Use and Safety of Kiellands Forceps

in Current Obstetric Practice

Naomi Burke,

MRCPI,

Katie Field,

MRCPI,

Fakhra Mujahid,

OBJECTIVE: We sought to evaluate the use and safety of

Kiellands rotational forceps for delivery in current obstetric practice at a tertiary care obstetric unit.
METHODS: Data were obtained pertaining to all such
attempted deliveries from 1997 through 2011. The outcomes analyzed included maternal obstetric features,
induction and duration of labor, use of analgesia, fetal
position and station, birth weight, seniority of the obstetrician, success and failure rates, and associated maternal
and neonatal morbidity.
RESULTS: There were 144 cases, of which 129 resulted in
successful vaginal delivery (89.6%) and 15 were unsuccessful (10.4%). A senior obstetrician was present at all
deliveries. The maternal morbidity was relatively low:
third-degree or fourth-degree tear less than 1%, postpartum hemorrhage 12.4%, and urinary incontinence 7.8%.
There were no cases of forceps-related neonatal trauma
or hypoxicischemic encephalopathy.
CONCLUSION: Contrary to earlier reports, in these circumstances, use of Kiellands forceps is associated with a
high successful delivery rate and apparently low maternal
and neonatal morbidity.
(Obstet Gynecol 2012;120:76670)
DOI: http://10.1097/AOG.0b013e3182695581

LEVEL OF EVIDENCE: III

n the past two decades there has been a major

decline in use of the obstetric forceps internationally in association with an increased clinician preference for use of the vacuum extractor, or ventouse, to
perform assisted vaginal deliveries.15 For assisted
From the Department of Obstetrics & Gynaecology, Clinical Science Institute,
National University of Ireland, Galway, Ireland.
Corresponding author: John J. Morrison, MD, FRCOG, Department of Obstetrics & Gynecology, Clinical Science Institute, National University of Ireland,
Galway, Ireland; e-mail: john.morrison@nuigalway.ie.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2012 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/12

766

VOL. 120, NO. 4, OCTOBER 2012

MRCOG,

and John J. Morrison,

MD, FRCOG

vaginal deliveries, when there is malposition of the

fetal head, the use of rotational forceps has declined
even more dramatically. Use of the Kiellands forceps, which is the most commonly used rotational
forceps, has been largely discontinued, or was never
initiated, by many obstetricians6 because of the controversy that has surrounded its use. This controversy
has arisen because of reports, from relatively small
case series, dated 20 30 years ago, from both European7 and U.S. groups,8 which described the adverse
outcomes associated with its use and, particularly, its
potential to cause fetal or maternal injury when used
inappropriately. In addition, it is possible that the
medicolegal environment that has pertained to this
area of obstetrics has influenced medical practice and
operator choice of instruments. Whether or not the
Kiellands forceps should be abandoned completely
remains an unsolved issue,8 and there are no real data
from randomized controlled trials to outline best
practice for midcavity rotational delivery, a relatively
common clinical scenario in obstetric practice. Interestingly, the use of rotational forceps has been reviewed and supported in the American College of
Obstetricians and Gynecologists Practice Bulletin
Number 17,9 which includes a recommendation that
it should be performed by only skilled health care
practitioners. The aim of this study was to evaluate the
use of the Kiellands forceps in current obstetric
practice at a tertiary care obstetric department over a
15-year period from 1997 to 2011.

PATIENTS AND METHODS

The data for this study were obtained from an obstetric computerized database to which the information
had been entered during the 15-year period from July
1997 to December 2011 inclusive at the Department
of Obstetrics and Gynecology, Galway University
Hospital, Ireland. This study was deemed exempt
from the institutional review board at our institution.
The database used was the Euroking System European Information Technology, Ottershaw, Surrey,

