Clinical pelvimetry and Forceps Assisted Vaginal Delivery
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This document discusses clinical pelvimetry and forceps-assisted vaginal delivery. It begins by outlining the objectives and key anatomical features assessed in a clinical pelvimetry exam. It then discusses the different types of forceps, indications for their use, application techniques, and complications. It emphasizes the importance of training residents on forceps use through lectures, workshops and opportunities to apply different forceps during cesarean deliveries in order to graduate with skills for operative vaginal delivery.
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Clinical pelvimetry and Forceps Assisted Vaginal Delivery
- 1. Arthur Greenwood, MD CLINICAL PELVIMETRY AND THE FORCEPS VAGINAL DELIVERY
- 2. CLINICAL PELVIMETRY OBJECTIVES ⢠Understand the importance of Clinical Pelvimetry and its role in modern day obstetrics ⢠Know the steps for a thorough vaginal exam ⢠Be better able to describe the pelvis in clinical terms ⢠Be better able to identify the type of pelvis your patient has and understand the significance ⢠Recognize the type of pelvis at increased risk for third and fourth degree perineal lacerations
- 3. FORCEPS ASSISTED VAGINAL DELIVERY OBJECTIVES ⢠Know the anatomy of forceps and be able to distinguish different types of forceps and their uses ⢠Understand the indications for a trial of forceps ⢠Know how to check for proper application of forceps ⢠Understand the potential use of forceps during cesarean deliveries ⢠Recognize the steps our program needs to take to ensure that Wake Forest continues to be a program where residents graduate with the knowledge to perform FAVD
- 4. THE CALDWELL-MALLOY CLASSIFICATION (1933, 1934)
- 5. KEY ANATOMIC FEATURES OF THE TRUE PELVIS ⢠Sacral promontory ⢠Retropubic angle ⢠Width of the sacrosciatic notch ⢠Anterior surface of the sacrum ⢠Ischial spines and tuberosities ⢠Inner surface of the ischium ⢠Suprapubic arch ⢠Descending pubic rami ⢠Coccyx
- 6. THE INLET ⢠Diagonal Conjugate â distance from the sacral promontory to the to the inferior margin of the symphysis pubis ⢠OC = DC-1.5cm ⢠Contracted: OC <10.5cm
- 7. THE INLET: THE RETROPUBIC ANGLE ⢠A.K..A. the forepelvis in older textbooks ⢠Performed by placing 2 fingers under the pubic arch, dropping wrist, and palpating the symphysis and both superior pubic rami ⢠ANDROID PELVIS: sharp and acute ⢠PLATYPELOID PELVIS: flat nearly 180degrees like a blackboard ⢠GYNECOID PELVIS: flat in the midline, curves gently backward laterally ⢠ANTHROPOID PELVIS: backward curve is detected earlier and curves back more sharply
- 8. THE MIDPLANE ⢠Lower sacral vertebrae ⢠Sacrum: Flat or hollow (flat is less common)
- 9. THE MIDPLANE ⢠Sacrospinous ligament ⢠Less than 2 fingerbreadths implies a narrow sacrosciatic notch ⢠A 3 fingerbreadth ligament directed more laterally than anteriorly suggests a platypeloid pelvis ⢠Anthropoid pelvis also is 3 fingerbreadths or more directed more anteriorly than laterally
- 10. THE MIDPLANE ⢠Ischial spines: prominent, blunt or average
- 11. THE MIDPLANE: BISPINOUS DIAMETER ⢠Not readily assessed clinically ⢠Separate examining fingers as wide as possible ⢠In the rare contracted pelvis one may be able to span the distance between spines
- 12. THE MIDPLANE ⢠Ischial spines: prominent, blunt or average ⢠Slope of the pelvic sidewall ⢠Straight ⢠Convergent: Funnel shaped or android pelvis ⢠Divergent: âBlunderbussâ pelvis
