Instrumental vaginal delivery refers to the use of

specially designed instruments, namely the

obstetric forceps and the vacuum extractor, to
facilitate delivery of the fetal head.
Their use is usually restricted to certain difficult
deliveries in order to shorten the second stage
of labour whenever fetal or maternal distress is
already present, or strongly anticipated.

The decision to choose between the obstetric

forceps or the vacuum extractor is
individualized according to each case and is
largely dependant on the clinician's state of
experience.
The liberal use of instrumental delivery in
obstetric practice has been hindered by the
increased maternal and fetal complications
associated with the inappropriate use of such
instruments.

In the last 2-3 decades, delivery by C.S. has

replaced most of the difficult instrumental
techniques.
 THE OBSTETRIC FORCEPS
THE INSTRUMENT
 The obstetric forceps is an instrument designed for
traction or combined traction and rotation of the
fetal head.
 It consists of two blades, each having two curves:
Cephalic curve to fit on each side of the fetal skull.
Pelvic curve to obtain a central grip on the head and to
promote flexion.
Each blade consists of:
- The Blade proper, that fits on the head.
- The Shank, that connects the blade to the handle.
- The Lock, where the two blades cross each other
- The handle, by which traction is done.

Each blade is fenestrated:

- To minimize compression
- To make its weight lighter
- To prevent slipping as the parietal eminences
protrudes through the fenestration
 CLASSIFICATION OF FORCEPS
OPERATIONS
Outlet forceps:
Fetal head is at the perineum
Sagittal suture in anterior or posterior diameter (DOA-DOP).
Rotation is < 45º (ROA-LOA).

Low Forceps:
Fetal head is at station (+2, or more), but not on perineum
Rotation is > 45º

Mid forceps:
fetal head at station (0 to +1), with rotation > 45
 TYPES OF OBSTETRIC FORCEPS

1. The Long curved forceps

3. The Short forceps

5. The Kielland forceps

7. The Pippers Forceps

The Long curved forceps
 The Long curved
forceps “15 inches”:
mainly used for mid
forceps delivery.
 The Short forceps
 The Short forceps “11 inches”: mainly used for
low forceps delivery.
 The handle & the shank are shortened.
 It is either:
Curved (Wrigley’s forceps)
Straight (Simpson forceps)
 The Kielland forceps
 It is a long forceps designed mainly to facilitate
traction and rotation of the fetal head in occipito-
posterior positions.
It is characterized by:
 The blades are called anterior & posterior.
 Beveled inner surface of the blade: to minimize
fetal head injury
 Minimal Pelvic Curve: allowing rotation &
Traction by single application.
 A Sliding lock: to allow application on asynclitic
head
 Knobs on the handle that should be directed
toward the fetal occiput.
 The Pippers Forceps
 It is a long forceps designed to facilitate delivery of the after
coming head in breech presentation.
 It is characterized by a long shank with the
presence of a perineal curve.

 It promotes flexion of the fetal head.

 It prevents sudden compression and

decompression on the fetal head.

 It allows safer traction on the after coming

head and not on the fetal neck.
 INDICATIONS FOR THE USE OF
FORCEPS

 Prolonged second stage of labour.

 To shorten second stage of labor.
 Inadequate maternal expulsive forces.
 Fetal distress if the cervix is fully dilated.
 Prolapsed pulsating cord with fully dilated
cervix.
 Some Malpositions & malpresentations:
- O.P. after failure of spontaneous rotation.
- After coming head in breech.
 PREREQUISITES BEFORE FORCEPS
APPLICATION

 The cervix should be fully dilated.

 The head should be engaged.
 Cephalopelvic disproportion should be excluded.
 The membranes (forewaters) should be ruptured.
 Presence of adequate uterine contractions
 Antisepsis and anaesthesia
 The bladder & rectum should be evacuated
CONTRAINDICATIONS TO FORCEPS
OPERATION

 Incompletely dilated cervix

 Unengaged head
 Cephaloopelvic disproportion
 Intact membranes
 Uterine inertia
N.B: The ideal application of forceps is Cephalo-
pelvic application.

