Forceps in childbirth - Wikipedia, the free encyclopedia

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Forceps in childbirth
From Wikipedia, the free encyclopedia

Forceps are a surgical instrument that

resembles a pair of tongs and can be
used in surgery for grabbing,
maneuvering, or removing various
things within or from the body.[1] They
can be used to assist the delivery of a
baby as an alternative to the ventouse
(vacuum extraction) method.

Forceps in childbirth
Intervention
ICD- 72.0 (http://icd9cm.chrisendres.com/index.php?
9srchtype=procs&srchtext=72.0&Submit=Search&action=search)-72.4
CM (http://icd9cm.chrisendres.com/index.php?
srchtype=procs&srchtext=72.4&Submit=Search&action=search)

Contents
1 Structure
1.1 Anglo-American types
2 Technique
2.1 Outlet, low, mid or high
3 Indications for use
4 History
5 Complications
5.1 Fetal
5.2 Mother
6 See also
7 References

Obstetrical Forceps, by Smellie (1792)

Structure
Obstetric forceps consist of two branches that are positioned around the fetal head. These branches are defined
as left and right depending on which side of the mother's pelvis they will be applied. The branches usually, but
not always, cross at a midpoint which is called the articulation. Most forceps have a locking mechanism at the
articulation, but a few have a sliding mechanism instead, allowing the two branches to slide along each other.
Forceps with a fixed lock mechanism are used for deliveries where little or no rotation is required, as when the
fetal head is in line with the mother's pelvis. Forceps with a sliding lock mechanism are used for deliveries
requiring more rotation.[2]
The blade of each forceps branch is the curved portion that is used to grasp the fetal head. The forceps should
surround the fetal head firmly, but not tightly. The blade characteristically has two curves, the cephalic and the
pelvic curves. The cephalic curve is shaped to conform to the fetal head. The cephalic curve can be rounded or
rather elongated depending on the shape of the fetal head. The pelvic curve is shaped to conform to the birth
canal and helps direct the force of the traction under the pubic bone. Forceps used for rotation of the fetal head
should have almost no pelvic curve.[2]
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The handles are connected to the blades by shanks of variable lengths. Forceps with longer shanks are used if
rotation is being considered.[2]

Anglo-American types
All American forceps are derived from French forceps (long forceps) or English forceps (short forceps). Short
forceps are applied on the fetal head already descended significantly in the maternal pelvis (i.e., proximal to the
vagina). Long forceps are able to reach a fetal head still in the middle or even in the upper part of the maternal
pelvis. At present practice, it is uncommon to use forceps to access a fetal head in the upper pelvis. So, short
forceps are preferred in UK and USA. Long forceps are still in use elsewhere.
Simpson forceps (1848) are the most commonly used among the types of forceps and has an elongated cephalic
curve. These are used when there is substantial molding, that is, temporary elongation of the fetal head as it
moves through the birth canal.[2]
Elliot forceps (1860) are similar to Simpson forceps but with an adjustable pin in the end of the handles which
can be drawn out as a means of regulating the lateral pressure on the handles when the instrument is positioned
for use. They are used most often with women who have had at least one previous vaginal delivery because the
muscles and ligaments of the birth canal provide less resistance during second and subsequent deliveries. In
these cases the fetal head may thus remain rounder.[2]
Kielland forceps (1915, Norwegian) are distinguished by
having no angle between the shanks and the blades and a
sliding lock. The pelvic curve of the blades is identical to all
other forceps. The common misperception that there is no
pelvic curve has become so entrenched in the obstetric
literature that it may never be able to be overcome, but it
can be proved by holding a blade of Kielland's against any
other forceps of one's choice. Probably the most common
forceps used for rotation. The sliding mechanism at the
articulation can be helpful in asyncletic births[2] (when the
fetal head is tilted to the side),[3] since the fetal head is no
longer in line with the birth canal.[2][2] Because the handles,
shanks and blades are all in the same plane the forceps can
be applied in any position to effect rotation. Because the
shanks and handles are not angled the forceps cannot be
applied to a high station as readily as those with the angle
since the shanks impinge on the perineum.
Wrigley's forceps are used in low or outlet delivery (see
explanations below),[4] when the maximum diameter is
about 2.5 cm above the vulva.[5] Wrigley's forceps were
designed for use by general practitioner obstetricians,
having the safety feature of an inability to reach high into
Drawing of childbirth with use of forceps by
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William Smellie
the pelvis.[5] Obstetricians now use these forceps most
commonly in cesarean section delivery where manual
traction is proving difficult. The short length results in a lower chance of uterine rupture.