- 14. THE OUTLET ⢠Coccyx: The shape and mobility should be described ⢠Suprapubic angle ⢠Gynecoid pelvis: suprapubic angle > 90 degrees. Suprpubic arch is characterized as âNormanâ ⢠Android pelvis: exam fingers will be forced to overlap at the top of the âGothicâ arch ⢠Bituberous diameter (BTD) ⢠Can be measured with a fist externally ⢠An narrow BTD (<8cm) increases the risk of deep perineal lacerations or extension of an episiotomy (odds ratio of 15) ⢠Narrow BTD is strongly indicative of an android pelvis ⢠Can also be found in an anthropoid pelvis
- 15. CLINICAL PELVIMETRY ⢠Sacral promontory ⢠Retropubic angle ⢠Width of the sacrosciatic notch ⢠Anterior surface of the sacrum ⢠Ischial spines and tuberosities ⢠Inner surface of the ischium ⢠Suprapubic arch ⢠Descending pubic rami ⢠Coccyx
- 16. FORCEPS ASSISTED VAGINAL DELIVERY
- 17. EDWARD DENNONâS FUNDAMENTAL RULES ⢠FAVD must be considered a surgical procedure ⢠It should be done by a trained, coordinated operating team including an operator, assistant, anesthesiologist, scrub and circulation nurse ⢠Fully equipped room to handle any emergency
- 18. THE INTERN ⢠âThe intern, before being allowed to perform a forceps delivery operation, should be given a series of painstaking lectures on the subject. He should be drilled in detail, repeatedly, on the manikin and he should assist at numerous operations which, in turn, should be reviewed on the manikin.â
- 21. THE SHANK Simpson type forceps have parallel separated shanks resulting in a long tapering cephalic curve for the long molded head. Elliot type forceps have overlapping shanks for the rounded unmolded head
- 22. THE LOCK ⢠French lock (top left ) ⢠English lock (top right ) ⢠German lock (middle left ) ⢠Sliding rock (middle right ) ⢠Pivot lock (bottom )
- 23. THE HANDLE ⢠Sliding Lock
- 24. THE HANDLE ⢠Sliding Lock
- 25. THE HANDLE ⢠Sliding Lock
- 26. SLIDING LOCK ⢠Luikarts Keilands Bartons
- 27. LUIKARTS ⢠Sliding Lock ⢠Allows for correction of asynclitism ⢠Psuedofenestrated blades ⢠Overlapping shanks ⢠Puts less tension on the perinium
- 29. TUCKER-MCLANE ⢠Nonfenestrated blades ⢠Overlapping shanks ⢠English lock ⢠Excellent for the round nonmolded head (multiparous)
- 30. MCLANE-LUIKART ⢠These are Tucker Mclane forceps with the Luikart modification (pseudofenestrated blades)
- 31. SIMPSON ⢠Fenestrated blades ⢠Parallel shanks ⢠English lock ⢠Excellent for the molded head
- 32. LUIKART SIMPSON ⢠Simpson forceps with the Luikart modification (pseudofenestration) ⢠Excellent for the molded head
- 33. BILLâS AXIS TRACTION BAR
- 34. BILLâS AXIS TRACTION BAR WITH TUCKER- MCLANE FORCEPS
- 35. DEWEE FORCEPS WITH BUILT IN AXIS TRACTION BAR
- 36. DEWEE FORCEPS WITH BUILT IN AXIS TRACTION BAR
- 37. BARTON FORCEPS
- 38. BARTON FORCEPS
- 39. BILLâS AXIS TRACTION BAR WITH TUCKER- MCLANE FORCEPS
- 40. LAUFE FORCEPS
- 41. LAUFE FORCEPS
- 42. LAUFE PIPERS
- 43. LAUFE PIPERS
- 44. INDICATION FOR OPERATIVE VAGINAL DELIVERY ⢠No indication for operative vaginal delivery is absolute ⢠Prolonged second stage ⢠Nulliparous women: 3 hours with regional anesthesia, or 2 hours without ⢠Multiparous women: 2 hours with regional anesthesia, or 1 hour without ⢠Suspicion of immediate or potential fetal compromise ⢠Shortening of the second stage for maternal benefit ACOG Practice Bulletin NO. 17
- 45. SUSPICION OF IMMEDIATE OR POTENTIAL FETAL COMPROMISE ⢠20 y/o G1 at 37wks EGA undergoing IOL for mild Pre E ⢠After 30 minutes of second stage labor, FHR tracing shows recurrent variable decelerations with increasing depth and minimal variability. ⢠Category II (indeterminate) tracing ⢠Ancillary test to ensure fetal well being or an attempt, for intrauterine resuscitation ⢠Expedited delivery is a valid option to avoid deterioration to Cat III and risk of asphyxia
