Obstetric forceps. Tool structure, types
The operation of applying obstetric forceps. Indications, conditions.
Obstetric forceps is an instrument designed to extract the fetus by the head. The operation of applying obstetric forceps is a delivery operation in which the fetus is artificially removed through the natural birth canal using a special instrument.
Obstetric forceps were invented at the beginning of the 17th century by the Scottish physician Chamberlain, who kept his invention strictly secret, and it did not become part of obstetric practice. Priority in the invention of obstetric forceps rightfully belongs to the French surgeon Palfin, who published his report in 1723. The tool and its application quickly became widespread. In Russia, pincers were first used in 1765 in Moscow by Professor Erasmus. Subsequently, domestic obstetricians N. M. Maskimovich-Ambodik, A. Ya. Krassovsky, I. P. Lazarevich, N. N. Fenomenov made a great contribution to the development of the theory and practice of the operation of applying obstetric forceps.
In modern obstetrics, despite the infrequent use of this operation, it is of great practical importance, since in some obstetric situations it is the operation of choice (Fig. 108).
The structure of obstetric forceps. The main model of forceps used in our country is the Simpson-Fenomenov forceps. The tongs consist of two branches (or spoons) - right and left. Each branch consists of 3 parts: the spoon itself, the locking part and the handle. The spoon itself is made fenestrated, and the handle is hollow in order to reduce the mass of the tongs, which is about 500 g. The total length of the instrument is 35 cm, the length of the handle with a lock is 15 cm, the length of the spoon is 20 cm. The spoon has the so-called head and pelvic curvature. The cephalic curvature reproduces the circumference of the fetal head, and the pelvic curvature reproduces the sacral cavity, corresponding to a certain extent to the wire axis of the pelvis. In Simpson-Fenomenov forceps, the distance between the most distant points of the head curvature of the spoons when closing the forceps is 8 cm, the tops of the forceps are at a distance of 2.5 cm. There are models of forceps with only one, head, curvature (straight Lazarevich forceps).
The lock is used to connect the branches. The structure of the locks is not the same in different models of tongs: the lock can be freely movable, moderately movable, motionless and completely motionless. The lock in the Simpson-Fenomenov forceps has a simple structure: on the left branch there is a recess into which the right branch is inserted. This structure of the castle ensures moderate mobility of the branches - the spoons do not diverge up and down, but have mobility to the sides. Between the lock and the handle on outside The forceps have side projections called Bushi hooks. When the tongs are folded, they should lie symmetrically in the same plane. After inserting the spoons and closing the lock, the plane in which the Bush hooks lie corresponds to the transverse or one of the oblique dimensions of the pelvis, in which the spoons of the forceps themselves are located. The handles of the forceps are straight, their outer surface is ribbed, which prevents the surgeon’s hands from slipping. The inner surface of the handles is smooth, and therefore, when the branches are closed, they fit tightly to each other. The branches of the forceps differ in the following signs: 1) on the left branch the lock and the lock plate are located at the top, on the right branch - at the bottom; 2) the Bush hook and the ribbed surface of the handle (if the tongs are lying on the table) on the left branch are facing to the left, on the right - to the right; 3) the handle of the left branch (if the forceps are on the table and the handles are directed towards the surgeon) is facing the left hand, and the handle of the right branch is facing the surgeon’s right hand. The left branch is always inserted with the left hand into left half pelvis, right - with the right hand in right half pelvis
Other most famous models of forceps include: 1) Lazarevich forceps (Russian model), which have one head curvature and non-crossing spoons; 2) Levret tongs (French model) - long tongs with two curvatures, intersecting handles and a screw lock that is screwed tightly; 3) German Nägele forceps, combining the main qualities of the Simpson-Fenomenov forceps (English forceps) and Levret models.
Indications for the application of obstetric forceps. The application of forceps is used in cases where urgent completion of labor during the expulsion period is required and there are conditions for performing this operation. There are 2 groups of indications: related to the condition of the fetus and the condition of the mother. Combinations of these are often observed.
Indications for applying forceps to best interests of the fetus is hypoxia, which developed as a result various reasons(premature abruption of a normally located placenta, prolapse of the umbilical cord, weakness of labor, late gestosis, short umbilical cord, entanglement of the umbilical cord around the neck, etc.). The obstetrician leading the birth is responsible for the timely diagnosis of fetal hypoxia and the selection of adequate management tactics for the woman in labor, including determining the method of delivery.
IN interests of the woman in labor application of forceps is performed for the following indications: 1) secondary weakness labor activity, accompanied by a stop in the forward movement of the fetus at the end of the expulsion period; 2) severe manifestations of late gestosis (preeclampsia, eclampsia, severe hypertension that is not amenable to conservative therapy); 3) bleeding in the second stage of labor, caused by premature detachment of a normally located placenta, rupture of blood vessels during the membrane attachment of the umbilical cord; 4) illness of cardio-vascular system in the stage of decompensation; 5) breathing disorders due to lung diseases, requiring the exclusion of pushing; 6) general diseases, acute and chronic infections, high fever in a woman in labor. 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 due to the inability of the abdominal muscles to provide full pushing. The use of obstetric forceps in some cases may be indicated for tuberculosis, diseases of the nervous system, kidneys, and organs of vision (the most common indication for the use of forceps is high myopia).
