FORCEPS DELIVERY An Overview

BY
ABHISHEK JAGUESSAR

Introduction
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.
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Introduction
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.
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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. This was kept as a family secret for over 100yrs and four generations. He had two sons.
Peter I - had greater distinction & attended notable women in society. Was summoned by R.C.P. & Jailed in 1612. He had no sons. Peter II - who had several sons, died in 1626.

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History
Dr Peter III- the most prominent one studied in Cambridge, Oxford, and Padua. Elected a fellow of R.C.P. Died in 1683 in Woodham Mortimer Hall.It is believed that the family treasure was kept buried here, which was latter unearthed in 1813 by the then occupant Mrs.Kembell. Hugh- had interest in politics, was forced to flee to France, where in 1673 he sold the family secret to Mauriceau. After few years he went to Holland & again sold the secret (only one blade) to Roser Roomhuysen.
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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. The Chamberlain family used four pairs of forceps of different sizes with only cephalic curve. Levret (1747)-introduced the pelvic curve Smellie (1751)- reinforced pelvic curve & introduced English lock and used in aftercoming head. Tarnier (1877)-introduced axis traction. Barton and Kjielland - introduced the two specialized forceps. Since then very few and minor developments have taken place. Moreover since the advent of Vacuum extractor, many of the earlier high forceps applications have become obsolete.
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Classification of forceps application

Classical (old) Classification : Low/outlet forceps (no distinction): - forceps applied when the foetal head/skull has reached the pelvic floor, sagital suture has reached the A- P diameter of pelvis and scalp is visible without separating the vulva. Mid forceps: - forceps applied when head is engaged but criteria for low forceps not reached. High forceps: - forceps applied when head is not engaged.

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Classification of forceps application

Newer classification as per A.C.O.G.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./Rt. 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./Rt. Occiputo anterior/posterior position The leading point of the skull is 2cm or less above the spine but head is engaged. Rotation not considered

Outlet forceps

Mid forceps High forceps

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EXCLUDED
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Types of Forceps
Several hundred types of forceps have been designed which can be classified into various types-.

Classical instruments: -Originally designed by James Young Simpson, Wrigley & George L.Elliot Jr in mid 19th century commonly used for outlet & low pelvic rotational delivery. Modified classical instruments: -Overlapping solid blades with extended shanks like Tucker-Melane forceps, Elliot type commonly used as mid pelvic rotators or outlet blades. May be occasionally pseudofenestrated like Luikart's modification. Specialized instruments : -Designed for specific indications like Barton's for transverse arrest in platypeloid pelvis, Keilland's for mid pelvic rotation & correction of asynclitism and Piper's for delivery of Aftercoming head in breech.
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Types of Forceps
Several hundred types of forceps have been designed which can be classified into various types-.

Divergent or parallel blades instrument: -.

Designed to limit foetal cranial compression. Examples Laufe, Shute & Moolgaoker.

Axis traction instruments: -.

As a separate handle like bill's handle to be attached to any standard forceps. Axis traction as an integral part of the forceps like HowkDennon's& de Wee's forceps.
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Functions
Traction: -This is the most important function. Pull required in a primigravida is 18 kgs & in a multipara it is 13 kgs. Compression effect: -This is minimal when properly applied & should not be more than necessary to grasp the head. However it has some pressure effect on the well-ossified base of the skull. 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. Protective cage: - When applied on a premature baby it protects from the pressure of the birth canal. When applied on the aftercoming head it lessens the sudden decompression effect. As a vectis: - By applying one blade to deliver the head in caesarean section.
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Indications for forceps delivery

Delay in second stage: -.
Due to uterine inertia. Failure of progress of labour- if no progress occurs for more than 20 to 30 minutes, with the head on the perineum.
Definition of prolonged second stage of labour redefined by A.C.O.G.(1988/1991): Nullipara <3 hrs with regional anaesthesia <2 hrs without regional anaesthesia Multipara <2 hrs with regional anaesthesia <1hr without regional anaesthesia
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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. Baby

Post maturity

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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

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(to be fulfilled before forceps application.)

Prerequisites

Suitable presentation & position: -.

Vertex, anterior face or aftrcoming head are the ideal positions.

Cervix must be fully dilated. Membranes must be ruptured. Baby should be living. Uterus should be contracting & relaxing. Bladder must be empty.
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(before forceps application )

Documentation: All instrumental deliveries should be dictated in medical record as any surgical procedure & it should include: Consent of the patient, indication for operation, anaesthesia, personnel involved, type of instrument, difficulties & remedies, resulting maternal & foetal complications or injuries and blood loss.

Preliminaries

Anaesthesia: Pudendal block or Labio-perineal infiltration for outlet forceps. Regional or General anaesthesia for low & mid forceps.

Catheterisation: Internal examination: To asses the state of cervix & membranes, presentation & position, pelvic outlet, TDO & sub pubic angle.

Episiotomy: Should be done either before application of forceps or during traction when the perineum bulges.
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Types of application
(of forceps blades )
Cephalic application -.
Blades are applied along the sides of the head, 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.

