The necessary conditions for applying obstetric forceps are: Preparation for the operation of applying obstetric forceps and pain relief

What called operation "Obstetric forceps"?

“Obstetric forceps” is an operation in which a living fetus is removed from the birth canal using obstetric forceps.

What such obstetric forceps And For what They intended?

Obstetric forceps are an instrument used to extract a live, full-term fetus by the head through natural birth canal. They are designed to -

would tightly grasp the head and replace the expelling forces with the attracting force of the doctor. The forceps are only a retraction instrument, not a rotational or compression instrument. Depending on the location of the head in the small pelvis, there are exit forceps (forceps minor) and cavity forceps (forceps major).

What's it like device forceps?

The tongs have two branches that are connected to each other by means of a lock. Each branch consists of three parts: a spoon, a lock and a handle. Spoon has a cutout (window), rounded ribs - top and bottom. The spoons are curved outward and concave from the inside, according to the shape of the fetal head. This curvature of the spoons is called the cephalic curvature. The ribs of the kidneys are also curved according to the shape of the pelvis, and this curve is called the pelvic curvature. Some models of forceps may have a bend in the middle of the branches - perineal curvature (Piper forceps) (Fig. 23.10).

Russian forceps are straight and have no pelvic curvature (Lazarevich, Pravosud, Gumilevsky). An analogue of straight forceps abroad is the Kielland model (Fig. 23.11).

Lock connects the branches of the forceps. Based on the design of the lock, there are several models, or types, of tongs: a) Russian tongs (Lazarevich) - the lock is freely movable; b) English-

Rice. 23.10. Piper obstetric forceps

Chinese tongs (Simpson) - the lock is moderately movable; c) German tongs (Negele) - the lock is almost motionless; d) French tongs (Levre) - the lock is motionless (Fig. 23.1 2).

Lever serves for grasping forceps and producing traction. The inner surface of the handles is smooth for better

Rice. 23.11. Kielland obstetric forceps

They fit closely together, the outer one is embossed with side hooks for better grip by hand.

Rice. 23.12. Obstetric forceps:

A - Lazarevich; b - Simpson;

V - Negele; G - Levre;

What with tongs more often Total enjoy V Russia And what does it feel like

their device?

In Russia, Simpson-Fenomenov forceps are most often used (Fig. 23.13). N. N. Fenomenov (Russian obstetrician) made an important change to the Simpson design, making the lock more movable. These tongs are 35 cm long, their branches intersect almost in the middle; The lock is designed simply and allows for considerable mobility. It is located on the left branch, and the right branch has a thinning designed for insertion into the lock. The greatest distance between the inner surfaces of folded spoons (head curvature) is 8 cm, the distance between the tops of the spoons is 2.5 cm. The pelvic curvature of the forceps is insignificant.

What are readings For overlays obstetric forceps?

The indication for the operation of applying obstetric forceps is the danger that has arisen for the mother or fetus during the expulsion period, which can be completely or partially eliminated by rapid delivery. Indications for surgery can be divided into two groups: indications from the mother and indications from the fetus. Indications on the part of the mother can be divided into: those associated with pregnancy and childbirth (obstetric indications) and those associated with extragenital diseases of the woman that require “switching off” pushing (somatic indications). A combination of the two is often observed.

Indications for the operation of applying obstetric forceps are as follows.

I. Indications from the mother:

1) obstetric indications:

Rice. 23.13. Simpson-Fenomenov obstetric forceps

Severe forms gestosis (preeclampsia, eclampsia, severe hypertension, uncontrollable conservative therapy) require “turning off” pushing;

Persistent weakness of labor and/or weakness of pushing, manifested by standing of the fetal head in one plane of the pelvis for more than 2 hours, in the absence of effect from the use of medications. Prolonged standing of the head in one plane of the small pelvis leads to an increased risk of birth trauma for both the fetus (a combination of mechanical and hypoxic factors) and the mother (genitourinary and intestinal-genital fistulas);

Bleeding in the second stage of labor, caused by premature detachment of a normally located placenta, rupture of the umbilical cord vessels during their membrane attachment;

Endometritis during childbirth;

2) somatic indications:

Diseases of cardio-vascular system in the stage of decompensation;

Breathing disorders due to lung diseases;

High myopia;

Acute infectious diseases;

Severe forms neuropsychiatric disorders;

Intoxication or poisoning.

The application of obstetric forceps may be required for women in labor who have undergone surgery on organs on the eve of childbirth abdominal cavity(inability of the abdominal muscles to provide full pushing).

II. Indications from the fetus:

Fetal hypoxia, which developed due to various reasons in the second stage of labor (premature abruption of a normally located placenta, weakness of labor, gestosis, short umbilical cord, entanglement of the umbilical cord around the neck, etc.).

Which conditions necessary For overlays obstetric forceps?

To apply obstetric forceps, the following conditions are required:

1) the presence of a living fetus;

2) complete opening of the uterine os;

3) absence of amniotic sac; if it is intact, then it must be opened before the operation;

4) the fetal head must be in the outlet or in the pelvic cavity, the sagittal suture must be straight or in one of the oblique dimensions;

5) the head should not be too small (prematurity, anencephaly) or too large (hydrocephalus, postmaturity);

"Obstetrics in Questions and Answers"

6) correspondence between the sizes of the mother’s pelvis and the fetal head.

How held Preparation To operations overlays obstetric forceps?

Preparation for the operation of applying obstetric forceps includes several points (choosing a method of anesthesia, preparing the woman in labor, preparing the obstetrician, vaginal examination, checking the forceps).

Which methods pain relief Can apply?

The choice of pain relief method is determined by the woman’s condition and indications for surgery. In cases where the woman’s active participation in childbirth seems appropriate (weakness of labor and/or intrauterine fetal hypoxia in a somatically healthy woman), the operation can be performed using long-term epidural anesthesia (DPA) or inhalation of nitrous oxide with oxygen. However, when applying abdominal forceps to somatically healthy women, it is advisable to use anesthesia, since applying spoons to the head located in the pelvic cavity is a difficult moment of the operation, requiring the elimination of resistance of the pelvic floor muscles. In women in labor for whom pushing is contraindicated, the operation is performed under anesthesia.

Anesthesia should not end after the baby is removed, since the operation of applying abdominal obstetric forceps is accompanied by a control manual examination of the walls of the uterine cavity.

IN how is Preparation women in labor And obstetrician

To operations overlays obstetric forceps?

The operation of applying obstetric forceps is carried out in the position of the woman in labor on her back with her legs bent at the knees

and hip joints. Before surgery, the bladder must be emptied. The external genitalia and inner thighs are treated with a disinfectant solution. The obstetrician's hands are treated as for a surgical operation.

What necessary do after graduation preparation women in labor To operations?

Immediately before applying forceps, it is necessary to carry out a thorough vaginal examination (it is better to do the examination with a half-hand, i.e., four fingers) in order to confirm the presence of conditions for the operation and determine the location of the head in relation to the planes of the pelvis. Depending on the position of the head, it is determined which type of operation will be used (abdominal or exit obstetric forceps). From what main moments consists of operation? The operation consists of five main points:

The first point is the introduction and placement of spoons;

The second point is the closure of the forceps;

The third point is trial traction;

The fourth point is removing the head;

The fifth point is removing the forceps.

Which exists rule at administered spoons?

When introducing spoons, there is a first “triple” rule:

1) left the spoon is taken in the left hand and inserted into the left side of the mother’s pelvis; the left spoon has a lock and is therefore inserted first under the control of the obstetrician’s right hand;

"Obstetrics in Questions and Answers"

2) right the spoon is taken into the right hand and inserted into right side maternal pelvis; the right spoon is inserted under the control of the obstetrician's left hand.

How introduced V generic ways right hand obstetrician, under control which superimposed left spoon? To control the position of the left spoon, the obstetrician inserts a half-hand into the vagina, i.e. four fingers (except the first) of the right hand. The half-arm should face the palmar surface towards the head and is inserted between the head and the left side wall of the pelvis. The right finger remains outside and is moved to the side. After insertion, the half-hands begin to apply the spoon.

How take handle forceps at administered spoons?

The handle of the tongs is grabbed in a special way: by type writing pen(the index and middle fingers are placed at the end of the handle opposite the thumb) or bow-type (opposite the thumb along the handle four others are placed widely spaced). A special type of gripping of the spoon with forceps allows you to avoid the application of force when inserting it.

How have branch forceps before introduction spoons V generic ways?

Before inserting the spoon into the birth canal, the handle of the forceps is moved to the side and placed parallel to the opposite inguinal fold, i.e. when introducing the left spoon parallel to the right inguinal fold, and vice versa. The top of the spoon is placed on the palmar surface of the half-hand located in the vagina. The posterior edge of the spoon is located on the lateral surface of the fourth finger and rests on the abducted thumb.

How introduce spoon?

The advancement of the spoon into the depths of the birth canal should be accomplished due to the instrument’s own gravity and by pushing the lower edge of the spoon with the first finger of the right hand. In this case, the trajectory of movement of the end of the handle should be an arc. As the spoon is inserted, the handle of the forceps moves downwards and takes a horizontal position (Fig. 23.14).

What's it like appointment half hand located V generic ways?

The half-arm, located in the birth canal, is a guide hand and controls the correct direction and position of the spoon. With its help, the obstetrician makes sure that the top of the spoon is not directed into the fornix, onto the side wall of the vagina and does not capture the edge of the cervix. After inserting the left spoon, it is handed over to the assistant to avoid displacement. Next, under the control of the left hand, the obstetrician inserts the right branch into the right half of the pelvis with the right hand in the same way as the left.

How introduce second (right) spoon?

