forceps and vacuum extraction

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FORCEPS DELIVERY AND VACUUM EXTRACTION

• Dr. Isaac Makanda
• HKMU
• OBGY Department .

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INTRODUCTION

• Forceps delivery is an operative delivery
  conducted with the help of obstetric forceps
• Obstetrics forceps is a pair of instruments
  specially designed to assist extraction of fetal
  head and thereby accomplishing delivery of the
  fetus.

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Forceps
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HISTORY OF FORCEPS

• The credit for design and early use of forceps
  goes to Chamberlen of England.
• The credit for using pelvic curve Levert (1747)
• Smellie gave us the English lock
• Tarnier -axis traction device.

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ANATOMY OF FORCEPS

• FORCEPS- These instruments consist of two
  crossing branches. Its components are
• BLADE- fenestrated for good grip of fetal head
• SHANK
• LOCK
• HANDLE
• CEPHALIC CURVE- conforms to shape of fetal head.
• PELVIC CURVE-corresponds to axis of birth canal.
• .
  

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• ANATOMY OF FORCEPS contd..
• A sliding lock is used in Kielland forceps.
• Total length of long obstetric forceps is 37cm.
• The distance between two tips - 2.5cm (when
  locked).
• The widest diameter between blade is 9cm.

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Components of forceps
Right and left blade
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VARIETIES OF LOCKS
French lock English lock German lock Gliding
lock Pivot lock
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VARIETIES OF OBSTETRIC FORCEPS

• CONVENTIONAL TRACTION FORCEPS

• SHORT FORCEPS-Wrigleys, Short Simpson
• LONG FORCEPS-Das Simpson
• LONG FORCEPS with AXIS TRACTION- Milne
  Murray,
• Haig Fergusen,
• Nevelles Barnes

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ELLIOTS FORCEPS

• OVERLAPPING SHANKS WITH SHORTER CEPHALIC CURVE

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TARNIER FORCEPS (AXIS TRACTION DEVICE)
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• ROTATION FORCEPS.
• FORCEPS FOR SPECIAL USE.

• Kielland, Moolgaokar, Barton(for transverse
  arrest in flat pelvis)
• AFTER COMING HEAD OF BREECH-Pipers.
• AT CAESARIAN SECTION-Hale

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PIPERS FORCEPS
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PIPER FORCEPS(AFTER COMING HEAD OF BREECH)
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NAEGELE FORCEPS (FORCEPS WITH SEPARATE PARELEL
SHANKS AND SLIGHTELY LONGER BLADES)
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• The current classification of ACOG(2000, 2002)
  emphasizes the two most important discriminators
  of risk for both mother and infant are station
  and rotation.
• Station is measured in cm -5 to 0 to 5.
  Deliveries are categorized as outlet, low, and
  mid-pelvic procedures.
• High forceps in which instruments are applied
  above 0 station have no place in contemporary
  obstetrics.

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CLASSIFICATION OF FORCEPS DELIVERY- ACCORDING TO
STATION AND ROTATION

• OUTLET FORCEPS-
• -Scalp is visible at the introitus without
  separating the labia.
• -Fetal scalp has reached pelvic floor.
• -Saggital suture is in antero-posterior diameter
  or right or left occiput anterior or posterior
  position
• -Fetal head is at or on perineum.
• -Rotation does not exceed 45 degrees.

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• LOW FORCEPS
• Leading point of fetal skull is at station
  greater or equal to 2cm and not on pelvic floor
  and
• Rotation is 45 degrees or less.
• Rotation is greater than 45 degrees.
• MIDFORCEPS- Station is between 0 and till 2cm.
• HIGH FORCEPS- Not included in classification

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FUNCTIONS OF FORCEPS

• The most important function of forceps is
  traction but can be used for rotation for occiput
  transverse and posterior positions.
• To provide a protective cage for the head in
  premature baby or to control delivery of after
  coming head of breech to lessen dangers of sudden
  decompression.
• One forceps blade may be used as a vectis to
  assist delivery of head in caesarian section.

