Forceps Delivery

Introduction

Obstetric forceps are a pair of specially designed instruments used to assist in the extraction of the fetal head, facilitating the delivery of the fetus. Forceps delivery is employed when it becomes impossible for the mother to complete the delivery through her own efforts. Additionally, forceps can be used to assist in the delivery of an aftercoming head, breech presentation, or, in some cases, to guide the fetal head upward and out of the pelvis during a cesarean section.

Design of forceps

The design of obstetric forceps comprises two matching metallic halves that articulate at the lock. Each half consists of a blade, shank, lock, shoulder, and handle. Each blade features two curves – the cephalic curve and the pelvic curve – which conform to the axis of the birth canal. The tip of the blades is referred to as the “toe.”

The concave side of the pelvic curve is the front of the forceps. The blades are designated as the right blade and left blade, corresponding to the side of the maternal pelvis they occupy after application.

The left blade is applied first, ensuring it is clearly positioned against the fetal head, and the right blade is applied subsequently. This process allows the shank of the right blade to engage with and lock onto the shank of the left blade as the handles are brought together.

Varieties of obstetric forceps

Long Curved Forceps: These forceps have long shanks and are commonly used in obstetrics.

Wrigley’s Short Forceps: These are short-shanked, lightweight forceps with a slight pelvic curve and marked cephalic curve.

Kielland’s Forceps: These are long, nearly straight special forceps designed for forceps rotation and delivery, primarily used in occipito-posterior positions.

Indications of forceps delivery

(A) Maternal Indications

• Delayed second stage of labour.
• Maternal exhaustion or distress.
• Pre-eclampsia or eclampsia in the second stage of labour (Pregnancy Induced Hypertension).
• Maternal medical disorders such as cardiac disease, severe anemia, TB, to shorten the second stage.
• Malposition of the fetal head, such as occipito-posterior or occipito-lateral positions.
• Failure of descent or internal rotation for 2 hours in primigravida (first-time mothers) and 1 hour in multipara (women who have previously given birth).

(B) Fetal Indications

• Fetal distress in the second stage of labour.
• Cord prolapse in the second stage of labour.
• Aftercoming head in breech delivery.
• Post-maturity.

Contraindications to the use of Forceps

• Absence of a proper indication.
• Absence of full cervical dilatation.
• Severe cephalopelvic disproportion (CPD) where the fetal head cannot safely pass through the birth canal.
• High station of the fetal head, not engaged in the pelvis.
• Cessation of uterine contractions, as forceps are typically used during contractions to aid in delivery.

Prerequisites for Forceps application

Certain condition must be satisfied prior to forceps applications

• The fetal head must be engaged, flexed, and preferably well-rotated.
• There should be no obvious cephalopelvic disproportion (CPD).
• The cervix must be fully dilated and effaced.
• The amniotic membranes must be absent (ruptured).
• The uterus must be contracting.
• The bladder must be empty.
• The rectum should preferably be empty.
• The fetal presentation and position must be suitable.
• The baby should be alive.
• There should be no undue obstruction.

Procedure and management

1. Explain the purpose of the procedure to the patient and obtain informed consent.
2. Prepare a sterilized delivery set, episiotomy set, forceps, catheter, emergency medication resuscitation set, suction equipment, and oxygen supply.
3. Inform the pediatrician and ensure all necessary equipment for neonatal care is ready.
4. Place the mother in the lithotomy position.
5. Ensure that the operators are dressed in sterile masks, gowns, and gloves.
6. Wash the vulva with an antiseptic solution and drape the area. Insert a sterile catheter to empty the bladder.
7. Prepare the setup as you would for a normal delivery.
8. Infiltrate the perineum and perform an episiotomy when indicated.
9. Assemble the forceps before application. Ensure that all parts fit together securely, and lubricate the blades of the forceps.
10. Choose the first left blade, and hold it vertically like a pen with your left hand, directing the cephalic curve toward the vulva. The middle and index fingers of the semi-supinated right hand are introduced into the posterior-lateral aspect of the vagina alongside the fetal head, while keeping the thumb and other fingers outside.
11. Gently introduce the left blade between the fetal head and internal fingers, with the convex border of the blade guided upward by the thumb of the vaginal hand.
12. Follow the same procedure to introduce the right blade.
13. Lock the blades, and if locking is difficult, apply pressure on the perineum. If further difficulties persist, withdraw the blades and conduct a thorough vaginal examination to check for any malposition of the fetal head.
14. Grip the forceps handles with the right hand and apply traction during a uterine contraction. In a low forceps operation, use a single continuous pull with traction directed downward, downward-forward, and finally upward.
15. Deliver the fetal head by extension and remove the blades after head delivery.
16. In case of forceps delivery failure, consider performing a cesarean section (C/S).
17. Actively manage the third stage of labor following the delivery of the head.
18. Resuscitate the newborn as needed and promote warmth through skin-to-skin contact.

Dangers of use of forceps

A. Maternal dangers

• Soft tissue injuries to cervix, vagina, perineum, and extension of episiotomy.
• Rupture of the uterus
• Injury to bladder or rectum
• Traumatic PPH and shock
• Infection
• Bladder atony
• Fracture of sacro-coccygeal joint
• Pelvic haematoma

 B. Fetal dangers

• Cephalohaematoma
• Fracture skull
• Intracranial hemorrhage
• Brain damage
• Marked depression of respiration and asphyxia
• Facial palsy/Brachial palsy
• Soft tissue injury to face, bruising and laceration
• Infection/convulsion/fetal death
• Cord compression.

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