The second (right) spoon is administered using the same techniques as

the first, observing the “triple” rule: the right spoon is taken in the right hand and inserted into the right side of the mother’s pelvis under the control of the left half-eye.

Rice. 23.14. Position of the forceps branch when inserting the spoon

How must be located spoons on head fetus? Spoons on the fetal head are placed according to the second “triple” rule:

1) their length passes through the ears from the back of the head to the chin along a large oblique dimension (diameter mento-occipitalis) (Fig. 23.15);

"Obstetrics in Questions and Answers"

2) in this case, the spoons grasp the head in its largest diameter so that the parietal tubercles are located in the windows of the spoons of the forceps;

3) the line of the handles of the forceps is facing the leading point of the head.

Rice. 23.15. Position of spoons for occipital presentation

How produce short circuit forceps?

To close the pliers, the left handle is taken in the left hand, and the right handle in the right hand so that the first fingers are located on the Bush hooks, and the handles themselves are covered by the remaining four fingers. After this, the handles are brought together and the forceps are closed (Fig. 23.1 6).

Always whether handles forceps adjacent Friend To friend close?

The inner surfaces of the handles of the forceps do not always fit closely to each other, since the distance between the spoons in the head curvature is 8 cm, and the transverse size of the head can be large.

Rice. 23.16. Closing the forceps

How enroll V such cases?

In such cases, place a sterile napkin folded 2-4 times between the handles. This prevents excessive compression of the head and ensures a good fit of the forceps spoons to the head.

What order execution third moment operations?

The third moment of the operation is test traction.

This necessary moment allows you to verify the correct

proper application of the forceps and no risk of them slipping. It requires a special positioning of the obstetrician's hands. How produce trial traction?

The obstetrician grabs the handles of the forceps with his right hand from above so that the index and middle fingers lie on the Bush hooks. He places his left hand on the back surface of his right, extends the index or middle finger and touches the fetal head in the area of ​​the leading point (Fig. 23.1 7). If the forceps are applied correctly, then during test traction the fingertip will always be in contact with the head. Otherwise, it moves away from the head, which indicates that the forceps are not applied correctly and will eventually slip off. In this case, the forceps must be repositioned.

How are located hands obstetrician when He produces extraction heads with tongs?

After test traction, they begin to remove the head. To do this, the index and ring fingers of the right hand are placed on the Bush hooks, the middle one is between the divergent

The branches of the tongs hang down, and the thumb and little finger cover the handles on the sides. With your left hand, grab the end of the handle from below.

Which character must have traction?

When removing the head with forceps, it is necessary to take into account the nature, strength and direction of traction. Traction of the head with forceps should imitate natural contractions. To do this you should:

1) imitate a contraction in terms of strength: start traction not sharply, but with a weak pull, gradually strengthen it and weaken it again;

2) when performing traction, do not develop excessive force and do not increase it by tilting your body back or resting your foot on the edge of the table;

3) between individual tractions it is necessary to pause for 0.5-1 minutes;

"Obstetrics in Questions and Answers"

4) after 4-5 tractions, open the forceps and rest the head for 1-2 minutes;

5) try to perform traction simultaneously with contractions, thus enhancing the natural expulsion forces. If the operation is performed without anesthesia, the woman in labor must be forced to push during traction.

Rocking and rotational pendulum-like movements are unacceptable. It should be remembered that forceps are a drag tool; traction should be performed smoothly in one direction.

IN which direction should produce traction?

The direction of traction is determined by the third “triple” rule - it exists in full when forceps are applied to the head located in the wide part of the pelvic cavity (cavitary forceps):

1) first direction traction (from wide parts cavities small pelvis To narrow) - downwards and backwards, corresponding to the wire axis of the pelvis (Fig. 23.18)*;

2) second direction traction parts cavities small pelvis before plane exit) - downwards (Fig. 23.1 9);

3) third direction traction (removal heads V tongs) - anteriorly (Fig. 23.20).

What order execution fourth moment operations -

withdrawals forceps?

The procedure for removing the forceps before cutting through the head is as follows:

1) take the right handle in your right hand, the left handle in your left hand and, spreading them apart, unlock the lock;

* All directions of traction are indicated in relation to the vertical position of the woman in labor.

Rice. 23.17. Test traction

2) bring out the spoons in the reverse order in which they were inserted, i.e., first bring out the right spoon, and then the left; when removing the spoons, the handles should be tilted towards the opposite thigh of the woman in labor.

Can whether withdraw head, no taking off forceps, and How This do?

You can remove the head without removing the forceps as follows:

1) stand to the left of the woman in labor and take the forceps with your right hand, grasping them in the lock area; place your left hand on the perineum as is done when protecting it;

2) direct traction more and more anteriorly as the head extends and erupts through the vulvar ring (Fig. 23.21);

3) make movements with one right hand and support the perineum with the left;

4) when the head is completely removed from the birth canal, open the lock and remove the forceps.

Rice. 23.21. Removing the head using forceps

Which difficulties can meet at administered spoons And

How their eliminate?

When inserting spoons, the following difficulties may occur:

1) the top of the spoon rests on something and does not move deeper, which may be due to the top of the spoon getting into the fold of the vagina or, more dangerously, into its vault. In such cases, with the fingers of the guide hand you need to find where the top of the spoon rests and go around this obstacle; Under no circumstances should you overcome an obstacle by force. To avoid this complication, the guide arm should be inserted to a sufficient depth in advance;

"Obstetrics in Questions and Answers"

2) it is impossible to move the guide hand deep enough, since the space between the head and the side wall of the pelvis is too narrow.

In such cases, it is necessary to insert the guide hand somewhat posteriorly, closer to the sacral cavity, and insert the spoon of forceps in the same direction. To place the spoon in transverse size pelvis, it should be moved. To do this, acting with a guide hand on the back edge of the spoon, move it forward and shift it in the desired direction and to the required distance.

Which difficulties can meet at short circuit forceps

And How their eliminate?

When closing the forceps, the following difficulties may occur:

1) the lock does not close because the spoons are not placed on the head in the same plane. You need to insert your fingers into the vagina and correct the position of the spoon;

2) the lock does not close because one of the spoons is inserted higher than the other. It is necessary to insert deeper the spoon that was not inserted deeply enough; this movement should be carried out under the control of a half-arm, which is inserted into the vagina for this purpose;

3) the lock has closed, but the handles of the tongs diverge greatly. This happens because the spoons did not lie across the diameter of the head, but grabbed it obliquely. To eliminate this, you need to correct the position of the spoons on the head. You should remove the spoons and perform a repeated vaginal examination to accurately

but determine the position of the head and apply the forceps again. A strong divergence of the ends of the handles can also be the result of the fact that both spoons are not inserted high enough and the head curvature does not adhere to the head along its entire length. Which difficulties can meet at extracting heads And How their eliminate?

When removing the head, you may encounter the following difficulties:

1) it is difficult to determine in which direction to perform traction. It is necessary to force the woman in labor to push: the movement of the handles will show where the attraction should be directed at the moment;

2) the head does not move along the birth canal, despite several tractions performed. This difficulty in removing the head can occur almost exclusively as a result of incorrect direction of traction. You should repeat the examination to check the position of the head in the pelvis and, if necessary, correct the position of the spoons. If the head still does not move, brute force should not be used;

3) spoons slip off the head. This is very formidable complication. If it is not noticed in time, the spoons can fall off the head and cause serious injury to the mother in labor. In order to timely notice the slipping of the forceps from the head, you should, in addition to the test attraction, re-check the position of the head in the pelvis and the position of the spoons on the head. Sometimes slipping of the forceps is indicated by the fact that their handles begin to diverge.

Weekend forceps

Output forceps are called forceps, applied to the head located at the outlet of the small pelvis with an arrow-shaped suture in the direct size of the latter.

"Obstetrics in Questions and Answers"

How located head By data vaginal research?

The internal rotation of the head is completed. The head stands on the pelvic floor, the entire sacral cavity, including the coccyx area, is occupied by the head, the ischial spines are not reached. The largest circle is in the exit plane,

threaded by the head, sagittal suture - in the direct size of the exit from the pelvic cavity. The small fontanel is determined below the large one (the head is bent - occipital insert) and is located in front (anterior view) or behind (rear view).

How introduce spoons?

Spoons are inserted according to the rules described earlier: first, the left spoon is inserted into the left side of the mother's pelvis, then the right spoon is inserted into the right side. The left branch is held with the left hand, the right branch with the right. When inserting the left spoon, the guide hand is the right half-hand and vice versa. Spoons are inserted in the transverse dimension of the pelvis. The handles of the forceps are located horizontally (Fig. 23.22).

How spoons capture head And How They on her are located?

The spoons grasp the head across and are positioned from the back of the head through the ears to the chin. The line that forms a mental continuation of the handles of the forceps rests on the leading point in the occipital presentation.

IN which direction produce attraction at front form

occipital presentation?

To imagine all the features of attraction, you need

Rice. 23.22. Exit tongs. Occipital presentation, anterior view

remember the movements that the head makes as it passes through the outlet of the pelvis front view occipital presentation (biomechanism of childbirth).

The head moves slightly downwards and reaches the pelvic floor. The back of the head appears more and more from the genital slit. The suboccipital fossa fits under the lower edge of the symphysis. After this, the head begins an extension movement and first the crown is born, then the forehead and face. It follows from this that attraction must first be carried out downwards and anteriorly until the suboccipital fossa approaches the lower edge of the symphysis. Then the drives are directed more and more anteriorly, as a result of which the head unbends and erupts in a circle passing through the small oblique size.

IN which direction produce attraction at rear form

occipital presentation?

Tractions are produced in horizontal direction until the anterior edge of the greater fontanel is in contact with the lower edge of the symphysis pubis (first point of fixation). Then traction is performed anteriorly until the area of ​​the suboccipital fossa is fixed at the apex of the coccyx (second point of fixation). After this, the handles of the forceps are lowered backwards - the head is extended and the fetus is born from under the pubic symphysis of the forehead, face and chin.