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IDENTIFICATION OF BLADE OF FORCEPS

• Take the blade of forceps
• Place it infront of maternal pelvis, tip of the
  forceps directed towards maternal head, concavity
  of pelvic curve directed toward the midline of
  pelvis
• The blade which correspond to left side of mother
  is left blade and right side right blade.

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INDICATION OF FORCEPS

• MATERNAL INDICATIONS-
• -Maternal exhaustion following prolonged labour.
• -Prolonged second stage of labour.
• -Maternal distress as shown by maternal
  tachycardia,dehydration,mild pyrexia
• -Maternal medical disorder( like cardiac disease,
  severe anaemia,tuberculosis, Hypertensive
  disorder of pregnancy , eclampsia )
  
  To shorten the second stage or
  obviate the need for prolonged bearing down.
• -Failure of decent or internal rotation for 2 hrs
  in primigravida and 1hr in multigravida in second
  stage of labour.

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FETAL INDICATIONS

• -Fetal distress in second stage of labour.
• -After coming head of breech.
• -Acute emergencies e.g. cord prolapse or cord
  loops around the neck causing severe hypoxia.

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• PROLONGED SECOND STAGE OF LABOUR-(ACCORDING TO
  ACOG 2002)
• IN NULLIPARA- more than three hour with or more
  than two hour without regional analgesia.
• IN MULTIPARAS- more than two hours with or more
  than one hour without regional anaesthesia.

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Indications for operative vaginal delivery
(RCOG Guideline)

• Fetal - Presumed fetal compromise
• Maternal - To shorten and reduce the effects of
  the second stage of labour on medical conditions-
• Cardiac disease -Class III or IV (N Y H
  Association Classification)
• Hypertensive crises,
• Myasthenia gravis,
• Spinal cord injury
• Patients at risk of autonomic dysreflexia,
• Proliferative retinopathy

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• Indications for operative vaginal delivery (RCOG
  Guideline) contd..
• Inadequate progress
• Nulliparous women Lack of continuing progress
  for 3 hours (total of active and passive
  second-stage labour) with regional anaesthesia,
  or 2 hours without regional anaesthesia
• Multiparous women lack of continuing progress
  for 2 hours (total of active and passive
  second-stage labour)
• With regional anaesthesia, or 1 hour without
  regional anaesthesia
• Maternal fatigue/exhaustion

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PREREQUISITES FOR FORCEPS APPLICATION

• The cervix must be completely dilated.
• The membranes must be ruptured.
• The head must be engaged.
• The fetus must be vertex, or present a face with
  chin anterior.
• The position of the fetal head must be known.

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PREREQUISITES FOR FORCEPS APPLICATION contd..

• There must be no cephalopelvic disproportion.
• Bladder must be emptied.
• Adequate analgesia
• Experienced operator
• Verbal or written consent.

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Prerequisites for operative vaginal delivery
(RCOG Green top guidelines)

• Head is 1/5th palpable per abdomen
• vaginal examination Vertex presentation.
• Cervix is fully dilated and the membranes
  ruptured.
• Exact position of the head can be determined so
  proper placement of the instrument can be
  achieved.
• Assessment of caput and moulding.
• Pelvis is deemed adequate. Irreducible moulding
  may indicate cephalopelvic disproportion.

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• Prerequisites for operative vaginal delivery
  (RCOG Green top guidelines)contd..
• Preparation of mother- Clear explanation should
  be given and informed consent obtained.
• Appropriate analgesia is in place for mid-cavity
  rotational deliveries. This will usually be a
  regional block.
• A pudendal block may be appropriate, particularly
  in the context of urgent delivery.
• Maternal bladder has been emptied recently.
  In-dwelling catheter should be removed or balloon
  deflated.
• Aseptic technique.

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• Prerequisites for operative vaginal delivery
  (RCOG Green top guidelines)contd..
• Preparation of staff- Operator must have the
  knowledge, experience and skill necessary.
• Adequate facilities are available (appropriate
  equipment, bed, lighting).
• Back-up plan in place in case of failure to
  deliver. When conducting mid-cavity deliveries,
  theatre staff should be
• immediately available to allow a caesarean
  section to be performed without delay (less than
  30 minutes).