- 46. PREREQUISITES FOR FAVD ⢠Complete cervical dilation ⢠Ruptured membranes ⢠Head engaged ⢠Position and station known ⢠Clinically adequate pelvis ⢠Assessment of fetopelvic relationship known ⢠Adequate anesthesia ⢠Patient properly positioned ⢠Perineal body evaluated (consider episiotomy and type) ⢠Empty bladder/rectum ⢠Cesarean delivery capability
- 47. MORBIDITY ASSOCIATED WITH SECOND STAGE CESAREAN DELIVERY ⢠Increased risk of maternal hemorrhage ⢠Prolonged hospital stay ⢠Increased risk of bladder trauma ⢠Extensions of uterine incision into broad ligament and vessels Murphy, BMJ 2006; 333:613-4
- 48. OUTLET FORCEPS ⢠Scalp is visible at the introitus without separating the labia ⢠Fetal skull has reached the pelvic floor ⢠Sagital suture is in an anteroposterior diameter or right or left occiput anterior or posterior position ⢠Fetal head is at or on the perineum ⢠Rotation does not exceed 45 degrees
- 49. LOW, MID AND HIGH FORCEPS ⢠Low forceps ⢠Leading point of the fetal skull is at station +2cm or more and not on the pelvic floor. ⢠Rotation is 45 degrees or less (LOA,ROA, LOP, ROP) ⢠Rotation is greater than 45 degrees ⢠Midforceps ⢠Station is above +2 cm but the head is engaged ⢠High Forceps ⢠Not included in classification
- 50. ELECTIVE LOW FORCEPS ⢠Carmona and associates ⢠Randomized trial comparing elective low âforceps delivery with spontaneous vaginal delivery in 50 term patients ⢠No significant immediate differences in maternal or neonatal outcomes ⢠Mean time to delivery was shorter (10.2 min versus 18 min) ⢠Cord pH higher (7.27 versus 7.23) Am J Obstet Gynecol 173:55, 1995
- 51. ACOG PRACTICE BULLETIN #17, JUNE 2000, REAFFIRMED 2009 ⢠Level A ⢠Forceps and Vacuum are acceptable and safe instruments for operative vaginal delivery. Operator experience should determine which instrument to use ⢠Vacuum is associated with increased incidence of neonatal cephalohematomas, retinal hemorrhages, and jaundice when compared with forceps delivery ⢠Level B ⢠Minimize duration of vacuum application ⢠Midforceps operations should be considered an appropriate procedure to teach and to use under correct circumstances by an adequately trained individual ⢠Incidence of intracranial hemorrhage is highest with cesarean following failed vacuum or forceps. The combination of vacuum and forceps has a similar incidence. Operative vaginal delivery should not be attempted when the probability of success is low
- 52. ACOG PRACTICE BULLETIN #17, JUNE 2000, REAFFIRMED 2009 ⢠Level C ⢠Operative vaginal delivery is not contraindicated in cases of suspected macrosomia or prolonged labor; however caution should be used because the risk of shoulder dystocia increases with these conditions ⢠Neonatal care providers should be made aware of the mode of delivery in order to observe for potential complications associated with operative vaginal delivery
- 53. APPLICATION OF FORCEPS ⢠The posterior blade or left blade for direct OA/OP is applied first
- 55. APPLICATION OF FORCEPS ⢠Posterior fontanelle is one fingerâs breadth anterior to the plane of the shanks ⢠The sagital suture is perpindicular to the plane of the shanks ⢠Not more than the tip of one finger can inserted into the fenestration in advance of the head
- 57. MODIFIED RITGEN
