Delivery

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© Springer Nature Singapore Pte Ltd. 2020
A. Sharma (ed.)Labour Room Emergencieshttps://doi.org/10.1007/978-981-10-4953-8_30



30. Instrumental Delivery



Parul Kotdwala1, 2, 3   and Munjal Pandya4


(1)
Department of Obstetrics and Gynecology, V.S. Hospital & N.H.L. Municipal Medical College, Ahmedabad, Gujarat, India

(2)
Zydus Hospital, Ahmedabad, Gujarat, India

(3)
Kotdawala Women’s Clinic, Ahmedabad, Gujarat, India

(4)
AMC MET Medical College, Sheth L.G. Hospital, Ahmedabad, Gujarat, India

 



 

Parul Kotdwala


30.1 Introduction


There has been mention of forceps in Sanskrit (1500 BC), Egyptian, Greek, Roman, and Persian writings and pictures, but thought to be used for the extraction of dead fetus. Around 1600 AD, Peter Chamberlen (England) used forceps on live fetus (Fig. 30.1). Levert (1747) introduced the pelvic curve. Sir James young Simpson (1845) developed a forceps appropriately fitting both cephalic and pelvic curvatures. James Haig Ferguson (1862–1934) modified Simpson’s forceps by shortening the handle and placing slots to allow the application of traction tapes increasing fetal head flexion. Joseph DeLee (1920) advocated prophylactic forceps delivery. Christian Kielland (1915) invented rotational forceps. William Smellie (1975) was the first one to describe “cephalic application” rather than previously performed “pelvic application.” He also designed English lock. Arthur Wrigley (1902–1983) invented Wrigley’s forceps useful for outlet forceps application. KN Das modified application of forceps at midcavity level (Fig. 30.2). Moolgaonkar (1962) developed his forceps, which is an improvement upon the Kjelland instrument (Fig. 30.3). He devised this specifically for narrower pelves of Indian women, though later this instrument has gained popularity in Britain also. The use of instrumental delivery is mostly to reduce the duration of the second stage of labor, but in modern practice, with the advent of fetal surveillance systems, the length of the second stage is not an absolute indication. Studies suggest that morbidity increases significantly only after 3–4 h in the second stage [1]. Instrumental deliveries are increased when epidural analgesia is used due to lack of Ferguson’s reflex [2].

The obstetric forceps is a unique instrument. A simple and honest implement, compared to many of man’s inventions. Its history is nevertheless complicated with confusion and irony and its inventions shrouded in secrecy. It probably has saved more lives than any instrument ever devised and yet it did not appear until countless generations of men struggled into the world without it, or failed to arrive. A real and solid thing, easily fabricated, it is yet capable of such subtle variations that its evolution has never stopped. It is designed specifically to rescue life, and yet it descended from an instrument of death! [3]


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Fig. 30.1

Chamberlen’s forceps


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Fig. 30.2

Kedarnath Das (1867–1936)


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Fig. 30.3

Das’s modified forceps


30.2 Indications for Operative Vaginal Delivery [4]





  1. 1.

    Fetal indications:



    • Fetal distress, based on abnormal heart rate pattern of fall in fetal scalp pH.


     

  2. 2.

    Maternal indications:



    • To shorten the second stage of labor and reduce the effects of the second stage of labor on medical conditions (e.g., cardiac disease class III or IV, hypertensive crisis, myasthenia gravis, spinal cord injury patients at risk of autonomic dysreflexia, proliferative retinopathy).


     

  3. 3.

    Inadequate progress:



    • Nulliparous women—lack of continuing progress for 3 h (total of active and passive second-stage labor) with regional anesthesia, or 2 h without regional anesthesia.



    • Multiparous women—lack of continuing progress for 2 h (total of active and passive second-stage labor) with regional anesthesia, or 1 h without regional anesthesia.



    • Maternal fatigue/exhaustion.


     

30.2.1 Contraindication to Operative Vaginal Delivery [4]






  • Relative contraindication: unfavorable attitude of fetal head, rotation >45° from occipitoanterior or occipitoposterior, midpelvic station



  • Absolute contraindication: Nonvertex or brow presentation, no engaged head. Fetal coagulopathy, incomplete cervical dilation, cephalopelvic disproportion


30.3 Parts of Forceps (Figs. 30.4, 30.5, and 30.6)


Forceps are composed of two blades, each one having four parts:



  • Blades: The blades are the parts which grasp the fetal head. Each blade has two curves: A cephalic curve, which fits in the shape of fetal head and a pelvic curve which corresponds to birth canal axis. Some forceps have blades which are fenestrated. The blade which will come in contact with the left maternal pelvic wall is called the left blade, and the one which will come in contact with the right pelvic wall is the right blade.



  • Shank: It is the part connecting handle with the blade. The shanks are parallel in the straight forceps, or crossing in some forceps.



  • Lock: There are many types of locks for articulation between shanks. English lock is more common where socket at the junction of the handle fits into the opposite shank.



  • Handles: These are the parts to hold the device and to give traction to the fetal head.


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Fig. 30.4

Parts of forceps


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Fig. 30.5

Anatomy of forceps


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Fig. 30.6

Tucker-McLane forceps


30.4 Types of Forceps





  1. 1.

    Simpson’s forceps (Fig. 30.7): It is a type of midcavity/low forceps. It is used when the sagittal suture is in direct anteroposterior position or within 45° from the midline.


     

  2. 2.

    Piper’s forceps (Fig. 30.8): Used for after-coming head of breech.


     

  3. 3.

    Wrigley’s forceps (Fig. 30.9): It is a type of outlet forceps, the most commonly used forceps.


     

  4. 4.

    Kielland’s forceps (Fig. 30.10): It is a type of rotational forceps when the occiput is in transverse or posterior position, requiring considerable experience and skill. It has minimal pelvic curve, longer shank, and a sliding lock. Shank has two knobs on the same side to identify the progressive rotation.


     

  5. 5.

    Axis traction forceps: Axis traction was devised by Tarnier in 1877 (Fig. 30.11). When straight forceps are applied in midcavity, traction becomes difficult. The traction rods enable traction to be applied in the axis of pelvic cavity. Neville-Barnes and Haig-Ferguson’s forceps belong to this category (Fig. 30.12).


     

  6. 6.

    Laufe’s forceps (Fig. 30.13): Specially designed to limit fetal cranial compression with divergent or parallel blades.


     

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Fig. 30.7

Simpson’s forceps


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Fig. 30.8

Piper’s forceps


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Fig. 30.9

Wrigley’s forceps


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Fig. 30.10

Kjelland’s forceps


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Fig. 30.11

Tarnier forceps


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Fig. 30.12

Haig Ferguson’s forceps


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Fig. 30.13

Laufe’s forceps


30.4.1 Functions of Obstetric Forceps





  1. 1.

    Traction


     

  2. 2.

    Compression


     

  3. 3.

    Rotation


     

  4. 4.

    Other functions:



    • Vectis



    • As a protective cage, for preterm head



    • Inducing a uterine contraction


     

30.5 ACOG Criteria for Types of Forceps Delivery [5]





  1. 1.

    Outlet forceps:



    • The scalp is visible at introitus, without separating labia.



    • The fetal skull has reached the pelvic floor.



    • The sagittal suture is in anteroposterior diameter, right or left occiput anterior or posterior position (i.e., the fetal head is at or on perineum and rotation does not exceed 45°).

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Mar 28, 2021 | Posted by in OBSTETRICS | Comments Off on Delivery

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