Thus, the indications for the application of obstetric forceps in the interests of the woman in labor may be due to the need to urgently end labor or the need to eliminate pushing. The listed indications in many cases are combined, requiring emergency termination of labor in the interests of not only the mother, but also the fetus. Indications for the application of obstetric forceps are not specific to this operation; they may also be indications for other operations (cesarean section, vacuum extraction of the fetus, fetal destruction operations). The choice of delivery operation largely depends on the presence of certain conditions that allow a specific operation to be performed. These conditions differ significantly, so careful assessment is necessary in each case to correctly select the method of delivery.
When applying forceps, the following conditions are necessary:
Live fruit. In the event of fetal death and there are indications for emergency delivery, fetal destruction operations are performed, and in rare extreme cases, a cesarean section. Obstetric forceps are contraindicated in the presence of a dead fetus.
Full opening of the pharyngeal pharynx. Deviation from this condition will inevitably lead to rupture of the cervix and lower segment of the uterus.
2. Absence amniotic sac . This condition follows from the previous one, since when proper management labor, when the uterine os is fully dilated, the fetal bladder must be opened.
The fetal head should be in the narrow cavity or at the outlet of the small pelvis. For other head position options, the use of obstetric forceps is contraindicated. Accurate determination of the position of the head in the pelvis is possible only during a vaginal examination, which must be performed before applying obstetric forceps. If the lower pole of the head is determined between the plane of the narrow part of the pelvis and the exit plane, then this means that the head is located in the narrow part of the pelvic cavity. From the point of view of the biomechanism of childbirth, this position of the head corresponds to the internal rotation of the head, which will be completed when the head descends to the pelvic floor, i.e., into the outlet of the small pelvis. When the head is located in a narrow part of the pelvic cavity, the sagittal (sagittal) suture is located in one of the oblique dimensions of the pelvis. After the head descends to the pelvic floor, during a vaginal examination, the sagittal suture is determined in straight size exit from the small pelvis, the entire pelvic cavity is filled with the head, its parts are not accessible for palpation. In this case, the head has completed the internal rotation, then the next moment of the biomechanism of childbirth follows - extension of the head (if there is an anterior view of the occipital insertion).
The fetal head should correspond to the average size of the head of a full-term fetus, i.e. not be too large (hydrocephalus, large or giant fetus) or too small (premature fetus). This is due to the size of the forceps, which are only suitable for the head of a medium-sized full-term fetus; otherwise, their use becomes traumatic for the fetus and the mother.
Sufficient pelvic dimensions, allowing the head to be removed by forceps to pass through. With a narrow pelvis, forceps are a very dangerous instrument, so their use is contraindicated.
The operation of applying obstetric forceps requires the presence of all the listed conditions. When starting delivery with forceps, the obstetrician must have a clear understanding of the biomechanism of childbirth, which will have to be artificially imitated. It is necessary to understand which moments of the biomechanism of labor the head has already completed and which it has to accomplish with the help of forceps. Forceps are a pulling tool that replaces the missing force of pushing. The use of forceps for other purposes (correction of incorrect head insertions, posterior view of the occipital insertion) as a corrective and rotational instrument has long been excluded.
Preparation for application of obstetric forceps. The forceps are applied in the position of the woman in labor on the operating table (or on a Rakhmanov bed) on her back, with her legs bent at the knees and hip joints. Before the operation, the intestines and bladder must be emptied, and the external genitalia must be disinfected. Before the operation, a thorough vaginal examination is performed to confirm the availability of conditions for applying forceps. Depending on the position of the head, it is determined which version of the operation will be used: abdominal obstetric forceps for the head located in the narrow part of the pelvic cavity, or exit obstetric forceps if the head has dropped to the pelvic floor, i.e., into the outlet of the small pelvis.
The use of anesthesia when applying obstetric forceps is desirable, and in many cases mandatory. In multiparous women (as an exception), exit obstetric forceps can be applied without anesthesia. The operation of abdominal obstetric forceps requires the use of anesthesia, since the introduction of spoons, one of which “wanders” in the pelvis, is a difficult moment of the operation, especially with muscle resistance pelvic floor, which is eliminated with the help of anesthesia. In addition, in many cases, the use of obstetric forceps is due to the need to eliminate pushing activity in the woman in labor, which can only be achieved with adequate anesthesia. Anesthesia is also required to relieve pain from this operation, which in itself is very important. When applying forceps, inhalation, intravenous anesthesia or pudendal anesthesia is used.
Due to the fact that when extracting the fetal head using forceps, the risk of perineal rupture increases, the application of obstetric forceps is usually combined with perineotomy.
Exit obstetric forceps. Exit obstetric forceps is an operation in which forceps are applied to the fetal head located at the pelvic outlet; At the same time, the head has completed its internal rotation, and the last moment of the biomechanism of childbirth before its birth is carried out using forceps. In the anterior view of the occipital insertion of the head, this moment is extension of the head, and in the posterior view, flexion followed by extension of the head. Exit obstetric forceps are also called typical in contrast to cavity, atypical, forceps.
