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Prof.S.N.Panda, M.S. Department of Obstetrics and Gynecology M.K.C.G.Medical College, Berhampur
• In the last several decades, obstetrics, as a science has undergone phenomenal development with a proper understanding of the entire process of pregnancy & childbirth. • The present day labour management is basically influenced by two factors:
– The availability of various modalities of antepartum & postpartum foetal monitoring that gives the obstetrician precise knowledge of the foetal condition, which enables him not only to terminate the pregnancy & labour but also document his decision. – The developments in the fields of anaesthesia, antibiotics, blood transfusion, surgical aids & techniques have made a once dreaded operation - "caesarean section ", very safe to-day.
12 October 2002 Forceps Delivery - Prof.S.N.Panda 2
• In view of these developments, the expectations of all concerned patient, relatives, attending doctors & authorities including legal system has undergone a sea change so that a small mishap will be viewed seriously. • In such a scenario, the practicing obstetrician of today is likely to have reservations about using instrumental labour management methods of unpredictable course & outcome. Hence today instrumental deliveries are becoming rarer and rarer. In the last two decades, not only very few developments have taken place in this field, many of the instrumental deliveries have become obsolete. • However in the present day concept of active management of labour , forceps still have their own place and should be considered in suitable cases, particularly in developing countries like India.
12 October 2002 Forceps Delivery - Prof.S.N.Panda 3
History • Earliest mention of instrumental delivery in Vedic era "Ankush." • Albucasis described forceps with teeth on the inner surface for dead foetus. • WILLIAM CHAMBERLAIN – – Fled from France in 1569 & practiced forceps delivery as a family secret in Southampton. Was summoned by R.had greater distinction & attended notable women in society. • Peter I .C. 12 October 2002 Forceps Delivery .Prof.P.Panda 4 .who had several sons. • Peter II . – He had two sons. He had no sons.N. died in 1626. This was kept as a family secret for over 100yrs and four generations.S. & Jailed in 1612.
Panda 5 .Prof. Died in 1683 in Woodham Mortimer Hall. which was latter unearthed in 1813 by the then occupant Mrs. After few years he went to Holland & again sold the secret (only one blade) to Roser Roomhuysen.N. was forced to flee to France. Oxford.had interest in politics.C. 12 October 2002 Forceps Delivery .History • Dr Peter III. • Hugh.Kembell. and Padua. Elected a fellow of R.It is believed that the family treasure was kept buried here. where in 1673 he sold the family secret to Mauriceau.the most prominent one studied in Cambridge.P.S.
12 October 2002 Forceps Delivery .History • Hugh (son of Hugh)-who was highly educated and respected had patients from best families including Duke of Buckingham allowed the family secret to leak. Moreover since the advent of Vacuum extractor.reinforced pelvic curve & introduced English lock and used in aftercoming head.Prof. many of the earlier high forceps applications have become obsolete. • The Chamberlain family used four pairs of forceps of different sizes with only cephalic curve.S. • Since then very few and minor developments have taken place. • Levret (1747)-introduced the pelvic curve • Smellie (1751).Panda 6 .N. • Barton and Kjielland . • Tarnier (1877)-introduced axis traction.introduced the two specialized forceps.
12 October 2002 Forceps Delivery .forceps applied when the foetal head/skull has reached the pelvic floor.S.Panda 7 .Classification of forceps application • Classical (old) Classification : – Low/outlet forceps (no distinction): . sagital suture has reached the A. – High forceps: .forceps applied when head is engaged but criteria for low forceps not reached.P diameter of pelvis and scalp is visible without separating the vulva.Prof.N.forceps applied when head is not engaged. – Mid forceps: .
