haig–Ferguson’s
forceps are also similar in shape and size.
Kielland’s forceps
These were originally designed to deliver the fetal head at a station at, or
above, the pelvic brim. They are now more commonly used for the rotation and
extraction of a baby whose head is in the deep transverse or occipuo posterior
malpositions. By comparison to the non-rotational forceps, the Kielland’s
forceps blades have fenestrated blades with a much-reduced pelvic curve (in
order to allow for the safe rotation of the fetus), longer shanks (to enable
rotation within the mid-cavity of the pelvis), and sliding lock to allow for
correction of any degree of asynclitism of the fetal head. These forceps should
be used only by an obstetrician skilled in their application and use, and indeed
in many units their use has been abandoned.

Procedure of Forceps Delivery

In addition to the key points outlined for ventouse, i.e. rationale, consent,
urinary bladder catheterization, FHR monitoring, and position of the woman’s
legs, specific issues to consider are:

• Consideration should be given as to the location of the birth – in the birthing

room (lift-out or low-cavity – non-rotational deliveries) or in the obstetric
theatre (all other forceps births).

• Unlike the ventouse, inhalational analgesia or a pudendal nerve block with

perineal infiltration is unlikely to be sufficient for a forceps birth. In the majority
of instances an epidural, if already in situ, maybe topped up, or spinal
anesthetics should be administered. These are mandatory before consideration
is given to using Kielland’s forceps.

• The forceps should be held discretely in front of the woman (to visualize how
they will be inserted per vaginum) and placed around the fetal head. The left
blade is inserted before the right blade, with the accoucheur’s hand protecting
the vaginal wall from direct trauma.

• The forceps blades come to lie parallel to the axis of the fetal head, and
between the fetal head and the pelvic wall. The operator then articulates and
locks the blades, checking their application before applying traction. The blades
must be repositioned or the procedure abandoned if the application is incorrect.

• Traction should be applied in concert with uterine contractions and maternal

expulsive efforts.
• As with the ventouse, the axis of traction changes during the birth and is
guided along the curve of Carus, the blades being directed to the vertical as the
head crowns.

Complications of instrumental vaginal birth ( Forceps Delivery )

Although forceps are less likely than the ventouse to fail to achieve a vaginal
birth, they are significantly more likely to be associated with third- or fourth-
degree tears (with or without the concurrent use of an episiotomy), vaginal
trauma, use of general anesthesia, flatal, faecal and urinary continence.
 Image credited Myles Text
Book of Midwives

Maternal Complications of Forceps Delivery

Complications may include:

• Trauma or soft tissue damage – occurring to the cervix, vagina or perineum.

• Dysuria or urinary retention, which may result from bruising or edema to the
tissues around the urethra.

• Perineal discomfort.
• Haemorrhage (both from tissue trauma and also uterine atony – the risk of
which is always increased following an assisted vaginal birth).

Neonatal Complications Forceps Delivery

Complications may include:

• Marks on the baby’s face and bruising (commonly caused by the pressure
from the forceps blades and around the caput succedaneum/chignon from the
ventouse – nearly all of which resolve within 48–72 hours after birth.

• Facial palsy, which may result from pressure from a blade compressing a
facial nerve (a transient problem in most instances).

■ Prolonged traction during birth with a ventouse will increase the likelihood of
scalp abrasions, cephalohaematoma, or sub-aponeurotic bleeding.

Some authors suggest that failure rates of <1% should be achieved using the
correct technique and with well-maintained equipment. Many authors feel that
this is an unrealistic target. Failure of the ventouse realistically arises in up to
20% of cases.

The following as factors will often be found to have contributed to failure:

With the ventouse

• Failure to select the correct cup type – inappropriate use of the silastic cup –
especially in the presence of deflexion of the fetal head, excess caput, ‘dense’
epidural block or fetal macrosomia (true CPD).

• Failure of the equipment to provide adequate traction as a consequence of a

leakage of the vacuum.

• Incorrect cup placement – too anterior or lateral, with or without inclusion of

maternal soft tissues within the cup.

With any instrument

• Inadequate initial case assessment – high head, misdiagnosis of the position
and attitude of the head.

• Traction along the wrong plane (often too anteriorly and not along the curve
of Carus).

• Poor maternal effort with inadequate use of syntocinon to maximize the

contribution from coordinated uterine activity.

Whatever the outcome, the midwife in attendance is vital to the success of any
maneuvers undertaken, encouraging the mother to be an active participant in
her birth, supporting the mother and her partner through what may be
perceived to be a ‘deviation from normal’ and importantly, to support the
clinician undertaking the assisted birth.