Cavity forceps

Abdominal forceps are called forceps that are applied to the head located in the pelvic cavity (in its wide or narrow part) with an arrow-shaped suture in one of the oblique sizes. The head will have to complete the internal rotation in the forceps and perform extension (in the anterior view of the occipital presentation) or additional flexion and extension (in the posterior view of the occipital presentation). Due to the incompleteness of the internal rotation, the swept seam is in one of the oblique dimensions. Obstetric forceps are applied in the opposite oblique size so that the spoons grasp the head in the area of ​​the parietal tuberosities. Applying forceps in an oblique manner presents some difficulty -

"Obstetrics in Questions and Answers"

ness. More complex than exit obstetric forceps are tractions, in which the internal rotation of the head is completed by 45° or more, and only then does extension of the head follow. Therefore, abdominal forceps are atypical, since with a given position of the head, in addition to traction, they also produce atypical function - rotation of the head.

Occipital presentation, first position, front view

How define location heads By data vaginal research?

The fetal head with its greatest circumference is located in the wide or narrow part of the pelvic cavity and fills the sacral cavity to the middle or completely. The sagittal suture is located in the right oblique dimension of the pelvis. The small fontanel is determined to the left (first position), anteriorly (anterior view) and below (the head is bent - occipital presentation) in relation to the large fontanel; the ischial spines are reached easily (the fetal head in the wide part of the pelvic cavity) or with difficulty (the fetal head in the narrow part of the pelvic cavity).

How impose forceps?

In order for the head to be covered biparietally by the spoons of the forceps, they should be applied in the left oblique dimension of the pelvis, since the sagittal suture is in the right oblique dimension.

How introduced And placed first (left) spoon?

When applying abdominal obstetric forceps, the order of insertion of the spoons is maintained. The left spoon is inserted under the control of the right guiding hand to the left and somewhat posteriorly, i.e., into the posterior-not-lateral part of the pelvis. The spoon is located on the area of ​​the left parietal tubercle of the head. This spoon is called fixed, since after insertion it is immediately located in the right place.

How introduced And placed second (right) spoon?

The right spoon should lie on the head on the opposite side, in the anterolateral part of the pelvis, where it cannot be inserted immediately, since the pubic arch prevents this. This obstacle is overcome by moving (“wandering”) the spoon. The right spoon is inserted in the usual way into the right

half of the pelvis, then, under the control of the left hand inserted into the vagina, the spoon is moved anteriorly until it is positioned in the area of ​​the right parietal tubercle. The spoon is moved by gently pressing on its lower edge with the second finger of the left hand. In this situation, the right spoon is called “vagus”.

Thus, the spoons lie opposite each other in the left oblique dimension of the pelvis (Fig. 23.23). In the first position of the anterior view of the occipital presentation, the left spoon is always “fixed”, the right one is “wandering”.

IN which direction produce traction?

Traction is performed downwards and backwards, the head makes an internal rotation, the sagittal suture gradually turns into the straight size of the pelvic outlet. Next, traction is directed first downwards until the occipital protuberance emerges from under the pubis, then forwards until the head is extended.

"Obstetrics in Questions and Answers"

Rice. 23.23. Cavity forceps. Occipital presentation, first position, anterior view

Occipital presentation, second position, front view

How located head?

The head is positioned in the same way as in the first position, only the sagittal seam is in the left oblique size; the small fontanelle is determined on the right (second position),

below (anterior view) and below (occipital presentation) in relation to the large fontanelle.

How impose forceps?

The forceps should be applied in the right oblique dimension, since the sagittal suture is located in the left oblique dimension.

How introduce And place spoons?

The left spoon is inserted first into left half pelvis, and then it is moved anteriorly to the anterolateral pelvis (vagus spoon). The right, fixed spoon is immediately inserted into the right posterolateral pelvis. Thus, the spoons are placed in the right oblique dimension of the pelvis biparietally (Fig. 23.24).

IN which direction produce attractions?

The movements are performed in exactly the same way as in the anterior view of the first position, only the head, together with the forceps, will rotate clockwise rather than counterclockwise as it moves forward.

Rice. 23.24. Cavity forceps. Occipital presentation, second position, anterior view

What are outcomes operations overlays obstetric forceps?

The use of obstetric forceps, subject to the conditions and technique, usually does not cause any complications for the mother and fetus. In some cases, this operation may cause some complications.

Which can be complications And By Which reason?

When performing the operation of applying obstetric forceps, the following complications may occur.

Damage generic ways. These include ruptures of the vagina and perineum, and less commonly, the cervix. Severe complications include ruptures of the lower segment of the uterus and injuries pelvic organs: bladder and rectum, usually occurring when the conditions for surgery and the rules of technique are violated. TO rare complications include damage to the bone birth canal - rupture of the pubic symphysis, damage to the sacrococcygeal joint.

Complications For fetus After surgery, swelling with a cyanotic color is usually observed on the soft tissues of the fetal head. With strong compression of the head, hematomas can occur. Strong pressure from a spoon on the facial nerve can cause paresis. Severe complications are damage to the bones of the fetal skull, which can be varying degrees- from bone depression to fractures. Great danger for the life of the fetus are cerebral hemorrhages.

Postpartum infectious complications. Delivery using obstetric forceps is not the cause of postpartum infectious diseases, however, it increases the risk of their development, and therefore requires adequate prevention of infectious complications in the postpartum period. Complications may be related and depend on whether pathological process or conditions of the woman in labor that were an indication for the application of obstetric forceps.

"Obstetrics in Questions and Answers"

Vacuum extraction fetus

What called operation vacuum extraction fetus?

Vacuum fetal extraction is a delivery operation performed to extract the fetus by the head using a special device - a vacuum extractor by creating negative pressure between the inner surface of the device's cup and the fetal head (Fig. 23.25).

What are readings To operations vacuum extraction fetus?

Unlike the operation of applying obstetric forceps,

kuum-extraction of the fetus requires the active participation of the woman in labor during traction of the fetus by the head, so the list of indications is very limited.

In general, the aphorism remains true: "Vacuum extraction - operation performed then when time For Caesarean sections already passed (endometritis), and For obstetric forceps more Not it has arrived."

Indications for vacuum extraction of the fetus:

Weakness of labor, not amenable to conservative therapy;

The onset of fetal hypoxia.

What are contraindications To operations vacuum extraction

fetus?

Contraindications to the use of vacuum fetal extraction surgery are as follows:

1) discrepancy between the sizes of the pelvis and the fetal head;

2) gestosis (nephropathy, preeclampsia, eclampsia);

3) diseases of the woman in labor that require “switching off” pushing (decompensated heart defects, hypertension, lung diseases, high degree of myopia, etc.);

4) extension presentation of the head;

5) severe prematurity of the fetus (up to 36 weeks).

The last two contraindications are associated with the peculiarity of the physical action of the vacuum extractor, so placing a cup on the head of a premature fetus or in the area of ​​a large fontanel is fraught with serious complications.

What are conditions For execution operations vacuum extraction?

To perform a vacuum extraction operation, the following conditions are required:

1) presence of a living fetus;

2) location of the head in the small pelvis;

3) complete opening of the uterine os;

4) absence of amniotic sac;

5) correspondence between the sizes of the pelvis and the fetal head;

6) occipital presentation of the fetus.

What is Preparation To operations?

Preparation for surgery corresponds to that for applying obstetric forceps (see “Obstetric forceps”).

What are methods pain relief?;

When performing a vacuum extraction operation, the active participation of the woman in labor is necessary, so anesthesia is not indicated. You can perform epidural or pudendal anesthesia.

What need to do directly before operation?

Immediately before the operation, it is necessary to perform another vaginal examination to clarify the obstetric situation: the degree of dilation of the uterine pharynx, the height of the head, the nature of the insertion of the head.

From what moments is composed technique operations vacuum extraction?

The technique of vacuum extraction of the fetus by the head consists of the following points:

"Obstetrics in Questions and Answers"

1) insertion of the cup and placing it on the head;

2) creation of negative pressure;

3) attraction of the fetus to the head;

4) removing the cup.

How introduced cup vacuum extractor?

A vacuum extractor cup size from No. 5 to No. 7 can be inserted in two ways:

Rice. 23.25. Vacuum extractor

1) under hand control;

2) by exposing the head using mirrors (under visual control).

Most often in practice, the cup is inserted under hand control. To do this, under the control of the left guide hand, insert a cup into the vagina with the right hand, bring it to the head and press it against it (Fig. 23.26). We must try to place the cup closer to the small fontanel. You cannot apply it to a large fontanel.

How create negative pressure?

To create negative pressure, it is necessary to connect the hoses from the cup and the vacuum device, create a tightness in the system with a hand pump, gradually bringing the negative pressure to 500 mm Hg. Art. according to the readings of the pressure gauge connected to the system.

How produce traction?

With one hand, the obstetrician grabs the hose near the cup or behind special device, located at the junction of the hoses, and simultaneously with pushing, produces traction in the direction corresponding to the mechanism of birth of the head, i.e., depending on the location of the head in the small pelvis (Fig. 23.27). During the pauses between attempts, no attraction is produced. When cutting through the vulvar ring of the parietal tubercles, the calyx is removed by breaking the seal in the apparatus. Subsequently, the head is removed by providing manual assistance.

Which can be complications at execution this operations?

Most a common complication is the slipping of the cup from the head, which occurs when the technique is violated, the strength of attraction increases, or the tightness in the apparatus is broken. If the cup slips, you can try to apply it a second time, but if the cup slips again, you cannot continue the operation and delivery by another method is necessary.