OBSTETRICS & GYNECOLOGY

United Kingdom. At the time of initial antenatal visit

for the woman, a series of medical and demographic
details pertaining to each woman was entered on the
database by a midwife. Similarly, at the completion of
delivery for every woman, and before discharge from
the delivery suite, a further entry was made by the
attending midwife, outlining the management of labor, mode of delivery, and neonatal details. In addition to the data entered on this database, the maternal
and neonatal case records for each pregnancy for
whom Kiellands forceps had been used were examined to validate all of the database findings. From
these, the following outcome measures related to use
of the Kiellands forceps were ascertained: 1) overall
prevalence; 2) maternal age, parity, and body mass
index (BMI, calculated as weight (kg)/[height (m)]2) at
first antenatal visit for all mothers; 3) total duration of
labor; 4) duration of second stage of labor; 5) presence of epidural analgesia; 6) position of the fetal
head before attempted delivery; 7) station of the fetal
head before attempted delivery; 8) indication for
forceps delivery, ie, suspected fetal compromise or
delayed second stage of labor (as defined below); 9)
location of attempted Kiellands forceps assisted delivery (delivery suite room or operating room); 10)
birth weight of neonates delivered; 11) degree of
perineal trauma observed (perineum intact, episiotomy (mediolateral), first- or second-degree tear, thirdor fourth-degree tear, or high vaginal laceration; 12)
shoulder dystocia; 13) postpartum complications of
hemorrhage or incontinence (urinary or fecal); 14)
neonatal Apgar scores less than 7 at 1 minute and less
than 7 at 5 minutes; 15) umbilical cord blood pH
values (less than 7.20, 7.20 7.25, greater than 7.25);
16) the occurrence of forceps related neonatal trauma,
neonatal encephalopathy, clavicular fracture, or brachial nerve palsy; 17) rate of admission to a neonatal
special care baby unit; and 18) seniority of operator
and presence or otherwise of a senior attending
(consultant) obstetrician at delivery.
All senior obstetricians participating in this study
had completed the Royal College of Obstetricians
and Gynecologists, London, requirements for accreditation, which involved a period of 10 years of postgraduate clinical training. The clinical practice used
was 1 hour of passive second stage after the diagnosis
of full dilatation followed by 1 hour of maternal
pushing. The second stage of labor was deemed
delayed when delivery was not imminent after 1 hour
of maternal pushing. Suspected fetal compromise
consisted of evidence of a nonreassuring cardiotocogram. The technique used was that of direct application of the forceps blades when the fetal position was

VOL. 120, NO. 4, OCTOBER 2012

Burke et al

occipitoposterior, and for the occipitotransverse position, the anterior blade was applied by a technique of
careful wandering of the blade over the fetal face
into position with direct application of the posterior
blade. After rotation, the delivery was completed
using the Kiellands forceps. During the time period
of the study (19972011), the overall operative delivery rates in the institution were as follows: the average
forceps rate was 5.4% (1997, 10%; 2011, 5.5%); the
average vacuum-assisted delivery rate was 13.2%
(1997, 8.6%; 2011, 12%); and the average cesarean
delivery rate was 24.8% (1997, 18.3%; 2011, 29.2%).
Microsoft Excel was used to tabulate and graphically summarize the data. The statistical package
SPSS 18 was used to perform descriptive statistics.
Finally, a logistic regression analysis for trend was
performed to examine for any potential variation in
the number of cases per year during the study.

RESULTS
During the time period of the study there were 45,335
neonates delivered, and Kiellands forceps was attempted in 144 cases (0.3%), leading to a successful
assisted delivery for 129 neonates, 89.6% (95% confidence interval [CI] 8394%), and a failed attempt in
15 cases (10.4%) (95% CI 6 17%). The results concerning the 15 cases of failed attempt at delivery are
outlined separately at the end of this section.
For successfully assisted delivery with Kiellands
forceps, the number of cases per year during the time
period of the study varied from three to 21 with a
mean of 8.6 cases (Fig. 1). There was no significant
linear increase or decrease observed in the number of
cases per year for the duration of the study (95% CI
0.931.02, P.266). The vast majority of women for
whom Kiellands forceps-assisted delivery took place
were nulliparous (n116; 89.9%), and the remaining
were parous women (n13; 10.1%). The mean age of
the group was 31.9 years (3.9, standard error of the
mean [SEM]) with a range in age from 20 43 years.
The rate of induction of labor for this group was
44.2% (n57), and the remaining 55.8% (n72) underwent spontaneous onset of labor. The indications
for forceps-assisted delivery were as follows: delayed
second stage of labor (n94; 72.9%) and suspected
fetal compromise (n35; 27.1%).
The BMI details of the 129 women delivered
using Kiellands forceps are demonstrated in Table 1.
It is evident that 48% (n59) were in the normal BMI
category with 2% (n2) in the low-weight category,
and 50% of the women (n61) were either overweight or obese (in seven cases the BMI was not
recorded). The mean duration of labor was 10 hours