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• Prerequisites for operative vaginal delivery
  (RCOG Green top guidelines)contd..
• A senior obstetrician competent in performing
  mid-cavity deliveries should be present if a
  junior trainee is performing the delivery.
• Anticipation of complications that may arise
  (e.g. shoulder dystocia, PPH)
• Presence of Personnel that are trained in
  neonatal resuscitation (RCOG Green-top Guideline)

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OUTLET FORCEPS DELIVERY

• FORCEPS APPLICATIONS-
• For application of left blade-two or more fingers
  of right hand are introduced inside the left
  posterior portion of vulva and into vagina beside
  the fetal head.
• The handle of left branch is then grasped between
  the thumb and two fingers of left hand and
  introduce under the guidance of right hand .
• For application of right blade-two or more
  fingers of left hand are introduced into the
  right posterior position of vagina to serve as
  guide for right blade.

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Application of right blade
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• APPLICATIONS OF BLADES-
• The biparietal diameter corresponds to the
  greatest distance between appropriately applied
  blades.
• The head of fetus is perfectly grasped only when
  long axis of blades corresponds to occipitomental
  diameter.
• If one blade is applied over brow and other on
  occiput, instrument cannot be locked and if
  locked , blades will slip off when traction is
  applied.

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TRACTION

• When it is certain that blades are applied
  satisfactorily then gentle ,intermittent,
  horizontal traction is exerted until perineum
  begins to bulge.
• With traction when vulva is distended by the
  occiput, an episiotomy may be given if indicated.

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• TRACTION contd
• Additional horizontal traction is applied, and
  the handles are elevated, pointing directly
  upwards as parietal bone emerge.
• As handles are raised, head is extended. During
  birth of head, spontaneous delivery should be
  simulated as closely as possible.

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• TRACTION contd..
• Traction should be intermittent ,and head should
  be allowed to recede in intervals as in
  spontaneous labour except in cases of fetal
  bradycardia.
• It is preferable to apply traction only with each
  uterine contraction.
• Maximum permissible force is (20kg) in the
  nullipara or (13kg) in multipara.

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• Line of axis of traction(perpendicular to plane
  of pelvis)
• 1-high2-mid3-low4-outlet

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ROTATION FROM ANTERIOR AND TRANSVERSE POSITION

• When occiput is obliquely anterior, it gradually
  rotates to symphysis pubis as traction is
  exerted.
• However when it is directly transverse a rotary
  motion of forceps is required.
• Rotation counter clockwise from left side to
  midline is required when occiput is directed
  towards left, and in reverse direction when it is
  directed towards right side of pelvis.

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• Rotation with simpson forceps from left
  occipitoanterior position to occipitoanterior
  position prior to traction.

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FORCEPS DELIVERY OF OCCIPUT POSTERIOR POSITION

• When occiput is directly posterior, horizontal
  traction should be applied until base of nose is
  under symphysis pubis.
• The handle should then be gradually elevated
  until occiput emerges from the perineum.
• Then forceps are directed in downwards motion and
  the nose, face and chin emerge from the vulva.

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• SCANZONI MANEUVER IN OCCIPUT POSTERIOR POSITION.

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• OCCIPUT POSTERIOR POSITION- COMPLICATION
• OCCIPUT POSTERIOR group had higher incidence of
  perineal lacerations and extensive episiotomy as
  compared to OCCIPUT ANTERIOR group.
• There is also high incidence of operative
  delivery in OCCIPUT POSTERIOR group
• Infants delivered from OCCIPUT POSTERIOR group
  had high incidence of ERBS and FACIAL NERVE PALSY.

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FACE PRESENTATION FORCEPS DELIVERY

• With mentum anterior face presentation, forceps
  can be used to affect vaginal delivery.
• The blades are applied to the sides of head along
  the occipitomental diameter with pelvic curve
  directed towards neck.
• Downwards traction is applied until chin appears
  under the symphysis. Then by upward movement the
  face is slowly extracted with nose, eyes, brow
  and occiput appearing in close succession over
  anterior margin of perineum.
• NB Forceps should never be applied to mentum
  posterior presentation because vaginal delivery
  is impossible.

