Forceps delivery is a means of extracting the fetus with the aid of obstetric forceps when it is inadvisable or impossible for the mother to complete the delivery by her own efforts The invention of obstetric forceps was around 1,600 AD by the chamberlen family, many designs were invented and modified. Forceps deliveries were formerly classified by the level of the head at the time the forceps were applied, i.e. high-cavity, mid-cavity and low cavity .lowcavity forceps is the one frequently performed, as caesarean section is usually preferred to the more traumatic high and mid-cavity operations

Low-cavity forceps can be divided in to rotational and non-rotational. Rotational forceps delivery refers to a maneuver of the fetal head from a malposition into a more favorable position with the aid of specially designed forceps usually Kielland’s. Examples of non rotational forceps are:Wrigley’s forceps and Simpson’s forceps ( low cavity) Neville – barne’s and Haig Ferguson’s forceps (high and mid – cavity forceps).

Only three varieties are commonly used in present day obstetrics. . Short curved forceps. Kielland’s forceps. They are:   Long curved forceps with or without axis traction device.

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It is relatively heavy and about 37 cm(15”) long  In india Das’s variety is used  Suitable for the small pelvis and small baby of Indian women  Measurements-length-37cm -Distance between the tips -2.5cm -Widest diameter.9cm  Blades :two blades named as right and left in relation to the meternal pelvis  Parts are blade  shank  lock  handle with or without screw  .

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which when articulated. and usually measures 6. It increases the length of the instrument and thereby.25 cm. facilitates locking of the blades outside the vulva. The cephalic curve on the flat surface. .  Shank: The shank is the part between the blade and the lock. The pelvic curve is designed to fit the curve on the axis of the birth canal is the concave side of the pelvic curve. Blade: The blades are fenestrated which facilitate a good grip of the fetal head. the shanks are not apposed together. There is usually a slot in the lower part of the fenestrum of the blades to allow the upper end of the axis traction rod to be fitted. When the blades are articulated. grasps the fetal head without compression. The blade has two curves.

It consists of traction rods and traction handle. It measures 12. The handle: The handles are apposed when the blades are apposed when the blades are articulated. The Lock: The common method of articulation consists of a socket system located on the shank at its junction with the handle. less force is necessary to deliver the head. especially following manual rotation of the head. commonly left. . It provides traction in the correct axis of the pelvic curve and as such.5 cm (5’’).   Axis traction device: It can be applied with advantage in midforceps operation. A screw may be attached usually at the end (or at the base) of one blade. to keep the blade in position.

It has a marked cephalic curve with a slight pelvic curve. . It is short due to reduction in the length of the shanks and handles. The instrument is used for very low forceps deliveries for the after-coming head of a breech delivery or at caesarean section. The instrument is lighter. shorter and stubbyhandled.

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Has got a sliding lock which facilitates the correction of asynclitism of the head .  Long and almost straight without any axis traction device.

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CHOICE OF FORCEPS OPERATION Mid forceps: (10%)  Used when head is at or near the level of ischial spine  Internal rotation of the head is often incomplete  Manual rotation may be needed before traction  Ocxtocin drip may be required if not contraindicated  Ventouse may be an alternative LOW FORCEPS: (90%)  The head is near the pelvic floor or visible at introitus  Commonly used OUTLET FORCEPS:  Low forceps  When the head is at perineum  .

Pelvic application Blades of the forceps are applied on the lateral pelvic walls ignoring the position of the head.puts serious compression effect on the cranium  Must be avoided  . got negligible effect on the cranium 2.TYPES OF APPLICATION OF THE FORCEPS BLADE 1. Cephalic application  The blade is applied along the sides of the head grasping the biperital diameter in between the widest part of the blades  The long axis of the blade corresponds more or less to the occipito mental plane of the fetal head  Ideal method of application.  If head remains unrotated .

FUNCTIONS  Traction  Its compression effect  Rotation of the head  To provide a protective cage  One forceps blade may be used as a vectis to assist delivery of the head in CS .

may be considered when the prerequisites have been fulfilled and there is a valid reason. Fetal  When the baby shows signs of abnormal heart rate. Reasons to perform an operative vaginal delivery can be related to situations in the baby or the mother. Maternal  Inadequate expulsive efforts  Maternal exhaustion  When the second stage of labor should be shortened because of a medical condition. in this case. Operative vaginal delivery is an option 1. Others  Prolonged second stage of labor  failure to progress in the second stage of labor . forceps delivery. To minimize the amount of pushing 2.INDICATIONS  Operative vaginal delivery.  Compression of the umbilical cord  Low birth weight baby  Post maturity 3.