Kiellands Forceps and Current Obstetric Practice

767

Deliveries using Kiellands forceps (n)

25

20

15

10

0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year

9 minutes (32 minutes, SEM). The mean duration of

the second stage of labor was 1 hour 48 minutes (4
minutes, SEM). Epidural analgesia was in place in
96.1% of women (n124), and five women (3.9%)
received a pudendal nerve block with local anesthetic
agent.
The details pertaining to both malposition and
station of the fetal head, at the time of application of
Kiellands forceps, are outlined in Table 1. A senior
obstetrician (consultant) was present at all of the
Kiellands forceps-assisted forceps deliveries, and the
vast majority (n124; 96.1%) were performed by this
attending consultant obstetrician. In a small number
of cases (n5; 3.9%), the forceps-assisted delivery was
performed by the junior obstetrician (residentspecialist registrar) under the supervision of the attending
consultant. For 90.7% (n117) of these cases. the
delivery took place in the delivery suite room with a
small proportion (n12; 9.3%) performed in the
operating room.
The mean birth weight of all neonates delivered
was 3, 563 g (44.2, SEM) ranging from 2,140 to
4,620 g. The details in relation to perineal trauma
observed at delivery are presented in Table 1. There
was one third-degree tear and no fourth-degree tear in
the women successfully delivered. There were no
cases of cervical laceration and seven cases of extension of high vaginal tears. For postpartum hemorrhage, there were 16 cases (12.4%). For one of these
cases, there was massive hemorrhage, which was
deemed to be the result of an atonic uterus. This
ultimately was managed with pharmacologic uterotonic therapy, examination under anesthesia, and a
laparotomy and the patient required 16 units of
blood. In this case there was no noteworthy vaginal
tear and a hysterectomy was not performed. For
urinary incontinence in the immediate postpartum

768

Burke et al

Fig. 1. Kiellands forceps deliveries per

year (n) over the duration of the study.
Burke. Kiellands Forceps and Current
Obstetric Practice. Obstet Gynecol 2012.

period, there were 10 documented cases (7.8%).

There were no cases of fecal incontinence.
Finally, the neonatal details are presented in
Table 1, including Apgar scores and cord vessel pH
values for the neonates. An Apgar score of less than 7
at 1 minute was recorded in six cases (4.6%), and there
were no cases of an Apgar score less than 7 at 5
minutes. Umbilical cord vessel blood gas pH values
were recorded in 102 cases (79%) and were missing or
unrecorded in 27 cases (21%). An acidotic pH (less
than 7.20) was recorded in 13 of 102 cases (12.7%).
The rate of admission to the neonatal intensive care
unit was 8.5% (n11). The reasons for admission to
the neonatal unit were as follows: neonatal tachypnea,
grunting, neonatal pyrexia, to rule out sepsis, or all of
these, n6; low Apgar scores, n3; hypothermia,
n1; and social admission (to facilitate the mother in
high-dependency care as a result of hemorrhage),
n1. There were no cases of neonatal trauma secondary to use of the forceps and no cases of hypoxic
ischemic encephalopathy. There was one case of
Erbs palsy deemed to be related to shoulder dystocia.
Of the 15 women for whom the attempt at
assisted delivery with Kiellands forceps was unsuccessful, they were all ultimately delivered by cesarean. The reasons for failure were as follows: failed
application, n3; failed rotation, n6; failed descent
with traction, n5; and unclear documentation n1.
For 10 (66.6%) of these women, the attempt at forceps
delivery was performed as a trial in the operating
room, and for two of these latter 10 cases, there was
an additional attempt at vacuum delivery after the
unsuccessful attempt with Kiellands forceps, ie, failed
sequential instruments. One of these neonates was
admitted to the neonatal intensive care unit with
Apgar scores of 3 at 1 minute and 8 at 5 minutes and
an umbilical cord blood pH value of 7.04. All other