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KIELLAND FORCEPS

• Named after Kielland of Norway(rotational forceps
  1916), Specialised forceps with no pelvic curve.
• Used in deep transverse arrest with asynclitism
  of fetal head.
• Advantages over long curved forceps are
  -It can be used in unrotated vertex or face
  presentation.
  -Facilitate grasping and
  correction of asynclitic head because of sliding
  lock.

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• METHODS OF APPLICATION
• 1-Classical(obslete)
• 2-Wandering
• 3-Direct.

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• KIELLAND FORCEPS

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• Method of Application-(KIELLAND FORCEPS)
• Wandering method is popular-in this anterior
  blade is applied first .Blade is inserted along
  side wall of pelvis and then wandered by swinging
  it round the fetal face to its anterior position.
• Posterior blade is inserted under guidance of
  right hand ,forceps handles are depressed down
  and handle tips are brought in alignment to
  correct asynclitism.
• The occiput is rotated anteriorly, slight upward
  dislodgement of head may facilitate rotation,
  traction is applied.
• DEEP MEDIOLATERAL EPISIOTOMY IS MANDATORY.

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MATERNAL MORBIDITY FROM FORCEPS

• -The greater the rotation, greater will be the
  morbidity in form of laceration and blood loss.
• Forceps deliveries are associated with
• higher episiotomy rates and 3rd and 4th
  degrees lacerations.
• Postpartum urinary retention and bladder
  dysfunction.
• Anal sphincter dysfunction
• Infection
• Pelvic haematoma.
• Traumatic post partum haemorrhage and shock.

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FETAL MORBIDITY

• Cephalhaematoma,
• Skull fracture and,
• Intracranial haemorrhage.
• Brain damage
• Marked depression of respiration and asphyxia.
• Facial palsy, brachial palsy.
• Soft tissue injury to face, bruising and
  laceration,
• Cord compression,
• Convulsions.

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CONTRAINDICATIONS FOR FORCEPS

• Absence of full dilatation of cervix.
• In case of CPD.
• High station of fetal head.
• If uterine contraction cease.
• Lack of experience of operator.
• Mentum posterior face presentation.
• Hydrocephalic infant.
• Brow presentation.

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TRIAL OF FORCEPS

• It is a tentative attempt of forceps delivery in
  case of suspected midpelvic contraction with a
  declaration of abandoning it in favor of
  caesarean section if moderate traction fails to
  overcome the resistance.
• Such an operation must be undertaken on an
  operating table in properly equipped operating
  theatre with an anaesthetist present.
• If there is difficulty at any stage from
  introduction of blades, locking of device or
  resistance to gentle traction then undue force is
  not used forceps withdrawn and caesarian section
  done.

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FAILED FORCEPS

• When a deliberate attempt in vaginal delivery
  with forceps has failed to expedite the process,
  it is called failed forceps.
• FORCEPS FAILED IF-
• Fetal head does not advance with each pull.
• Fetus is undelivered after three pulls with no
  descent or after 30minutes
• If forceps fails caesarian section is performed.

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• Higher rates of failure are associated with
• Maternal body mass index gt 30
• Estimated fetal weight gt 4000 g or clinically
  big baby
• Occipito-posterior position
• Mid-cavity delivery or when 1/5th of the head
  palpable per abdomen
• African American race, increased maternal age.
• Diabetes, polyhydramnios,
• Dysfuctional labour, induction of labour

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PROPHYLACTIC FORCEPS(ELECTIVE)

• Named after DeLee.
• It refers to forceps delivery only to shorten the
  second stage of labour when maternal and or fetal
  complications are anticipated.
• INDICATIONS Eclampsia, heart disease ,previous
  history of caesarean section,postmaturity,
  lowbirth weight baby, to curtail the painful
  second stage, patient under epidural analgesia.
• Prophylactic forceps should not be applied until
  the criteria of low forceps are fulfilled.

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Vacuum Extraction (Ventouse)
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Vacuum Extraction (Ventouse)

• It is an instrumental device designed to assist
  delivery by creating a vacuum between it and the
  fetal scalp
• It is referred to as the vacuum extractor in the
  United states,whereas in Europe it is called as
  Ventouse- from the french word literally meaning
  soft cup.