- 58. TEACHING LAUFE-PIPER FORCEPS TECHNIQUE AT CESAREAN DELIVERY ⢠University of Texas Galveston, Locksmith, Yeomans, Hankins et al ⢠Objective: To present a method of teaching forceps during cesarean breech deliveries using Laufe-Piper forceps and to evaluate its usefulness ⢠For several years residents were taught this method of delivery. To assess residents experience, recent graduates and 3rd and 4th year residents completed a survey as well as matched controls from other programs were this was not taught. ⢠Responses from 32 (74%) study subjects and 63 (71%) controls. ⢠Study subjects rated themselves more comfortable using piper forceps and noted greater annual use of forceps for vertex deliveries. ⢠CONCLUSION: Laufe-Pipers can be used for cesarean delivery of breech-presenting infants. This practice promotes confidence and skill for their use at vaginal delivery. J Reprod Med 2001 May; 46(5):457-61
- 59. LAUFE PIPERS
- 60. TEACHING LAUFE-PIPER FORCEPS TECHNIQUE AT CESAREAN DELIVERY
- 61. PIPERS TO THE AFTERCOMING HEAD
- 62. TEACHING LAUFE-PIPER FORCEPS TECHNIQUE AT CESAREAN DELIVERY ⢠No maternal or neonatal complications have been attributed to this practice ⢠Because the Laufe-pipers lack handles they are shorter than conventional pipers; this offers a distinct advantage at cesarean ⢠The similarities of application of forceps at cesarean provide practice for vaginal breech application of pipers to the aftercoming head ⢠After application, head flexion is ensured by elevating the shanks slightly and lowering the infants body against them. ⢠Extraction is accomplished by pulling outward and raising the grips
- 63. TEACHING LAUFE-PIPER FORCEPS TECHNIQUE AT CESAREAN DELIVERY ⢠Vaginal breech delivery is rarely performed ⢠In an emergency situation it may be the best option ⢠It may be used for breech extraction of twin B ⢠Because the rarity of breech deliveries in residency, educational opportunities are sparse ⢠Laufe-Pipers for breech cesarean has been found to be of educational benefit
- 64. BABY SIMPSONS AT CESAREAN ⢠We have forceps in every cesarean tray ⢠Please see Williams Obstertrics, chapter on Forceps through the Coy Carpenter Library and watch the animated video forceps during cesarean. ⢠Excellent option for the floating head ⢠Excellent option for the difficult delivery
- 65. RESIDENT GENDER ⢠>350,000 deliveries ⢠By >800 OBGYN residents in the US from 1994-1998 ⢠Percentage of total deliveries performed with forceps during residency was higher among male residents ⢠Percentage of vaginal deliveries with forceps was also higher ⢠Percentage of overall operative vaginal deliveries was significantly higher for males ⢠Percentage of vacuum deliveries did not vary by gender Am J Obstet Gynecol. 2000 May;182(5):1050-1
- 66. CONCLUSION ⢠Proactive residents ⢠Proactive faculty ⢠Include Forceps as part of the Summer Lecture Series ⢠Include a hands on forceps workshop as part of that series ⢠Obtain Laufe-Pipers and have them available for every breech cesarean delivery ⢠Incorporate Clinical Pelvimetry into our daily practice
Hinweis der Redaktion
- I really believe that these two topics go hand-in-hand. You have to be able to thoroughly evaluate a pelvis before you can perform a FAVD. Have any of the residents heard a lecture on this topic during residency? I chose this topic for my grand rounds because I believe it is a topic that is largely ignored and it not taught during residency. Some may remember when women would get an x-ray of the pelvis while in labor only to deliver in the hallway or on the way back from x-ray. There was time when nearly every vaginal delivery was a forceps delivery. This aspect of our training has been so ignored that residents feel comfortable as describing the pelvis as âroomyâ indicating that a vaginal delivery will be no problem or âtinyâ and adding that there is no way a baby will fit through that pelvis. Residents in many programs all across the country feel comfortable not even knowing the very basics about forceps and could not identify what type of forceps their hospital has.