/Rt.Panda 8 . Occiputo anterior/posterior position Outlet forceps Mid forceps High forceps 12 October 2002 The leading point of the skull is 2cm or less above the spine but head is engaged.Classification of forceps application Newer classification as per A.G.O.S.C. Rotation not considered EXCLUDED Forceps Delivery .N./Rt.1981(revised in 1991):- Low forceps Foetal scalp is visible without separating the vulva Foetal skull has reached the pelvic floor Sagital suture is in the A.P.diameter or in the Lt. Occiputo anterior/posterior position Rotation does not exceed 45degrees The leading point of the skull is 2cm or more below the ischeal spine but not on the pelvic floor Sagital suture is in the A.P.diameter or in the Lt.Prof.
• Modified classical instruments: -Overlapping solid blades with extended shanks like Tucker-Melane forceps.N. Wrigley & George L.Prof. 12 October 2002 Forceps Delivery .Elliot Jr in mid 19th century commonly used for outlet & low pelvic rotational delivery. • Specialized instruments : -Designed for specific indications like– Barton's for transverse arrest in platypeloid pelvis.S.Panda 9 .Types of Forceps Several hundred types of forceps have been designed which can be classified into various types-. May be occasionally pseudofenestrated like Luikart's modification. • Classical instruments: -Originally designed by James Young Simpson. – Keilland's for mid pelvic rotation & correction of asynclitism and – Piper's for delivery of Aftercoming head in breech. Elliot type commonly used as mid pelvic rotators or outlet blades.
S. Shute & Moolgaoker. 12 October 2002 Forceps Delivery . • Axis traction instruments: -. Examples Laufe. – As a separate handle like bill's handle to be attached to any standard forceps.Prof.Types of Forceps Several hundred types of forceps have been designed which can be classified into various types-. • Divergent or parallel blades instrument: -. – Axis traction as an integral part of the forceps like HowkDennon's& de Wee's forceps.Panda 10 .N. – Designed to limit foetal cranial compression.
Panda 11 . • Compression effect: -This is minimal when properly applied & should not be more than necessary to grasp the head. • Rotation of head: -This occurs with the use of Kejilland's forceps and also in low forceps cephalic application with the occiput in the 2 or 10 'o' clock position. When applied on the aftercoming head it lessens the sudden decompression effect.When applied on a premature baby it protects from the pressure of the birth canal. • As a vectis: .S.N.Prof. 12 October 2002 Forceps Delivery . However it has some pressure effect on the well-ossified base of the skull.Functions • Traction: -This is the most important function. Pull required in a primigravida is 18 kgs & in a multipara it is 13 kgs.By applying one blade to deliver the head in caesarean section. • Protective cage: .
– Failure of progress of labour.Panda 12 . with the head on the perineum.Indications for forceps delivery • Delay in second stage: -.O.(1988/1991): – Nullipara• <3 hrs with regional anaesthesia • <2 hrs without regional anaesthesia – Multipara• <2 hrs with regional anaesthesia • <1hr without regional anaesthesia 12 October 2002 Forceps Delivery .N.if no progress occurs for more than 20 to 30 minutes. – Due to uterine inertia.G.Prof.C.S. Definition of prolonged second stage of labour redefined by A.
Indications for forceps delivery • Foetal indications: – Foetal distress in second stage when prospect of vaginal delivery is safe: • Abnormal heart rate pattern • Passage of meconium • Abnormal scalp blood ph – Cord prolapse in second stage – Aftercoming head of breech – Low birth wt.Panda 13 .S.N. Baby – Post maturity 12 October 2002 Forceps Delivery .Prof.
Indications for forceps delivery • Maternal indication: – – – – – – Maternal distress Pre-eclampsia Post caesarian pregnancy Heart diseases Intra partum infection Neurological disorders where voluntary efforts are contraindicated or impossible 12 October 2002 Forceps Delivery .N.Prof.S.Panda 14 .
Membranes must be ruptured. • • • • • Cervix must be fully dilated.N. – Vertex. anterior face or aftrcoming head are the ideal positions. Forceps Delivery .Panda 15 12 October 2002 .(to be fulfilled before forceps application. Baby should be living.Prof.) Prerequisites • Suitable presentation & position: -. Bladder must be empty.S. Uterus should be contracting & relaxing.