The fetus is sometimes subject to trauma: cephalohematomas are observed on the fetal head, brain symptoms, convulsions, etc. occur. The causes of such complications are violation of the technique of performing the operation, untimely use of it, as well as the severity of the pathological

Rice. 23.26. Applying the vacuum extractor cup

Rice. 23.27. Traction with a vacuum extractor

condition of the woman in labor, which served as an indication for surgery.

Obstetric forceps are an instrument that replaces the missing or missing force of uterine contractions during childbirth. Obstetric forceps serve as an extension of the obstetrician’s hands (“iron hands” of the obstetrician).

The application of obstetric forceps is one of the most important and responsible operations in the practice of an obstetrician. In terms of technical difficulty, the operation occupies one of the first places in operative obstetrics. When applying obstetric forceps, it is possible various damages and complications.

Device of obstetric forceps - see Obstetric and gynecological instruments. The most common model in the USSR is the English Simpson obstetric forceps modified by N. N. Fenomenov. In some obstetric institutions, Russian obstetric forceps by I.P. Lazarevich are used - without pelvic curvature (straight forceps) and with non-crossing spoons (forceps with parallel spoons); Kielland obstetric forceps (a widely used model abroad) are built according to the type of forceps of I.P. Lazarevich.

The main action of obstetric forceps is purely mechanical: compression of the head, straightening and extraction. Compression of the head, inevitable when applying forceps, should be minimal, in any case not exceed that observed during childbirth with the natural configuration of the head. Otherwise, the bones, blood vessels and nerves of the fetal head will inevitably suffer. Obstetric forceps are only a grasping and attracting instrument, but in no way correct incorrect presentation and insertion of the head.

Indications and contraindications. Previously, obstetric forceps were applied at the personal discretion of the obstetrician, but now certain indications for their application have been developed. Obstetric forceps are applied in cases where it is necessary to quickly complete childbirth in the interests of the mother, the fetus, or both together: with eclampsia, premature placental abruption, umbilical cord prolapse, incipient fetal asphyxia, maternal diseases complicating the course of the expulsion period (heart defects, nephritis), febrile condition, etc. In case of secondary weakness of labor, obstetric forceps are used in cases where the period of expulsion in first-time mothers lasts more than 2 hours. (3-4 hours), and for multiparous women - more than an hour.

It is necessary to strictly take into account contraindications to the use of obstetric forceps. They follow from following conditions conditions for which this operation can be used: the pelvis is sufficiently large to allow the head to pass through - the true conjugate must be at least 8 cm; the fetal head should be neither excessively large (hydrocephalus, severe post-term pregnancy) nor too small (forceps should not be applied to the head of a fetus less than 7 months old); the head should stand in the pelvis in a position convenient for applying obstetric forceps (a movable head is a contraindication); the cervix should be smoothed, the uterine os should be fully open, its edges should extend beyond the head; the amniotic sac must be ruptured; the fetus must be alive.

Among the listed conditions, the height of the head in the pelvis is especially important. For practical work can be used the following diagram determining the location of the head. 1. The head stands above the entrance to the small pelvis (Fig. 1), easily moves when pushed, returning back (balloting). Application of forceps is contraindicated. 2. The head entered the pelvis as a small segment (Fig. 2). Its largest circumference (biparietal diameter) is located above the entrance to the pelvis. The cervico-occipital groove stands three transverse fingers above the symphysis; the head has limited mobility, slightly fixed. During vaginal examination, the promontory is accessible to the examining finger; sagittal suture - in the transverse or slightly oblique size of the pelvis. Forceps should also not be used. 3. The head is at the entrance to the pelvis with a large segment (Fig. 3); with a biparietal diameter it passed the entrance to the pelvis, motionless; The cervico-occipital groove stands two fingers above the symphysis. During vaginal examination, the promontory cannot be reached; the head is occupied in front - the upper edge and upper third the posterior surface of the symphysis pubis, behind - the promontory and the inner surface of the first sacral vertebra. The arrow-shaped seam is in one of the oblique sizes, sometimes closer to the transverse one. Wire point almost reaches the line main plane passing through the lower edge of the symphysis. It is not recommended to use forceps, especially for a novice obstetrician (high forceps). 4. The head is in the wide part of the pelvic cavity (Fig. 4); its greatest circumference passed the plane of the wide part of the cavity, the cervico-occipital groove - approximately one finger above the symphysis. During vaginal examination, the ischial spines are reachable, the sacral cavity is almost complete, the promontory cannot be reached. The wire point almost reaches the spinal line, the sagittal suture is oblique. III and IV can be easily palpated sacral vertebrae and tailbone. Application of forceps is permitted (atypical forceps, difficult operation). 5. The head is in the narrow part of the pelvic cavity (Fig. 5); It is not defined above the entrance to the pelvis (the cervico-occipital groove is level with the height of the symphysis). During vaginal examination, the ischial spines are not identified, the sacrococcygeal joint is free. The head comes close to the pelvic floor, its biparietal size occupies the plane of the narrow part of the pelvic cavity. Small fontanelle (wire point) - below the spinal line; the head has not yet completely completed rotation, the sagittal suture is in one of the oblique dimensions of the pelvis, closer to the straight one. Forceps may be applied. 6. Head at the pelvic outlet (Fig. 6). It and its cervico-occipital groove above the entrance to the pelvis are not defined. The head has completed internal rotation (rotation), the sagittal suture is in the direct size of the pelvic outlet. Favorable conditions for applying forceps (typical forceps).

“Obstetric forceps” is the conventional name for the operation of extracting the fetus by applying special forceps to the presenting part.

In the Soviet Union, the Simpson-Fenomenov model of forceps was most common (see).

Indications. Application of obstetric forceps is indicated when required quick ending childbirth in the interests of the mother or fetus, more often than both of them (threatening, weakness of labor during the expulsion period, turning off pushing during, etc. Conditions for the operation: sufficient size of the pelvis (true conjugate at least 8 cm); full opening of the uterine pharynx; motionless, standing the head is convenient for applying obstetric forceps; the head is of sufficient size (should not be too large or too small); torn; alive (the latter is conditional).

Preparing for surgery. Obstetric forceps are applied with the woman in the supine position on or on the Rakhmanov bed; The legs should be brought towards the stomach, held by an assistant (or held with a leg holder). Before the operation, the woman needs to empty her bladder and bowels (cleansing enema). Toilet the external genitalia. Obstetric forceps are applied, usually under anesthesia.

Types of obstetric forceps. Depending on where in the pelvis (in the inlet, cavity or outlet) the fetal head is located, exit or typical obstetric forceps are distinguished [the head, having completed rotation (internal rotation), is located at the bottom of the pelvis, it is better if it is at the exit]; cavity, or atypical (the head in the pelvic cavity with incomplete rotation), and the so-called high (the height of atypicality) obstetric forceps (the head, with the help of forceps, must go through the entire mechanism of childbirth). The application of high forceps is not performed in routine obstetric practice.

Technique for applying output (typical) obstetric forceps. The exit obstetric forceps are applied by an obstetrician. Before applying obstetric forceps, it is necessary to first perform a thorough vaginal examination of the woman in labor (to determine the degree of opening of the uterine pharynx, the condition of the amniotic sac, the position of the sagittal suture and fontanelles). If you have insufficient knowledge of the technique, it is necessary to perform a vaginal examination with a half-hand (thumb outside the genital opening).

The exit forceps are placed on the head, which has performed all the rotating movements: the small fontanel is located under the symphysis, the sagittal suture is in the direct size of the pelvic outlet, the head is on the bottom of the pelvis, performing the entire sacral cavity. Output (typical) forceps are applied in the transverse dimension of the pelvis and on the transverse (biparietal) dimension of the head.

Introduction of spoons. The left spoon is always inserted first. When closing the forceps, it should lie under the right one (otherwise closing will be difficult). In order not to make a mistake in choosing a spoon, before insertion you should fold the forceps and, holding the handles with both hands, place them in front of you so that both spoons are next to each other: the left one is on the left, the right one is on the right (Fig. 1). The spoon is taken with the left hand, held like a pen or bow (you cannot grab the spoon with your entire hand, as this can develop great force and cause injury to the mother and fetus). Before inserting the left tray, four (not two) fingers of the right hand (control hand) are inserted to control and protect the soft tissues. The fingers of the control hand must be inserted so that they extend beyond the parietal tubercles of the fetal head.

Rice. 1. Tongs and folded.

Grasping the handle of the left spoon with your left hand, place its lower edge in the groove between the middle and index fingers. Rear end The lower edge of the spoon lies on the outstretched thumb. The end of the spoon (its top) should be directed forward, towards the mother. The handle of the spoon should be held in an elevated, close to vertical position, parallel to the right inguinal fold of the woman in labor.

The forward movement of the spoon of the tongs should be carried out mainly due to the force of its gravity; Progress can be partly helped by placing the thumb of the control right hand on the outside (lightly pushing on the lower edge of the spoon) and the same light and careful pushing of the handle. With the remaining fingers of the right (control) hand, inserted inside, direct the spoon of the forceps forward so that it rests on the head from the side, in the plane of the transverse dimension of the pelvic outlet. The correct position of the inserted spoon in the pelvis can be judged by Busch hooks: they must stand strictly in the transverse dimension of the pelvic outlet.

The spoon must certainly go beyond the ends of the fingers of the control hand, that is, beyond the parietal tubercle. The spoon must be inserted with great care, easily, without any force.

The handle of the inserted spoon is passed to an assistant, who must hold it in this position. Any use of a spoon can lead to complications in the future.

