Forceps DeliveryForcep delivery is a means of extraction the fetus head with the aid of obstetric forceps when it is impossible for the mother to complete delivery by her own effort.Obstetric forceps is a pair of instrument specially designed to assist extraction of the head and thereby accomplishing delivery of the fetus.Structure of the ForcepsObstetric forceps consist of two branches that are positioned around the fetal head. These branches are defined as left and right depending on which side of the mother's pelvis they will be applied. The branches usually, but not always, cross at a midpoint which is called the articulation. Most forceps have a locking mechanism at the articulation, but a few have a sliding mechanism instead, allowing the two branches to slide along each other. Forceps with a fixed lock mechanism are used for deliveries where little or no rotation is required, as when the fetal head is in line with the mother's pelvis. Forceps with a sliding lock mechanism are used for deliveries requiring more rotation.The blade of each forceps branch is the curved portion that is used to grasp the fetal head. The forceps should surround the fetal head firmly, but not tightly. The blade characteristically has two curves, the cephalic and the pelvic curves. The cephalic curve is shaped to conform to the fetal head. The cephalic curve can be rounded or rather elongated depending on the shape of the fetal head. The pelvic curve is shaped to conform to the birth canal and helps direct the force of the traction under the pubic bone. Forceps used for rotation of the fetal head should have almost no pelvic curve. The handles are connected to the blades by shanks of variable lengths. Forceps with longer shanks are used if rotation is being considered.

Types of forcepsLong curved forceps: Long curved forceps is relatively heavy and is about 37 cm (15) long. It has blade, shank, Lock, handle with or without screw.Simpson forceps (1848) are the most commonly used among the types of forceps and has an elongated cephalic curve. These are used when there is substantial molding, that is, temporary elongartion of the fetal head as it moves through the birth canal.Elliot forceps (1860) are similar to Simpson forceps but with an adjustable pin in the end of the handles which can be drawn out as a means of regulating the lateral pressure on the handles when the instrument is positioned for use. They are used most often with women who have had at least one previous vaginal delivery because the muscles and ligaments of the birth canal provide less resistance during second and subsequent deliveries. In these cases the fetal head may thus remain rounder.Kielland forceps (1915, Norwegian) are long almost straight distinguished by an extremely small pelvic curve and without anu axis traction device and has sliding lock. Probably the most common forceps used for rotation. The sliding mechanism at the articulation can be helpful in asynclitic births (when the fetal head is tilted to the side), since the fetal head is no longer in line with the birth canal. On the other hand, Kielland forceps lack traction because they have almost no pelvic curve. Wrigley's forceps (Short curved obstetric forceps) are used in low or outlet delivery (see explanations below), when the maximum diameter is about 2.5cm above the vulva. Wrigley's forceps were designed for use by general practitioner obstetricians, having the safety feature of an inability to reach high into the pelvis. Obstetricians now use these forceps most commonly in cesarean section delivery where manual traction is proving difficult. The short length results in a lower chance of uterine rupture.Piper's forceps have a perineal curve to allow application to the after-coming head in breech delivery.Parts of the forceps:Blade: Obstetric forceps consist two separate blades, each with handle. Each blade is marked L (left) or R (right). Blade has two curves that are pelvic curve and cephalic curves. The cephalic curve which permit an accurate and safe grip of the fetal head and are spoon shaped. The pelvic curve which confirms to the axis of the birth canal.The tip of the blade called toe.Shank: It is the part between the blade and the lock. It facilitates locking blade outside the vulva.Lock: the lock is located on the shank at its junction with the handle.Handle: the handles are apposed when the blades are articulated and apply traction to the fetal head.