The technique of applying both typical and atypical forceps includes the following points: 1) insertion of spoons, which is always carried out in accordance with the following rules: the left spoon is inserted first with the left hand into left side(“three left”), the second is the right spoon with the right hand in right side(“three right”); 2) closing the forceps; 3) test traction to ensure that the forceps are applied correctly and that there is no risk of them slipping; 4) traction itself - extraction of the head with forceps in accordance with the natural biomechanism of childbirth; 5) removing the forceps in the reverse order of their application: the right spoon is removed first with the right hand, the left spoon is removed second with the left hand.
Technique for applying exit obstetric forceps with anterior view of the occipital insertion. The first point is the introduction of spoons. Folded tongs are placed on the table to accurately identify the left and right spoons. The left spoon is inserted first, since when closing the forceps it must lie under the right one, otherwise closing will be difficult. The obstetrician takes the left spoon into left hand, grasping it like a pen or bow. Before inserting the left hand into the vagina, four fingers of the right hand are inserted on the left side to control the position of the spoon and protect the soft tissues of the birth canal. The hand should be facing the head with the palmar surface and inserted between the head and the side wall of the pelvis. The thumb remains outside and is moved to the side. Before its insertion, the handle of the left spoon is installed almost parallel to the right inguinal fold, the top of the spoon is located at the genital slit in the longitudinal (antero-posterior) direction. The lower edge of the spoon rests on the first finger of the right hand. The spoon is inserted into the genital opening carefully, without force, by pushing the lower rib I with the finger of the right hand, and only partly the insertion of the spoon is facilitated by the slight advancement of the handle. As the spoon penetrates deeper, its handle gradually moves down towards the perineum. Using the fingers of his right hand, the obstetrician helps guide the spoon so that it rests on the side of the head in the plane of the transverse dimension of the pelvic outlet. The correct position of the spoon in the pelvis can be judged by the fact that the Bush hook is strictly in transverse size exit from the pelvis (in the horizontal plane). When the left spoon is correctly placed on the head, the obstetrician removes the inner hand from the vagina and passes the handle of the left spoon of the forceps to the assistant, who must hold it without moving it. After this, the obstetrician spreads the genital slit with his right hand and inserts 4 fingers of his left hand into the vagina along its right wall. The second one inserts the right spoon of the forceps with the right hand into the right half of the pelvis (Fig. 109, b). The right spoon of the tongs should always lie on the left. Correctly applied forceps grasp the head through the zygomatic-parietal plane, the spoons lie slightly in front of the ears in the direction from the back of the head through the ears to the chin. With this placement, the spoons grasp the head in its largest diameter, the line of the tongs handles faces the wire point of the head. The second point is the closure of the forceps. Separately inserted spoons must be closed so that the forceps can serve as a tool for grasping and removing the head. Each of the handles is taken with the same hand, while the thumbs are located on the Bush hooks, and the remaining 4 fingers clasp the handles themselves. After this, you need to bring the handles closer together and close the tongs. For proper closure, a strictly symmetrical arrangement of both spoons is required.
When closing the spoons, the following difficulties may occur: 1) the lock does not close, since the spoons are not placed on the head in the same plane, as a result of which the locking parts of the tool do not coincide. This difficulty is usually easily eliminated by pressing with the thumbs on the side hooks; 2) the lock does not close because one of the spoons is inserted higher than the other. The deeper spoon is moved slightly outward so that the Bush hooks coincide with each other. If, despite this, the tongs do not close, it means that the spoons have been applied incorrectly and must be removed and reapplied; 3) the lock is closed, but the handles of the tongs diverge. This is due to the fact that the size of the head is slightly greater than the distance between the spoons in the head curvature. In this case, bringing the arms closer together will cause compression of the head, which can be avoided by placing a folded towel or diaper between them.
Having closed the forceps, you should perform a vaginal examination and make sure that the forceps do not capture soft tissue, the forceps are positioned correctly and the wire point of the head is in the plane of the forceps.
The third point is test traction (Fig. 111). This is a necessary check to ensure that the forceps are applied correctly and that there is no risk of them slipping. The test traction technique is as follows: the right hand clasps the handles of the forceps from above so that the index and middle fingers lie on the side hooks; The left hand lies on top of the right, and its index finger is extended and touches the head in the area of the wire point. The right hand carefully makes the first traction. Traction should be followed by forceps, the left hand positioned on top with an outstretched index finger and head. If during traction the distance between the index finger and the head increases, this indicates that the forceps are not applied correctly and will eventually slip off.
Fourth point- extraction of the head with forceps (actual traction). During traction (Fig. 112), the forceps are usually grasped in the following way: with the right hand, they cover the lock from above, placing (with Simpson-Fenomenov forceps) the third finger in the gap between the spoons above the lock, and the second and fourth fingers on the side hooks. With your left hand, grasp the handles of the tongs from below. The main traction force is developed with the right hand. There are other ways to grasp the forceps. N.A. Tsovyanov proposed a method of grasping forceps, allowing simultaneous traction and abduction of the head into the sacral cavity (Fig. 113). With this method, the II and III fingers of both hands of the obstetrician, bent with a hook, grasp the outer and upper surface of the instrument at the level of the side hooks, and the main phalanges of these fingers with Bush hooks passing between them are located on the outer surface of the handles, the middle phalanges of the same fingers - on the upper surface, and the nail phalanges are on the upper surface of the handle of the opposite spoon of the 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. Thumbs, being under the handles, rest against the middle third of the lower surface of the handles. The main work with this grip of the forceps falls on the IV and V fingers of both hands, especially on the nail phalanges. By pressing these fingers on the upper surface of the branches of the forceps, the head is retracted from the pubic joint. This is also facilitated by the thumbs, which exert pressure on bottom surface handles, pointing them upward.
