Instrumental Instrumental Delivery Delivery

Forceps DeliveryForceps Deliveryindicationsindications

A.A. Indicated :Indicated :

1.1. AnesthesiaAnesthesia

2.2. Heart diseaseHeart disease

3.3. Pulmonary diseasePulmonary disease

4.4. Fetal distressFetal distress

5.5. After coming headAfter coming head

6.6. In cesarean section In cesarean section

B.B. Selected : Selected :

1.1. Poor cintractions Poor cintractions

2.2. Fatigue Fatigue

3.3. Op position Op position

4.4. Prevention of cystocele and Prevention of cystocele and

rectocele ?rectocele ?

5.5. Prevention of hemorrohid?Prevention of hemorrohid?

ContraindicationsContraindications

• • Extreme prematurity (< 34 Extreme prematurity (< 34

weeksweeks))

•• Suspected bleeding disorderSuspected bleeding disorder

• • Macrosomia, suspected or USG Macrosomia, suspected or USG

established established

Prerequisitions for forcepsPrerequisitions for forceps1.1. Full dilatation Full dilatation 2.2. Engagement Engagement 3.3. Empty bladderEmpty bladder4.4. Known position (of the fetal Known position (of the fetal

head)head)5.5. Ruptured membranes Ruptured membranes 6.6. Adequate anesthesia Adequate anesthesia 7.7. Episiotomy Episiotomy 8.8. R/O C.P.DR/O C.P.D9.9. Skilled operatorSkilled operator

Parts of EquipmentParts of Equipment1.1. Cup size 40, 50, 60 mm.Cup size 40, 50, 60 mm.2.2. Types of cupTypes of cup

• • MalestormMalestorm • • BirdBird • • Siliastic (Mety-vac)Siliastic (Mety-vac) • • M-cup.M-cup.

3.3. Vacuum tubing.Vacuum tubing.4.4. Traction chain.Traction chain.5.5. Suction apparatus—which has capacity Suction apparatus—which has capacity

to produce 0.8to produce 0.8 kg/cm2 negative kg/cm2 negative suction @ 550-600 mm Hg.suction @ 550-600 mm Hg.

6.6. Traction force max @ 22.7 kg Traction force max @ 22.7 kg

required before detachment or required before detachment or

pop-off takes place. This is the pop-off takes place. This is the

safetyend point.safetyend point.

7.7. Application distance: is 3 cm Application distance: is 3 cm

from post edge of anterior from post edge of anterior

fontanelle of fetal sclap till the fontanelle of fetal sclap till the

anterior outer edge of traction anterior outer edge of traction

cup.cup.

8.8. Site of applicationsSite of applications

a- Flexing mediana- Flexing median

b. Hexing paramedian Result inb. Hexing paramedian Result in

c. Deflexing median Asyncilitismc. Deflexing median Asyncilitism

d. Deflexing paramediand. Deflexing paramedian

Failure for Failure for

correct correct

tractiontraction

Parts of Forcep'sParts of Forcep's • • Has two crossing blade branchesHas two crossing blade branches

• • Each branch blade has four componentsEach branch blade has four components

1. The blade1. The blade

2. Shank2. Shank

3. Lock—English and/or sliding type3. Lock—English and/or sliding type

4. Handle4. Handle

• • Each blade has two curvesEach blade has two curves

a. Cephalic-coniorms to shape of fetal a. Cephalic-coniorms to shape of fetal headhead

b. Pelvic-confoims to pelvic curvatureb. Pelvic-confoims to pelvic curvature

Common Types of Forceps in UseCommon Types of Forceps in Use

1. Wringly's outlet forceps1. Wringly's outlet forceps

2. Simpson's2. Simpson's

3. Tucker-McIane3. Tucker-McIane

4. Kielland forceps4. Kielland forceps

5. Piper's forceps5. Piper's forceps

6. Hay's forceps 6. Hay's forceps

Classification of Forceps DeliveryClassification of Forceps Delivery(Instrumental Delivery) (ACOG 2000)(Instrumental Delivery) (ACOG 2000)

Procedure CriteriaProcedure CriteriaOutlet forceps Outlet forceps 1. Sclap visible and at 1. Sclap visible and at interoitus without interoitus without separating labiaseparating labia 2. Fetal skull at pelvic floor2. Fetal skull at pelvic floor 3. Sagittal suture in AF dia or3. Sagittal suture in AF dia or LOA or ROA positionLOA or ROA position 4. Fetal head is or at pelvic4. Fetal head is or at pelvic perineum (leading pole)perineum (leading pole) 5. Rotation needed does not5. Rotation needed does not exceed 45°exceed 45°