The right spoon of obstetric forceps is inserted in the same way as the left one: with the right hand - to the right side, under the protection of the fingers inserted into the left hand. The right spoon of the tongs should always lie above the left. It is more difficult to insert the right spoon than the left one. This is often explained by the fact that the handle of the left spoon is not lowered down enough, towards the perineum. [The expressions “anterior”, “posterior”, “right”, “left” are applied to the vertical (“standing”) position of a woman: “anterior” - to the symphysis, “posterior” - to the sacrum, “right”, “left” - to the side of the woman in labor, regardless of the position of the doctor.]
Closing (closing) obstetric forceps. Before closing the obstetric forceps, you need to check whether the skin of the perineum or the vaginal mucosa is caught in the lock. For proper closure, the handles of the pliers must lie in the same plane and parallel.

Test traction. To ensure that traction is applied correctly. To do this, the left hand should be placed on top of the right; her extended index finger should be in contact with the fetal head in the area of ​​the small fontanelle (Fig. 2). During traction, the head should follow the forceps and index finger left hand.

The head is removed using obstetric forceps (traction itself) while standing. With the right hand, located on the handle and in the area of ​​the Bush hooks, energetic attraction (traction) is applied. The left hand should be placed on top, with the index finger in the recess located near the lock. In this position, it provides energetic assistance to the right during traction. The forceps together with the head should move along the wire line of the pelvis, that is, change direction, gradually moving forward and upward (along an arc). Traction is performed along an arc until the back of the head and the suboccipital fossa appear. It is not allowed to do joint traction with four hands (two at once or in shifts, one after the other). If 8-10 tractions do not give success, further tractions should be abandoned. When removing the head with forceps, you need to imitate natural contractions, alternating traction with pauses. Each traction begins slowly, gradually increasing its strength and, having reached a maximum, goes into a pause, reducing the strength of traction. Pauses should be long enough.

Rice. 2. Test traction.

When extracting the head using forceps, you should not make any rocking, rotating, or pendulum-like movements - in which direction the traction began, it should be completed. To prevent unnecessary, sometimes excessive squeezing of the head, it is recommended to place a towel folded in several layers between the handles of the spoons of the tongs.

Passing the head under the symphysis and removing it. The head is passed under the pubic arch so that it rolls over the suboccipital fossa (rotation point). In this case, the head moves from a bent position to an extension position (Fig. 3). Traction is done in a horizontal direction until the back of the head appears and the suboccipital fossa reaches the lower edge of the symphysis. At this moment, they begin to remove the head. To do this, stand on the right side of the woman in labor, grab the forceps with your left hand, and protect the perineum with your right while the head is cutting through. Carefully, slowly, centimeter by centimeter, slightly pulling the head with tongs, lift the handle of the tongs upward.

Rice. 3. Removal of the head.

Removing the forceps (opening). The forceps are removed after the head is outside the genital slit (birth of the head). They are carefully opened by pushing both spoons apart. Each spoon is taken into the hand of the same name and removed in the same way as they were applied, but in reverse order, that is, the right spoon, describing an arc, is taken to the left inguinal fold, the left - to the right. The spoons should slide smoothly, without jerking. After removing the head, the fetal body is removed according to the general rules (see).

Cavity forceps, or atypical ones, can only be applied by an obstetrician. In these cases, forceps are applied to the head, which is located almost at the bottom of the pelvis. In the forceps, the head must complete internal rotation (rotation), cutting and cutting. When the head is positioned in an oblique size of the pelvis, forceps are applied only in an oblique size. When applying them, the same rules apply as when applying exit forceps; it is only important to accurately determine which of the oblique dimensions of the pelvis (right or left) the fetus is located in. On the head, standing with an arrow-shaped suture in one of the oblique dimensions, forceps are applied in the opposite oblique dimension. The second feature of applying forceps to the head, which is located in the oblique size of the pelvis, concerns the technique of inserting spoons. One spoon is inserted behind the head and left here - this is the back, or fixed, spoon. Another spoon is first inserted from behind, and then a 90° arc is made to reach the parietal tubercle lying in front. This is the so-called wandering spoon. Depending on the position of the arrow-shaped seam, either the right or the left spoon will be fixed (back): in the first (left) position (arrow-shaped seam in the right oblique size), the left spoon will be fixed, in the second (right) position (arrow-shaped seam in the left oblique size ) - right. The spoons should be placed so that their ends are always facing the wire point (forward).

Management of the postpartum mother and newborn after applying forceps. After the application of obstetric forceps, injuries and ruptures of the cervix, vagina, perineum, etc. often occur, so after childbirth it is necessary to carefully examine the soft birth canal. Tears must be sewn up.

Currently, a new delivery device has been introduced into obstetric practice - a vacuum extractor (see), which is more gentle and gentle than obstetric forceps.

After childbirth, a woman must follow a regimen as after an obstetric operation (see). A child sent to the nursery should receive the same care as children born after a difficult birth or surgery receive (see).

OBSTETRIC FORCEPS (forceps obstetricia) - 1) an operation of artificial extraction of a live full-term or almost full-term fetus by the head (rarely by the buttocks) with urgent need finish the second stage of labor using a special tool - obstetric forceps; 2) obstetric instrument. The design of obstetric forceps and their various models - see Obstetric and gynecological instruments.

The first description of obstetric forceps was made in the second edition of Heister's manual of surgery (L. Heister, 1683-1758), published in Holmstedt in 1724. (see Obstetrics). The purpose of obstetric forceps is to replace the expelling force of the uterus and abdominal press of a woman in labor with the attracting force of the doctor. Obstetric forceps are only a retraction instrument, not a rotational or compression instrument. The known compression of the head, inevitable when applying obstetric forceps, should be minimal.

More or less compression of the head depends on whether the obstetric forceps are applied correctly and whether the direction of the drive corresponds to the mechanism of fetal birth. Excessive compression of the head with obstetric forceps is dangerous for the life of the fetus (fractures of the skull bones, hemorrhage in the brain).

Indications, conditions and contraindications for the operation of applying obstetric forceps. The application of obstetric forceps is indicated in all cases where the mother, the fetus, or both are in danger during the expulsion period, which can be eliminated by immediate removal of the fetus. Indications may include: insufficiency of labor (in case of secondary weakness of labor forces, obstetric forceps should be applied if the expulsion period for primiparous women lasts more than 2 hours, and for multiparous women - more than one hour); severe nephropathy and eclampsia that cannot be eliminated by appropriate conservative treatment; premature placental abruption; diseases of the mother without stable compensation or remission (endocarditis, heart defects, hypertension, nephritis, pneumonia, tuberculosis and others); febrile state parturients with high fever, fetal hypoxia. Certain conditions are required to apply obstetric forceps. The dimensions of the pelvis must be sufficient for the passage of the head removed with forceps. Forceps can only be applied when the external pharynx of the cervix is ​​fully dilated (the insertion of spoons and especially the removal of the head when the pharynx is not fully dilated inevitably leads to rupture of the cervix and lower segment of the uterus).

Before applying obstetric forceps, the obstetrician must clearly understand in which part of the pelvis (cavity or outlet) the fetal head is located and what its position is. The forceps can be applied to the fetal head, standing as a large segment in the cavity (the wide and narrow part of it) or at the pelvic outlet. If the fetal head has dropped into the cavity or to the pelvic floor, this is convincing evidence no discrepancy between the sizes of the pelvis and the fetus, except in very rare cases of a funnel-shaped pelvis (it is important to measure the plane of exit of the pelvis!). Forceps should, as a rule, only be used for cephalic presentations. The head should not be too large (hydrocephalus) or too small (forceps should not be applied to the head of a fetus less than 7 months old), it should have normal density (otherwise the forceps will slip off the head during attraction). Amniotic sac must be torn and the membranes tucked behind the largest circumference of the head: the forceps do not hold well on the membranes, and if they do, the attraction to the membrane will cause premature abruption of the placenta. The fetus must be alive. If the fetus is dead, then the operation of craniotomy rather than forceps is less traumatic for the mother. Obstetric forceps should not be used if there is a threatening or existing uterine rupture, as well as with a posterior view of the facial presentation (chin posterior).

Preparation for the operation of applying obstetric forceps and pain relief

Before applying obstetric forceps, it is necessary to carry out an internal examination and accurately determine the location of the head, the wire point of the head, navigate the position of the sagittal suture, the degree of opening of the external pharynx of the cervix, etc. When applying obstetric forceps, it is desirable to use inhalation anesthesia (see). When exiting obstetric forceps, you can limit yourself to bilateral anesthesia of the pudendal nerves or intravenous administration epontola. Obstetric forceps are applied with the woman in labor on her back; it must be laid on operating table or a Rakhmanov bed with legs brought to the stomach, held by assistants; in the absence of the latter, leg holders are used. The bladder is emptied using an elastic catheter. For this purpose, when the presenting part is low, insert 2-3 fingers of the right hand into the vagina between the symphysis and the head, with the back surface to the pubis, spread the fingers slightly and try to carefully insert a catheter into the urethra. A metal catheter should not be inserted, as this may damage the urethra. Thoroughly disinfect the external genitalia, top part inner thighs and tissue in the perineal area.

General principles of applying obstetric forceps with pelvic curvature (the most commonly used is the Fenomenov-Simpson model). When applying forceps, first of all, it is necessary to clearly and accurately know the mechanism of fetal birth and remember three basic rules: 1) the forceps must capture the largest surface of the head, the tops of the spoons of the forceps must extend beyond the parietal tubercles; Failure to comply with this rule may result in the spoons of the tongs slipping; 2) the forceps should be applied so that the tops of their spoons are directed towards the wire point, and the concavity of the pelvic curvature of the instrument is facing the pubis; 3) the tongs must be locked in such a way that the wire point is always in the plane of the head curvature of the instrument, that is, by placing the locking parts of the tongs in the same plane, their handles should be connected so that the spoons grip the proper surface of the head.

