Operative Vaginal Delivery PDF

Operative Vaginal
Delivery: The Art of

Obstetrics
EF Pat Magann MD FACOG FRANZCOG
MFM Division and Fellowship Director
University of Arkansas for the Medical Sciences
Little Rock, Arkansas
Objectives
Define the classification of operative vaginal
delivery performed.
Understand the indications for performing
operative vaginal delivery.
Properly apply both forceps
No disclosures
Timing of Delivery
I am a fetus in the womb
I fear it may become my tomb
If only I could give a shout
To make my doctor get me out
Unknown medical student, Dublin Ireland BJOG
Overview of Forceps
700+ varieties
3 categories
Classical
Parallel shanks: Simpson, DeLee, Irving,
Hawks-Dennen
Overlapping shanks: Elliott, Tucker-McLane
Rotational (Kielland, Leff)
Special (Piper)
Types of Forceps
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 of
the fetal head. ,
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 when there is
minimal moulding
Types of Forceps
Kielland forceps (1915, Norwegian) are
distinguished by an extremely small pelvic curve
and a sliding lock. The most common forceps used
for rotation. The sliding lock is helpful in asynclitic
Kielland forceps lack traction because they have
almost no pelvic curve
Wrigley's forceps are used in low or outlet delivery
and 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.
Anatomy of the Forceps: Elliott and

Simpson Forceps
Anatomy of the Forceps
Forceps Locks
Sir James Y. Simpson 1845
Luikart-Simpson
Luikart R. A modification
of the Kielland, Simpson,
and Tucker-McLane forceps
to simplify their use and
improve function and safety.
Am J Obstet Gynecol
1937;34:686
pseudofenestrated blade
Elliot
Overlapping shanks
Short, rounder cephalic
curve
Set screw between
handles (reduce
cephalic compression)
For unmolded heads
Anatomy of the Forceps:Elliot

Forceps with Adjustable Pin
Tucker-McLane 1880s
Arthur H. Bill Axis Traction

Handle 1920s
Christian Kielland 1915
Edmund B. Piper 1924
Long shanks of the forceps are curved backwards like a

reverse pelvic curve
This design drops the handles below the blades
The unique construction of the shanks provide more spring to
the blades and results in less head compression
Operative Vaginal Delivery

Applying direct traction to the fetal skull (forceps)
or the fetal scalp (vacuum) along with maternal
expulsive efforts to effect a vaginal delivery
Incidence estimated at 8-15%
Fetal head must be engaged
Membranes ruptured
Cervix completely dilated
Bladder empty of urine
Operative Vaginal Delivery

Indications for operative vaginal delivery
Prolonged second stage of labor (nulliparous 3
hours with regional anesthesia or 2 hours
without) multiparous (2 hours with regional
anesthesia and 1 hour without regional
anesthesia)
Fetal compromise
Shorten of the second stage of labor for maternal
indications
Prerequisites for Forceps

Delivery
The head should be engaged and the station of the
head accurately known
The cervix should be completely dilated.
The exact position of the head should be known.
Occasionally ultrasound may help if the degree of
molding creates confusion.
The type of pelvis should be known. Certain pelvic
types will not allow for rotation. For example, a
fetus in a posterior position in an android or
anthropoid pelvis is best delivered in the
occipitoposterior (OP) position.
Prerequisites for Forceps

Delivery
The operator should be familiar with the
advantages and disadvantages of the different
forceps.
There should be adequate anesthesia for the
forceps delivery contemplated. A low or outlet
forceps delivery can be performed under pudendal
block ; a forceps rotation of greater than 45 or a
midforceps procedure requires a good epidural
The bladder should be empty.
This is an operative procedure, and it should be
accorded the same respect and care for aseptic
technique as any other operative procedure.
Contraindications for Operative