When removing the head with forceps, it is necessary to take into account the direction of traction, their nature and strength. The direction of traction depends on in which part of the pelvis the head is located and what aspects of the biomechanism of labor need to be reproduced when removing the head with forceps.
In the anterior view of the occipital insertion, extraction of the head with exit obstetric forceps occurs due to its extension around the fixation point - the suboccipital fossa. The first tractions are performed horizontally until the suboccipital fossa appears from under the pubic arch. After this, the tractions are given an upward direction (the ends of the handles are directed by the obstetrician towards his face) so that the head is extended. Tractions must be performed in one direction.
Rocking, rotating, pendulum-like movements are unacceptable. Traction must be completed in the direction in which it was started. The duration of an individual traction corresponds to the duration of the pushing, tractions are repeated at intervals of 30-60 s. After 4-5 tractions, the forceps are opened to reduce compression of the head. The strength of the tractions imitates a contraction: each traction begins slowly, with increasing strength and, having reached a maximum, gradually fades away and goes into a pause.
Tractions are performed by the doctor standing (less often sitting), the obstetrician’s elbows should be pressed to the body, which prevents the development of excessive force when removing the head.
The fifth point is opening and removing the tongs. The fetal head is brought out using forceps or manually after removing the forceps, which in the latter case is carried out after the largest circumference of the head has erupted. To remove the tongs, take each handle with the same hand, open the spoons, then move them apart and after that the spoons are removed in the same way as they were applied, but in reverse order: the right spoon 1 is removed first, with the handle retracted to the left inguinal fold, the left spoon is removed second, its handle is retracted to the right inguinal fold.
Abdominal obstetric forceps. Cavity forceps are used in cases where the head is located in a narrow part of the pelvic cavity. The head will have to complete the internal rotation in the forceps and perform extension (with an anterior view of the occipital insertion). Due to the incompleteness of the internal rotation, the sagittal (sagittal) suture is located 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. The application of forceps in the oblique size of the pelvis presents certain difficulties. More challenging than the weekend obstetric forceps are tractions in which the internal rotation of the head is completed by 45° or more, and only then the head is extended.
Technique for applying abdominal obstetric forceps with anterior view of the occipital insertion, the first position of the fetus. In the first position, the sagittal suture is in the right oblique dimension. In order for the head to be grasped biparietally with spoons, forceps must be applied in the left oblique size,
The first point is the introduction of spoons. When applying abdominal forceps, the order of insertion of the spoons is maintained: first, the left spoon is inserted with the left hand into the left half of the pelvis, the second, the right spoon is inserted with the right hand into the right half of the pelvis. The left spoon is inserted under the control of the right guide hand into the posterolateral part of the pelvis and is immediately placed in the area of the left parietal tubercle of the head; the handle of the tongs is handed over to the assistant. 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 installed in the area of the right parietal tubercle. The spoon is moved by carefully pressing the second yoke of the left hand on its lower rib; the handle of the forceps moves slightly backward and clockwise.
The second point - closing the forceps - is performed when the forceps rest on the head biparietally and are in the left oblique dimension of the pelvis.
The third point - test traction -
The fourth point is the removal of the head(actually traction). Completing the internal rotation, the head simultaneously makes two movements: it moves more and more downwards and at the same time turns the back of the head forward. The head reaches the pelvic floor by turning counterclockwise by approximately 45°, and is located with a sagittal suture in the direct dimension of the pelvic outlet. To imitate the natural biomechanism, traction is performed first downward and somewhat posteriorly. As it moves, the head, together with the forceps, will rotate counterclockwise until it reaches the pelvic floor, where the spoons will be positioned transversely. In this case, only extraction should be active, while the rotation of the forceps occurs due to the independent rotation of the head as it moves along the birth canal. After the head has reached the pelvic floor, further traction is performed in the same way as with exit obstetric forceps: first horizontally until the suboccipital fossa appears from under the pubic arch, then anteriorly upward so that the head is extended.
Fifth point - opening and removing the tongs - is performed in the same way as with exit forceps.
Technique of surgery for the second position of the fetus. In the second position, the sagittal suture is in the left oblique size, the forceps should be applied in the opposite size of the pelvis, i.e. in the right oblique.
First point - The insertion of spoons is carried out in the usual sequence, i.e. the left spoon is inserted first, the right one is inserted second. In order for the spoons to lie in the right oblique size, the left spoon must be located in the anterolateral part of the pelvis, therefore, in this case this spoon will be “wandering”. After the usual insertion into the posterolateral pelvis, the left spoon is moved anteriorly. The right spoon is inserted immediately into the required position - into the posterolateral section of the right half of the pelvis. As a result, the spoons are located biparietally in the plane of the right oblique dimension.
Second and third points operations are performed normally.
Fourth point - traction itself is performed in the same way as in the first position. The differences are that as you move, the head together with the forceps will rotate not counterclockwise, but clockwise by 45°.