Depending on the height of the head, the forceps can be closed: a) directly on the obstetrician (horizontally); b) with the handles raised anteriorly (upwards); c) with the handles lowered backwards. Obstetric forceps can be applied typically and atypically. Typical A. shch. applied to the fetal head, which has completely completed the internal rotation (rotation), to its transverse (biparietal) size and in the transverse size of the pelvis. Such obstetric forceps are also called output forceps, since the head is located at the outlet of the pelvis. With typical obstetric forceps, the head is grasped in the temporoparietal region. With this grip, the above three rules for applying forceps are observed. Obstetric forceps, which have to be applied to the head, which has not yet completed rotation, located in the pelvic cavity (in its narrow or wide part), are called atypical, or cavitary. Atypical obstetric forceps have to be applied: 1) to the head, which has not completely completed the internal rotation (the sagittal suture is located in one of the oblique dimensions of the pelvis); 2) with a low transverse position of the head. When applying atypical obstetric forceps, one general rule should be followed: they must be applied in the oblique size of the pelvis, opposite the sagittal suture or facial line. If the sagittal suture is located in the left oblique dimension, then the spoons of the forceps are located in the right oblique dimension and vice versa. In both cases, the forceps grasp the head in the ear area (perfect capture). When the transverse position of the head is low, obstetric forceps with pelvic curvature are applied according to the general rule: in one of the oblique dimensions where the wire point is deviated - the small (posterior) fontanel. The forceps grasp the parietal tubercle and temporal region. This capture of the head is not perfect, but it manages to meet the requirement that the pelvic curvature of the forceps and the birth canal almost coincide. High forceps are atypical when they grasp and try to remove the fetal head located above or at the entrance to the pelvic cavity. Currently, high obstetric forceps are not used, since this operation is very difficult and traumatic for the mother and fetus. In cases where it is necessary to quickly complete childbirth with this position of the head, they resort to a cesarean section (see) or vacuum extraction (see) of the fetus.

Technique for applying obstetric forceps with pelvic curvature (general rules). The technique of applying both typical and atypical obstetric forceps includes the following five points: 1) insertion of spoons; 2) closing the forceps; 3) test traction; 4) traction itself (pulling the head with forceps); 5) removing the forceps. Positive result The operation can only be guaranteed if a thorough study of the purpose, purpose and technique of each of these points is carried out.

The first moment of the operation. The left spoon is introduced first. When closing the tongs, it must lie under the right one, otherwise closing the tongs will be difficult, since a significant part of the lock (pin, pin, plate) is always on the left spoon. In order not to make a mistake when choosing a spoon, you should make it a rule to fold the forceps before insertion (Fig. 1) in order to clearly see which of the spoons is the left and which is the right. Then the obstetrician spreads the genital slit with his left hand and inserts four fingers of his right hand into the vagina along its left wall.

If the edges of the external os of the cervix are still preserved, then it is necessary to determine the gap between its edges and the head. Next, with the left hand they take (like a pen or a bow) the handle left branch forceps and lift the handle anteriorly and to the right inguinal fold of the woman in labor so that the tip of the spoon of the forceps enters the genital slit according to its longitudinal (antero-posterior) diameter. The lower edge of the spoon rests on the thumb of the right hand. The spoon is inserted into the genital slit, pushing its lower rib with the thumb of the right hand and under the control of the fingers inserted into the vagina (Fig. 2). The spoon should slide between your index and middle fingers. When inserted correctly, the spoon should lie so that the head curvature of the forceps does not capture the edge of the pharynx and fits well to the head; the insertion of the obstetrician's right hand is intended to control the advancement of the spoon. As the spoon moves into the birth canal, the handle of the forceps should approach the midline and descend posteriorly. The spoon must be inserted with great care, easily, smoothly, without any violence. The correct position of the spoon in the pelvis can be judged by the fact that the Bush hook is positioned strictly in the transverse dimension of the pelvic outlet (in the horizontal plane). The inserted left spoon must certainly go beyond the ends of the fingers, therefore, beyond the parietal tubercle, located in the temporo-parietal region of the head. If the spoon is inserted deep enough, the lock is close to the external genitalia. When the left spoon fits well on the head, its handle is handed over to the assistant. The right (second) spoon of the forceps is inserted in the same way as the left one (Fig. 3), with the right hand to the right side under the protection of the fingers of the left hand inserted into the vagina.

The second moment of the operation. To close the pliers, each handle is grasped with the same hand so that the thumbs are located on the Bush hooks. After this, the handles are brought together and the forceps are easily closed (Fig. 4). Correctly applied obstetric forceps tightly grasp the head along its large oblique size (in the direction from the back of the head through the ears to the chin) - biparietally. The sagittal suture occupies a mid-position between the spoons, the curved tops of which are directed anteriorly, the leading point of the head (posterior fontanel) is in the plane of the forceps (Fig. 5). The inner surfaces of the handles of the pliers should be close to each other (or almost close). A sterile napkin folded 2-4 times is placed between the handles; This ensures good alignment of the spoons of the forceps to the head and avoids the possibility of excessive compression in the forceps. Having closed the tongs, you should make thorough examination whether they have captured the soft tissues of the birth canal.

The third moment of the operation. Test traction allows you to once again verify the correct application of the forceps (whether the head follows the forceps). To do this, the obstetrician grabs the handles of the forceps with his right hand from above so that the index and middle fingers lie on the Bush hooks. Simultaneously left hand he places it on the back surface of the right one, with the end of the extended index or middle finger touching the head (Fig. 6). If the forceps are applied correctly, then during the attraction process the fingertip will always be in contact with the head. Otherwise, it slowly moves away from the head, the distance between the lock of the tongs and the head increases, and their handles diverge: the tongs begin to slip and they must be immediately repositioned.

The fourth moment of the operation. After making sure that the forceps are applied correctly, they begin to extract the fetus with forceps (traction itself). To do this, the index and ring fingers of the right hand are placed on the Bush hooks, the middle finger is placed between the diverging branches of the forceps, and the thumb and little finger cover the handles on the sides. The left hand clasps the handles from below (Fig. 7). The main traction force is developed by the right hand. When extracting a fetus using obstetric forceps, it is necessary to carry out all manipulations in accordance with the mechanism of its birth in each individual case and take into account three points: the direction of traction, the strength, and the nature of the traction. The direction of traction is divided posteriorly (with horizontal position women in labor - from top to bottom), towards themselves (parallel to the horizon) and forward (from bottom to top). These directions are determined by the desire to imitate the natural mechanism of birth and advancement of the fetal head along the wire axis of the birth canal when applying obstetric forceps. The direction of traction must strictly correspond to the position of the head in the birth canal: the higher the head is in the pelvic cavity, the more posterior the direction of traction should be. When the head is positioned at the outlet of the pelvis, traction during its eruption is performed in the third position, from bottom to top. Due to the fact that in obstetric forceps with pelvic curvature the direction of movement of the handles does not coincide with the direction of movement of the spoons, N. A. Tsovyanov proposed the following method of grasping (Fig. 8) and traction with forceps: the bent II and III fingers of both hands of the obstetrician grasp from under the handles obstetric forceps at the level of Bush hooks, their outer and top surface, and the main phalanges of the indicated fingers with Bush hooks passing between them are located on the outer surface of the handles, the middle phalanges of the same fingers are on the upper surface; nail phalanges are also located on the upper surface of the handle, but only on the other (opposite) spoon of obstetric forceps; The fourth and fifth fingers, also slightly bent, grasp the parallel branches of the forceps extending from the lock from above and move as high as possible, closer to the head. The thumbs, being under the handles, rest against the middle third of the lower surface of the handles with the flesh of the nail phalanges. The main work when extracting the head falls on the nail phalanges of the IV and V fingers of both hands. By pressing your fingers on the upper surface of the parallel branches of the forceps extending from the lock, the head is moved away from the symphysis pubis. This prevents its inevitable friction against the posterior surface of the pubis and ensures correct movement along the pelvic axis towards the sacral cavity. This same movement is facilitated by the thumbs, which exert pressure on bottom surface handles, directing them upward (anteriorly). The action of the main phalanges of the II and III fingers of both hands, squeezing the outer surface of the handles at the level of the Bush hooks, is reduced to capturing and holding the head under a certain and constant pressure throughout the entire operation. Thus, the obstetrician’s fingers, located above and below the forceps, acting simultaneously in different directions, ensure the production of traction and advancement of the head along the axis of the birth canal. The force of traction should be commensurate with the strength of the obstetrician and the available resistance. The pulling force should not be excessive.

It is not allowed to perform traction with four hands (two obstetricians at once or one after the other). If 8-10 tractions are unsuccessful, further use of obstetric forceps should be abandoned. During traction, the obstetrician strives to complete the unfinished stages of the birth mechanism. The extraction of the fetus with obstetric forceps should not occur continuously, but with intervals of 30-60 seconds. The duration of an individual traction corresponds to the duration of pushing; it should begin, like an effort, slowly, gradually increase in strength and, having reached a maximum, go into a pause, gradually fading away. After 4-5 tractions, open the forceps and take a break for 1-2 minutes. No rocking, rotating, pendulum-like or other movements should be made during traction. Rotating the head with forceps is unacceptable; the tongs should turn along with the head due to its rotation; during traction, imitating the natural mechanism of fetal birth, the head is rotated in forceps.

Fifth moment of the operation. Obstetric forceps are removed either after the head is removed, or when it is still erupting. In the latter case, the forceps are carefully opened, both spoons are moved apart, each spoon is taken in the corresponding hand of the same name and removed in the same way as they were applied, but in the reverse order, that is, the right spoon, describing an arc, is taken to the left groin fold, the left - to the right (Fig. 9). The spoons should slide smoothly, without jerking. It is necessary to consistently focus on both the pelvic and cephalic curvature. After the birth of the head, the fetal body is removed according to general rules.