Vaginal Delivery
Unengaged fetal head
In ability to determine fetal position
Malpresentation (face or brow)
CPD actual or suspected
Prematurity (< 34 weeks vacuum)
Repeated scalp pH (vacuum)
Inability to apply instrument correctly
Incompletely dilated cervix
Position of the fetal head
Position of the Fetal Head
Outlet Forceps
Scalp is visible at the introitus without separating
the labia
Fetal skull has reached the pelvic floor
Sagittal suture in A-P diameter, or Right or Left
anterior or posterior position
Fetal head is at or near the perineum
Rotation does not exceed 45 degrees
ACOG
Outlet Forceps
Lift out deliveries and at CS
Wrigley's
forceps
The fetal scalp is visible without separating the labia
The fetal skull has reached the pelvic floor
The sagittal suture is in the anteroposterior diameter or right
or left occiput anterior or posterior position (rotation does not
exceed 45 degrees)
The fetal head is at, or on, the perineum
RCOG
Low Forceps
Leading point of skull at or > +2 and not on pelvic
floor
Rotation is 45 degrees or less (R or L ant to OA or
R or L posterior to OP)
Rotation is > 45%
ACOG
Midforceps
Stations is above +2 but the head is engaged
High forceps are no longer included in the
classification
ACOG
Rotational Forceps
Kielland's forceps
Forceps Delivery OA, LOA,

ROA
Checks for proper placement

Sagittal suture lies in the midline of the
shanks
No more than one finger can be placed
between the fetal head and the blades or
fenestrations on either side
Posterior fontanelle is not more than one
fingers breadth above the plane of the
shanks (in OA position)
Pajot-Saxtorph Maneuver
Rotation with Forceps
Recent Publication Obstet Gynecol

2013;121:1032-9 (May issue)
Rotational Forceps
Classical Application
Direct Application
Wandering Application
Piper Forceps
Application to the after-coming head in a breech delivery

Overall morbidity decreased by 50% with use of forceps
Controls the flexion attitude of the head, avoids
hyperextension, no traction on the cervical spine or trunk
Avoid delayed descent and possible hypoxia
Piper Forceps: Technique
Application: shoulder and arms delivered with head in pelvis

Infants body is held horizontal by an assistant (towel sling)
Operator assumes low sitting or kneeling position
Insertion from below and upward the handle is swept in a

downward arc toward the midline L blade inserted into L side
of pelvis over infants R ear (Direct Application)
Application of the blade guided by 2 fingers of the R hand
Piper Technique
The fetus is then swung towards the maternal L thigh and the R
blade is inserted from below and upward, the R handle being
swept in a downward arc toward the midline with the R blade
inserted into R side of pelvis over infants L ear (Direct
Application)
Application of the blade guided by 2 fingers of the R hand
If resistance is met, the toe of the blade is introduced more
posteriorly and wandered into place
After the shanks are locked the infant is straddling the

forceps
The handles rest in the upturned palm with middle finger in
the space between the shanks
The neck is splinted by the fingers of the operators L hand
The fetus is then delivered over the perineum by flexion

without removal of the forceps ( Note how the application of
the forceps keeps the head flexed and prevents
deflexion/extension of the fetal head
Mauriceau Maneuver: index and middle finger are applied
over the maxiall to flex the fetal head while the body is
elevated towards to abdomen
Mauriceau Maneuver
Index and middle finger are applied over the maxilla to flex
the fetal head while the body is elevated towards to abdomen
Occiput Posterior

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Operative Vaginal

Delivery: The Art of

Unknown medical student, Dublin Ireland BJOG

Anatomy of the Forceps: Elliott and

Anatomy of the Forceps

Sir James Y. Simpson 1845

Anatomy of the Forceps:Elliot

Arthur H. Bill Axis Traction

Christian Kielland 1915

Edmund B. Piper 1924

Long shanks of the forceps are curved backwards like a

Operative Vaginal Delivery

Operative Vaginal Delivery

Prerequisites for Forceps

Prerequisites for Forceps

Contraindications for Operative

Position of the fetal head

Position of the Fetal Head

Forceps Delivery OA, LOA,

Checks for proper placement

Rotation with Forceps

Recent Publication Obstet Gynecol

Application to the after-coming head in a breech delivery

Piper Forceps: Technique

Application: shoulder and arms delivered with head in pelvis

Piper Forceps: Technique

Insertion from below and upward the handle is swept in a

Piper Forceps: Technique

After the shanks are locked the infant is straddling the

Piper Forceps: Technique

The fetus is then delivered over the perineum by flexion

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