Kiellands Forceps and Current Obstetric Practice

OBSTETRICS & GYNECOLOGY

Table 1. Successful Kiellands Forceps Deliveries

(n129): Maternal and Neonatal Features
Maternal outcomes
Age (y)
2
BMI (kg/m )
Lower than 20
2025
2630
Higher than 30
Not recorded
Parity
Nulliparous
Multiparous
Analgesia used
Epidural
Pudendal block
Location of delivery
Labor ward
Theatre
Position
Occipitoposterior
Occipitotransverse
Not documented
Station
Above spines
At spines
Below spines
Not documented
Perineal injury
Episiotomy
High vaginal wall
laceration
Anal sphincter injury
Duration of second stage of
labor (h:min:sec)
Neonatal outcomes
Birth weight
Apgar score
Less than 7 at 1 min
Less than 7 at 5 min
Umbilical cord pH (n102)
Less than 7.2
7.27.25
Higher than 7.25
Intensive care unit admission
Neonatal trauma

Mean 31.9 (range 2043)

2 (1.6)
59 (48.4)
49 (40.2)
12 (9.8)
7
116 (89.9)
13 (10.1)
124 (96.1)
5 (3.9)
117 (90.7)
12 (9.3)
31 (24)
92 (71.3)
6 (4.7)
4 (3.1)
69 (53.5)
42 (32.5)
14 (10.9)
124 (96.1)
n7
Third- or fourth-degree tear,
n1
01:48:53 (00:04:24 SEM)

3,563 g (44.2 SEM)

6 (4.6)
0
13 (12.7)
14 (13.7)
75 (73.5)
11 (8.5)
0

BMI, body mass index; SEM, standard error of mean.

Data are n (%) unless otherwise specified.

neonates had Apgar scores greater than 7 at 1 and 5

minutes and umbilical cord blood gas pH readings
greater than 7.10.

DISCUSSION
The findings from this study indicate that use of the
Kiellands forceps for assisted rotational vaginal
delivery, in selected circumstances, in current obstetric practice, with the fetal head mainly at the

VOL. 120, NO. 4, OCTOBER 2012

Burke et al

level of the ischial spines, or below, and in the

presence of, or performed by, a senior attending
consultant obstetrician, is associated with a high
rate of successful vaginal delivery and apparently
low rates of maternal and neonatal morbidity. The
strengths of this study include the large number of
rotational forceps procedures included, that the
series is recent in timing, that the data were all
entered prospectively at the time of delivery, that
the findings were all validated with the medical
case notes and, finally, that the maternal and
neonatal follow up are complete. The weaknesses of
this study are that it is essentially observational and
retrospective in nature, is nonrandomized, and the
results have all emanated from one tertiary care
center.
The first notable observation from this study is
that the successful vaginal delivery rate for rotational
deliveries in this study, using Kiellands forceps, was
89.6% during the time period 19972011. This represents a failure rate of 10.3%, which compares favorably with previously reported failure rates for use of
this forceps, which varied between 5.9% and 17.5%,
in a tertiary care referral U.K. obstetric unit, during
the years 19922001.1 For vacuum-assisted deliveries,
in comparison, the success rates reported using soft
cup instruments have been reported to be between
66% and 79%9,10 and for the more traditional rigid
vacuum cup to be between 79% and 81%.9,11 These
reported success rates for vacuum-assisted deliveries
pertain to cohorts of patients in which the position of
the fetal head was occipitoanterior in the majority of
cases, ie, less than half of the deliveries were rotational. The data from our study clearly highlight the
low failure rate associated with use of the Kiellands
forceps for rotational deliveries and outline the established principle that use of the forceps is less likely
to fail to achieve a vaginal birth than use of the
vacuum extractor.12 However, when failure is encountered, it is recognized that persistent efforts to
achieve a vaginal delivery using other instruments
is not advisable and may be associated with a
higher degree of fetal or maternal injury.9,13 In our
case series, such use of sequential instruments was
observed in two of the 15 cases of failed instrumental delivery. Finally, in view of the fact that five of
the 15 failed delivery attempts in this study occurred in the delivery room, it is our view that a
more liberal approach to forceps delivery in the
operating room should be recommended.
The other interesting finding from this study is
that the neonatal morbidity associated with use of the
Kiellands forceps was low. In 1979, analysis of a case