Fifth point performed normally.
Difficulties arising when applying obstetric forceps. Difficulties in inserting spoons may be due to the narrowness of the vagina and resistance of the pelvic floor, which requires dissection of the perineum. Sometimes the spoon of the forceps encounters an obstacle and does not move deeper, which may be due to the top of the spoon getting into the fold of the vagina or (which is more dangerous) into its fornix. The spoon must be removed and then reinserted under careful control with the fingers of the guide hand. Sometimes difficulties when inserting spoons are caused by a sharp configuration of the head when there is a discrepancy between the head curvature of the spoon and the changed shape of the head. By carefully overcoming this difficulty, it is possible to correctly insert and apply the spoon.
In some cases, difficulties may also arise when closing the spoons, which usually arise if the spoons do not lie in the same plane. In such cases, the handles of the forceps should be lowered posteriorly towards the perineum and try to close the forceps. If this fails, then, under the control of fingers inserted into the vagina, the spoons are moved until they are in the same plane. If this technique does not achieve the goal, the forceps must be removed and reapplied. If the handles of the forceps diverge when you try to close them, this may be due to insufficient depth of insertion of the spoons, poor girth of the head in an unfavorable direction, or excessive size of the head. If the depth of insertion of the spoons is insufficient, their tops put pressure on the head and when trying to compress the spoons, severe damage to the fetus can occur, including a fracture of the skull bones. Difficulties in closing the spoons also arise in cases where the forceps are applied not transversely, but in an oblique and even fronto-occipital direction. Incorrect position of the spoons is associated with errors in diagnosing the location of the head in the pelvis and the location of the sutures and fontanelles on the head, therefore, to eliminate it, a repeated vaginal examination and corresponding movement or reinsertion of the spoons are necessary.
Obstetric forceps - designed to extract a living fetus by the head in strict accordance with the natural biomechanism of childbirth.
The frequency of use of obstetric forceps in modern obstetrics is 1%.
The following types of obstetric forceps are distinguished: a) Simpson forceps - used for traction in anterior occipital presentation; b) Tooker-McLean forceps - used to rotate from the posterior view of the occipital presentation to the anterior view of the occipital presentation and extract the fetus; c) Kielland and Barton forceps - with a transverse arrangement of the sagittal suture for rotation to the anterior view of the occipital presentation; d) Piper forceps - designed to remove the head during breech presentation.
Device of obstetric forceps. The forceps have 2 spoons (branches), each of which consists of three parts - the spoon itself (which grasps the head of the fetus, it is fenestrated, window length 11 cm, width 5 cm); castle part; handle (hollow, the outer side of the handle is wavy). On the outer side of the tongs near the lock there are protrusions, Bush hooks, which, when folding the tongs, should be facing different sides, i.e. laterally, and lie in the same plane. Most models of forceps have two curvatures - the head (calculated for the circumference of the head) and the pelvic (runs along the edge of the spoon, curvature along the plane of the pelvis). The ends of the folded spoons do not touch each other, the distance between them is 2-2.5 cm. The cephalic curvature in folded tongs is 8 cm, the pelvic curvature is 7.5 cm; the maximum width of the spoons is no more than 4-4.5 cm; length - up to 40 cm; weight - up to 750 g.
Indications for applying obstetric forceps:
1. Indications from the parturient: weakness of labor is not amenable drug therapy, fatigue; weakness of pushing; bleeding from the uterus at the end of the first and second stages of labor; contraindications for pushing (severe gestosis; extragenital pathology - cardiovascular, renal, high myopia, etc.; feverish conditions and intoxication); severe forms neuropsychiatric disorders; chorioamnionitis during childbirth, if labor is not expected to end within the next 1 to 2 hours.
2. Indications from the fetus: acute intrauterine hypoxia fetus; loss of umbilical cord loops; threat of birth trauma.
Contraindications for applying obstetric forceps: dead fetus; hydrocephalus or microcephaly; anatomically (II - III degree narrowing) and clinically narrow pelvis; very premature fetus; incomplete opening of the uterine os; frontal presentation and anterior type of facial presentation; pressing the head or positioning the head with a small or large segment at the entrance to the pelvis; threatening or incipient uterine rupture; breech presentation fetus
Conditions for applying obstetric forceps:
1. Full opening of the uterine os.
2. Opened amniotic sac.
3. Empty bladder.
4. Head presentation and the presence of the head in the cavity or in the outlet of the small pelvis.
5. Correspondence of the size of the fetal head to the size of the mother’s pelvis.
6. Average head sizes.
7. Live fruit.
Complications after applying obstetric forceps:
1. For the mother: damage to the soft birth canal; rupture of the symphysis pubis; damage to the roots of the sciatic nerve with subsequent paralysis lower limbs; bleeding; uterine rupture; formation of a vaginal-vesical fistula.
2. For the fetus: damage to the soft parts of the head with the formation of hematomas, paresis of the facial nerve, eye damage; bone damage - depression, fractures, separation of the occipital bone from the base of the skull; compression of the brain; hemorrhages into the cranial cavity.