Piper's forceps have a perineal curve to allow application to the after-coming head in breech delivery.

Technique
The cervix must be fully dilated and retracted and the membranes ruptured. The urinary bladder should be
empty, perhaps with the use of a catheter. High forceps are never indicated in the modern era. Mid forceps can
occasionally be indicated but require operator skill and caution. The station of the head must be at least +2 in
the lower birth canal. The woman is placed on her back, usually with the aid of stirrups or assistants to support
her legs. A mild local or general anesthetic is administered (unless an epidural anesthesia has been given) for
adequate pain control. Ascertaining the precise position of the fetal head is paramount, and though historically
was accomplished by feeling the fetal skull suture lines and fontanelles, in the modern era, confirmation with
ultrasound is essentially mandatory. At this point, the two blades of the forceps are individually inserted, the left
blade first for the commonest occipito-anterior position; posterior blade first if a transverse position, then
locked. The position on the baby's head is checked. The fetal head is then rotated to the occiput anterior position
if it is not already in that position. An episiotomy may be performed if necessary. The baby is then delivered
with gentle (maximum 30 lbf or 130 Newton[6]) traction in the axis of the pelvis.[7]

Outlet, low, mid or high

The accepted clinical standard classification system for forceps deliveries according to station and rotation was
developed by ACOG and consists of:
Outlet forceps delivery, where the forceps are applied when the fetal head has reached the perineal floor
and its scalp is visible between contractions.[8] This type of assisted delivery is performed only when the
fetal head is in a straight forward or backward vertex position or in slight rotation (less than 45 degrees to
the right or left) from one of these positions.[9]
Low forceps delivery, when the baby's head is at +2 station or lower. There is no restriction on rotation for
this type of delivery.[9]
Midforceps delivery, when the baby's head is above +2 station. There must be head engagement before it
can be carried out.[9]
High forceps delivery is not performed in modern obstetrics practice. It would be a forceps-assisted
vaginal delivery performed when the baby's head is not yet engaged.[9]

Indications for use

Advantages to forceps use include avoidance of C-section, reduction of delivery time, general applicability with
cephalic presentation. Complications include the possibility of bruising, deformation, rectovaginal fistula, nerve
damage, Descemet's membrane rupture (extraordinarily rare),[10] skull fractures, and cervical cord injury.
Maternal factors
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1. Maternal exhaustion
2. Prolonged second stage
3. Maternal illness; such as heart disease, hypertension, glaucoma, aneurysm, or other things which make
pushing difficult or dangerous
4. Haemorrhage
5. Analgesic drug-related inhibition of maternal effort (especially with epidural/spinal anaesthesia)
Fetal Factors
1. Non-reassuring fetal heart tracing
2. After-coming head in breech delivery

History
The obstetric forceps, allowing during birth, the extraction of a living child, was invented by the eldest son of
the Chamberlen family of surgeons. The Chamberlens were French Huguenots from Normandy origin but
working in Paris before they immigrated to England in 1569 to flee from religious violence perpetrated in
France. William Chamberlen, the patriarch of the family, was most likely a surgeon; he had two sons, both
named Pierre, who became maverick surgeons that specialized in midwifery.[11] William and the eldest son
practiced in Southampton and then settled in London. The inventor was probably the eldest Pierre (then Peter in
England), who became obstetrician-surgeon of Queen Henriette, wife of King Charles I of England and
daughter of Henry IV, King of France.
He was succeeded by his nephew, Dr. Peter Chamberlen (also known as Doctor Peter, being the first to be
graduated "Doctor", because barbers-surgeons were not Doctors), as royal obstetrician. The success of this
dynasty of obstetricians with the Royal family and high nobles was related in part to the use of this "secret"
instrument allowing release of live child in difficult cases.
In fact, the instrument was kept secret for 150 years by the Chamberlen
family, although there is evidence for its presence as far back as 1634.
Hughes Chamberlen, grandnephew of Peter the eldest, tried to sell the
instrument in Paris in 1670, but the demonstration he did in front of
Franois Mauriceau, responsible for Paris Hotel-Dieu maternity, was a
resounding failure which resulted in the death of mother and child. The
secret may have been sold by Hughes Chamberlen to Dutch obstetricians
at the start of the 18th century in Amsterdam, but there are doubts about
the authenticity of what was actually provided to buyers.
The forceps were used most notably in difficult childbirths. The forceps
could avoid some infant deaths when previous approaches (involving
hooks and other instruments) extract them in parts. In the interest of
secrecy, the forceps were carried into the birthing room in a lined box
and would only be used once everyone was out of the room and the
mother blindfolded.[12]
Chamberlen forceps (Maldon)