Kiellands Forceps and Current Obstetric Practice

769

series of 86 Kiellands forceps deliveries reported that

the neonatal mortality rate was 3.5%, associated birth
trauma was 15.1%, and abnormal neonatal neurologic
behavior was 23%.7 In 2001, a Scottish study, which
included 93 women delivered by Kiellands rotational
forceps, reported a 2% risk of physical trauma to the
neonate.14 In this study of 129 women similarly
delivered, there were no neonatal deaths, 12.7% of
neonates demonstrated a cord pH value less than
7.20, and the rate of admission to the neonatal unit
was 8.5% for all neonates delivered with use of the
Kiellands forceps. There were no cases of forcepsrelated fetal trauma and no neonates were classified as
having hypoxicischemic encephalopathy.
It is difficult to speculate, or understand, why the
neonatal morbidity, and mortality, associated with the
use of this forceps are lower than reported from
earlier series7,8 on consideration of the findings presented in this study. There are many possible explanations. Case selection may have improved in current
practice. There may be a lower threshold for performing a cesarean delivery in current practice, and hence
the forceps deliveries described in this study may
have been easier or more amenable for assisted
vaginal delivery than earlier reported cases. The
presence of a senior and experienced obstetrician at
all of these deliveries was likely to have had a positive
influence on outcome.
In summary, the data from this study support a
continuing use of rotational forceps in current obstetric practice. It is apparent that in well-selected cases,
and using the expertise of a senior obstetrician with
experience in using the instrument, that it achieves a
relatively high rate of successful delivery with low
neonatal and maternal morbidity. Although use of
this instrument remains controversial, the challenge
for the future is that of training junior obstetricians in

770

Burke et al

the skill of rotational forceps after many decades of

decreasing use.
REFERENCES
1. Loudon JAZ, Groom KM, Hinkson L, Harrington D, PatersonBrowne S. Changing trends in operative delivery performed at
full dilatation over a 10-year period. J Obstet Gynaecol 2010;
30:370 5.
2. Kozak LJ, Weeks JD. US trends in obstetric procedures,
1990 2000. Birth 2002;29:157 61.
3. Patel RR, Murphy DJ. Forceps delivery in modern obstetric
practice. BMJ 2004;328:13025.
4. Bailey PE. The disappearing art of instrumental delivery: time
to reverse the trend. Int J Gynaecol Obstet 2005;91:89 96.
5. Yeomans ER. Operative vaginal delivery. Obstet Gynecol
2010;115:64553.
6. Meager C, Griffiths A, Penketh R. The use of Kiellands
forceps and obstetricians anxiety trait. J Obstet Gynaecol
2008;38:700 2.
7. Chiswick ML, James DK. Kiellands forceps: association with
neonatal morbidity and mortality. Br Med J 1979;1:79.
8. Hankins GD, Rowe TF. Operative vaginal deliveryyear 2000.
Am J Obstet Gynecol 1996;175:225 82.
9. American College of Obstetricians and Gynecologists. Operative vaginal delivery. Practice Bulletin 17. Washington, DC:
ACOG; 2000.
10. Attilakos G, Sibanda T, Winter C, Johnson N, Draycott T. A
randomised controlled trial of a new handheld vacuum extraction device. BJOG 2005;112:1510 5.
11. Groom KM, Jones BA, Miller N, Paterson-Browne S. A
prospective randomised controlled trial of the Kiwi Omnicup
versus conventional ventouse cups for vacuum-assisted vaginal
delivery. BJOG 2006;113:1839.
12. O Mahony F, Hofmeyr GJ, Menon V. Choice of instruments
for assisted vaginal delivery. The Cochrane Database of Systematic Reviews 2010, Issue 11. Art. No.: CD005455. DOI:
10.1002/14651858.CD005455.pub2.
13. Edozien LC, Williams JL, Chattopadhyay I, Hirsch PJ. Failed
instrumental delivery: how safe is the use of a second instrument? J Obstet Gynaecol 1999;19:460 2.
14. Hinton L, Ong S, Danielian PJ. Kiellands forceps deliveryquantification of neonatal and maternal morbidity. Int J
Gynaecol Obstet 2001;74:289 91.

Kiellands Forceps and Current Obstetric Practice

OBSTETRICS & GYNECOLOGY