3. Postpartum infectious complications.
Three triple rules for applying obstetric forceps:
1. About the sequence of insertion of the forceps spoons:
the left spoon is inserted with the left hand into the left half of the pelvis of the woman in labor (“three on the left”), under the control of the right hand;
the right spoon is inserted with the right hand into the right half of the pelvis under the control of the left hand (“three to the right”).
2. Orientation of spoons on the fetal head with forceps applied:
the tops of the spoons of the tongs should be facing the wire point;
the forceps should grasp the parietal tubercles of the fetus;
the wire point of the head should lie in the plane of the forceps.
in the plane of entry - obliquely downwards, towards the toes of the sitting obstetrician;
in the pelvic cavity - horizontally, on the knees of a sitting obstetrician;
in the exit plane - from bottom to top, onto the face of a sitting obstetrician.
Moments of the operation of applying obstetric forceps:
1. Insertion of forceps spoons. Performed after a vaginal examination. The left spoon of the forceps is inserted first. Standing, the doctor inserts four fingers of the right hand (half-hand) into the vagina into the left half of the pelvis, separating the fetal head from the soft tissues of the birth canal. The thumb remains outside. Taking the left branch of the forceps with your left hand, the handle is moved to the right side, placing it almost parallel to the right inguinal fold. The top of the spoon is pressed against the palmar surface inserted into the vagina of the hand, so that the lower edge of the spoon is located on the fourth finger and rests on the abducted thumb. Then, carefully, without any effort, the spoon is moved between the palm and the fetal head deep into the birth canal, placing the lower edge between the third and fourth fingers of the right hand and resting on the bent thumb. In this case, the trajectory of movement of the end of the handle should be an arc. The advancement of the spoon into the depths of the birth canal should be done due to the instrument’s own gravity and by pushing the lower edge of the spoon with 1 finger of the right hand. 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 branch.
2. Closing the pliers lock. To close the pliers, each handle is grabbed with the same hand so that the first fingers of the hands are located on the Bush hooks. After this, the handles are brought together and the tongs are easily closed. Correctly applied forceps lie across the sagittal suture, which occupies a mid-position between the spoons. The lock elements and bush hooks should be located at the same level.
3. Test traction. This necessary moment allows you to ensure that the forceps are applied correctly and that there is no risk of them slipping. It requires a special positioning of the obstetrician's hands. To do this, the doctor covers the handles of the forceps from above with his right hand so that the index and middle fingers lie on the hooks. He places his left hand on the back surface of his right, and the extended middle finger should touch the fetal head in the area of the leading point. If the forceps are positioned correctly on the fetal head, then during test traction the fingertip will always be in contact with the fetal head. Otherwise, it moves away from the head, which indicates that the forceps are not applied correctly and, in the end, they will slip off. In this case, the forceps must be applied again.
4. The actual traction for extracting the fetus. After trial traction, making sure that the forceps are applied correctly, they begin their own traction. Traction of the fetal head with forceps should imitate natural contractions. To do this you should:
imitate a contraction in terms of strength: start tractions not sharply, but with a weak pull, gradually strengthening them and weakening them again towards the end of the contraction;
When performing traction, do not develop excessive force by tilting your torso back or resting your foot on the edge of the table. The obstetrician's elbows should be pressed to the body, which prevents the development of excessive force when removing the head;
Between tractions it is necessary to pause for 0.5-1 minutes. After 4-5 tractions, the forceps are opened for 1-2 minutes to reduce the pressure on the head;
try to perform traction simultaneously with contractions, thus strengthening the natural expulsion forces. If the operation is performed without anesthesia, the woman in labor must be forced to push during traction.
Rocking, rotating, pendulum-like movements are unacceptable
5. Removing the forceps. To remove the forceps, each handle is taken with the same hand, the spoons are opened and removed in the reverse order: the first is the right spoon, with the handle taken to the groin fold, the second is the left spoon, its handle is taken to the right groin fold.
1. The head is movable above the entrance to the pelvis; during external examination it moves.
2. The head is slightly pressed against the entrance to the small pelvis - this means that during an external examination it is motionless, but during a vaginal examination it is pushed away.
3. The head is pressed into the small pelvis - this is the norm in the absence of labor in first-time mothers.
4. The head is a small segment at the entrance to the small pelvis, the smaller part of the head has passed the plane of the entrance.
5. The head is a large segment at the entrance to the small pelvis, most of the head has passed the plane of the entrance.
6. Head in the pelvic cavity:
a) in the wide part of the pelvic cavity b) in the narrow part of the pelvic cavity.
7. Head in the exit cavity.
Transverse and oblique position of the fetus. Causes, diagnosis, obstetric tactics.
Transverse position – clinical situation, in which the axis of the fetus intersects the axis of the uterus at a right angle.
Oblique position is a clinical situation in which the axis of the fetus intersects the axis of the uterus at an acute angle. In this case, the lower part of the fetus is located in one of the iliac fossa of the large pelvis. The oblique position is a transitional state: during childbirth it turns into either longitudinal or transverse.
a) Excessive fetal mobility: with polyhydramnios, multiple pregnancy(second fetus), with malnutrition or premature fetus, with flabbiness of the muscles of the anterior abdominal wall in multiparous women.
b) Limited fetal mobility: with oligohydramnios; large fruit; multiple births; in the presence of uterine fibroids, deforming the uterine cavity; at increased tone uterus in case of threat of miscarriage, in the presence of a short umbilical cord.
c) Obstruction to insertion of the head: placenta previa, narrow pelvis, presence of uterine fibroids in the lower segment of the uterus.
d) Anomalies of the uterus: bicornuate uterus, saddle uterus, septum in the uterus.
e) Fetal developmental anomalies: hydrocephalus, anencephaly.
