FORCEPS DELIVERY

Judeilan A. Macahilo-Layawon,
MD
 G2P1(1001) IUP
38 6/7 wks AOG,
ASSISTED History of RHD
VAGINAL DELIVERY
UNDER
IE: 60%,2D
-2,Echo:
5-6cm, EPIDURAL ANESTHESIA
cephalic, intact BOW
Mitral Valve Prolapse,
FHB 130s
Trivial
Joint Mitral
service withRegurgitation,
Department of IM
Mild Aortic Regurgitation
ECG: Normal
 10
9 -4
8 -3
7 Delivered to a live baby Girl, AGA, -2
Cervical Dilatation

BW = 2410 grams, Apgar Score of 8

Station
6 -1
5 and 9, Pediatric Age of 39 weeks
0
4 via outlet forceps extraction under
RBOW +1
3 spinal anesthesia
+2
2 +3
1 +4
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Hours of Labor
 IMMEDIATE POSTPARTUM
• BP 110/70
• CR 90
• RR 20
• O2 sat 97%

• Well contracted uterus

• Minimal blood loss
 4th day POST PARTUM
• BP 110/70
• CR 82
• RR 17
• Temp 37
• Voids freely
• Minimal bleeding
• Discharged
 FINAL DIAGNOSIS
G2P2 (2002)
Pregnancy uterine delivered to a term,
cephalic, live baby girl by outlet forceps
extraction under spinal anesthesia

Gravidocardiac Functional Class I (Mitral

Valve Prolapse, Trivial Mitral
Regurgitation, Mild Aortic Regurgitation)
S/P Outlet Forceps Extraction -2013
CASE DISCUSSION
ANATOMY
PHYSIOLOGIC
CONSIDERATIONS IN
PREGNANCY –
CARDIOVASCULAR
 Changes in cardiac function become
apparent during the first 8 weeks of
pregnancy.

Cardiac output is increased as early as

the fifth week and reflects a reduced
systemic vascular resistance and an
increased heart rate.
 The resting pulse rate increases about
10 beats/min during pregnancy.

Between weeks 10 and 20, plasma volume expansion

begins and preload is increased.

Ventricular performance during pregnancy is influenced

by both the decrease in systemic vascular resistance and
changes in pulsatile arterial flow.
 Chest Radiograph of the Heart

• The apex is
moved laterally
causing a larger
cardiac silhouette
• Normal pregnancy induces no
characteristic ECG changes other than
slight left-axis deviation
» Enein and colleagues, 1987
 Normal cardiac examination
findings in the pregnant woman
 Cardiac output
in the lateral
Mean arterial recumbent
Blood volume
pressure and position
and basal
vascular increases and
metabolic rate
resistance continues to
increase
decrease increase and
remains
elevated

Duvekot and colleagues, 1993; Mabie and

co-workers, 1994
• Cardiac output at term increase 1.2 L/min
– 20%

• Supine position, the large pregnant uterus

rather consistently compresses venous
return from the lower body and may
compress the aorta  cardiac filling may
be reduced with diminished cardiac output
» Bieniarz and associates, 1968

» Bamber and Dresner (2003)

• Fetal oxygen saturation is approximately 10%
higher when a laboring woman is in a lateral
recumbent position

• First stage of labor, cardiac output increases

moderately; second stage, with vigorous
expulsive efforts, it is appreciably greater; and
pregnancy-induced increase is lost after
delivery, at times dependent on blood loss.