Low forceps Low forceps • • Leading point ^ +2 station andLeading point ^ +2 station and not on pelvic floornot on pelvic floor • • Rotation is 45° or less. LOA/Rotation is 45° or less. LOA/ ROA to occiput ant and/orROA to occiput ant and/or LOP/POP with occiput pos-LOP/POP with occiput pos- teriorterior • • Rotation is > 45°Rotation is > 45° Mid forceps Mid forceps Station above +2 cm but headStation above +2 cm but head is Engaged (Abdomen palpableis Engaged (Abdomen palpable vertex is I/5th only)vertex is I/5th only) High forcepsHigh forceps Not included in this classification Not included in this classification

Function of ForcepsFunction of Forceps Used as traction, rotation or Used as traction, rotation or

both, both,

by and large used as a tractor by and large used as a tractor Possible Max Force UsedPossible Max Force Used

Upto 60 kg max after which fetal Upto 60 kg max after which fetal

skull damage is assured. Generally skull damage is assured. Generally

with forceps at elbow along side with forceps at elbow along side

body leads to force of 22-27 kgs body leads to force of 22-27 kgs

per tractor pull.per tractor pull.

Preparation of Forcep ApplicationPreparation of Forcep Application1.1. Pudendal block or regional anesthesiaPudendal block or regional anesthesia2.2. Lithotomy positionLithotomy position3.3. Bladder assured emptyBladder assured empty4.4. Perineum cleaned and drapedPerineum cleaned and draped5.5. Forceps are constructed outside as to Forceps are constructed outside as to

be appliedbe applied6.6. Precise knowledge of exact position of Precise knowledge of exact position of

fetal head either by suture direction or fetal head either by suture direction or by locating posteriorby locating posterior earear

7.7. Application as for biparital or bi malar Application as for biparital or bi malar position, is only safe application of position, is only safe application of forcepsforceps..

IndicationsIndications

A. MaternalA. Maternal

• • ExhausationExhausation

• • Poor/absent maternal expulsive effortsPoor/absent maternal expulsive efforts

• • Need to avoid maternal expensive effort,Need to avoid maternal expensive effort,

cardiac disease/CVAcardiac disease/CVA

• • Lack of effortLack of effort

B. FetalB. Fetal

• • Nonreassuring fetal CTG testNonreassuring fetal CTG test

C. Prolonged 2nd stageC. Prolonged 2nd stage

•• Primi > 2 hr without regional anesthesiaPrimi > 2 hr without regional anesthesia

•• Multi > 1 hr anesthesia (for with RA addl hrMulti > 1 hr anesthesia (for with RA addl hr))

•• Desired selective shortening of 2nd stageDesired selective shortening of 2nd stage

PrerequisitesPrerequisites

A. MaternalA. Maternal

• • Lithotomy positionLithotomy position

•• ReassuranceReassurance

• • ConsentConsent

• • Adequate analgesiaAdequate analgesia

• • Empty bladderEmpty bladder

• • Adequate assessed pelvisAdequate assessed pelvis..

B. FetalB. Fetal

•• Cephalic presentationCephalic presentation

• • Membranes rupturedMembranes ruptured

• • Engaged fetal headEngaged fetal head

•• Position of head-knownPosition of head-known

•• Station +2Station +2

•• Flexed attitudeFlexed attitude

• • Moulding of head +1 onlyMoulding of head +1 only..

C. OthersC. Others

•• Cervix fully dilatedCervix fully dilated

• • No placenta praeviaNo placenta praevia

• • Experienced operatorExperienced operator

•• Ability to do less, with facilities Ability to do less, with facilities

existing prtoi to attemptingexisting prtoi to attempting..

IndicationsIndications

MaternalMaternal

• • Heart diseaseHeart disease

• • Pulmonary injury or severe COFDPulmonary injury or severe COFD

• • Severe intrapartum infectionSevere intrapartum infection

• • Neurological conditions such as cord Neurological conditions such as cord

injury or neuromuscular diseasesinjury or neuromuscular diseases

• • Prolonged 2nd stage.Prolonged 2nd stage.

Fetal IndicationsFetal Indications

• • Prolapse of umbilical cordProlapse of umbilical cord

• • Premature separation of placentaPremature separation of placenta

• • Non-assuring CTG tracing, persistant.Non-assuring CTG tracing, persistant.

OthersOthers

• • Lack of maternal expulsive effortLack of maternal expulsive effort

• • Elective shortening of 2nd stage Elective shortening of 2nd stage

(prophylactive) or social need.(prophylactive) or social need.

PrerequisitesPrerequisites

1.1. Vertex presentation or face with Vertex presentation or face with chin out (mento-anterior)chin out (mento-anterior)

2.2. Head must be engagedHead must be engaged

3.3. Position of fetal head well knownPosition of fetal head well known

4.4. Cervix fully dilatedCervix fully dilated

5.5. Bladder completely emptyBladder completely empty

6.6. Membranes rupturedMembranes ruptured

7.7. No CPD assessedNo CPD assessed

8.8. Informed mother's consentInformed mother's consent..