Pelvic application: -.
Blades are applied on the lateral pelvic wall ignoring the position of the head if the head is not rotated. Serious compression effect on the cranium can occur, so it should be avoided. When the head is sufficiently rotated, pelvic & cephalic applications naturally coincide and so pelvic application is only justified in low forceps operations.

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(of low & outlet forceps application )

Technique

1. Identification of blades & their application The instrument should be placed in front of the pelvis with the tip pointing upwards and pelvic curve forwards. First the left blade should be applied guided by the right hand & then the right blade with the left hand.

2. Locking of blades: The blades should articulate with ease indicting correct application.

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(of low & outlet forceps application )

Technique

3. Clinical checks for correct forceps application: Sagital suture lies in the midline of the shanks. The operator is unable to place more than a fingertip between the fenestration of the blade and the foetal head on either side. Posterior frontanalle is not more than one finger breadth above the plane of the shanks of the forceps.

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(of low & outlet forceps application )

Technique

4. Traction: Steady & intermittent traction to be applied during contraction, first downwards (horizontal), backwards, forwards & lastly upwards. In outlet forceps - Only two fingers are to be introduced. Traction is applied straight horizontal, upward & then forwards. Removal of blades - Right blade should be removed first.

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(of low & outlet forceps application )

Technique

5. In Occiputo-posterior position
Blades are to be applied as usual but they should be equidistant from sinciput & occiput Traction - Horizontal till the root of the nose is under the pubic symphysis, then upward till the occiput emerges over the perineum & finally downwards.

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(of low & outlet forceps application )

Technique

6. In face presentation

Blades are to be introduced along the Occiputo-mental diameter. Traction is applied downwards till the chin appears under the symphysis pubis & then upwards delivering the nose, eyes, brow & occiput.

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(of mid forceps application )

Forceps used are - long curved with or without axis traction device & Keillands. Indication - following manual rotation in occiputo posterior position. General anaesthesia is preferable. Blades are to be introduced only after manual correction of malposition of occiput. Traction - same as low forceps without axis traction. With axis traction, the traction rods should remain parallel with the shanks and should be removed when the base of the occiput comes under the symphysis.
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Technique

Forceps for Aftercoming head

Piper's forceps are specially designed for this purpose. Forceps to be applied when the occiput lies against the back of the symphysis Blades to be applied from below after raising the legs. Traction to be maintained in an arc, which follows the axis of the birth canal.

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Keilland's forceps application

Indication: Can be applied in unrotated vertex / face presentation and for correction of asynclitism.

Application: Anterior blade is applied first followed by the posterior blade. In Wondering method in deep transverse arrest:- The anterior blade is applied over the face and then moved over to the anterior parietal bone. The posterior blade is applied between the head and the sacrum. Blades also can be applied directly over the parietal bones.
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Keilland's forceps application

Complication: Disengagement of the head may occur leading to cord prolapse.

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. Then blades are removed and reapplied.

Traction is applied as per Pajot's maneuver: Traction is applied horizontally with the right hand while pressing downward with the left hand.

General anaesthesia is necessary.

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Complications / Dangers
Complications/dangers of forceps delivery: - are mostly due to faulty technique rather than the instrument. Maternal Injury-.
Extension of the episiotomy involving anus & rectum or vaginal vault. Vaginal lacerations and cervical tear if cervix was not fully dilated.

Post partum haemorrhage .

Due to trauma, Atonic uterus or Anaesthetisia.

Shock .
Due to blood loss, dehydration or prolonged labour.

Sepsis .
Due to improper asepsis or devitalisation of local tissues.

Anaesthetic hazards.

Delayed or long-term sequel .

Chronic low backache, genital prolapse & stress incontinence.
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Complications / Dangers
Complications/dangers of forceps delivery: - are mostly due to faulty technique rather than the instrument. Fetal Asphyxia. Trauma Intracranial haemorrhage. Cephalic haematoma. Facial / Brachial palsy. Injury to the soft tissues of face & forehead. Skull fracture

Remote-cerebral palsy. Foetal death-around 2%.

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Prophylactic/Elective forceps
Introduced by Dee Lee (1920), refers to outlet forceps delivery, only to shorten the second stage of labour to prevent anticipated maternal or foetal complications in Eclampsia Heart disease Previous c.s. Post maturity Low birth wt babies During epidural anaesthesia
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Trial forceps
Knowing that a certain degree of disproportion at mid pelvis may make the procedure incompatible, low/mid forceps delivery is attempted, abandoning it at the earliest in favour of Caesarean section. So it should be done only in the O.T., keeping everything ready for C.S.
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Failed forceps
When a vigorous but unsuccessful attempt is made with the forceps, anticipating a successful forceps delivery. Mostly it is due to lack of obstetric skill and poor clinical judgment Factors responsible areDisproportion, Incomplete cervical dilatation & malposition of foetal head
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Conclusion
Considering all aspects, forceps delivery has still got a place in modern obstetric practice and should be considered in certain cases. If performed judiciously by proper selection of cases and careful & timely application, forceps delivery can be useful in reducing not only unnecessary caesarean sections but also foetal & maternal complications due to prolonged labour

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Towards a safe motherhood

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