- The Caldwell-Malloy classification is based on measurement of the greatest transverse diameter of the inlet and its division into anterior and posterior segments. *Android Pelvis: âHeart shapedâ The posterior sagital diameter at the inlet is much shorter than the anterior sagital diameter limiting the use of the posterior space by the fetal head. *Anthropoid: âlong narrow ovalâ the anteroposterior diameter diameter of the inlet is grerater than the transverse *Platylepoid pelvis: âshort wide ovalâ has a short anteroposterior diameter and wide transverse diameter. *In a survey of six standard obstetric texts, Sizer and Nirmal (2000) ďŹnd that anthropoid and android pelvic shapes constitute the most signiďŹcant factors thought to be associated with the fetal malposition occiput-posterior.
- Sacral promontory Retropubic angle âformed by the union of the left and right superior pubic rami on their posterior aspects -Proceding inferiorly- Width of the sacrosciatic notch â or converted to the greater sciatic foramen by the sacrospinous ligament Anterior surface of the sacrum Ischial spines and tuberosities Inner surface of the ischium Suprapubic arch Descending pubic rami Coccyx It is insufficient to classify a particular pelvis into one of the 4 basic types secondary to mixed tendencies in actual practice
- DC provides information with respect to the AP diameter. To ever reach the sacral promontory , the examiner must drop both the wrist and the elbow and reach cephalid with the tip of the middle finger. Most often the sacral promontory is not reached. When the presenting part has entered the true pelvis the DC cannot be evaluated. This is usually done at the initial OB visit.
- In all pelvic types the lower sacral vertebrae can be palpated. *A forward lower 1/3 of the sacrum should alert the examiner to the possibility of an ANDROID pelvis, the most dangerous type if instrumentation is contemplated Follow the anterior aspect of the sacrum superiorly to determine if the sacrum is hallow or flat Move the fingers to the lateral border of the sacrum and follow the band like structure to the ischial spines. The s
- In all pelvic types the lower sacral vertebrae can be palpated. *A forward lower 1/3 of the sacrum should alert the examiner to the possibility of an ANDROID pelvis, the most dangerous type if instrumentation is contemplated Follow the anterior aspect of the sacrum superiorly to determine if the sacrum is hallow or flat Move the fingers to the lateral border of the sacrum and follow the band like structure to the ischial spines. The s
- Following the sacrospinous ligament from the lateral border of the sacrum to the ischial spine is the best method for identifying the ischial spines and essential for performance of a pudendal nerve block Anterior to the ischial spine is the interior surface of the ischium. Place the thumb of the opposite hand on the ipsilateral ischial tuberosity externally, and identify the slope of the pelvic sidewall âBlunderbussâ pelvis was described by Plauche, Morrison, and Oâ Sullivan in Phillidelphia in 1992 to describe a pelvis having divergent sidewalls. It is an archaic term that I use to see if residents have read the clinical pelvimetry article that I have asked them to read. blunderbuss ( Type: noun - Domain: weapons ) : old-fashioned gun with a wide mouth, firing many bullets or small shot at once at short range
- Following the sacrospinous ligament from the lateral border of the sacrum to the ischial spine is the best method for identifying the ischial spines and essential for performance of a pudendal nerve block Anterior to the ischial spine is the interior surface of the ischium. Place the thumb of the opposite hand on the ipsilateral ischial tuberosity externally, and identify the slope of the pelvic sidewall âBlunderbussâ pelvis was described by Plauche, Morrison, and Oâ Sullivan in Phillidelphia in 1992 to describe a pelvis having divergent sidewalls. It is an archaic term that I use to see if residents have read the clinical pelvimetry article that I have asked them to read.