Technique for applying direct obstetric forceps

The first moment of the operation. When applying straight parallel Lazarevich forceps, it does not matter which spoon is inserted first, since this is not prevented by the locking device. When applying straight but crossing forceps, the left (with the lock) branch is inserted first. When inserting a spoon with straight forceps, each branch is held horizontally and the spoon is inserted under control inner hand, describing an arc corresponding to the circumference of the fetal head. The design of straight obstetric forceps allows them to be applied to the presenting part of the fetus not only in the transverse and oblique, but also in the direct dimension of the small pelvis. However last option unsafe (possibility of injury to the urethra, bladder, rectum).

Second and third moments of the operation- closing the forceps and testing traction - have no features compared to the operation of applying obstetric forceps with pelvic curvature.

The fourth moment of the operation- traction itself. When using straight forceps, you can more accurately control and direct the movements of the head, since the direction of movement of the handles of straight forceps coincides with the direction of movement of the fetal head. When removing the head using straight obstetric forceps, you should never lift the handles of the forceps high (as when using forceps with pelvic curvature), as this will lead to significant trauma to the perineum and vagina.

Fifth moment of the operation- opening the lock and removing straight forceps is also done after the birth of the head or during its eruption. If the forceps are removed during the process of eruption of the head, then (unlike obstetric forceps with pelvic curvature) it does not matter which branch is removed first - the forceps are removed when the handle is moved to the side, and each branch of the forceps describes an arc corresponding to the circumference of the head. In the crust, straight forceps (more convenient when applied to a high head) due to the refusal to use high obstetric forceps are used much less frequently than forceps with pelvic curvature.

Typical (exit) obstetric forceps with the anterior view of the occipital presentation, it is used most often. On palpation through the anterior abdominal wall, the head is not identified above the entrance to the pelvis. During vaginal examination, the sagittal suture of the head is located in the direct size of the pelvic outlet, the leading point is the small (posterior) fontanel, in relation to the large (anterior) fontanel it is located downward and anteriorly, under the pubis; the sacral cavity is completed, the ischial spines are not reached. The forceps should be applied in the transverse dimension of the pelvic outlet, that is, biparietally on the head. If the head has approached the lower edge of the pubic fusion with the occipital protuberance, then traction is performed along a horizontal line until the occipital protuberance emerges from under the pubis. Then the head is brought out, slowly and carefully lifting the handles of the forceps anteriorly, and the movement characteristic of this moment of childbirth should occur - extension of the head around the point of fixation, that is, the area occipital bone. The perineum is supported by hand, preventing rapid eruption of the frontal tubercles.

In the posterior view of the occipital presentation, the position of the head at the pelvic outlet is characterized by the fact that the occiput has completed a posterior rotation, the sagittal suture is located in the direct size of the outlet, the leading point is the posterior (small) fontanelle, in relation to the anterior (large) fontanel it is located downward and posteriorly. The posterior view of the occipital presentation is a variant of the normal mechanism of fetal birth, therefore the head must be removed in the posterior view. When applying forceps in the posterior view, you should remember all the details of the mechanism for cutting the head, trying to imitate it when removing it with obstetric forceps. Apply forceps and perform traction in the same way as with the anterior view of the occipital presentation. When cutting through the head, you must remember about two points of fixation of the head: one to enhance flexion and the other to extend. As soon as, with horizontal traction, the area of ​​​​the border of the scalp of the forehead appears under the symphysis (the anterior point of fixation), you should proceed to extracting the head in the direction along the anterior arc (Fig. 10). At the same time, the head is bent even more to allow the back of the head and both parietal tubercles to emerge (special attention to protecting the perineum!). After the birth of the occiput, they begin to straighten the head around another fixation point (occipital bone), which is fixed in front of the coccyx. To do this, the handles of the forceps are lowered posteriorly towards the perineum.

In case of anterior cephalic presentation, typical obstetric forceps are applied to the head when its sagittal suture is in the direct size of the pelvic outlet, the anterior (large) fontanel is located anteriorly, the posterior (small) fontanel is posterior and is difficult to reach. The anterior (large) fontanel lies below, the small one - above. The insertion of spoons is carried out, as usual, in the transverse dimension of the pelvis. Closing is done with the handles relatively raised. To avoid further extension, the first spoon is held by an assistant with the handle raised anteriorly. Ideal grip through the parietal region is impossible, spoons are applied accordingly vertical size heads. The first tractions are done with relatively raised handles, and later - in a horizontal direction until the area of ​​the bridge of the nose (anterior fixation point) appears under the symphysis. Then the head is flexed by traction anteriorly (Fig. 11), until the occipital region is born above the perineum (remember the possibility of rupture of the perineum!). After this, the handles of the forceps are lowered posteriorly, the head is extended around the occipital protuberance (posterior fixation point), and the face is released from under the pubis. The lock is opened and the spoons are removed only after the head has been removed. Correction of anterior cephalic presentation with obstetric forceps (translation into a more physiological one - occipital or facial) is currently not used.

In case of facial presentation, typical obstetric forceps are rarely used. The technique of applying forceps for facial presentations is much more complicated than for occipital presentations. Only an experienced obstetrician can perform the operation, with a strict assessment of the indications. The application of forceps is permissible only in cases where the head is on the pelvic floor and the chin is facing anteriorly. If the chin is turned posteriorly, childbirth is impossible (if there are no conditions for cesarean section, a craniotomy is performed). Forceps are applied in the transverse dimension of the pelvis with the handles raised anteriorly, since in these presentations the wire point (chin) is always located at the pubic symphysis, and the bulk of the head lies in the recess of the sacral bone. The spoons are placed perpendicular to the vertical dimension (Fig. 12). After closing the spoons and testing traction, traction is done somewhat posteriorly in order to bring the chin out from under the pubis; then the handles of the forceps are raised anteriorly, the head is bent around hyoid bone(fixation point) and the forehead, parietal tubercles and the back of the head are brought out above the perineum.

Atypical (cavitary) obstetric forceps

If with typical exit forceps, when removing the head, they reproduce the process of cutting in, cutting through and birth of the head, then with abdominal forceps Preliminarily performed during traction and internal rotation of the head in the forceps. This is due to the fact; that the fetal head standing in the pelvic cavity has not completed the internal rotation, and its sagittal suture may be in one of the oblique or transverse dimensions of the pelvic cavity. The peculiarities of the technique concern only the first moment (insertion of spoons) and the fourth (traction).

In the first position of the fetus, occipital presentation, anterior view, atypical obstetric forceps are applied in the biparietal size of the head, that is, in the left oblique size of the pelvic cavity (Fig. 13). The left spoon is inserted first (as with typical forceps), but somewhat posteriorly - so that the spoon rests on the head in the area of ​​the left parietal tubercle. The right spoon of the forceps is also first inserted from behind, then, together with the fingers of the control hand, it is carefully raised (the handle of the forceps is lowered at this time) to the right parietal tubercle (the spoon “wanders”), after which the forceps are closed and a test traction is performed. The direction of traction is first done downwards and somewhat posteriorly. At the same time, feeling the rotation of the head (with the posterior fontanelle counterclockwise - to the right and anteriorly), they contribute to this movement. When the rotation of the head is complete (posterior fontanel at the pubis, sagittal suture in the direct size of the pelvic outlet), traction is performed horizontally until the birth of the occipital protuberance from under the pubis, and then anteriorly - extension and birth of the head.

Atypical obstetric forceps for the second position of the fetus, occipital presentation, anterior view are also applied in the biparietal size of the head, but in the right oblique size of the pelvic cavity (Fig. 14). To do this, the left spoon is inserted into the left half of the pelvis, and then it is moved anteriorly and to the right until it rests on the left parietal tubercle. The right spoon is inserted so that it rests on the right parietal tubercle. Traction is done slightly backwards and downwards; when the head begins to descend, it is rotated in the forceps by the posterior (small) fontanel anteriorly and to the left, that is, clockwise by 45°. Next, traction is performed as with typical obstetric forceps: horizontally and anteriorly.

Atypical obstetric forceps for the first position of the fetus, occipital presentation, posterior view are applied in the right oblique dimension of the pelvic cavity so that they cover the head biparietally. The insertion of spoons is carried out in the same way as in the second position, anterior view. With traction downward (towards oneself) and somewhat posteriorly, the head is rotated by the posterior (small) fontanelle posteriorly (very rarely anteriorly, in these cases the spoons of the forceps are shifted accordingly). Then the direction, strength and nature of traction are determined by the same rules as with typical obstetric forceps.

Atypical obstetric forceps for the second position of the fetus, occipital presentation, posterior view are applied in the left oblique dimension of the pelvic cavity to the biparietal dimension of the head. The technique for inserting forceps is the same as for the anterior view of the occipital presentation of the first position. Only when the head is lowered during traction does its posterior fontanelle rotate posteriorly in the forceps. This is followed by additional flexion and extension of the head.

Rice. 15. Application of atypical forceps with a low transverse position of the head (bottom view). The arrows show the movement (wandering) of the right and left spoons (the initial position of the right and left spoons of the forceps is shaded): 1 - in the first position (the spoons of the forceps in the left oblique size); 2 - in the second position (spoon tongs in the right oblique size)

Atypical obstetric forceps with a low transverse position of the head is a very difficult operation. Obstetric forceps regular type(with pelvic curvature) are applied, like atypical ones, in the oblique size of the pelvic cavity, in accordance with the wire point (posterior fontanelle): in the first position of the fetus - in the left oblique size of the pelvic cavity (Fig. 15, 1), and in the second position - in the right oblique size of the pelvic cavity (Fig. 15, 2). Among the features of the technique, we should mention the transfer of spoons of tongs. When the sagittal suture, after several tractions, becomes oblique, the forceps are removed and then applied again to the transverse dimensions of the head in the oblique dimension of the pelvis. In this position of the head, straight obstetric forceps are also used, which do not need to be repositioned, since they are placed on the biparietal size of the head and in the direct size of the pelvic cavity. First, a spoon is inserted, the edges should lie on the front side of the head. Take any spoon and insert it into the vagina towards the sacroiliac cavity closest to the face, then the spoon by transfer (“wandering”) is passed through the forehead and face to the front side of the head to the front end of the true conjugate. The posterior spoon is inserted through the same cavity as the first and advanced towards the posterior end of the conjugate.