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Models derived from the Chamberlen instrument finally appeared gradually in England and Scotland in 1735.
About 100 years after the invention of the forceps by Peter Chamberlen Sr. a surgeon by the name of Jean
Palfyn presented his obstetric forceps to the Paris Academy of Sciences in 1723. They contained parallel blades
and were called the Hands of Palfyn.
These "hands" were possibly the instruments described and
used in Paris by Gregoire father and son, Dusse, and
Jacques Mesnard.[13]

Palfyn "hands" in different versions

In 1813, Peter
Chamberlens
midwifery tools
were discovered at
Woodham Mortimer
Hall near Maldon
(UK). In the attic of
the house, the
instruments were
found along with
gloves, old coins and

trinkets.[14] The
tools discovered also contained a pair of forceps that were presumably
invented by the father of Peter Chamberlen, assumed so because of the
barbaric nature of the design.[15]
Dussee French forceps (circa 1725)

The Chamberlen family's forceps were based on the idea of separating

with two different locks
the two branches of "sugar clamp" (as those used to remove "stones"
from bladder), which were put in place one after another in the birth
canal. This was not possible with conventional tweezers previously tested. However, they could only succeed in
maternal pelvis of normal dimensions and on fetal heads already well engaged (i.e. well lowered into maternal
pelvis). Abnormalities of pelvis were much more common in the past than today, which complicated the use of
Chamberlen forceps. The absence of pelvic curvature of the branches (vertical curvature to accommodate the
anatomical curvature of maternal sacrum) prohibited blades from reaching upper-part of the pelvis and
exercising traction in the natural axis of pelvic excavation.
In 1747, French obstetrician Andre Levret, published "Observations sur les causes et accidents de plusieurs
accouchements laborieux" (Observations on the Causes and Accidents of Several difficult Deliveries), in which
he described his modification of the instrument to follow the curvature of the maternal pelvis, this "pelvic
curve" allowing a grip on a fetal head still high in the pelvic excavation, which could assist in more difficult
cases.
This improvement was published in 1751 in England by William Smellie in the book " A Treatise on the theory
and practice of midwifery." After this fundamental improvement, the forceps would become a common
obstetrical instrument for more than two centuries.

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The last improvement of the instrument was added in 1877 by a French obstetrician, Stephan Tarnier in
"descriptions of two new forceps." This instrument featured a traction system misaligned with the instrument
itself, sometimes called the "third curvature of the forceps". This particularly ingenious traction system, allowed
the forceps to exercise traction on the head of the child following the axis of the maternal pelvic excavation,
which had never been possible before.
Tarnier's idea was to "split"
mechanically the grabbing of the
fetal head (between the forceps
blades) on which the operator
does not intervene after their
correct positioning, from a
mechanical accessory set on the
forceps itself, the "tractor" on
which the operator exercises
traction needed to pull down the
fetal head in the correct axis of
the pelvic excavation. Tarnier
forceps (and its multiple
derivatives under other names)
remained the most widely used
system in the world until the
development of the cesarean
section.

First illustration of Levret's pelvic

curve 1747

French forceps, Levret-Baudelocque

type (17601860) with perforator and
hook at the end of the handles
Tarnier forceps with tractor handle
(1877) and USA Dewey model (1900)

Hodge "Eclectic" forceps USA

(1833)

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Elliott forceps with "pressure

regulating" screw at the end of
handles USA (1860)

Forceps had a profound influence on obstetrics as it allowed for the speedy delivery of the baby in cases of
difficult or obstructed labor. Over the course of the 19th Century, many practitioners attempted to redesign the
forceps, so much so that the Royal College of Obstetrics and Gynecologists' collection has several hundred
examples.[16] In the last decades, however, with the ability to perform a cesarean section relatively safely, and
the introduction of the ventouse or vacuum extractor, the use of forceps and training in the technique of its use
has sharply declined.