Elliott forceps with "pressure regulating" screw at the end of handles USA (1860 Classification of forceps delivery according stationOutlet, low, mid or highThe accepted clinical standard classification system for forceps deliveries according to station and rotation was developed by ACOG and consists of:1. Outlet forceps delivery, where the forceps are applied when the fetal head has reached the perineal floor and its scalp is visible between contractions.This type of assisted delivery is performed only when the fetal head is in a straight forward or backward vertex position or in slight rotation (less than 45 degrees to the right or left) from one of these positions. 2. Low forceps delivery (90%), when the baby's head is at +2 station or lower. There is no restriction on rotation for this type of delivery. 3. Midforceps delivery (10%), when the baby's head is above +2 station. There must be head engagement before it can be carried out, rotation >4504. High forceps delivery is not performed in modern obstetrics practice. It would be a forceps-assisted vaginal delivery performed when the baby's head is not yet engaged. Types of application of forceps blades1. Cephalic applicationThe blades are applied along the sides of the grasping the biparietal diameter in between the widest part of the blades. The long axis of the blades corresponds more or less to the occipito-mental plane of fetal head. It is the ideal method of application as it has got a negligible compression effect on the cranium.2. Pelvic applicationWhen the blades of the forceps are applied on the lateral pelvic walls ignoring the position of the head, it is called pelvic application. If the head remains unrotated, this type of application puts serious compression effect on the cranium and thus must be avoided.Indications of forcep deliveryMaternal1. Inadequate expulsive efforts2. Maternal exhaustion (distress) in second stage3. Delayed second stage of labour.4. Pre-eclampsia, eclampsia5. Post caesarean pregnancy6. Maternal illness; such as heart disease, hypertension, glaucoma, aneurysm, pulmonary disease, which make pushing difficult or dangerous7. Malposition: occipito posterior and occipito lateral positions.8. Neurological disorders where voluntary efforts are contraindicated.9. Failure of descent or internal rotation for 2 hours in primigravidae and 1 hour in multipara.Fetal indication1. Fetal distress in second stage of labour2. vertex presentation or face presentation 3. After coming head in breech delivery4. Low birth weight baby5. Post maturity6. Cord prolapse in second stage of labourContraindication1. Absence of proper indication2. Absence of full dilatation of cervix3. CPD4. High station of fetal head5. Uterine contraction cease.Advantages1. Avoidance of C-section2. Reduction of delivery time3. Can be used for pre term delivery4. Can be used for face and after coming head of breech.5. General applicability with cephalic presentation.

Disadvantage1. Difficult to apply2. More likely to cause trauma to both mother and babyPre requisite for forcep delivery1. Cervix must be fully dilated2. The fetal head at +2 or +3 station or 0/5 palpable above the symphysis pubis3. The sagital suture should be in the middle4. The membranes must be absent5. Bladder must be empty6. The rectum should be empty7. The uterine contraction must well8. Suitable presentation and position9. Adequate analgesia (lacal anaesthesia)10. There should be no cephalopelvic disproportion11. Baby must be living. Equipments for forcep delivery1. Normal delivery set2. Episiotomy set3. Cather4. Sterile obstetric forecp 1 pair5. Resuscitation trolley for babyProcedures:1. Explain the mother about the purpose and procedure 2. Take written consent 3. Prepare the sterilized delivery set, episiotomy set, forceps, catheter, emergency medicine, resuscitation set, suction, oxygen etc.4. Inform pediatrician and make ready all the necessary equipments and articles.5. Mother is placed in lithotomy position.6. Put the personal protective barriers.7. Wash vulva with antiseptics solution, drapping is placed.8. Empty the bladder with catheterization.9. Give the episiotomy when indicated.10. Check the forceps before application that is parts fit together and lock well and lubricate the blade of the forceps.11. The left blade is applied first. Insert two fingers (middle and index) of the right hand into the vagina on the side of the fetal head. Slide the left blade gently between the head and fingers to rest on the side of head. 12. Introduce the right blade in same manner as with left blade but with right hand.The left blade is introduced by left hand into left side of pelvis and right blade is introduced by right hand into right side of pelvis as follows two or more fingers of the right hand are introduced inside the left postero lateral portion of the vulva and into the vagina beside the head. 13. Depress the handles and lock the forceps. Difficulty in locking forceps and the handles are depressed on the perinium indicates that the application is incorrect. If incorect application, remove the blade and recheck the position of head.14. After locking the handles of the forcep are gripped with the right hand and apply steady traction downwards, downwards forward and finally upwards with each contraction.15. Between contractions check fetal heart rate and application of forceps.16. Thus the head is delivered by extension.17. Remove the forceps after delivery of head.18. Clean the eyes, nose and mouth of the baby. Then proceed as in normal delivery.19. Examined the baby carefully for injury or trauma caused by forceps.20. Manage the third stage of labour actively.21. If vaginal or cervical injury is present repair it.22. Resuscitate the newborn if needed and keep the newborn warm with skin to skin contact.Failure:Forceps fails if:1. Fetal head does not advance with each pull, only 2 or 3 pull should be necessary.2. Fetus is undelivere after three pulls with no descent or after 30 minutes.3. Dont persist if the head does not descend with every pull. ComplicationsFetal Soft tissue injury to face and bruises Occasionally, (usually temporary) facial nerve injury can occur rarely, clavicle fracture Intracranial hemorrhage sometimes leading to death Cephalohaematoma Brain damage Facial palsy/ brachial palsy Cord compression Remote cerebral palsy Infection ConvulsionMother Increased postnatal recovery time and pain problems going to the toilet during the recovery time Tears of the genital tract Uterine rupture Injury to bladder or rectum Post partum haemorrhage due to atonic or trauma Vesico vaginal and recto vaginal fistula Shock Fracture of sacro-coccygeal joint Pelvic haematoma Genital prolapse Extension of episiotomy