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Historical background

• In 1705, Yonge described an attempted vaginal
  delivery using a cupping glass
• In 1848 Simpson devised a bell shaped device
  called an air tractor vacuum extractor
• In 1953 Malmstrom developed a metal cup extractor.

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Description

• Vacuum extractor is composed of
• A specially designed cup with a diameter of 3,
  4, 5 or 6 cm.
• A rubber tube attaching the cup to a glass
  bottle with a screw in between to release the
  negative pressure.
• A manometer fitted in the mouth of the glass
  bottle to declare the negative pressure.
• Another rubber tube connecting the bottle to a
  suction piece which may be manual or electronic
  creating a negative pressure that should not
  exceed - 0.8 kg per cm2.

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VACUUM EXTRACTOR
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Types of vacuum extractors

• Vacuum extractors are divided on the basis of the
  type of cup- -metal or
  plastic
• 1.Metal cup vacuum extractors
• 2.Soft cup vacuum extractors

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• Metal cup
• The metal-cup vacuum extractor is
• A mushroom-shaped metal cup varying from 40 to
  60 mm in diameter.
• Have a higher success rate and easier cup
  placement in the occipitoposterior (OP) position,
  
• The rigidity of metal cups can make application
  difficult and uncomfortable, and their use is
  associated with an increased risk of fetal scalp
  injuries.

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• Soft cup
• Traditionally soft cups are bell or funnel
  shaped.
• Soft-cup instruments
• Can be used with a manual vacuum pump or an
  electrical suction device.
• Soft-cup vacuum extractors may be disposable or
  reusable.
• Can cause fewer neonatal scalp injuries as
  compared with metal-cup devices,
• Soft-cup vacuum extractors.
• However, these instruments have a higher failure
  rate.

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Indications of vacuum extraction

• It is generally reserved for fetuses who have
  attained a gestational age of 34 weeks.
• Otherwise, the indications and pre-requisites for
  its use are the same as for forceps delivery(acog)

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INDICATION FOR VACUUM EXTRACTION

• MATERNAL INDICATIONS-
• -Maternal exhaustion following prolonged labour.
• -Prolonged second stage of labour.
• -Maternal distress as shown by maternal
  tachycardia,dehydration,mild pyrexia
• -Maternal medical disorder( like cardiac disease,
  severe anaemia,tuberculosis, pregnancy induced
  hypertension, eclampsia )
  
  To shorten the second stage or obviate the
  need for prolonged bearing down.
• -Failure of decent or internal rotation for 2 hrs
  in primigravida and 1hr in multigravida in second
  stage of labour.

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FETAL INDICATIONS

• -Fetal distress in second stage of labour.
• -After coming head of breech.
• -Acute emergencies e.g. cord prolapse or cord
  loops around the neck causing severe hypoxia.

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• PROLONGED SECOND STAGE OF LABOUR-(ACCORDING TO
  ACOG 2002)
• IN NULLIPARA- more than three hour with or more
  than two hour without regional analgesia.
• IN MULTIPARAS- more than two hours with or more
  than one hour without regional anaesthesia.

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Indications for operative vaginal delivery
(RCOG Guideline)

• Fetal - Presumed fetal compromise
• Maternal - To shorten and reduce the effects of
  the second stage of labour on medical conditions-
• Cardiac disease -Class III or IV (N Y H
  Association Classification)
• Hypertensive crises,
• Myasthenia gravis,
• Spinal cord injury
• Patients at risk of autonomic dysreflexia,
• Proliferative retinopathy

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Contraindications

• Operator inexperience
• Inability to assess fetal position
• High station(above 0 station)
• Suspicion of cephalopelvic disproportion
• Other presentations than vertex.
• Premature fetus(lt34 weeks).
• Intact membranes.

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• PROLONGED SECOND STAGE OF LABOUR-(ACCORDING TO
  ACOG 2002)
• IN NULLIPARA- more than three hour with or more
  than two hour without regional analgesia.
• IN MULTIPARAS- more than two hours with or more
  than one hour without regional anaesthesia.

