Forceps Assisted Birth Delivery
A forceps delivery is a type of assisted vaginal delivery. It sometimes needed in the course of
vaginal childbirth. In a forceps delivery, a health care provider applies forceps – a steel instrument
shaped like a pair of large spoons or salad tongs – to the baby’s head to help guide the baby out of the
birth canal.
Although no longer used routinely, forceps maybe necessary with any of the following conditions:
A woman unable to push with contractions in the pelvic division of labor such as might happen
with a woman who received regional anesthesia or has a spinal cord injury.
Cessation of descent in the second stage of labor occurs
A fetus is in abnormal position
A fetus is distress from a complication such as prolapsed of cord
Before forceps are applied:
Membranes must be ruptured
CPD must not be present
The cervix must be fully dilated
The woman’s bladder must be empty
Kinds of Forceps:
Fenestrated or Pseudofenestrated Blades have an opening within or depression along the blade
surface respectively
True Fenestrated reduces the degree of head slipping during forceps rotation.
o Disadvantage: It can increase friction between the blade and the vaginal wall.
Pseudofenestration – the forceps blade is smooth on the outer maternal side but indented on
the inner fetal surface,
o The goal is to reduce head slipping yet improve the ease and safety of application and
removal of forceps.
Indications
The fetal indication is commonly a non-reassuring tracing when the vertex is well below the ischial
spines which may preclude a cesarean delivery.
Maternal indications include maternal exhaustion and prolonged second stage of labor
(nulliparous: 4 hours with regional anesthesia and 3 hours without, multiparous: 3 hours with regional
anesthesia and 2 hours without). Both imply adequate maternal pushing efforts with contractions.)
The following criteria are necessary before processing with either vacuum or forceps delivery
1. Cervix fully dilated
2. Rupture of membranes
3. Fetal head engaged (vertex presentation)
4. Knowledge of the fetal position
5. Fetal weigh has been estimated
6. Maternal pelvis adequate for vaginal delivery
7. Anesthesia administered
8. The maternal bladder is empty
9. Maternal consent obtained, risks and benefits thoroughly explained
10. A back up plan if the operative delivery method fails
11. Maternal cardiac or neurologic disease when maternal pushing is not feasible
Contraindications
Absolute maternal contraindications for operative vaginal delivery include the following:
Cervix not fully dilated
Membranes intact
Fetal head not engaged
Unknown fetal position
Cephalopelvic disproportion
Preparation:
The first step in preparing for a forceps delivery is to counsel and consent the patient, which
includes explaining the risks and benefits of a forceps delivery and cesarean section. It is also wise to
consent for a cesarean section at the same time in case the forceps delivery is unsuccessful. The
operating room team should also be alerted and be ready in case the emergency cesarean section is
necessary particularly with a non-reassuring tracing.
The next step is to ensure the preferred forceps are readily available and in working order.
Consider having a back-up instrument ready. Additionally, because perineal and vaginal lacerations are a
common complication of forceps delivery, instruments and sutures for laceration repair should also be
set up on the obstetric operative table.
It is also vital in the preparation process to include the anesthesia and pediatric teams. Notify
both teams ahead of time, so they have ample time to prepare for their role in the delivery process.
Usually forceps delivery requires regional anesthesia such as epidural or pudendal block as well as a
local perineal since episiotomy, particularly right mediolateral is common to allow for more space and
fewer lacerations. Preparation for acid-base cord blood sampling should be included for all complicated
deliveries.
Before forceps application, routine emptying of the bladder should take place which allows the
fetal head to descent uninhibited. It is also helpful in case the forceps delivery fails, and an emergent
cesarean section is necessary.
The use of prophylactic antibiotics is a debated topic. Based on limited evidence, their use does
not significantly lower rates of maternal endometritis or maternal length of hospital stay.
Types of Forceps Application
1. Cephalic Application – the forceps is applied on the sides of the fetal head in the mento-vertical
diameter so the injury of the fetal face, eyes and facial nerves are avoided,
2. Pelvic Application – the forceps is applied along the maternal pelvic wall irrespective to the
position of the head. It is easier for application but carries a great risk of fetal injuries.
3. Cephalo-Pelvic Application – it is the ideal application and possible when the occiput is directly
anterior or posterior or in direct mento-anterior position.
Forceps Application
Forceps Failure
- Fetal head does not advance with each pull
- Fetus is undelivered after three pulls with no descent or after 30 minutes (WHO)
o Every application should be considered a trial of forceps
o Do not persist if there is no descent with every pull
o If forceps delivery fails, perform a caesarian section
Complication of forceps
Properly performed outlet forceps operation should have morbidity rate similar to spontaneous
vaginal delivery.
Maternal complication:
o Uterine, cervical or vaginal lacerations
o Extension of episiotomy
o U.B or urethral injury
o Hematoma
Fetal complications
o Cephalo-hematoma, bruising and laceration
o Facial nerve and brachial plexus palsies
o Skull fracture and intracranial hemorrhage
