Forceps delivery is a type of assisted vaginal birth where a healthcare provider uses a specialized instrument obstetrical forceps to guide the baby’s head out of the birth canal during the second stage of labor. These forceps resemble large, curved tongs designed to cradle the baby’s head safely.
Definition
Assisting with application of forceps to extract fetal head and thereby accomplishing delivery of fetus.
Indications
1.Maternal:
- Maternal exhaustion (distress).
- Severe pre-eclampsia.
- Heart disease
2.Fetal:
- Fetal distress.
- Low birth weight baby.
- Postmature baby.
- After coming head of breech.
Types of forceps application according to the station of fetal head
- High forceps: Application on a nonengaged fetal head. This method is not practiced in modern-day obstetrics.
- Mid forceps: Application on fetal head that is engaged in the pelvis, but presenting part is above +2 station.
- Low forceps: Presenting part of the fetal head is at +2 station or below, but has not reached the pelvic floor.
- Outlet forceps: Forceps are applied on the fetal head Iying on the perineum and is visible at the introitus between contractions. It is the widely practiced type of application (90%).
Classification of obstetric forceps
- Long curved forceps with or without axis traction device.
- Short curved forceps (Wrigley’s).
- Kielland forceps.
Criteria for application of forceps
Fetal criteria:
- Fetal head must be engaged.
- The position and station of the head must be suitable to apply the blades correctly to the sides of the head.
Maternal criteria:
- No major cephalopelvic disproportion.
- Bladder must be empty.
- Adequate analgesia should be given.
- Cervix must be fully dilated and effaced.
- Membranes must be ruptured.
- Presence of good uterine contractions.
- Others: Written consent.
Mnemonic for FORCEPS:
F-Favourable head position and cervix.
0-Open os.
R-Ruptured membranes.
C-Contractions present.
E-Engaged head and empty bladder.
P-Pelvimetry (no obvious CPD).
S-Stirrups (lithotomy position).
Articles
All articles for conducting delivery plus forceps.
Procedure
| Nursing action | Rationale | |
| 1. | Explain to mother and family the need for forceps delivery. | Helps in obtaining cooperation. |
| 2. | Obtain informed consent. | Prevents chances of legal problems. |
| 3. | Assess FHR. | Ascertains fetal well-being. |
| 4. | Assess the state of cervix, membranes, presentation and position of head by an internal examination. | Determines the level of progress of labor. |
| 5. | Empty the bladder by catheterization. | Full bladder interferes with contractions. |
| 6. | Infiltrate the perineum with local anesthetic (1% lignocaine). | To reduce discomfort during episiotomy. |
| 7. | Give an episiotomy when the perineum becomes bulged and thinned out by the advancing head. | Helps in insertion of forceps blades. |
| 8. | Assess FHR frequently (every 5-10 minutes), if not on continuous fetal monitoring. | Ensures fetal well-being. |
| 9. | Physician identifies the forceps blades. | Helps to select the blade to be inserted first. |
| 10. | Inserts four fingers of the semi supine right hand along the left lateral vaginal wall, the palmar surface of the fingers rest against the side of the fetal head. | The fingers are to guide the blade during application and to protect the vaginal wall. |
| 11. | The handle of the left blade is taken in the left hand in a pen-holding manner and is held vertically. The fenestrated portion of the blade is then introduced between the internal fingers and fetal head, manipulated by the left thumb when correctly applied, the blade should be over the parietal eminence the shank in contact with the perineum, and the handle directed upward). | As the blade is pushed up, the handle is carried downward and backward. |
| 12. | Introduction of the right blade is done after introducing two fingers of the left hand into the right lateral wall of the vagina along the side of baby’s hand. Right blade is introduced in the same manner as with the left one but holding it with the right hand. | Fingers in the vagina guide the blade inside preventing injury to vaginal wall. |
| 13. | With the right blade over the left one, the physician articulates and locks the blades In case of difficulty in locking, the blades are removed and reapplied. With correct application, locking is easy. | Helps for correct application of forceps on fetal head. |
| 14. | During the next uterine contraction, the physician gives steady but intermittent traction. In outlet forceps, the traction may be continuous, and contraction is not awaited as the head is already on the perineum. | The direction of the pull corresponds to the axis of the birth canal. |
| 15. | Once the head is crowned, the direction of pull is gradually changed to upward and forward toward the mother’s abdomen to deliver the head by extension. | |
| 16. | Once the baby’s head is delivered, the blades are removed one after the other, the right one first. | |
| 17. | Further steps are to be followed as in normal vaginal delivery. IV methergine is to be administered with the delivery of the anterior shoulder. | Prevents chances of increased blood loss. |
| 18. | Episiotomy is repaired in the usual manner. |
Complications
1. Maternal Complications
Immediate
- Injury: Vaginal laceration, cervical tear, extension of episiotomy, and complete vaginal tear.
- Nerve injury: Femoral, lumbosacral trunk with midforceps delivery.
- Postpartum hemorrhage.
- Anesthetic complications.
- Puerperal sepsis and maternal morbidity.
Remote Complications
- Painful perineal scars.
- Dyspareunia.
- Low backache.
- Genital prolapse.
- Stress urinary incontinence.
- Sphincter dysfunction.
2. Fetal
Immediate Complications
- Asphyxia.
- Facial bruising.
- Intracranial hemorrhage.
- Cephalhematoma.
- Facial palsy.
- Skull fractures.
- Cervical spine injury.
Remote Complication
Cerebral or spastic palsy due to residual cerebral injury.
Special points
- The direction of the pull for extracting fetal head corresponds to the level at which the forceps is applied on fetal head.
- In low forceps, the direction of the pull is downward and backward until the head comes to the perineum. The pull is then directed downward till the head is almost crowned (horizontally straight toward the operator). The direction of the pull is gradually changed to upward and forward toward the mother’s abdomen to deliver the head by extension.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Annamma Jacob, Manual of Midwifery and Gynaecological Nursing, 4th Edition, 2023, Jaypee Publishers, ISBN: 978-9356961593
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