- blunderbuss ( Type: noun - Domain: weapons ) : old-fashioned gun with a wide mouth, firing many bullets or small shot at once at short range
- The coccyx can sometimes be sharply angulated anteriorly in a fish-hook or J-shape Suprapubic angle is not to be confused with the retropubic angle of the inlet. The suprapubic angle is measured by placing two exam fingers , ventral side up, all the way to the lower border of the symphysis without being displaced.
- I have tried to give you a framework for describing the pelvis that goes beyond the four basic types. I challenge you to make a better effort to evaluate the pelvis, especially in those with epidural anesthesia, or when performing an EUA for a gynecology case.
- During the thirteen years from 1941-1953 on the service at the N.Y Polyclinic Hospital, there were a total of 9237 forceps operations performed. During that same time there were 4583 spontaneous births. For many reasons FAVD is on the endangered skills list for OBGYNs. There are fewer and fewer faculty that teach forceps. Many residents have no desire to even learn how to use forceps. I would like to thank all the attending that have allowed me to use forceps: Yeomans, Berliner, Merrill, Mertz, Smith, Brown, Hopkins, Grandis, Stone, Chen, Fernadez, OâNeill, DeFrancesco, Botti and Nitsche Reasons to learn forceps: #1: To avoid the complications associated with cesarean deliveries during the second stage of labor 2nd stage labor #2: The maternal death rate in 2007 is 12/100,000 live births. Deneux-Tharaux and colleagues reported that the risk of post partum death was 3.6 times higher after cesarean delivery than after vaginal birth. The maternal death may not occur with the first cesarean but may with her 3 or 4th when she has a placenta accreta or uterine rupture. #3. Avoid the complications associated with VAVD such as subgalial hematomas which are reported to be 26-45 per 1,000. Subgalial hematomas can be associated with much higher blood loss and even exsanguination. #4. Increased rate of cesarean deliveries in women with obesity and the ever increasing rate of obesity #5. Financial considerations. Pregnancy home decreases payment for a cesarean rate greater than 33%
- FAVD must be considered a surgical procedure, it should be given the thought , attention, dignity, and respect accorded to any other branch of surgery
- One blade is attached to the shank by a hinge, making it flexible over 90 degrees. The other blade has a deep cephalic curve. The thin hinged blade allows for easy and accurate application by the wandering maneuver to transverse heads.
- Fetopelvic relationship known*** Adequate anesthesia â pudendal is acceptable for most outlet/low FAVD Episiotomy Dr. Thorpe UNC has argued that episiotomies are never necesarry C/S delivery capability. One should consider a double setup for more difficult situations. The MFM network, Green, Nov 2009, FIALED OPERATIVE VAGINAL DELIVERY. 3,189 women underwent second stage cesareans, 640 had attempted operative vaginal delivery (FAVD+VAVD) -- those with attempted operative vag del were more likely to undergoe cesarean for NRFHT 18% v. 13.9% --wound complications 2.7% v. 1.0% --require gen anesthesia 8% v 4.1% ----neonatal outcomes of pH<7, Apgars of 3 or less at 5min, hypoxic ischemic encephalopathy were more comon in operative vag attempts CONCLUSION: C/D after attempted operative vag delivery was not associated with adverse neonatal outcomes in the absence of NRFHT --
- Alexander in the Green journal 2007 also reported increase in fetal injury primarily due to laceration
- Carmona F, Martinez-Roman S, Manau D, et al: Immediate maternal and neonatal effects of low forceps delivery according to the new criteria of the ACOG compared with spontaneous vaginal delivery in term pregnancies. Am J Obstet Gynecol 173:55, 1995 A larger randomized study by Yancey et al. 333 patients showed no difference however there was increased perineal truama in primiparous women
- No maternal or neonatal complications have been attributed to this practice Because the Laufe-pipers lack handles they are shorter than conventional pipers; this offers a distinct advantage at cesarean The similarities of application of forceps at cesarean provide practice for vaginal breech application of pipers to the aftercoming head After application, head flexion is ensured by elevating the shanks slightly and lowering the infants body against them. Extraction is accomplished by pulling outward and raising the grips
- An informal poll among my class and the third year class is consistent with these findings.