Forceps Delivery

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS

Conditions Required for Instrumentation

  • Vertex presentation
  • Complete cervical dilation
  • Ruptured membranes
  • No known severe cephalopelvic disproportion
  • Willingness to abandon the procedure and proceed to cesarean section if instrumentation is unsuccessful
  • Establishment of adequate anesthesia

Maternal Indications for Instrument-Assisted Delivery

  • Maternal exhaustion
  • Prolonged second stage
  • Medical conditions for which the strain of the second stage of labor would be deleterious

Maternal and Fetal Indications for Instrument-Assisted Delivery

  • Relative cephalopelvic disproportion
  • Malposition (occiput posterior or occiput transverse)
  • Malpresentation (face or breech)
  • Hemorrhage

Fetal Indications for Instrument Delivery

  • Nonreassuring fetal heart tracing
  • Rapid deterioration of the tracing or any condition that makes instrument delivery unsafe for the fetus
  • Premature placental separation
CONTRAINDICATIONS

Absolute

  • Fetal head not engaged
  • Position of the head not determined

Relative

  • History of failed forceps or vacuum delivery with a macrosomic fetus
  • Incomplete cervical dilation (only exceptions are the urgent delivery of a second twin and a severely abnormal tracing without immediately available cesarean section)
  • Delivery requiring excessive traction
  • Prematurity
  • Malpresentation
EQUIPMENT

Equipment for Vaginal Delivery

  • Oxygen with flowmeter (one setup for mother and another for infant)
  • Delivery bed
  • Setup for infant (infant warmer, oxygen with bag and mask, suction with DeLee aspirator, infant laryngoscope, intubation equipment, umbilical catheter, medications, and monitoring equipment for resuscitation)
  • Sterile equipment tray or table containing the following:
    • 10-mL tube for cord blood
    • Two scissors (blunt Mayo-Noble straight scissors for cutting the cord and/or episiotomy and sharp scissors for cutting suture and dressings)
    • Bulb syringe
    • One plastic cord clamp (may use curved forceps for the other)
    • Four curved hemostats
    • Two straight forceps
    • Two ring forceps clamps (also called a sponge stick or placenta forceps)
    • Drapes and towels (including under buttocks drape with fluid pouch)
    • Placenta basin
    • Gown (optional) and sterile gloves (latex free recommended)
  • Optional equipment for sterile tray or table
    • Two needle holders
    • Nontraumatic forceps, Allis clamps (for third- or fourth-degree repair)
    • Two thumb tissue forceps (one with teeth and one without teeth)
    • Gelpi retractor (for added visualization during a third- or fourth-degree repair)
    • Weighted speculum (offers greater visualization of the vaginal wall and cervix)
    • 10-mL syringe
    • 22-gauge, 1½-inch needle (for local anesthesia)
    • 1% lidocaine, without epinephrine
    • Two 3-0 absorbable sutures with tapered needles
    • Gauze pads (4 × 4)
    • Sterile speculum
    • Povidone-iodine (Betadine), chlorhexidine, or surgical solution for preparation
  • Emergency kit (for precipitous deliveries):
    • Sterile gloves (large size)
    • Two sterile towels
    • One pair of blunt-ended scissors
    • One plastic cord clamp
    • Two curved forceps
    • Gauze pads (4 × 4)
    • Bulb syringe
    • Placenta basin

Instruments for Instrumented Delivery

  • Tucker-McLean or Simpson forceps
ANATOMY

Fetal Presentation

  • Vertex presentation: Cephalic presentation (the head presents first)

Fetal Skull

  • Anterior fontanelle lies at the junction of the posterior aspect of the two frontal bones and the anterior aspect of the two parietal bones.
  • Posterior fontanelle is roughly triangular and lies at the junction of the posterior ends of the two parietal bones and anterior to the occipital bone.

Cardinal Movements in Labor

  • Engagement
    • Occurs when the largest transverse diameter of the fetal head reaches the level of the maternal ischial spines

Assessment of Station

  • Station ranges from -5 to +5, with 0 as the midpoint at the maternal ischial spines.
    • The maternal ischial spines can be palpated at 4 o'clock and at 8 o'clock.
    • Station -5 is in the upper part of the pelvic inlet.
    • Station +5 is at the pelvic outlet.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Discuss on the first postpartum day the need for the instrument delivery and maternal perceptions regarding the delivery.
  • Advise the patient to monitor the following and report any changes to the practitioner:
    • Bleeding
    • Fevers
    • Dysuria and urinary retention
    • Pelvic pain
COMPLICATIONS
  • Vaginal or cervical lacerations or both
  • Postpartum hemorrhage
  • Fetal birth trauma
  • Subgaleal hematoma
  • Shoulder dystocia
  • Hyperbilirubinemia
  • Fetal cervical trauma
  • Perineal tears
  • Maternal discomfort at delivery
  • Maternal urinary retention
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