Forceps delivery (forceps delivery; forceps extraction; forceps delivery) is an obstetric surgical procedure used to assist vaginal birth (birth through the vagina). Forceps is an obstetric device used to terminate birth from the cranial position during the expulsion phase. The origins of forceps surgery date back to the 17th century. The Englishman Chamberlen is said to have developed the first forceps. In 1723, the jealously guarded secret of this instrument was revealed. After that, obstetricians around the world developed various models of forceps.
Indications [2, 3, Guideline 1]
Termination of labor from the cranial position (SL) in the expulsion phase due to subsequent indications:
- Mother
- Child
Contraindications [2, 3, Guideline 1]
- Suspicion of disproportion
- Height level: above the interspinous level (IE; results from the line connecting the two spinae ischiadicae/seat bone spine) at occipital setting.
- Guiding point between the interspinal plane and the pelvic floor in the case of transverse arrow suture or deflexion posture (most of the head circumference has not yet entered the pelvis in this situation).
Prerequisites: [2, 3, Guideline 1]
- Accurate altitude diagnostics.
- Exclusion of contraindications (contraindications).
- Empty urinary bladder, so as not to interfere with deep treading of the fetal head and to prevent maternal injury.
The surgical procedure
Instrumentation
The obstetric forceps consist of:
- two blades, they include
- one spoon each with
- A head bend with which the child’s head is embraced
- A pelvic curvature that mimics the leading line
- a lock with which the two sheets are brought together either
- Crossed (cross pliers) or
- Parallel (parallel pliers)
- Two pliers handles parallel to each other after closing the pliers.
- one spoon each with
In Germany, the most common are the crossed pliers according to Naegele and Kjelland, as parallel pliers named after Shute or Bamberger divergent pliers. Technique
- Holding out the closed forceps
- Insertion of the left spoon
- Insertion of the right spoon
- Walking a forceps spoon
- Closing the tongs
- Night keys
- Test train
- Traction synchronous tractions (traction).
- Changing the direction of traction according to the guidance line
- Development of the head
Holding out the closed forceps
After the exact height level diagnosis and the determination of the setting of the child’s head, the forceps is assembled and held down in the closed state as it is to be positioned on the child’s head, i.e. straight or oblique according to the situation of the head. Insertion of the left spoon
The left spoon is always inserted first, after the right spoon has been put down after being held out. The right index and middle fingers are inserted as deeply as possible in the direction of the child’s head. With the left hand, the forceps spoon is held vertically in front of the vulva (outer area of the female primary sexual organs) and slides into the vagina (vagina) by lowering the handle on the inserted index finger between the pelvic wall and the head, guided by the right thumb. Insertion of the right spoon
Entering with the index and middle fingers of the left hand in the direction of the sacral cavity. The little finger holds the inserted left spoon. With the right hand, the forceps spoon is held vertically in front of the vulva and slides in by lowering on the inserted index finger in the direction of the sacral cavity, guided by the left thumb.Moving the tong bucket
If the arrow seam is straight, it is not necessary to move one of the buckets. If the arrow seam is slanted, one of the buckets must move. Which one it will be can be seen by holding the closed forceps before insertion. Closing the forceps
After exact positioning, the two blades can be joined in the lock. Night key
After the forceps have been applied and closed, palpation is performed to rule out any entrapment of soft tissues of the mother. Trial pull
The test pull is performed with the left hand gripping the lock from above. The right hand grips the two pincer handles and controls the lowering of the head during the trial pull. Contraction synchronous traction
During the next contraction, with the hands in the same position in the guide line, often accompanied by the Kristeller handle (a method that is intended to or can accelerate the birth of the child through contraction-synchronous pressure on the uterine roof in the expulsion phase), traction is applied until the so-called stem point has reached the lower symphysis rim (pubic symphysis rim). As the head is lowered, the handles, which were initially pulled in a horizontal direction, are slowly lifted in a guiding line. Depending on the situation, any necessary rotation of the head during traction is followed in the case of an irregular posture. After reaching the stem point, the pincer grips are almost vertical. The surgeon steps on the left or right side of the deliverer and performs perineal protection with one hand. In all cases, an episiotomy is useful before the head emerges to reduce the traction and compression of the forceps spoons on the fetal head.
Potential complications [2-4, Guideline 1]
Child
- Abrasions of the skin
- Hematomas (bruises)
- Passenger paresis of the facial nerve (temporary paralysis of the facial nerve).
- Cephalhematoma (head hematoma): the incidence (frequency of new cases) is reported to be 3-4% in forceps deliveries (vacuum deliveries about 10-12%, spontaneous deliveries about 2%) [4, Guideline 1]. It is a subperiosteal hematoma (bruise below the periosteum/periosteum) and results from rupture of vessels between the periosteum and bone due to shear forces. Because the periosteum is firmly fused to the bone at the cranial sutures, it does not cross the cranial sutures (unlike subgaleal hemorrhage, see below). Because of the confinement, blood loss is limited and has no clinical relevance. In most cases, the hematoma resorbs within a few days. In pronounced findings, however, it can sometimes take several weeks.
- Intracranial hemorrhage (cerebral hemorrhage):Intracranial hemorrhage can occur as a result of mechanical forces applied to the child’s skull by the forceps and occurs in approximately 1% of forceps extractions. However, this complication should not occur with proper surgical technique [Guideline 1].
- Subgaleal hemorrhage (subgaleal hematoma):Subgaleal hemorrhage can be induced by forceps spoons and occurs between the periosteum (periosteum) and galea aponeurotica (muscle aponeurosis) due to detachment of the aponeurosis (planar, broad tendon) from the periosteum and bleeding into this anatomically preformed space. It may extend to the anatomic margins of the aponeurosis. This is a potentially life-threatening complication of forceps extraction, as up to 80% of the fetal blood volume may be lost, resulting in hypovolemic shock. The incidence is reported to be 1-4% for forceps deliveries as well as for vacuum extractions (about 0.4/1000 for spontaneous deliveries). Mortality can be as high as 25%.
- Retinal hemorrhage (retinal hemorrhage):Retinal hemorrhages occur more frequently after forceps deliveries than after spontaneous deliveries, as they do after vacuum extractions. They are harmless and regress spontaneously within 4 weeks without ophthalmologic follow-up. Permanent visual disturbances do not occur.
- Hyperbilirubinemia (increased occurrence of bilirubin in the blood): hyperbilirubinemias occur more frequently after forceps deliveries, as well as after vacuum extractions than after spontaneous deliveries. Only occasionally phototherapeutic treatment (phototherapy/light therapy) is necessary.
Mother
- Extensive vaginal tears
- Perineal tears of III. and IV. Degree
- Occult anal sphincter injuries (hidden injury to the sphincter of the anus; occurrence up to 70% of cases; in spontaneous delivery about 30%).
Vacuum or forceps?
It is not clear from the publications whether forceps or vacuum extraction is more beneficial for birth termination. The consensus is that forceps extraction is technically more difficult than vacuum extraction and requires much more practice and experience for correct and atraumatic performance for both mother and child. This is certainly the reason why forceps deliveries have steadily declined in recent decades.
