Conditions for applying obstetric forceps are not included. Indications for use
Over the past three centuries, medical and public opinion on the use of obstetric forceps has been opposite, but not as categorical as the above points of view. However, if the use of obstetric forceps was abolished, then the 5-25% of women in labor who are delivered using this method would have two options: C-section or, as before the invention of forceps, a second stage of labor over long hours or even days.
Over the past three centuries, more than 700 types have been proposed, and new ones continue to be invented. Typically, in clinical practice, Simpson forceps are used, as well as similar Neville-Barnes, Ferguson, and Tucker-McLane forceps with plate-shaped spoons. The tongs consist of two branches, right and left, each of which includes a spoon, a lock and a handle. The cephalic curvature of the spoon, concave from the inside and convex from the outside, corresponds to the shape of the fetal head, and the pelvic curvature is expressed in the bending of the spoons in the shape of an arc, which corresponds to the curvature of the mother’s birth canal. The branches of the tongs close in the area of the lock and handles. Forceps designed for rotation (most often Kielland forceps) are distinguished by a pronounced cephalic curvature and a weakly expressed pelvic curvature of the spoons. This device allows for rotation in the pelvic cavity and reduces the risk of trauma to the mother’s tissues, because reduces the arc of rotation due to narrowing of the tops of the spoons. When applying rotary forceps, one is often faced with asynclitic insertion, which is why these forceps have a sliding lock. Each obstetrician prefers his own model of forceps, depending on his skills and awareness. In clinical practice, the obstetrician needs to be familiar with two types - classic Simpson forceps and Kielland rotary forceps. More detailed information about the structure various types forceps can be found in the literature, a list of which is presented at the end of this chapter.
Classic obstetric forceps
After the indications for the application of obstetric forceps have been determined and performed preliminary preparation, the patient is placed in the lithotomy position with appropriate leg support. The spoons of the forceps are designed in such a way that when they are placed in the pelvic cavity in a transverse position, they maintain an amplitude of safe movement of 45 in each direction from the original: the boundaries are the iliopubic eminence and the sacroiliac joint. Application of forceps should be done in the following way: a spoonful of forceps is placed on the child’s head in the area between the eye sockets and ears. This arrangement of spoons is biparietal and bimalar, i.e. they are placed on the parietal and zygomatic bones, and the pressure on the head is distributed so that the most vulnerable parts of the skull do not experience it. If the application of the forceps spoons is asymmetrical, for example on the area of the eyebrow and mastoid process, the subsequent pressure during traction is also distributed asymmetrically - the pressure on the falciform processes of the cerebellum and the tentorium of the cerebellum increases, which leads to an increased risk of intracranial hematoma.
When the view and position of the fetal head are accurately established, for example, the anterior view of the occipital presentation, the first or second position, both branches of the forceps are taken in the hands and folded in front of the patient's perineum in such a way as if placing it on the fetal head. The left branch of the obstetric forceps is taken with the left hand, inserted from the left side and placed in front of the left ear of the fetus. During this action, the fingers of the right hand are inserted into the vagina, and the thumb of the left hand rests on left branch forceps. The handle of the left branch of the forceps is held in the left hand, then it is rotated in an arcuate manner, using the fingers of the right hand to guide the spoons of the forceps to the desired position. Then the hands are changed and the procedure for inserting the right spoon is carried out. Most classic pliers have an “English lock” in which the right branch fits into the left. Thus, there is no need to manipulate the parts of the forceps separately from each other, because they are connected. For the first or second position when front view occipital presentation, the method of applying forceps is the same, but the location of the head must be taken into account. Applying spoons of forceps to the head and closing the lock should be done without effort. If any difficulties arise when inserting spoons or closing the branches of the forceps into the lock, you should stop and double-check the location of the fetal head.
If the branches of the tongs close into the lock without difficulty, you should check the correct placement of the tong spoons in the following ways:
- the small fontanelle should be located in the middle of the distance between the spoons of the forceps, the lines of the lambdoid suture should be equidistant from the spoons of the forceps;
- the small fontanelle should be at a distance equal to the width of one finger from the surface of the forceps in the lock area. If the small fontanel is located further from the specified surface, then traction will lead to extension of the head, and it will pass through the birth canal with its large size;
- the arrow-shaped seam should be perpendicular to the locking surface of the forceps along its entire length. The location of the locking surface of the forceps obliquely in relation to the sagittal suture means that the spoons of the forceps are applied asymmetrically, closer to the areas of the eyebrow and mastoid process;
- the palpable parts of the openings of the forceps trays should be equal on both sides. When the forceps are applied correctly, the holes in the spoons should almost not be palpable, and no more than one finger should pass between them and the head.