Complications
Fetal
Cuts and bruises
Occasionally, (usually temporary) facial nerve injury can occur
rarely, clavicle fracture
Intracranial hemorrhage sometimes leading to death: 4/10,000 (OMahony F, Settatree R, Platt C, et al.
Review of singleton fetal and neonatal deaths associated with cranial trauma and cephalic delivery during
a national intrapartum-related confidential enquiry. BJOG 2005;112:61926.)
Improper twisting of the neck can cause damage to cranial nerve VI, resulting in strabismus.

Mother
Increased risk of perineal lacerations, pelvic organ prolapse and incontinence
Increased postnatal recovery time and pain
Increased difficulty evacuating during the recovery time

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See also
Instruments used in general surgery

References
1. Forceps.American Heritage Medical Dictionary 2nd ed. Boston: Houghton Mifflin Co., 2008. 310
2. Healthline > Types of Forceps Used in Delivery (http://www.healthline.com/yodocontent/pregnancy/assisted-deliverytypes-forceps.html) February 2006. Reviewer: Douglas Levine, Gynecology Service/Department of Surgery, Memorial
Sloan Kettering Cancer Center, New York, NY.
3. Asyncletism in labor (http://spinningbabies.com/index.php?option=com_content&task=view&id=60&Itemid=28),
spinningbabies.com
4. Family Practice Notebook > Forceps Assisted Delivery (http://www.fpnotebook.com/OB/LD/FrcpsAstdDlvry.htm)
written by Scott Moses, MD. This page was last revised before 5/10/08
5. Chamberlain, G.; Steer, P. (1999). "ABC of labour care: Operative delivery"
(http://www.hawaii.edu/hivandaids/ABC%20Of%20Labour%20Care%20%20%20Operative%20Delivery.pdf) (PDF).
BMJ 318 (7193): 12604. doi:10.1136/bmj.318.7193.1260 (https://dx.doi.org/10.1136%2Fbmj.318.7193.1260).
PMC 1115650 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115650). PMID 10231260
(https://www.ncbi.nlm.nih.gov/pubmed/10231260).
6. Derived from the lbf value with 1 lbf 4.45 N
7. Dennen, Edward H. (1989). Dennen's Forceps Deliveries (3rd ed.). F.A. Davis. ISBN 0-8036-2511-1.
8. biology-online.org > Dictionary O Outlet forceps delivery (http://www.biologyonline.org/dictionary/Outlet_forceps_delivery) Page last modified 21:16, 3 October 2005.
9. Types of Forceps Deliveries: Outlet, Low, Mid, and High (http://www.healthline.com/yodocontent/pregnancy/forcepsassisted-delivery.html) Reviewer: Douglas Levine. Healthline Pregnancy Guide, February 2006
10. Loughnan, Michael S.; Adrian S. Bruce (2002). Anterior Eye Disease and Therapeutics A-Z. Oxford: ButterworthHeinemann. p. 91. ISBN 0-7506-5261-6.
11. Moore, W. (2007). "Keeping mum" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839178). BMJ 334 (7595): 698.
doi:10.1136/bmj.39157.514815.47 (https://dx.doi.org/10.1136%2Fbmj.39157.514815.47). PMC 1839178
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839178).
12. Watts, Geof. 2001. Special Delivery. New Scientist. 21 April 4848
13. 1886. The Last Lyons Forceps. The Medical News. 2 January 14
14. Murphy, Edwardw. (1845). "Lectures on the Mechanism and Management of Natural and Difficult Labours". The Lancet
46 (1140): 1. doi:10.1016/S0140-6736(02)86183-9 (https://dx.doi.org/10.1016%2FS0140-6736%2802%2986183-9).
15. Aveling, J.H. 1882. The Chamberlens and the Midwifery Forceps 224
16. Robson, Steve (2009). "Forceps Delivery: Science Wears its Art on its Sleeve" (http://eprints.jcu.edu.au/17236/). O&G
Magazine 11 (4): 1920.

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