Diagnostics.
1. Examination of the abdomen. The shape of the uterus is elongated in transverse size. The abdominal circumference always exceeds the norm for the period of pregnancy at which the examination is carried out, and the height of the uterine fundus is always less than the norm.
2. Palpation. There is no large part in the fundus of the uterus, large parts are found in the lateral parts of the uterus (round dense on one side, soft on the other), the presenting part is not determined. The fetal heartbeat is best heard in the navel area.
The position of the fetus is determined by the head: in the first position the head is palpated on the left, in the second - on the right. The type of fetus, as usual, is recognized by the back: the back is facing anteriorly - anterior view, the back is backward - posterior.
3. Vaginal examination. At the beginning of labor, with a whole amniotic sac, it is not very informative; it only confirms the absence of the presenting part. After the outpouring amniotic fluid with sufficient opening of the pharynx (4-5 cm), the shoulder, scapula, spinous processes of the vertebrae, and axilla can be identified. The type of fetus is determined by the location of the spinous processes and scapula, and the position is determined by the armpit: if the cavity is facing to the right, then the position is the first, in the second position axilla open to the left.
The course of pregnancy and childbirth.
Most often, pregnancy in transverse positions proceeds without complications. Sometimes when increased mobility The fetus has an unstable position - frequent changes in position (longitudinal - transverse - longitudinal).
Complications of pregnancy with a transverse position of the fetus: premature birth with prenatal rupture of amniotic fluid, which is accompanied by loss of small parts of the fetus; hypoxia and infection of the fetus; bleeding with placenta previa.
Complications of childbirth: early rupture of amniotic fluid; fetal infection; the formation of an advanced transverse position of the fetus - loss of fetal mobility with intense early rupture of amniotic fluid; loss of small parts of the fetus; hypoxia; overstretching and rupture of the lower segment of the uterus.
In case of limb loss, it is necessary to clarify what fell into the vagina: an arm or a leg. The handle, lying inside the birth canal, can be distinguished from the stem by the longer length of the fingers and the absence of a calcaneal tubercle. The hand is connected to the forearm in a straight line. The fingers are separated, especially the thumb is abducted. It is also important to determine which handle fell out - right or left. To do this, they kind of “hello” the right hand with the dropped pen; if this succeeds, the right handle falls out, if it fails, the left one falls out. The dropped handle makes it easier to recognize the position, position and type of the fetus. The handle does not interfere with internal rotation of the fetus onto the stem; its reduction is an error that complicates fetal rotation or embryotomy. A prolapsed arm increases the risk of ascending infection during childbirth and serves as an indication for faster delivery.
Umbilical cord prolapse. If, during a vaginal examination, loops of the umbilical cord are felt through the amniotic sac, they speak of its presentation. The detection of umbilical cord loops in the vagina with a ruptured amniotic sac is called umbilical cord prolapse. The umbilical cord usually falls out when your water breaks. Therefore, in order to detect such a complication in a timely manner, it is necessary to immediately vaginal examination. Prolapse of the umbilical cord with a transverse (oblique) position of the fetus can lead to infection and, to a lesser extent, to fetal hypoxia. However, in all cases of umbilical cord prolapse with a living fetus, urgent assistance is necessary. In a transverse position, full opening of the uterine pharynx and a mobile fetus, such help is to turn the fetus onto its leg and then remove it. If the pharynx is not fully dilated, a caesarean section is performed.
Output tongs
1. Preparation:
- placing the woman in labor on a “transverse” bed;
- treatment of the hands of the operator and assistant (the method is the fastest possible under these conditions);
- treatment surgical field(external genitalia, inner thighs, perineum) with an antiseptic solution;
- bladder catheterization;
- anesthesia (preferably general anesthesia, pudendal anesthesia - with exit forceps);
- collecting the tongs and laying the branches on the work table (Figure 1);
- internal research"half-hand" or two fingers to clarify the state of the birth canal, presentation, type, position, position, sagittal suture and determine the level of the head.
Rice. 1. Collecting the tongs and laying the branches on the work table
2. Operation technique:
- insertion and placement of forceps spoons. Four fingers of the right hand are inserted into the left half of the pelvis in the direction of the sacroiliac joint (Fig. 2). With the left hand, the left spoon of the forceps is grasped by the handle in the form of a bow or with three fingers, its top is placed in the groove between the index and middle fingers, and the handle is deflected towards the opposite groin. Under the control of the hand inserted into the vagina, the thumb moves along the lower branch, without violence the spoon itself is placed on the head along its greatest curvature, and the parietal tubercle is grabbed. The handle of the left spoon is easily lowered. The spoon is passed to the assistant, who holds it in the given position. The right spoon is also inserted under the control of the left hand (Fig. 3).