In case of breech presentation, obstetric forceps are used very rarely and only if the buttocks are fixed in the cavity or are located at the bottom of the pelvis. Forceps are applied to the pelvic end of the fetus, if possible, only in a transverse dimension. When the buttocks are standing in the direct size of the pelvis, apply one spoon of forceps to the sacrum and the other to the back of the thighs. In this position of the buttocks, straight obstetric forceps are also used, applying them in the direct size of the pelvis.

Outcomes of the operation of applying obstetric forceps

Applied in a timely manner, technically correct, according to established indications, in compliance with the appropriate conditions, rules of asepsis and antisepsis and in the absence of contraindications, the operation of applying abdominal and exit obstetric forceps usually makes it possible to deliver a live fetus without compromising the health of the woman in labor. In some cases, this operation can cause a number of complications: damage to the birth canal (ruptures of the cervix, vaginal walls and perineum), injuries to the fetus (damage to the skin, depressions of the skull bones, paresis facial nerve, intracranial hemorrhages), postpartum diseases infectious origin. These complications may be due to non-compliance with the conditions and technical errors during the operation, but they are often the result of pathological condition mother or fetus, which served as an indication for the application of obstetric forceps Rare cases genitourinary fistula(see) after the operation, the application of obstetric forceps should be explained by the excessive duration of the birth act and their belated application.

Postoperative period

Compliance with the strictest sanitary and hygienic regime. If there are sutures (staples) on the perineum, in addition to the usual thorough washing of the external genitalia, wiping the tissues in the area of ​​the sutures with alcohol after each urination and defecation is indicated. If an infectious process occurs, appropriate treatment is carried out. Duration bed rest determined individually. Before discharge, the woman should be carefully examined for gynecological chair. After the application of obstetric forceps, postpartum leave for a woman in labor is extended to 70 days.

Bibliography: Lankowitz A. V. Operation of applying obstetric forceps, M., 1956, bibliogr.; Malinovsky M. S. Operative obstetrics, M., 1967; Practical obstetrics, ed. A. P. Nikolaeva, p. 321, Kyiv, 1968; Tsovyanov N. A. On the technique of applying obstetric forceps, M., 1944, bibliogr.

Over the past three centuries, medical and public opinion on the use of obstetric forceps has been opposite, but not as categorical as the above points of view. However, if the use of obstetric forceps was abolished, then the 5-25% of women in labor who are delivered using this method would have two options: C-section or, as before the invention of forceps, a second stage of labor over long hours or even days.

Over the past three centuries, more than 700 types have been proposed, and new ones continue to be invented. Usually in clinical practice Simpson forceps are used, as well as similar Neville-Barnes, Ferguson, and Tucker-McLane forceps with plate-shaped spoons. The tongs consist of two branches, right and left, each of which includes a spoon, a lock and a handle. The cephalic curvature of the spoon, concave from the inside and convex from the outside, corresponds to the shape of the fetal head, and the pelvic curvature is expressed in the bending of the spoons in the shape of an arc, which corresponds to the curvature of the mother’s birth canal. The branches of the tongs close in the area of ​​the lock and handles. Forceps designed for rotation (most often Kielland forceps) are distinguished by a pronounced cephalic curvature and a weakly expressed pelvic curvature of the spoons. This device allows for rotation in the pelvic cavity and reduces the risk of trauma to the mother’s tissues, because reduces the arc of rotation due to narrowing of the tops of the spoons. When applying rotary forceps, one is often faced with asynclitic insertion, which is why these forceps have a sliding lock. Each obstetrician prefers his own model of forceps, depending on his skills and awareness. In clinical practice, the obstetrician needs to be familiar with two types - classic Simpson forceps and Kielland rotary forceps. More detailed information about the structure various types forceps can be found in the literature, a list of which is presented at the end of this chapter.

Classic obstetric forceps

After the indications for the application of obstetric forceps have been determined and performed preliminary preparation, the patient is placed in the lithotomy position with appropriate leg support. The spoons of the forceps are designed in such a way that when they are placed in the pelvic cavity in a transverse position, they maintain an amplitude of safe movement of 45 in each direction from the original: the boundaries are the iliopubic eminence and the sacroiliac joint. The application of forceps should be performed as follows: a spoon of forceps is placed on the child’s head in the area between the eye sockets and ears. This arrangement of spoons is biparietal and bimalar, i.e. they are placed on the parietal and zygomatic bones, and the pressure on the head is distributed so that the most vulnerable parts of the skull do not experience it. If the application of the forceps spoons is asymmetrical, for example on the area of ​​the eyebrow and mastoid process, the subsequent pressure during traction is also distributed asymmetrically - the pressure on the falciform processes of the cerebellum and the tentorium of the cerebellum increases, which leads to an increased risk of intracranial hematoma.

When the view and position of the fetal head are accurately established, for example, the anterior view of the occipital presentation, the first or second position, both branches of the forceps are taken in the hands and folded in front of the patient's perineum in such a way as if placing it on the fetal head. The left branch of the obstetric forceps is taken with the left hand, inserted from the left side and placed in front of the left ear of the fetus. During this action, the fingers of the right hand are inserted into the vagina, and the thumb of the left hand rests on the left branch of the forceps. The handle of the left branch of the forceps is held in the left hand, then it is rotated in an arcuate manner, using the fingers of the right hand to guide the spoons of the forceps to the desired position. Then the hands are changed and the procedure for inserting the right spoon is carried out. Most classic forceps have " english castle", in which the right branch enters the left. Thus, there is no need to manipulate the parts of the forceps separately from each other, because they are connected. For the first or second position with an anterior view of the occipital presentation, the method of applying forceps is the same, but the location of the head must be taken into account. Applying spoons of forceps to the head and closing the lock should be done without effort. If any difficulties arise when inserting spoons or closing the branches of the forceps into the lock, you should stop and double-check the location of the fetal head.

If the branches of the tongs close into the lock without difficulty, you should check the correct placement of the tong spoons in the following ways:

• the small fontanel should be located in the middle of the distance between the spoons of the forceps, the lines of the lambdoid suture should be equidistant from the spoons of the forceps;
• the small fontanel should be at a distance equal to the width of one finger from the surface of the forceps in the lock area. If the small fontanel is located further from the specified surface, then traction will lead to extension of the head, and it will pass through the birth canal with its large size;
• the arrow-shaped seam should be perpendicular to the locking surface of the forceps along its entire length. The location of the locking surface of the forceps obliquely in relation to the sagittal suture means that the spoons of the forceps are applied asymmetrically, closer to the areas of the eyebrow and mastoid process;
• the palpable parts of the openings of the forceps trays should be equal on both sides. When the forceps are applied correctly, the holes in the spoons should almost not be palpable, and no more than one finger should pass between them and the head.

If not all of these conditions are met, the overlay must be corrected or performed again.

Sufficient compression force on the spoons of tongs is still one of the most important aspects. In this case, it is easier to achieve the required compression force on the spoons by placing your fingers as close as possible to the locking area of ​​the tongs, further from the end of the handles. The index and middle fingers are held together and the other hand is placed in a lock, which helps with downward traction (Payo maneuver). It is necessary to ensure that such tractions correspond to the wire axis of the pelvis and do not put pressure on the pubic bone.

Tractions should be carried out during a contraction, combining them with pushing, and with their help, move the head along the wire axis of the pelvis - the Carus curvature. When performing traction, the obstetrician can stand or sit, his arms should be bent at the elbows. It is difficult to describe how strong the traction should be, but less strong effective traction is better. A recent study used isometric determination of traction force. It has been shown that young obstetricians should be trained to perform traction with an "ideal" force of 14-20 kg. Physically developed obstetricians of both sexes are able to apply significant and not always necessary forces when applying obstetric forceps. The basic principle is that traction should be of moderate strength and soft, in addition, it is necessary to evaluate their effectiveness. The result of traction together with pushing is the lowering and birth of the fetal head. In fact, after the first traction it becomes clear whether it is going down. In cases of mechanical obstacles to the passage of the head, a very definite sensation occurs during the first traction, the presence of which means that further attempts to complete the birth using obstetric forceps should be abandoned.

When the head descends to the perineum and the back of the head passes under the pubic symphysis, the direction of traction should gradually change anteriorly and upward at approximately an angle of 45°. When the fetal head is embedded, the branches of the forceps are raised at an angle of 75°, one hand begins to hold the perineum, or, if necessary, an episiotomy is performed. When the fetal head is almost born, the forceps spoons can be removed by reversing the steps followed when applying them. Usually the right spoon of the forceps is removed first. If it takes too much force to remove the trays, you can gently promote the birth of the head with forceps applied to it.

If the sagittal suture is in the right or left oblique size, then after correct application of the forceps spoons, it is necessary to gradually and carefully, without traction, rotate the head by 45 degrees towards the midline. This can be done by slightly lifting the handles of the tongs and slowly turning them in an arc, allowing soft tissues mothers adapt to changes in the position of the fetal head. After turning the head, you need to check again that the tong spoons are positioned correctly, because they could slip off.