If not all of these conditions are met, the overlay must be corrected or performed again.
Sufficient compression force on the spoons of tongs is still one of the most important aspects. In this case, it is easier to achieve the required compression force on the spoons by placing your fingers as close as possible to the locking area of the tongs, further from the end of the handles. Index and middle fingers held together, and the other hand placed on the lock, which helps with downward traction (Payo maneuver). It is necessary to ensure that such tractions correspond to the wire axis of the pelvis and do not put pressure on the pubic bone.
Tractions should be carried out during a contraction, combining them with pushing, and with their help, move the head along the wire axis of the pelvis - the Carus curvature. When performing traction, the obstetrician can stand or sit, his arms should be bent at the elbows. It is difficult to describe how strong the traction should be, but less strong effective traction is better. A recent study used isometric determination of traction force. It has been shown that young obstetricians should be trained to perform traction with an "ideal" force of 14-20 kg. Physically developed obstetricians of both sexes are able to apply significant and not always necessary forces when applying obstetric forceps. The basic principle is that traction should be of moderate strength and soft, in addition, it is necessary to evaluate their effectiveness. The result of traction together with pushing is the lowering and birth of the fetal head. In fact, after the first traction it becomes clear whether it is going down. In cases of mechanical obstacles to the passage of the head, a very definite sensation occurs during the first traction, the presence of which means that further attempts to complete the birth using obstetric forceps should be abandoned.
When the head descends to the perineum and the back of the head passes under the pubic symphysis, the direction of traction should gradually change anteriorly and upward at approximately an angle of 45°. When the fetal head is embedded, the branches of the forceps are raised at an angle of 75°, one hand begins to hold the perineum, or, if necessary, an episiotomy is performed. When the fetal head is almost born, the forceps spoons can be removed by repeating reverse order actions performed when they are applied. Usually the right spoon of the forceps is removed first. If it takes too much force to remove the trays, you can gently promote the birth of the head with forceps applied to it.
If the sagittal suture is in the right or left oblique size, then after correct application of the forceps spoons, it is necessary to gradually and carefully, without traction, rotate the head by 45 degrees towards the midline. This can be done by slightly lifting the handles of the forceps and slowly turning them in an arc, allowing the mother's soft tissues to adapt to the change in the position of the fetal head. After turning the head, you need to check again that the tong spoons are positioned correctly, because they could slip off.
OBSTETRIC FORCEPS (forceps obstetricia) - 1) an operation of artificial extraction of a live full-term or almost full-term fetus by the head (rarely by the buttocks) with urgent need finish the second stage of labor using a special tool - obstetric forceps; 2) obstetric instrument. The design of obstetric forceps and their various models - see Obstetric and gynecological instruments.
The first description of obstetric forceps was made in the second edition of Heister's manual of surgery (L. Heister, 1683-1758), published in Holmstedt in 1724. (see Obstetrics). The purpose of obstetric forceps is to replace the expelling force of the uterus and abdominal press of a woman in labor with the attracting force of the doctor. Obstetric forceps are only a retraction instrument, not a rotational or compression instrument. The known compression of the head, inevitable when applying obstetric forceps, should be minimal.
More or less compression of the head depends on whether the obstetric forceps are applied correctly and whether the direction of the drive corresponds to the mechanism of fetal birth. Excessive compression of the head with obstetric forceps is dangerous for the life of the fetus (fractures of the skull bones, hemorrhage in the brain).
Indications, conditions and contraindications for the operation of applying obstetric forceps. The application of obstetric forceps is indicated in all cases where the mother, the fetus, or both are in danger during the expulsion period, which can be eliminated by immediate removal of the fetus. Indications may include: insufficiency labor activity(in case of secondary weakness of labor forces, obstetric forceps should be applied if the expulsion period for primiparous women lasts more than 2 hours, and for multiparous women - more than one hour); severe nephropathy and eclampsia, not eliminated by appropriate conservative treatment; premature placental abruption; diseases of the mother without stable compensation or remission (endocarditis, heart defects, hypertonic disease, nephritis, pneumonia, tuberculosis and others); febrile state women in labor with high temperature, fetal hypoxia. Certain conditions are required to apply obstetric forceps. The dimensions of the pelvis must be sufficient for the passage of the head removed with forceps. Forceps can only be applied when the external pharynx of the cervix is fully dilated (the insertion of spoons and especially the removal of the head when the pharynx is not fully dilated inevitably leads to rupture of the cervix and lower segment of the uterus).
