Forceps Delivery

Currently, forceps deliveries are divided into outlet, low, mid, and high forceps, determined by the station of the fetal head. In an outlet forceps delivery the fetal head has reached the pelvic floor and is seen at the introitus without separating the labia. The fetal head may be right, left, or straight occiput anterior or posterior, and delivery is accomplished without rotation of greater than 45 degrees. A low forceps delivery is one in which the fetal head is at least +2 cm (on a 0 to +5 cm scale of station), but not on the pelvic floor. Rotation may be greater than or less than 45 degrees. A mid forceps delivery occurs when the head is engaged, but less than +2 cm station. A high forceps delivery, when the fetal head is unengaged, is no longer performed in modern obstetrics.

The choice of forceps to use is based on the operator's training and the type of forceps delivery. Typically, Simpson (or Simpson-DeLee) or Elliot forceps are used for low and outlet deliveries. After requirements for operative vaginal deliveries are met, the operator faces the maternal perineum with forceps held in the position desired. The left blade is generally placed first. The operator's right hand is fitted between the fetal head and the left vaginal side wall, and the left blade is placed by holding the handle at 12 o'clock and rotating counterclockwise as the blade slips between the fetal head and the operator's right hand. After adequate placement, the majority of the blade is no longer visible. In a similar fashion, the operator's left hand then aids in placement of the right blade. When properly placed, the handles should come together easily. Appropriate placement is then ascertained. The sagittal suture should be equidistant from both blades and perpendicular to the shanks, with the posterior fontanelle exactly between the two blades. The posterior fontanelle should be palpable about 1 fingerbreadth above the interdigitated shanks. Failure to apply the forceps symmetrically will increase risk of injury and failure of the technique.

Holding the handles together with moderate pressure, the operator rotates the fetal head if needed so that the occiput is directly anterior or posterior (sagittal suture is perpendicular

Figure 21-19 Outlet forceps delivery. The direction of traction is first downward so that the fetal head negotiates the pubic symphysis and then upward to deliver in extension.

to the floor). This rotation should be done during uterine muscle relaxation, just before a contraction. A mild degree of flexion of the fetal head during rotation will make rotation easier. With a contraction and additional expulsive forces from the mother, the operator applies traction. Traction direction should be guided by the maternal pelvis. Initial traction is downward (toward the floor) until the fetal head clears the symphysis pubis. Then, traction is directed more upward as the fetal head delivers with extension (Fig. 21-19). Although in some cases early episiotomy is beneficial to forceps delivery, most often episiotomy should be cut if needed when the fetal head is bulging the perineal tissues. In many cases, removal of the forceps at this time will preclude need for episiotomy. Removal of the forceps before delivery of the head should be in the opposite direction and order of placement. Maternal expulsive forces during a contraction can then often deliver the remainder of the fetal head. The vagina and cervix should be carefully inspected for lacerations.

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