FORCEPS DELIVERY

•	Indications.
•	Pre-requisites. 
•	Types of forceps.
•	Technique.
•	Complications.

Indications

1.	Prolonged second stage:

a.	Power: inadequate uterine contractions or poor voluntary effort.

b.	Passage: contracted pelvis.

c.	Passenger:

i.	macrosomnia.

ii.	persistent OP or deep transverse arrest.

iii.	malpresentation.

2.	Fetal distress:

a.	Cord prolapse.

b.	Placental insufficiency.

c.	Prolonged or difficult labor.

3.	Maternal distress:

a.	Prolonged first stage.

b.	Underlying disease, e.g. hypertension. 

4.	Other indications:

a.	Preterm delivery to minimize injury.

b.	Aftercoming head in breech delivery.

c.	Malposition: Kielland’s forceps to rotate to OA position.

d.	Caesarean section.

Prerequisites

1.	Favorable presentation: cephalic + vertex, face with chin anterior.

2.	Os fully dilated.

3.	Ruptured membrane.

4.	Contractions present.

5.	Engaged head.

6.	Position must be known.

7.	Sterile.

Types of Forceps

1.	Parts of a forceps:

a.	Blade.

b.	Shank.

c.	Lock.

d.	Handle.

2.	Wrigley’s forceps:

a.	“Outlet” forceps: used when head is at perineum.

b.	No need to use much force: just “lift up”.

3.	Neville Barnes’ forceps:

a.	“Mid-cavity” forceps.

b.	Notch in shank: middle finger to be inserted here for traction.

c.	Ridges in handle for better grip. 

4.	Kielland’s forceps:

a.	“Mid-cavity + rotational traction” forceps.

b.	No pelvic curve: rotation possible with minimal injury.

c.	Sliding lock: to correct for asynclitism (when sagittal suture is not mid-way between sacral promontory and pubic symphysis).

d.	Knob in handle: indicate where occiput is.

e.	Use for malposition: OP / OT. 

Technique

1.	Clean, drape and catheterize in lithotomy position.

2.	VE to ensure prerequisites are fulfilled.

3.	Give adequate analgesia: local / pudendal block / epidural.

4.	Check the maximum diameter between the two blades: the maximum diameter should be at least 9cm.

5.	Insertion:

a.	Insert left blade using left hand while guarding vagina with right hand.

b.	Same procedure is followed by the other blade.

c.	The blades should lock easily and should not be forced to close.

6.	Traction:

a.	Wrigley’s: traction applied downward and then upward with contractions.

b.	Kielland’s: rotate the head to OA position without exerting traction.

Complications

1.	Trauma:

a.	Genitalia tear: laceration of cervix, vagina, rupture of uterus.

b.	3rd degree tear to rectum.

c.	Bladder injury.

d.	Abrasions and lacerations to fetal skull.

2.	Haemorrhage.

3.	Infection.