» Simpson and James (2005)

• Right heart catheterization was performed
in 10 healthy nulliparous women at 35 to
38 weeks, and again at 11 to 13 weeks
postpartum
– Late pregnancy was associated with
increases in heart rate, stroke volume, and
cardiac output
» Clark and colleagues (1989)
• Brachial artery pressure when sitting is
lower

• Arterial pressure usually decreases to a

nadir at 24 to 26 weeks and rises
thereafter

» (Bamber and Dresner, 2003)

• Venous blood flow in the legs is retarded
during pregnancy  stagnation of blood in
the lower extremities during the latter part
of pregnancy  occlusion of the pelvic
veins and inferior vena cava by the
enlarged uterus
» Wright and co-workers (1950)
• Elevated venous pressure returns to normal
when the pregnant woman lies on her side and
immediately after delivery

• Alterations contribute to edema and to the

development of varicose veins in the legs and
vulva, hemorrhoids  deep-venous thrombosis

» (McLennan, 1943)
• Supine compression of the great vessels by the
uterus causes arterial hypotension (supine
hypotensive syndrome)
» Kinsella and Lohmann, 1994

• When in supine, uterine arterial pressure—and

blood flow—is significantly lower than that in the
brachial artery, may directly affect fetal heart
rate patterns, and also occurs with hemorrhage
or with spinal analgesia
» Tamás and colleagues, 2007
HEART DISEASE IN
PREGNANCY
DIAGNOSIS OF HEART
DISEASE
 Clinical Indicators of Heart Disease During
Pregnancy

Symptoms Clinical Findings

• Progressive dyspnea or • Cyanosis
orthopnea • Clubbing of fingers
• Nocturnal cough • Persistent neck vein distension
• Hemoptysis • Systolic murmur grade 3/6 or
• Syncope greater
• Chest pain • Diastolic murmur
• Cardiomegaly
• Persistent arrhythmia
• Persistent split second sound
• Criteria for pulmonary
hypertension
 Diagnostic Studies
• Echocardiography

• Chest Radiography

• Electrocardiography
CLINICAL CLASSIFICATION
OF HEART DISEASE
 New York Heart Association (NYHA)
• Uncompromised—no limitation of physical activity:
Class I These women do not have symptoms of cardiac
insufficiency or experience anginal pain.

• Slight limitation of physical activity: These women

are comfortable at rest, but if ordinary physical activity
Class II is undertaken, discomfort in the form of excessive
fatigue, palpitation, dyspnea, or anginal pain results

• Marked limitation of physical activity: These

Class women are comfortable at rest, but less than ordinary
activity causes excessive fatigue, palpitation, dyspnea,
III or anginal pain.

• Severely compromised—inability to perform

Class any physical activity without discomfort:
Symptoms of cardiac insufficiency or angina may
IV develop even at rest. If any physical activity is
undertaken, discomfort is increased.
 American College of Obstetrician and Gynecologists (ACOG) 1992
CARDIAC DISORDER MORTALITY (%)

GROUP 1 – MINIMAL RISK 0-1

Atrial Septal Defect

Ventricular Septal Defect
Patent Ductuc Arteriosus
Pulmonic or Tricuspid Disease
Fallot tetralogy, corrected
Bioprosthetic value
Mitral stenosis, NYHA Classes I and II

GROUP 2 – MODERATE RISK 5-15

2A:
Mitral stenosis, NYHA classes III and IV
Aortic stenosis
Aortic coarctation without valvar involvement
Fallot tetralogy, uncorrected
Previous myocardial infarction
Marfan syndrome, normal aorta
2B:
Mitral stenosis with atrial fibrilation
Artificial valve

GROUP 3 – MAJOR RISK 25-50

Pulmonary hypertension
Aortic coarctation with valvar involvement
Marfan syndrome, with aortic involvement
 Predictors of Cardiac Complications
• Prior heart failure, transient ischemic attack, arrhythmia,
or stroke

• Baseline NYHA class III or IV or cyanosis

• Left-sided obstruction

• Ejection fraction <40%

 Preconceptional Counseling
• Significant worsening of NYHA class in 26 of
579 pregnancies—4.4 percent—in which the
baseline class was I or II
» Siu and colleagues (2001)

• No maternal deaths in 1041 women with class I

or II disease
» McFaul and co-workers (1988)
• Life-threatening cardiac abnormalities can be
reversed by corrective surgery, and subsequent
pregnancy is less dangerous

