Nursing

1. Forceps Delivery
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2. Obstetric forceps
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• Definition:
• Obstetric forceps is a double-bladed metal
instrument used for extraction of the foetal
head.

3. Types
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• Long curved obstetric forceps
• Wrigley’s forceps
• Kielland's forceps
• Piper’s forceps
• Barton's forceps

4. Action of the Forceps
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• Traction: is the main action.
• Rotation: in deep transverse arrest, persistent
occipito-posterior and mento-posterior.

5. Indications of Forceps Delivery
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• Prolonged 2nd stage
• It is prolongation for more than 1 hour in
primigravidae or 30 minutes in multiparae. This
may be due to:
* Inertia and poor voluntary bearing down.
* Large foetus.
* Rigid perineum.
* Malpositions: persistent occipito-posterior and
deep transverse arrest.

6. Maternal indications
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* Maternal distress manifested by:
>Exhaustion.
> Pulse >100 beats / min.
> Temperature >38oC .
> Signs of dehydration.
* Maternal diseases as:
> Heart disease.
> Pulmonary T.B.
> Pre-eclampsia and eclampsia.

7. Foetal indications
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* Foetal distress.
* Prolapsed pulsating cord.
* Preterm delivery.
• After-coming head in breech delivery.
• During caesarean sectionOne (used as a lever)
or the two blades may be used to extract the
head through the uterine incision.

8. Type Description
Outlet forceps The foetal head is at the perineum.
The scalp is visible at the introitus without separating the labia.
Sagital suture is in anteroposterior diameter, right or left
occipito-anterior or posterior.
Rotation does not exceed 450.
Low forceps The leading point of the skull is at station +2 or more and
divided into: i-Rotation ≤450. ii- Rotation >450
Mid forceps The head is engaged, but the leading point is above station +2.
High forceps Not included in the classification. It is abandoned in favour of
caesarean section.
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9. Pre-requisites for Forceps Application
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* Anaesthesia: general, epidural, spinal or
pudendal block.
* Adequate pelvic outlet.
* Aseptic measures.
* Bladder and Bowel evacuation.
* Contractions of the uterus should be present.
* Dilatation of the cervix should be fully.
* Engaged head.

10. Pre-requisites for Forceps Application
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* Forewater rupture.
* Favourable position and presentation:
>Occipito-anterior.
> Occipito-posterior
> Face presentation.
>After-coming head in breech.

11. Types of Forceps Application
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* Cephalic application: the forceps is applied on the sides
of the foetal head in the mento-vertical diameter so
injury of the foetal face, eyes and facial nerve is
avoided .
* Pelvic application: The forceps is applied along the
maternal pelvic wall irrespective to the position of the
head. It is easier for application but carries a great risk
of foetal injuries.
* Cephalo-pelvic application: It is the ideal application
and possible when the occiput is directly anterior or
posterior or in direct mento-anterior position.

12. How to know Right and Left Blades
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• Putting in consideration that the mother is in
the lithotomy position, the blade will be
applied with the pelvic curve directed
anteriorly and the cephalic curve directed
medially. If the blade will be applied to the left
maternal side it is a left blade and vice versa.

13. Technique of Forceps Delivery
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• In occipito- anterior position
* The left blade is applied first. It is held by its
handle between the thumb and fingers of the left
hand almost parallel with the right inguinal
ligament and passed along the left side of the
maternal pelvis between the guiding palm of the
right hand and foetal head.
* As the blade passes into the birth canal the
handle is carried backwards and towards the
midline. It is now the lower blade.

14. Technique of Forceps Delivery
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* The fingers of the left hand are introduced
along the right side of the pelvis and the right
blade is held and passed in the same manner.
It is now the upper blade.
* The 2 blades should be locked easily, if not this
means that they were not correctly applied
and should be removed and re-assess the
position of the head.

15. Clinical checks for correct forceps
application:
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* The sagittal suture lies in the midline of the
shanks.
* The operator cannot place more than a finger
tip between the fenestration of the blade and
the foetal head.
* The posterior fontanelle is not more than one
finger- breadth above the plane of the shanks.

16. Traction should be:
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* gentle by the force of the arm only,
* intermittent with uterine contractions only,
* in correct direction i.e. downwards and
backwards till the occiput appears at the
vulva, then downwards and forwards.
* The 2 blades are unlocked between
contractions to minimise the period of head
compression.

17. Kielland forceps in deep transverse
arrest
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• The forceps is locked outside with the knobs
towards the occiput to know the anterior
blade.
• The anterior blade is applied first by one of
the following methods:

18. • The wandering method: The anterior blade is guided
into the lateral side of the pelvis with the cephalic
curve facing the foetal head. It is then slid over the
forehead to fit against the anterior parietal eminence.
• The direct method: when the head is low down in the
pelvis, the anterior blade is slid between the head and
symphysis pubis with the cephalic curve facing the
foetal head.
• The old (classical) method: The anterior blade is
applied with the cephalic curve towards the symphysis
pubis then it is rotated 1800 to fit with the head. This
method is not recommended as the lower uterine
segment and bladder may be injured.
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19. • The posterior blade is applied along the
concavity of the sacrum.
• The 2 blades are locked, head is rotated and
extracted as occipito-anterior.
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20. Complications of Forceps Delivery
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• Maternal complications
• Foetal complications

21. Maternal complications
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• Complications of anaesthesia.
• Lacerations:
> Extension of the episiotomy.
> Perineal tear.
> Vaginal tears.
> Cervical lacerations.
> Bladder injury.
> Ureteric injury.
> Rupture uterus.

22. Maternal complications
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• Bone injuries: to pelvic joints, coccyx or
symphysis pubis.
• Pelvic nerve injuries.
• Postpartum haemorrhage: due to lacerations
or atony.
• Puerperal infections.
• Remote effects: genital prolapse, stress
incontinence, cervical incompetence and
genito-urinary fistulas.

23. Foetal complications
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• Fracture of the skull.
• Cephalohaematoma.
• Intracranial haemorrhage.
• Facial nerve palsy.
• Trauma to the face, eyes or scalp.
• Asphyxia due to:
> intracranial haemorrhage or,
> cord compression between the head and the
forceps.

24. FAILED FORCEPS
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• Failure to extract the foetus by the forceps
which may be due to failure to apply the
forceps or to deliver the head with it

25. FAILED FORCEPS
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• Causes
* Cephalo-pelvic disproportion.
* Contracted outlet.
* Incomplete cervical dilatation.
* Constriction ring.
* Head is not engaged.
* Malpositions as persistent occipito-posterior.
*Malpresentations as brow.
* Foetal congenital anomalies as hydrocephalus, ascitis
and conjoined twins.

26. Management
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* Reassessment: The forceps is removed and the
patient is re-examined to detect the cause and
correct it if possible.
* Caesarean section: is indicated in
uncorrectable causes as cephalo-pelvic
disproportion, and contracted outlet.
* Exploration of the birth canal: for any injuries.