 The degree of molding of the baby's head Maternal criteria  Bladder must be emptied  Adequate analgesia Other criteria  Experienced operator  Verbal or written consent .  The baby's head must be at or below zero station (engaged). Fetal criteria  The cervix must be completely dilated  Membranes (bag of waters) must be ruptured.PREREQUISITES Before any forceps delivery can be attempted.

TYPES OF FORCEPS DELIVERIES:  Outlet  Low  Mid  High .

. There is no restriction on rotation for this type of delivery. Low forceps delivery is forceps-assisted delivery performed when the baby's head is at +2 station or lower. This type of assisted delivery is performed only when the baby's head is in a straight forward or backward position (facing either toward the mother's pubic bone or toward the mother's tailbone) or in slight rotation (less than 45 degrees to the right or left) from one of these positions.  Outlet forceps delivery is forceps-assisted delivery performed when the baby's scalp is visible at the vaginal opening.

High forceps delivery would be a forcepsassisted vaginal delivery performed when the baby's head is not yet engaged. . The head must be engaged. These types of deliveries are not performed in modern practice.  Mid forceps delivery is forceps-assisted delivery performed when the baby's head is above +2 station.

LOW FORCEPS OPERATION  Preliminaries  Anesthesia  Catheterization  Internal examination  episiotomy .

middle. thumb in a pen holding manner and is held vertically almost parallel to the right inguinal ligament. index. The handle of the left blade is taken lightly by three fingers of the left hand .Steps Identification of the blade and their application  The left or the lower blade is to be introduced first  The four fingers of the right hand are inserted along the left lateral vaginal wall. The fingers are to guide the blade during application and to protect the vaginal wall. . the palmar surface of the finger rest against the side of the head.

the two fingers of the left hand are now introduced into the right lateral wall of the vagina alongside the baby’s head. As the blade is pushed up and up. the handle is carried downwards and back words. When correctly applied the blade should be over the partial eminence.  The blade is introduced between the guiding internal fingers and the fetal head. The right blade is introduced in the same manner as with left hand but holding it with the right hand. manipulated by the thumb. the shank should be in contact with the perineum and the superior surface of the handle should be directed upward. . Introduction of the right blade. transversing wide arc of a circle towards the left until the shank is to lie straight on perineum.

the blades are to be reinserted. The handles should never be forced to lock them. the blades should be articulated with ease. Minor difficulty in locking can be corrected by depressing the handles on the perineum. .Locking of the blades  When correctly applied. In case of major difficulty.

the right one is first. . correct application of the blades is to be ensured. The blades are then removed one by one. Steady but intermittent traction should be given if possible during contraction.  Direction of the pull. However in outlet forceps the pull is continuous. firm gripping of the head on the biperital diameter.corresponds the axis of the birth canal. The direction of the pull is downwards and backwards until the head comes to the perineum. The pull is then directed horizontally straight towards the operator till the head is almost crowned. As evidenced by easy locking.Traction and removal of blades  Before traction is applied.

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 Enlargement of the cord or fetal parts inside the blades.Difficulties in Forceps Operation Difficulty in locking are caused by:-. .  Application on un-rotated head.  Improper insertion of the blade (not for enough in).  Failure to depress the handle against the perineum.

sphincter dysfunction.MATERNAL FETAL Immediate Injury Nerve injury PPH Anesthetic complications Puerperal sepsis Meternal morbidity Immediate Asphexia Facial bruishing Intracranial haemorrhage Cephalohaematoma Facial palsy Skull fractures Cervical spine injury. Remote – genital prolapse Painful perineal scars. stress urinary incontinence. Dyspareunea. Low backache Remote Cerebral or spastic palsy .

 Refusal of the patient to verbally consent to the procedure  Cervix not fully dilated or retracted  Inability to determine the presentation and fetal head position  Inadequate pelvic size  Confirmed cephalopelvic disproportion  Unsuccessful trial of vacuum extraction (relative contraindication)  Absence of adequate anesthesia/analgesia  Inadequate facilities and support staff  Inexperienced operator .CONTRAINDICATIONS  Any contraindication to vaginal delivery.

Failure in the operative delivery may be due to improper application or failure of descend of the head even with forcible contraction. it is called failed forceps.       .Failed Forceps  When a deliberate attempt in vaginal delivery with forceps has failed to expedite the process. Causes for Failed Forceps Incompletely dilated cervix. Large baby with the shoulders impacted at the brim. Constriction ring. Undiagnosed brow or hydrocephalous or fetal ascites. Unrotated occipito-posterior position. It is predominantly due to lack of obstetric skill with poor clinical judgement.

Management      Assess the effect on mother and fetus. . The women should be shifted to an equipped hospital. Administer parenteral antibiotic. Exclude rupture of uterus and plan for other modes of delivery. Start IV infusion with 5 percent dextrose if one is not already in place.