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Pre-requisites of the Procedure

• Explain the procedure the patient and ask for the
  consent
• Emotional support and encouragement
• Lithotomy position.
• Empty the urinary bladder.
• Antiseptic measures for the vagina, vulva and
  perineum.
• PVE for pelvic capacity, cervical dilatation,
  presentation, position, station and degree of
  flexion of the head and the state of the membranes

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Application of the cup

• Identification of the flexion point-
• -It is situated 3 cm in front of the posterior
  fontanelle.
• -Centre of the cup should be overlying the
  flexion point. This placement promotes flexion
  ,descent and autorotation.
• If traction is directed from this point the fetal
  head is flexed to the narrowest
  sub-occipitobregmatic diameter(9.5 cm).

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• Precautions-
• The largest cup that can be easily passed is
  introduced sideways into the vagina by pressing
  it backwards against the perineum.
• Be sure that there is no cervical or vaginal
  tissues nor the umbilical cord or a limb in
  complex presentation is included in the cup.

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Creating the negative pressure

• For the rigid cups, the negative pressure is
  gradually increased by 0.2 kg/cm2 every 2 minutes
  until - 0.8 kg/cm2 is attained. This creates an
  artificial caput within the cup.
• With soft cups negative pressure can be
  increased to 0.8 kg/cm2 over as little as 1
  minute

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Episiotomy

• An episiotomy may be needed for proper placement
  of the cup
• If not, then delay the episiotomy till the head
  stretches the perineum or perineum interferes
  with the axis of traction
• This will minimize unnecessary blood loss.

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Traction

• Traction should be intermittent and co- ordinated
  with maternal expulsive efforts and with uterine
  contractions.
• Traction should be in line of the pelvic axis and
  perpendicular to the plane of the cup

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• Traction contd..
• Traction may be initiated by using a two handed
  technique
• Fingers of one hand are placed against the
  suction cup while the other hand grasps the
  handle of the instrument
• This allows one to detect negative traction.
• Manual torque to the cup should be avoided as it
  may cause cephalhaematoma and scalp lacerations.

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Traction
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• Traction contd..
• Between contractions, check for fetal heart rate
  and proper application of the cup
• Check for sacral hand wedge if the head has
  descended to the perineum with traction but
  further progress is slow.

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Release

• When the head is delivered the vacuum is reduced
  as slowly as it was created using the screw as
  this diminishes the risk of scalp damage.
• The chignon should be explained to the patient
  and the relatives.

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Reapplication of the cup

• If the cup detaches for the first time, reassess
  the situation.
• If favorable ,then reapply.
• If cup detaches for the second time, reassess if
  vaginal delivery is safe or move to caesarean
  section
• Caesarean section is necessary if there is
  inadequate descent and rotation

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Failure of vacuum

• Vacuum extraction is considered failed if-
• -Fetal head does not advance with each pull
• -Fetus is undelivered after 3 pulls with no
  descent or after 30 minutes
• -Cup slips off the head twice at the proper
  direction of pull with the maximum negative
  pressure.

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Advantages of Vacuum over Forceps

• Regional Anaesthesia is not required so suitable
  in cardiac and pulmonary patients.
• The ventouse is not occupying a space beside the
  head as forceps.
• Less compression force (0.77 kg/cm2) compared to
  forceps (1.3 kg/cm2) so injuries to the head is
  less common.
• Less genital tract lacerations.
• Can be applied before full cervical dilatation.
• It can be applied on non-engaged head.

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Complications

• Maternal
• Lacerations Perineal, vaginal ,labial,cervical
  and periurethral.
• Annular detachment of the cervix when applied
  with incompletely dilated cervix.
• Cervical incompetence and future prolapse if used
  with incompletely dilated cervix.

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Complications

• Fetal
• Cephalohaematoma.
• Scalp lacerations and bruising
• Subgaleal hematomas
• Intracranial haemorrhage.
• Neonatal jaundice
• Subconjunctival haemorrhage
• Injury of sixth and seventh cranial nerves
• Retinal hemorrhage
• Fetal death

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