Forceps Delivery

Forceps Delivery

Forceps delivery is a means of facilitating the birth of the baby's head by providing traction and rotation with the aid of obstetric forceps when it is impossible for the mother to complete the delivery by her own effort.

Forceps deliveries are classified by the level of the head at the time the forceps were applied i.e. high-cavity, mid-cavity or low-cavity.

Low-cavity or out let forceps applications are done when thefetal head is visible on the perineum. 

Mid-cavity or Mid forceps applications are for those in whichthe head is at the level of ischial spines and engaged.

High-cavity or High forceps applications are those in whichforceps are applied through the cervix before the head is engaged in the bony pelvis.

Pre requisites of forceps delivery

There are certain conditions which must exist before forceps application including those conditions that require a shortened second stage labour: when mother or fetus is in jeopardy or when assistance with maternal bearing-down is needed.

·        The fetal head must be engaged in the maternal pelvis.

·        The cervix must be fully dilated.

·        The membrane should be ruptured

·        The bladder and bowel should not be distended to avoid trauma

·        Positive identification of presentation and position

·        Absence of cephalo pelvic disproportion, sacral or pelvic out let abnormalities.

·        Adequate anesthesia must be used

Indication for forceps delivery

·        Fetal distress in the second stage of labour

·        Delay in the second stage of labour – if the duration of the second stage exceeds 11/2 hours or more than one hour of pushing, or if the fetal head is delayed on the perineum for more than 30 minutes.

·        Malposition: occipeto lateral, occipito posterior position

·        Maternal exhaustion or distress

·        For the delivery of the after coming head of a breach presentation.

·        Preterm delivery: this is still a matter of debate, but some obstetricians and pediatricians like to protect the fetal head, with its soft skull bones, if delivery occurs before about the 36^th week of gestation.

·        Conditions in which pushing is undesirable, such as cardiac conditions or moderate to sever hypertension. 

Preparation of the woman

A woman about to be delivered with forceps will often be get fully explanation about the procedure itself and the need for it is likely to result in greater retrospective satisfaction and relief. Once the decision has been made, adequate and appropriate analgesia must be offered.

When such analgesia has been instituted the woman's legs are placed in the lithotomy position. Both legs must bepositioned simultaneously to avoid strain on the woman's lower back and hips. This is uncomfortable position, especially for a tired woman with a weighty gravid uterus who is in advanced labour. The woman's legs should not be placed in the stirrups for longer than is necessary, and the vulval area should remain covered whenever possible. The minimum number of staff should be present, and interruptions should be discouraged she should be tilted towards the left at an angle of 150 to prevent aortovanacaval occlusion. Preparations must also have been made for the baby and resuscitation equipment checked and in working order. 

Procedure

The woman's vulval area is thoroughly cleaned and draped with sterile towels using aseptic technique; the bladder is emptied. The obstetrician will perform a vaginal examination in order to confirm the station and exact position of the fetal head. It is to positively identify the forceps blades by assembling them briefly before proceeding.

Complications

Failure- Undue force should never be used. If the head does not advance with steady traction the attempt is abandoned and the baby is delivered by cesarean section.

In the infant:

Bruising: Severe bruising will cause marked jaundice whichmay be prolonged

Cerebral irritability - A traumatic forceps delivery may causecerebral edema or hemorrhage.

Cephal haematoma - is a swelling on the neonate's skull, aneffusion of blood under the periosteum covering it, due to friction between the skull and pelvis.

Tentorial tear- results from compression of the fetal head bythe forceps. The compression causes elongation of the head and consequent tearing of the tentorial membrane.

Facial palsy-occasionally the facial nerve may be damagedsince it is situated near the mastoid process where it has little protection.

In the mother:

Bruising and trauma to the urethra this may cause dysuriaand occasionally haematuria or a period of urinary retention or incontinence.

Vaginal and Perineal trauma the vaginal wall may be tornduring forceps delivery and the vagina must be inspected carefully prior to perineal repair. The episiotomy may extend or be accompanied by a further perinea tear and these must be repaired with care. As with any damaged perineum there may be bruising, oedema or occasionally haematoma formation.

Rupture of the uterus with increased risk of infection

Increased risk of uterine atony and excessive bleeding

Fracture of the coccyx and bladder trauma

Implications for nursing care

The nurse must be prepared to locate the appropriate types of forceps when requested. The nurse must support the mother if she is awake, explaining what is being done. Maternal comfort level should be observed closely; forceps applications should involve sensations of pressure but adequate anesthesia or analgesia should be established so that no pain results.

The nurse should monitor the FHR closely during application and traction. Fetal bradycardia may be observed as a result of head compression and is transient. The neonate delivered with forceps should be carefully examined for cerebral trauma or nerve damage.

The nurse must be alert for possible sequele of forceps deliveries. The mother should be observed carefully for excessive bleeding, severe perineal bruising and pain, difficulty in voiding, and cervical or vaginal lacerations