• Women with mechanical valves taking warfarin

 fetal considerations predominate
 Congenital Heart Disease in Offspring
Maternal Heart Congenital Heart Disease in Fetus (%)
Disease
Cardiac Lesion Previous Sibling Father affected Mother affected
Affected
Marfan syndrome NS 50 50
Aortic stenosis 2 3 15-18
Pulmonary stenosis 2 2 6-7
Ventricular septal defect 3 2 10-16
Atrial septal defect 2.5 1.5 5-11
Patent ductus arteriosus 3 2.5 4
Coarctation of the aorta NS NS 14
Fallot tetralogy 2.5 1.5 2-3
GENERAL MANAGEMENT
Management of NYHA Class
I and II Disease
• Onset of congestive heart failure is gradual

• First warning sign: persistent basilar rales, frequently

accompanied by a nocturnal cough

• Serious heart failure: A sudden diminution in ability to

carry out usual duties, increasing dyspnea on exertion,
or attacks of smothering with cough

• Clinical findings: hemoptysis, progressive edema, and

tachycardia

» Jessup and Brozena (2003)

• Infection with sepsis syndrome – precipitating
factor

• Bacterial endocarditis – deadly complication

• Pneumococcal and influenza vaccines are

recommended

• Cigarette smoking, drug use – prohibited

• Vaginal delivery is preferred

• Induction is generally safe.

» Oron and colleagues, 2004

• Invasive monitoring – rarely indicated

• In a semirecumbent position with lateral tilt

• Vital signs should be monitored

• Relief from pain and apprehension

• Intravenous analgesics, continuous epidural

analgesia

• Major problem with conduction analgesia 

maternal hypotension
dangerous in women with intracardiac shunts, in
whom blood may flow from right to left within the heart
and bypasses the lungs
 life-threatening with pulmonary hypertension or aortic
stenosis  narcotic conduction analgesia or general
anesthesia may be preferable
• Epidural analgesia given with intravenous sedation
– Minimize intrapartum cardiac output fluctuations and
allows forceps or vacuum-assisted delivery

• Subarachnoid blockade is not generally

recommended

• For cesarean delivery  epidural analgesia is

preferred

• General endotracheal anesthesia with thiopental,

succinylcholine, nitrous oxide, and at least 30-
percent oxygen has also proved satisfactory.
• Intrapartum Heart Failure  proper therapeutic
approach depends on the specific hemodynamic
status and the underlying cardiac lesion
• Women who have shown little or no evidence of
cardiac distress during pregnancy, labor, or
delivery may still decompensate postpartum
» (Keizer and colleagues, 2006; Zeeman, 2006)

• Postpartum hemorrhage, anemia, infection, and

thromboembolism – serious complications
• If tubal sterilization is to be performed after
vaginal delivery
– Should be hemodynamically near normal, afebrile, not
anemic, and ambulates normally

• Other women are given detailed contraceptive

advice
Management of Class III and
IV Disease
• Only 3% of approximately 600 pregnancies
were complicated by NYHA class III heart
disease, and no women had class IV when
first seen
» Siu and associates (2001)

• If women make that choice, they must

understand the risks and cooperate fully with
planned care
– severe cardiac disease should consider
pregnancy interruption
– If the pregnancy is continued, prolonged
hospitalization or bed rest is often necessary
• Epidural analgesia for labor and delivery is
usually recommended.

• Vaginal delivery is preferred in most cases, and

labor induction can usually be done safely.
» Oron and associates, 2004

• Cesarean delivery is usually limited to obstetrical

indications
– Considerations: specific cardiac lesion, overall
maternal condition, and availability of experienced
anesthesia personnel and general support facilities
 Mitral Valve Prolapse
• Myxomatous degeneration – pathological connective
tissue disorder which may involve the valve leaflets
themselves, the annulus, or the chordae tendineae

• Mitral insufficiency may develop

• Women with symptoms have anxiety, palpitations,

atypical chest pain, and syncope

• Those with redundant or thickened mitral valve leaflets

are at increased risk for sudden death, infective
endocarditis, or cerebral embolism
» Braunwald, 2005
• Pregnant women with mitral valve prolapse rarely have cardiac
complications

