FORCEPS DELIVERY

PRESENTED BY
MISS NISHA KHULAL
 INTRODUCTION
• Operative vaginal delivery refers to a delivery in which the operator
uses force or vacuum device to extract the fetus from the vagina, with
or without the assistance of maternal pushing. The decision to use an
instrument to deliver the fetus balances the maternal, fetal, and
neonatal impact of the procedure against the alternative options of
cesarean birth or expectant management.
 DEFINITION

• Obstetric forceps is a pair of instruments, especially designed to assist

extraction of the fetal head and thereby accomplishing delivery of the
fetus when it is inadvisable or impossible for the mother to complete
the delivery by her own efforts
 PREVALENCE
UNITED STATES
• 3.3 percent of all deliveries in 2017 were accomplished via an operative
vaginal approach. Forceps deliveries accounted for 0.6 percent of vaginal
births.
INDIA (since 10 yrs. As reported on 2018)
• The incidence of instrumental delivery was 0.67% of all deliveries.
Vaccum delivery accounted for 0.63% where as forceps delivery was
0.04%.
 INDICATIONS
• Much before caesarean sections were possible, forceps were used to
help a baby stuck in the birth canal.
• They can only be used when the first stage is complete and the cervix
is fully dilated.
• Nearly all premature babies are delivered by forceps to protect their
delicate skull bones through the birth canal
 CONTRAINDICATIONS

Instrumental delivery is contraindicated if the clinician or patient believes

that the risk to mother or fetus is unacceptable

• Extreme fetal prematurity.

• Fetal demineralizing disease (eg, osteogenesis imperfecta).
• Fetal bleeding diathesis (eg, fetal haemophilia)
• Unengaged head.
• Unknown fetal position.
• Brow or face presentation.
• Suspected feta pelvic disproportion.
 VARIETIES OF OBSTETRIC FORCEPS

Only three varieties are commonly used in present day obstetrics.

They are:-

• Long curved forceps with or without axis traction device.

• Short curved forceps.
• Kielland’s forceps.
 LONG-CURVEDOBSTETRIC FORCEPS

• Long-curved obstetric forceps is relatively

heavy and is about 37 cm (15") long. In
India, Das’s variety (named after Sir
Kedar Nath Das) is commonly used with
advantages. It is comparatively lighter
and slightly shorter than its Western
counterpart but is quite suited for the
comparatively small pelvis and small baby
of Indian women.
MEASUREMENTS: Length is 37 cm; distance in between the tips is 2.5 cm and
widest diameter between the blades is 9 cm.

BLADES: There are two blades and are named right or left in relation to maternal
pelvis in which they lie when applied.

• Each blade consists of the following parts:

• Blade
• Shank
• Lock and
• Handle with or without screw.
SHORT CIURVED FORCEPS (WRIGLEY’S FORCEPS)

• The instrument is lighter,shorter

and stubby handled.it is short due
to reduction in the length of the
shanks and handles.it has a marked
cephalic curve with a slight pelvic
curve.the instrument is used for
very low forceps deliveries for the
aftercomming head of a breech
delivery or at caesarean section.
 KIELLAND’S FORCEPS
• The forceps was designed and named
after Kielland (Kielland) of Norway
(Rotational forceps, 1916). In the
hands of an expert, it is an useful and
preferred instrument.
• Its advantages over the widely used long curved forceps are:
• It can be used with advantages in unrotated vertex or face
presentation
• Facilitates grasping and correction of asynclitic head because of its
sliding lock.
 PREREQUISITES
The prerequisites for forceps delivery are similar to those for vacuum
delivery:
• Informed consent
• Engaged head
• Fully dilated and retracted cervix
• Ruptured membranes
• Exact position of the head determined
 CONT’D…............
• Adequate pelvis
• Empty bladder
• Appropriate anesthesia in effect, if available
• Adequate facilities and backup available
• Health care provider knowledgeable about the instruments, their use and
the complications that can arise from their use
• Ongoing fetal and maternal assessment
 PREPARATION OF THE WOMEN

• The woman should be prepared in advance for the possibility of a forceps delivery if
this looks likely. Fully explanation of the procedure and the need for it must be given to
the woman. Once the decision has been made, adequate and appropriate analgesia must
be offered.
• When the analgesia has been instituted and the obstetrician is ready to proceed, the
woman’s leg are placed in lithotomy position. Both legs must be placed simultaneously
to avoid strain on the woman’s back and hips.
• The woman should be tilted toward the left at an angle of 15 degree by the use of a
pillow or a rubber wedge under the mattress to prevent aortocaval occlusion.
• Preparations must also be done for the baby including equipment for resuscitation in
the hospital a pediatrician will also be present.
 PROCEDURE FOR FORCEPS APPLICATION

• The woman’s vulva area is thoroughly

cleaned and draped with sterile towels
using antiseptic technique. The bladder is
emptied using a straight catheter.