N.B.: One of advantages of forceps is that it can be

applied on face presentation and on after coming
head in breech deliveries.

Prematurity is a relative contraindication, it may be

injurious if used with excessive force, in the same
time it may protect the head from sudden
compression and decompression.
 COMPLICATIONS OF FORCEPS
PROCEDURES
A) Maternal complications:
1. Maternal birth injuries
2. Postpartum hemorrhage (PPH)

B) Fetal complications:
1- Intracranial hemorrhage
2- Head & Skull injuries
 HISTORICAL REVIEW
 The introduction of obstetric forceps in modern
obstetrics has been credited to Chamberlen's
family, who practiced midwifery in England for
four generations, in the 18th century. They kept
their forceps as a family secret for nearly 100
years.

 During the next 200 years, endless innovations

have been introduced to the original simple
instrument.
• Special types of forceps have been designed to
facilitate its use in certain situations as with the
Kielland forceps and Piper's forceps.

• The most commonly used forceps nowadays are

the short forceps (Wrigley & Simpson forceps),
used mainly in low and outlet forceps.
THE VACUUM EXTRACTOR
 INTRODUCTION
 The use of vacuum–cup deliveries to
facilitate vaginal birth dates back to 18th
century. The idea was to apply traction to
fetal scalp guiding the head down out of the
birth canal. In 1954, Malmstrom, (a Swedish
obstetrician), developed the currently used
vacuum extractor.
 Original Malmstrom ventouse used a
metal cup applied on fetal scalp for traction,
and a glass jar and pump to create a
negative pressure.

 Current instruments use pliable plastic and

polyethylene cups, and electric suction
instruments for negative pressure
production.
 PREREQUISITES FOR THE USE OF
VACUUM EXTRACTOR

(AS FORCEPS):
 The cervix should be fully dilated.
 The head should be engaged.
 Cephalopelvic disproportion should be excluded.
 The membranes (forewaters) should be ruptured.
 Presence of adequate uterine contractions
 Antisepsis and anaesthesia
 The bladder & rectum should be evacuated
 INDICATIONS FOR USE OF VACUUM
EXTRACTOR

(AS FORCEPS):
 Prolonged second stage of labour.
 To shorten second stage of labor.
 Inadequate maternal expulsive forces.
 Fetal distress if the cervix is fully dilated.
 Prolapsed pulsating cord with fully dilated cervix.
 Some Malpositions & malpresentations:
- O.P. after failure of spontaneous rotation.
- After coming head in breech.
 CONTRAINDICATIONS TO THE USE OF
THE VACUUM EXTRACTOR
 Incompletely dilated cervix
 Unengaged head
 Cephaloopelvic disproportion
 Intact membranes
 Uterine inertia

 Non vertex presentations, as in face and breech

presentations.
 Premature infants, to avoid serious complications.
 Marked fetal distress, as it needs a longer period of
application than the forceps.
 Advantages of the Vacuum extractor
 Allows easy and gentle traction on the fetal head,
due to limited force.

 Promotes flexion and helps internal rotation of the

fetal head in O.P. positions.

 Less encroachment on maternal pelvic space,

resulting in less trauma to maternal birth canal,
and less serious lacerations
 Complications of the vacuum
extractor
A) Maternal complications:
 Vaginal and perineal lacerations.
 Cervical lacerations.
 Rarely rupture uterus, (non engaged head, or
non fully dilated cervix).

B) Fetal complications:
 Cephalhaematoma.
 Scalp lacerations, (excessive force and
repeated slipping of the cup).
 Cerebral hemorrhage (tear of vein of Gallen).
 Technical Considerations
 To promote flexion of the fetal head with
traction, the suction cup is placed over the
' median flexing point ‘.
 Low suction (100 mmHg) is applied. After ensuring
that no maternal soft tissue is trapped between the
cup and fetal head, suction is increased to 500-
600 mmHg and sustained downward traction is
applied along the pelvic curve in concert with
uterine contractions.
 Suction is released between contractions.

 The procedure should be abandoned if the cup

detaches three times or if no descent of the
head is achieved.