Rice. 2. Placement of the left spoon of forceps
Rice. 3. Insertion of the right spoon with forceps
- closing the forceps: the right spoon, when correctly applied to the head, easily fits into the lock of the left one: Bush hooks are at the same level for shock absorption, a diaper is placed between the jaws (Fig. 4),
Rice. 4. Closing the forceps
- control of the correct application of the forceps: with two fingers of the right hand, check whether the cervix is captured between the jaws of the forceps and the head. The left hand supports the pliers by the handles,
- test traction (Fig. 5). We place the right hand on top of the handle of the forceps - the left one overlaps the right one, the middle finger touches the head. Light traction is applied. If this does not increase the distance between the head and the finger - therefore the forceps do not slip - they are applied correctly. If the distance increases, the forceps are applied incorrectly; they must be removed by removing the spoons in the reverse order, first the right one, tilting the handle of the forceps to the left groin of the woman in labor, and then the left one;
Rice. 5. Test traction
- traction itself. Hand position: 1) classic - the right hand grabs the handles in such a way that the index and middle fingers rest on the hooks (Fig. 6). The left hand repeats the position of the right, or also grabs the handles of the tongs from below. 2) according to Tsovyanov - after inserting the spoons and closing the forceps, the second and third fingers of both hands, bent with a hook, grasp the outer and upper surface tool. Main phalanges index fingers are located on the outer surface of the handles, with Bush hooks passing between the main phalanges of the index and middle fingers. The fourth and fifth fingers grasp parallel forceps. The thumbs are under the handles of the tongs.
Rice. 6. Traction itself
Tractions are performed along the axis of the birth canal, taking into account the biomechanism of labor and the nature of the operation (abdominal or exit). Tractions are produced in horizontal direction and up (in 2 positions). The amount of traction depends on the position of the head in the cavity or at the pelvic outlet.
2) If the wire point is facing to the right, the forceps are applied in the right oblique size, the fixing spoon will be the right one.
Since the forceps are not a rotating instrument, but a pulling instrument, during traction the head produces an internal rotation, and the forceps follow the head. After turning the head and establishing a sagittal suture in a straight size, remove the head using the method described above using exit forceps.
During the eruption of the parietal tubercles, an episiotomy is performed on one or both sides.
Ed. K.V. Voronina
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), feverish 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 arise from the following conditions under 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 You can use the following diagram for 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 the upper third of the posterior surface of the pubic symphysis, in the back - 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. The III and IV sacral vertebrae and coccyx can be easily palpated. 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, it 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).
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 the 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 from the mother can be divided into: those related to pregnancy and childbirth ( obstetric indications) and associated with extragenital diseases of women requiring “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 that does not respond to conservative therapy) require “switching 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, with no effect from use medications. Prolonged standing of the head in one plane of the small pelvis leads to an increased risk of developing birth trauma both the fetus (a combination of mechanical and hypoxic factors) and the mother (genitourinary and enterogenital 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 the cardiovascular system in the stage of decompensation;
Breathing disorders due to lung diseases;
High myopia;
Acute infectious diseases;
Severe forms of neuropsychic disorders;
Intoxication or poisoning.
The application of obstetric forceps may be required for women in labor who have had childbirth the day before surgical intervention on the abdominal organs (the 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 detachment 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, you need following conditions:
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);
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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 Active participation women in labor 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 (LPA) or inhalation of nitrous oxide with oxygen. However, when applying abdominal obstetric forceps to somatically healthy women It is advisable to use anesthesia, since placing spoons on 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;
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2) right the spoon is taken in the right hand and inserted into the right side of the mother’s 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 tongs moves downwards and takes 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);
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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. Left hand he places it on the back surface of the right one, extends the index or middle finger and touches the fetal head with it 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. For this, the index finger and ring fingers the right hand is placed on the Bush hooks, the middle one is placed 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;
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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 vertical position the body of a 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;
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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 the transverse dimension of the 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 this moment attraction should be directed;
2) the head does not move along 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.
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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. Left branch hold with the left hand, the right 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 when passing the pelvic outlet in the anterior view of the 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?
Traction is performed in a horizontal direction until the anterior edge of the greater fontanelle comes into contact with the lower edge of the symphysis pubis (the 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 -
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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 on 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 to 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 down to the exit occipital protuberance from under the pubis, then anteriorly until the head is straightened.
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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 fontanel.
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 the left half of the pelvis, and then it is moved anteriorly to the anterolateral part of the 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 are ruptures of the lower segment of the uterus and damage to the pelvic organs: the bladder and rectum, which usually occur when the conditions for the operation 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 barely operations on soft tissues swelling of the fetal head with a cyanotic color is usually observed. With strong compression of the head, hematomas can occur. Strong pressure spoons on facial nerve may cause paresis. Severe complications are damage to the bones of the fetal skull, which can be varying degrees- from bone depression to fractures. Brain hemorrhages pose a great danger to the life of the fetus.
Postpartum infectious complications. Delivery using obstetric forceps is not the cause of postpartum infectious diseases, however, increases the risk of their development, and therefore requires adequate prevention infectious complications V postpartum period. Complications may be associated and depend on the pathological process or condition of the woman in labor that was an indication for the application of obstetric forceps.
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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 apparatus - a vacuum extractor by creating negative pressure between inner surface calyx apparatus and 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 related to the peculiarity physical action 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:
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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 fontanelle.
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, and brain symptoms, convulsions, etc. 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.