Panda 16 . 12 October 2002 Forceps Delivery . resulting maternal & foetal complications or injuries and blood loss. TDO & sub pubic angle. type of instrument.(before forceps application ) • Documentation: – All instrumental deliveries should be dictated in medical record as any surgical procedure & it should include: Consent of the patient. anaesthesia.Prof. presentation & position. – Regional or General anaesthesia for low & mid forceps. • Episiotomy: – Should be done either before application of forceps or during traction when the perineum bulges. • Catheterisation:• Internal examination: – To asses the state of cervix & membranes.S.N. Preliminaries • Anaesthesia:– Pudendal block or Labio-perineal infiltration for outlet forceps. difficulties & remedies. personnel involved. pelvic outlet. indication for operation.
12 October 2002 Forceps Delivery . so it should be avoided. Serious compression effect on the cranium can occur. – Blades are applied on the lateral pelvic wall ignoring the position of the head if the head is not rotated. pelvic & cephalic applications naturally coincide and so pelvic application is only justified in low forceps operations. • Pelvic application: -.S.N.Panda 17 .Prof. – Blades are applied along the sides of the head. – When the head is sufficiently rotated. grasping the biparietal diameter in between the widest part of the blades and the long axis of the blades correspond to the occiputo-mental plane.Types of application (of forceps blades ) • Cephalic application -.
S. First the left blade should be applied guided by the right hand & then the right blade with the left hand.Prof. Identification of blades & their application– The instrument should be placed in front of the pelvis with the tip pointing upwards and pelvic curve forwards. 2.Panda 18 . 12 October 2002 Forceps Delivery .(of low & outlet forceps application ) Technique 1. Locking of blades: – The blades should articulate with ease indicting correct application.N.
– The operator is unable to place more than a fingertip between the fenestration of the blade and the foetal head on either side.S.Panda 19 .Prof. 12 October 2002 Forceps Delivery . Clinical checks for correct forceps application: – Sagital suture lies in the midline of the shanks.N. – Posterior frontanalle is not more than one finger breadth above the plane of the shanks of the forceps.(of low & outlet forceps application ) Technique 3.
upward & then forwards.Right blade should be removed first.(of low & outlet forceps application ) Technique 4. Traction: – Steady & intermittent traction to be applied during contraction. first downwards (horizontal). forwards & lastly upwards. backwards.N. – Removal of blades .S.Panda 20 . 12 October 2002 Forceps Delivery . – In outlet forceps . Traction is applied straight horizontal.Only two fingers are to be introduced.Prof.
Prof. then upward till the occiput emerges over the perineum & finally downwards.S.Panda 21 .(of low & outlet forceps application ) Technique 5.N. 12 October 2002 Forceps Delivery .Horizontal till the root of the nose is under the pubic symphysis. In Occiputo-posterior position – – Blades are to be applied as usual but they should be equidistant from sinciput & occiput – Traction .
Panda 22 .N.S. Traction is applied downwards till the chin appears under the symphysis pubis & then upwards delivering the nose. 12 October 2002 Forceps Delivery . In face presentation– – Blades are to be introduced along the Occiputo-mental diameter. brow & occiput. eyes.Prof.(of low & outlet forceps application ) Technique 6.
following manual rotation in occiputo posterior position. With axis traction. 12 October 2002 Forceps Delivery . the traction rods should remain parallel with the shanks and should be removed when the base of the occiput comes under the symphysis.long curved with or without axis traction device & Keilland’s.same as low forceps without axis traction. • General anaesthesia is preferable. • Blades are to be introduced only after manual correction of malposition of occiput.(of mid forceps application ) • Forceps used are .Panda 23 Technique . • Indication .S.Prof. • Traction .N.