• Women without evidence of pathological myxomatous change may

in general expect excellent pregnancy outcome
» Chia and associates, 1994

• β-blocking drugs are given to decrease sympathetic tone, relieve

chest pain and palpitations, and reduce the risk of life-threatening
arrhythmias

• Mitral valve prolapse with regurgitation or valvular damage is

considered to be a moderate risk for bacterial endocarditis
FORCEPS DELIVERY
 FORCEPS

Tucker–McLane
forceps
Simpson’s forceps
 Classification of Forceps Delivery
according to Station and Rotation
Procedure Criteria
Outlet forceps 1. Scalp is visible at the introitus without separating the labia
2. Fetal skull has reached pelvic floor
3. Sagittal suture is in anteroposterior diameter or right or
left occiput anterior or posterior position
4. Fetal head is at or on perineum, and
5. Rotation does not exceed 45 degrees

Low forceps Leading point of fetal skull is at station ≥+2 cm, and not on
the pelvic floor, and:
• Rotation is 45 degrees or less, or
• Rotation is greater than 45 degrees.

Midforceps Station is between 0 and +2 cm.

 Indications for Forceps
Maternal indications Fetal indication
• heart disease • prolapse of the umbilical
• pulmonary injury or cord
compromise • premature separation of
• intrapartum infection the placenta
• neurological conditions • nonreassuring fetal
• exhaustion heart rate pattern
• prolonged second-
stage labor
 Prerequisites for Forceps Application
The cervix must be completely dilated.

The membranes must be ruptured.

The head must be engaged.

The fetus must present a vertex, or present a face with the chin
anterior.

The position of the fetal head must be precisely known.

There should be no suspected cephalopelvic disproportion.

OUTLET FORCEPS
• The left handle of the
forceps is held in the
left hand. The blade
is introduced into the
left side of the pelvis
between the fetal
head and fingers of
the operator’s right
hand.
• The fetus is presenting
as vertex with occiput
anterior crowning. The
application of the left
blade of the Simpson
forceps.

• Next, the right blade is

applied and the blades
are articulated.
• The vertex is now occiput
anterior, and the forceps are
symmetrically placed and
articulated.
• Incorrect application
of forceps.

• One blade over the

occiput and the other
over the brow.
Forceps cannot be
locked. With incorrect
placement, blades
tend to slip off with
traction.
• Forceps have been locked.
Vertex is rotated from left
occiput anterior to occiput
anterior.

• When it is certain that the

blades are placed
satisfactorily, then gentle,
intermittent, horizontal
traction is exerted until the
perineum begins to bulge.

• With traction, as the vulva

is distended by the occiput,
an episiotomy may be
performed if indicated.
• Upward arching
traction is used as
the head is
delivered.

• Upward traction is
continued as the
head is delivered.
• Forceps may be
disarticulated as the
head is delivered.

• Modified Ritgen
maneuver may be
used to complete
delivery of the head.
LOW- AND MIDFORCEPS
OPERATION
 Left Occiput Anterior Position
• The right hand serves as a guide for introduction of the left
branch of the forceps, which is held in the left hand and
applied over the left ear.

• Two fingers of the left hand are then introduced into the right
posterior portion of the pelvis.

• The right branch of the forceps, held in the right hand, is then
introduced along the left hand as a guide.

• It must then be applied over the anterior ear of the fetus by

gently sweeping the blade anteriorly until it lies directly
opposite the blade that was introduced first.
 Right Occiput Anterior Position
• The blades are introduced similarly as LOA, but in the
opposite directions off the vertical.

• After the blades have been applied to the sides of the

head, the left handle and shank lie above the right.
 Occiput Transverse Positions
• The forceps are introduced similarly, but with the
first blade applied over the posterior ear and the
second rotated anteriorly to a position opposite
the first.