• A vaginal examination is performed by the

obstetrician to confirm the station and
exact position of the fetal head.
• A pudendal block, supplemented by perineal and labial infiltration with 1%lignocaine
hydrochloride is given to produce effect local anaesthesia.

• An episiotomy may be done prior to introduction of the blades or during traction when
the perineum becomes bulged and thinned out by the advanced head.

• The forceps are identified as left or right by assembling them briefly before proceeding.

• The left blade is passed gently between the perineum and fetal head with the first two
figures of the operator’s right hand lying alongside the fetal head protecting the maternal
tissue. The tip of the forceps blade slides lightly over the head, into the hollow of the
sacrum and is then “wandered” to the left side of the pelvis where it should sit alongside
the head.
• The procedure is repeated with the right blade until it sits on the right of the
pelvis.it should then be easy to lock the two blades and there should be little or no
gap between the handles. A significant gap suggests that the forceps are wrongly
positioned and they should be reapplied after carefully checking the position of
the head.
• • During the application stage of the forceps, the woman should be given full
support and attention by the midwife.

• • The fetal heart rate is to be monitored throughout.

• As soon as the operator is ready and the
uterus contracts, the woman is
encouraged to push.to supplement her
efforts, the obstetrician exerts steady,
downward traction on the forceps.
Traction is released between
contractions. Intermittent traction is
continued in a downward direction until
the head comes to the perineum. The
pull is then directed horizontally straight
towards the operator until the head is
almost crowned. The direction of pull is
gradually changed toward the mother’s
abdomen to deliver the head by
extension.
• The blades are removed one after the
other, the right one first.
• Following the birth of the head, usual
procedures are to be followed as in normal
delivery.

• I.V methergine 0.2mg is to be

administered with the delivery of the
anterior shoulder. Episiotomy is repaired
as quickly as possible and the woman is
made comfortable
 COMPLICATIONS OF FORCEPS
DELIVERY

• The complications of the forceps operation are mostly related to the faulty
technique and to the indication for which the forceps are applied rather than the
instrument.
• The complications are grouped into:
• MATERNAL.
• FETAL.
MATERNAL

IMMEDIATE:

•Injury: Vaginal laceration or sulcus tear, cervical tear, extension of

episiotomy to involve the vaginal vault, complete perineal tear
•Nerve injury: Femoral (L2, 3, 4), lumbosacral trunk (L4, 5) with
midforceps delivery.

•Postpartum hemorrhage may be—(i) traumatic or (ii) atonic, requiring

blood transfusion or (iii) both, may cause shock
•Anesthetic complications (following local or general anesthesia
•Puerperal sepsis and maternal morbidity
REMOTE:
• Painful perineal scars, dyspareunia, low backache, genital prolapse, stress urinary incontinence
and anal sphincter dysfunction

• FETAL

IMMEDIATE:
• Asphyxia, facial bruising, intracranial haemorrhage (rupture of the great vein of Galen).
Cephalohematoma, facial palsy, skull fractures, cervical spine injury (rotational forceps)

REMOTE:

• Cerebral or spastic palsy due to residual cerebral injury (rare)

 FAILED FORCEPS

• When a deliberate attempt in vaginal delivery with forceps has failed to

expedite the process, it is called failed forceps. It is predominantly due to lack of
obstetric skill with poor clinical judgment. Failure in the operative delivery may
be due to improper application or failure of descend of the head even with
forcible contraction.
 CAUSES FOR FAILED FORCEPS

• Incompletely dilated cervix.

• Unrotated occipito-posterior position.
• Undiagnosed brow or hydrocephalous or fetal ascites.
• Constriction ring.
• Large baby with the shoulders impacted at the brim.
 MANAGEMENT:
• To assess the effect on the mother and the fetus.
• To start a Ringer’s solution drip and to arrange for blood transfusion, if
required
• To administer parenteral antibiotic
• To exclude rupture of the uterus
• The procedure is abandoned and delivery is done by cesarean section and
• Laparotomy should be done in a case with rupture of uterus.
 CHOICE OF INSTRUMENT:

Both forceps and vacuum are acceptable instruments for operative vaginal delivery. Our
approach depends on patient specific factors;

• The choice of instrument is determined by the clinician's expertise with the various forceps
and vacuum devices, availability of the instrument, level of maternal anesthesia, and
knowledge of the risks and benefits associated with each instrument in various clinical
settings.

• Vacuum delivery is generally less traumatic for the mother than forceps delivery, while
forceps delivery is less traumatic for the fetus than vacuum delivery.
 SUMMARY:
• Today we discuss about;
• definition
• indication
• contraindication of forceps delivery
• varieties of forceps
• complications
• management of forceps delivery
 CONCLUSION
• This art of delivery is a reasonable option to the obstetrician to reduce the rising
caesarean section rates. However, extreme caution and judicial use of this
instrument is required in expert hands to prevent risks for mother and fetus.
Training programs should be conducted to impart knowledge about its
indications, technique of use and quality control.
 THANK
YOU ALL