S.Panda 24 . • Forceps to be applied when the occiput lies against the back of the symphysis • Blades to be applied from below after raising the legs.N. • Traction to be maintained in an arc. 12 October 2002 Forceps Delivery . which follows the axis of the birth canal.Forceps for Aftercoming head • Piper's forceps are specially designed for this purpose.Prof.
Keilland's forceps application • Indication: – Can be applied in unrotated vertex / face presentation and for correction of asynclitism.N.Panda 25 . The posterior blade is applied between the head and the sacrum. – In Wondering method in deep transverse arrest:. – Blades also can be applied directly over the parietal bones.S. 12 October 2002 Forceps Delivery . • Application: – Anterior blade is applied first followed by the posterior blade.The anterior blade is applied over the face and then moved over to the anterior parietal bone.Prof.
N. • Scanzoni-Smellie maneuver: – Twice application. First the posterior blade is applied posteriorly over the posterior ear and then the anterior blade is applied over the anterior ear and head is rotated for 45o towards sacrum or 135 o towards symphysis.Keilland's forceps application • Complication: – Disengagement of the head may occur leading to cord prolapse. • General anaesthesia is necessary.S. • Traction is applied as per Pajot's maneuver: – Traction is applied horizontally with the right hand while pressing downward with the left hand.Prof.Panda 26 . Then blades are removed and reapplied. 12 October 2002 Forceps Delivery .
• Vaginal lacerations and cervical tear if cervix was not fully dilated. – Shock –. – Post partum haemorrhage –.are mostly due to faulty technique rather than the instrument. – Delayed or long-term sequel –. • Extension of the episiotomy involving anus & rectum or vaginal vault. genital prolapse & stress incontinence. • Maternal– Injury-. dehydration or prolonged labour. 12 October 2002 Forceps Delivery .Prof. – Sepsis –.S. • Due to blood loss. • Chronic low backache. • Due to trauma.Panda 27 . – Anaesthetic hazards. Atonic uterus or Anaesthetisia.Complications / Dangers Complications/dangers of forceps delivery: . • Due to improper asepsis or devitalisation of local tissues.N.
– Foetal death-around 2%. 12 October 2002 Forceps Delivery .are mostly due to faulty technique rather than the instrument.N. – Trauma• • • • • Intracranial haemorrhage. • Fetal– Asphyxia.Prof.Panda 28 . Skull fracture – Remote-cerebral palsy. Cephalic haematoma.S. Injury to the soft tissues of face & forehead. Facial / Brachial palsy.Complications / Dangers Complications/dangers of forceps delivery: .
only to shorten the second stage of labour to prevent anticipated maternal or foetal complications in • • • • • • Eclampsia Heart disease Previous c.s.Prof.Prophylactic/Elective forceps Introduced by Dee Lee (1920).S.N.Panda 29 12 October 2002 . refers to outlet forceps delivery. Post maturity Low birth wt babies During epidural anaesthesia Forceps Delivery .
. • So it should be done only in the O.N. 12 October 2002 Failed forceps • When a vigorous but unsuccessful attempt is made with the forceps.T.S.Trial forceps • Knowing that a certain degree of disproportion at mid pelvis may make the procedure incompatible. • Mostly it is due to lack of obstetric skill and poor clinical judgment • Factors responsible areDisproportion.S. Incomplete cervical dilatation & malposition of foetal head 30 Forceps Delivery .Prof. low/mid forceps delivery is attempted. keeping everything ready for C. anticipating a successful forceps delivery.Panda . abandoning it at the earliest in favour of Caesarean section.
N.Conclusion • Considering all aspects. forceps delivery can be useful in reducing not only unnecessary caesarean sections but also foetal & maternal complications due to prolonged labour 12 October 2002 Forceps Delivery .Panda 31 .Prof. • If performed judiciously by proper selection of cases and careful & timely application.S. forceps delivery has still got a place in modern obstetric practice and should be considered in certain cases.
N.Prof.Towards a safe motherhood 12 October 2002 Forceps Delivery .S.Panda 32 .
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