• In this case, one blade lies in front of the sacrum

and the other behind the symphysis.
 Rotation from Anterior and Transverse
Positions
• When the occiput is obliquely anterior, it gradually
rotates spontaneously to the symphysis pubis as traction
is exerted.

• Rotation counterclockwise from the left side toward the

midline is required when the occiput is directed toward
the left, and in the reverse direction when it is directed
toward the right side of the pelvis.

• Regardless of the original position of the head, delivery

eventually is accomplished by exerting traction
downward until the occiput appears at the vulva.
 Occiput Posterior Positions
• Prompt delivery may at times become necessary when
the small occipital fontanel is directed toward one of the
sacroiliac synchondroses in right occiput posterior or left
occiput posterior positions.

• When the hand is introduced into the vagina to locate the

posterior ear, the occiput rotates spontaneously toward
the anterior, indicating that manual rotation of the fetal
head might easily be accomplished.
 MORBIDITY FROM
FORCEPS OPERATIONS
 Maternal Morbidity
• Lacerations and Episiotomy

• 13% rate of third- and fourth-degree episiotomy extensions

and vaginal lacerations for outlet forceps
• 22% for low forceps with less than 45 degrees rotation and
44% for low forceps with more than 45 degrees rotation
• 37% for midforceps deliveries
» Hagadorn-Freathy and co-workers (1991)

• Forceps deliveries were associated with higher episiotomy

rates as well as third and fourth-degree lacerations compared
with those of spontaneous delivery.
» Goldberg and colleagues (2002)
 Maternal Morbidity
• Urinary and Fecal Incontinence

• Short-term effects of forceps and vacuum deliveries,

especially midcavity deliveries, include postpartum
urinary retention and bladder dysfunction.
» (Carley and co-workers, 2002)

• Urinary incontinence after forceps delivery was more

likely to persist than incontinence associated with
vacuum or spontaneous delivery
» Arya and colleagues (2001)
• Long-term effects, there are a now a number of studies
indicating that even spontaneous vaginal delivery will, in
some women, be followed by urinary and fecal
incontinence.

• Because forceps deliveries are associated with an

increased incidence of episiotomy and extension or
laceration, it has been associated in some reports with
higher rates of anal and urinary incontinence.
» Baydock and coworkers, 2009
 Maternal Morbidity

• Febrile Morbidity

• Postpartum uterine infection and pelvic cellulitis are

more frequent, and often more severe, in women
following cesarean delivery compared with that following
operative vaginal delivery.
» Robertson and colleagues, 1990
 Perinatal Morbidity
• Facial nerve palsy in 0.9% of 8415 infants delivered
by forceps compared with 0.02% among 35,877
delivered spontaneously or by cesarean
» Falco and Eriksson (1990)

• Brachial plexus injury was reported among infants

delivered with forceps (5%) or vacuum (4%) than
those delivered spontaneously (1.5%)
» Gilbert and co-workers (1999)

• Forceps and vacuum deliveries were associated with

intracranial hemorrhage more commonly than
spontaneous delivery
» Towner and colleagues (1999).
- THE END -
• Vacuum extraction is reserved for fetuses
who have attained a gestational age of at
least 34 weeks. Otherwise, the in-
dications and prerequisites for its use are
the same as for forceps delivery
 Contraindications
• operator inexperience, inability to assess
fetal position, high sta- tion, and suspicion
of cephalopelvic disproportion. Contraindi-
cations for delivery using vacuum
extraction include face or other nonvertex
presentations, or fetal coagulopathy.
 Complications
• Complications of the vacuum extractor
include scalp lacera- tions and bruising,
subgaleal hematomas,
cephalohematomas, intracranial
hemorrhage, neonatal jaundice,
subconjunctival hemorrhage, clavicular
fracture, shoulder dystocia, injury of sixth
and seventh cranial nerves, Erb palsy,
retinal hemorrhage, and fetal death
• higher frequency of maternal trauma and
blood loss in the forceps group, but an
increase in the incidence of neonatal
jaundice in the vacuum group