Forceps delivery is a means of extracting the fetus with the aid of obstetric forceps when it is inadvisable or impossible for

the mother to complete the delivery by her own efforts The invention of obstetric forceps was around 1,600 AD by the chamberlen family, many designs were invented and modified. Forceps deliveries were formerly classified by the level of the head at the time the forceps were applied, i.e. high-cavity, mid-cavity and low cavity .lowcavity forceps is the one frequently performed, as caesarean section is usually preferred to the more traumatic high and mid-cavity operations

Low-cavity forceps can be divided in to rotational and non-rotational. Rotational forceps delivery refers to a maneuver of the fetal head from a malposition into a more favorable position with the aid of specially designed forceps usually Kiellands. Examples of non rotational forceps are:Wrigleys forceps and Simpsons forceps ( low cavity) Neville barnes and Haig Fergusons forceps (high and mid cavity 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. Kiellands forceps.

It is relatively heavy and about 37 cm(15) long In india Dass variety is used Suitable for the small pelvis and small baby of Indian women Measurements-length-37cm -Distance between the tips -2.5cm -Widest diameter- 9cm Blades :two blades named as right and left in relation to the meternal pelvis Parts are blade shank lock handle with or without screw

Blade: The blades are fenestrated which facilitate a good grip of the fetal head. There is usually a slot in the lower part of the fenestrum of the blades to allow the upper end of the axis traction rod to be fitted.

The blade has two curves. The pelvic curve is designed to fit the curve on the axis of the birth canal is the concave side of the pelvic curve. The cephalic curve on the flat surface, which when articulated, grasps the fetal head without compression.

Shank: The shank is the part between the blade and the lock, and usually measures 6.25 cm. It increases the length of the instrument and thereby, facilitates locking of the blades outside the vulva. When the blades are articulated, the shanks are not apposed together.

The Lock: The common method of articulation consists of a socket system located on the shank at its junction with the handle. The handle: The handles are apposed when the blades are apposed when the blades are articulated. It measures 12.5 cm (5). A screw may be attached usually at the end (or at the base) of one blade, commonly left, to keep the blade in position.

Axis traction device: It can be applied with advantage in midforceps operation, especially following manual rotation of the head. It provides traction in the correct axis of the pelvic curve and as such, less force is necessary to deliver the head. It consists of traction rods and traction handle.

The instrument is lighter, shorter and stubbyhandled. 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 after-coming head of a breech delivery or at caesarean section.

Long and almost straight without any axis traction device. Has got a sliding lock which facilitates the correction of asynclitism of the head

CHOICE OF FORCEPS OPERATION Mid forceps: (10%) Used when head is at or near the level of ischial spine Internal rotation of the head is often incomplete Manual rotation may be needed before traction Ocxtocin drip may be required if not contraindicated Ventouse may be an alternative LOW FORCEPS: (90%) The head is near the pelvic floor or visible at introitus Commonly used OUTLET FORCEPS: Low forceps When the head is at perineum

TYPES OF APPLICATION OF THE FORCEPS BLADE 1. Cephalic application The blade is applied along the sides of the head grasping the biperital diameter in between the widest part of the blades The long axis of the blade corresponds more or less to the occipito mental plane of the fetal head Ideal method of application, got negligible effect on the cranium 2. Pelvic application
Blades of the forceps are applied on the lateral pelvic walls ignoring the position of the head. If head remains unrotated ,puts serious compression effect on the cranium Must be avoided

FUNCTIONS Traction Its compression effect Rotation of the head To provide a protective cage One forceps blade may be used as a vectis to assist delivery of the head in CS

INDICATIONS Operative vaginal delivery, in this case, forceps delivery, may be considered when the prerequisites have been fulfilled and there is a valid reason. Reasons to perform an operative vaginal delivery can be related to situations in the baby or the mother. Operative vaginal delivery is an option 1. Maternal Inadequate expulsive efforts Maternal exhaustion When the second stage of labor should be shortened because of a medical condition. To minimize the amount of pushing 2. Fetal When the baby shows signs of abnormal heart rate. Compression of the umbilical cord Low birth weight baby Post maturity 3. Others Prolonged second stage of labor failure to progress in the second stage of labor

PREREQUISITES Before any forceps delivery can be attempted, Fetal criteria The cervix must be completely dilated Membranes (bag of waters) must be ruptured. The baby's head must be at or below zero station (engaged), The degree of molding of the baby's head Maternal criteria Bladder must be emptied Adequate analgesia Other criteria Experienced operator Verbal or written consent

TYPES OF FORCEPS DELIVERIES: Outlet Low Mid High

Outlet forceps delivery is forceps-assisted delivery performed when the baby's scalp is visible at the vaginal opening. This type of assisted delivery is performed only when the baby's head is in a straight forward or backward position (facing either toward the mother's pubic bone or toward the mother's tailbone) or in slight rotation (less than 45 degrees to the right or left) from one of these positions. Low forceps delivery is forceps-assisted delivery performed when the baby's head is at +2 station or lower. There is no restriction on rotation for this type of delivery.

Mid forceps delivery is forceps-assisted delivery performed when the baby's head is above +2 station. The head must be engaged. High forceps delivery would be a forcepsassisted vaginal delivery performed when the baby's head is not yet engaged. These types of deliveries are not performed in modern practice.

LOW FORCEPS OPERATION Preliminaries Anesthesia Catheterization Internal examination episiotomy

Steps Identification of the blade and their application The left or the lower blade is to be introduced first The four fingers of the right hand are inserted along the left lateral vaginal wall, the palmar surface of the finger rest against the side of the head. The fingers are to guide the blade during application and to protect the vaginal wall. The handle of the left blade is taken lightly by three fingers of the left hand , index, middle, thumb in a pen holding manner and is held vertically almost parallel to the right inguinal ligament.

The blade is introduced between the guiding internal fingers and the fetal head, manipulated by the thumb. As the blade is pushed up and up, the handle is carried downwards and back words, transversing wide arc of a circle towards the left until the shank is to lie straight on perineum. When correctly applied the blade should be over the partial eminence, the shank should be in contact with the perineum and the superior surface of the handle should be directed upward. Introduction of the right blade- the two fingers of the left hand are now introduced into the right lateral wall of the vagina alongside the babys head. The right blade is introduced in the same manner as with left hand but holding it with the right hand.

Locking of the blades When correctly applied, the blades should be articulated with ease. Minor difficulty in locking can be corrected by depressing the handles on the perineum. In case of major difficulty, the blades are to be reinserted. The handles should never be forced to lock them.

Traction and removal of blades Before traction is applied, correct application of the blades is to be ensured. As evidenced by easy locking, firm gripping of the head on the biperital diameter. Steady but intermittent traction should be given if possible during contraction. However in outlet forceps the pull is continuous. Direction of the pull- corresponds the axis of the birth canal. The direction of the pull is downwards and backwards until the head comes to the perineum. The pull is then directed horizontally straight towards the operator till the head is almost crowned. The blades are then removed one by one, the right one is first.

Difficulties in Forceps Operation

Difficulty in locking are caused by:-. Application on un-rotated head. Improper insertion of the blade (not for enough in). Failure to depress the handle against the perineum. Enlargement of the cord or fetal parts inside the blades.

MATERNAL

FETAL

Immediate
Injury Nerve injury PPH Anesthetic complications Puerperal sepsis Meternal morbidity

Immediate
Asphexia Facial bruishing Intracranial haemorrhage Cephalohaematoma Facial palsy Skull fractures Cervical spine injury.

Remote genital prolapse Painful perineal scars, stress urinary incontinence, sphincter dysfunction. Dyspareunea, Low backache

Remote Cerebral or spastic palsy

CONTRAINDICATIONS Any contraindication to vaginal delivery. Refusal of the patient to verbally consent to the procedure Cervix not fully dilated or retracted Inability to determine the presentation and fetal head position Inadequate pelvic size Confirmed cephalopelvic disproportion Unsuccessful trial of vacuum extraction (relative contraindication) Absence of adequate anesthesia/analgesia Inadequate facilities and support staff Inexperienced operator

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 judgement. 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

Assess the effect on mother and fetus. Start IV infusion with 5 percent dextrose if one is not already in place. Administer parenteral antibiotic. Exclude rupture of uterus and plan for other modes of delivery. The women should be shifted to an equipped hospital.