Before applying obstetric forceps, the obstetrician must clearly understand in which part of the pelvis (cavity or outlet) the fetal head is located and what its position is. The forceps can be applied to the fetal head, standing as a large segment in the cavity (the wide and narrow part of it) or at the pelvic outlet. If the fetal head has dropped into the cavity or to the pelvic floor, this is convincing evidence no discrepancy between the sizes of the pelvis and the fetus, except in very rare cases of a funnel-shaped pelvis (it is important to measure the plane of exit of the pelvis!). Forceps should, as a rule, only be used for cephalic presentations. The head should not be too large (hydrocephalus) or too small (forceps should not be applied to the head of a fetus less than 7 months old), it should have normal density (otherwise the forceps will slip off the head during attraction). The amniotic sac must be ruptured and the membranes tucked behind the largest circumference of the head: the forceps do not hold well on the membranes, and if they do, the attraction to the membrane will cause premature abruption of the placenta. The fetus must be alive. If the fetus is dead, then the operation of craniotomy rather than forceps is less traumatic for the mother. Obstetric forceps should not be used if there is a threatening or existing uterine rupture, as well as with a posterior view of the facial presentation (chin posterior).
Preparation for the operation of applying obstetric forceps and pain relief
Before applying obstetric forceps, it is necessary to internal research and accurately determine the location of the head, the wire point of the head, navigate the position of the sagittal suture, the degree of opening of the external os of the cervix, etc. When applying obstetric forceps, it is desirable to use inhalation anesthesia (see). When exiting obstetric forceps, you can limit yourself to bilateral anesthesia of the pudendal nerves or intravenous administration of epontol. Obstetric forceps are applied with the woman in labor on her back; she should be laid on the operating table or Rakhmanov bed with her legs brought to her stomach, held by assistants; in the absence of the latter, leg holders are used. The bladder is emptied using an elastic catheter. For this purpose, when the presenting part is low, insert 2-3 fingers of the right hand into the vagina between the symphysis and the head, with the back surface to the pubis, spread the fingers slightly and try to carefully insert a catheter into the urethra. A metal catheter should not be inserted, as this may damage the urethra. Thoroughly disinfect the external genitalia, top part inner thighs and tissue in the perineal area.
General principles of applying obstetric forceps with pelvic curvature (the most commonly used is the Fenomenov-Simpson model). When applying forceps, first of all, it is necessary to clearly and accurately know the mechanism of fetal birth and remember three basic rules: 1) the forceps must capture the largest surface of the head, the tops of the spoons of the forceps must extend beyond the parietal tubercles; Failure to comply with this rule may result in the spoons of the tongs slipping; 2) the forceps should be applied so that the tops of their spoons are directed towards the wire point, and the concavity of the pelvic curvature of the instrument is facing the pubis; 3) the tongs must be locked in such a way that the wire point is always in the plane of the head curvature of the instrument, that is, by placing the locking parts of the tongs in the same plane, their handles should be connected so that the spoons grip the proper surface of the head.
Depending on the height of the head, the forceps can be closed: a) directly on the obstetrician (horizontally); b) with the handles raised anteriorly (upwards); c) with the handles lowered backwards. Obstetric forceps can be applied typically and atypically. Typical A. shch. applied to the fetal head, which has completely completed the internal rotation (rotation), to its transverse (biparietal) size and in the transverse size of the pelvis. Such obstetric forceps are also called output forceps, since the head is located at the outlet of the pelvis. With typical obstetric forceps, the head is grasped in the temporoparietal region. With this grip, the above three rules for applying forceps are observed. Obstetric forceps, which have to be applied to the head, which has not yet completed rotation, located in the pelvic cavity (in its narrow or wide part), are called atypical, or cavitary. Atypical obstetric forceps have to be applied: 1) to the head, which has not completely completed the internal rotation (the sagittal suture is located in one of the oblique dimensions of the pelvis); 2) with a low transverse position of the head. When applying atypical obstetric forceps, one general rule should be followed: they must be applied in the oblique size of the pelvis, opposite the sagittal suture or facial line. If the sagittal suture is located in the left oblique dimension, then the spoons of the forceps are located in the right oblique dimension and vice versa. In both cases, the forceps grasp the head in the ear area (perfect capture). If the transverse position of the head is low, obstetric forceps with pelvic curvature are applied along general rule: in one of the oblique sizes, where the wire point is deviated - the small (posterior) fontanel. The forceps grasp the parietal tubercle and temporal region. This capture of the head is not perfect, but it manages to meet the requirement that the pelvic curvature of the forceps and the birth canal almost coincide. High forceps are atypical when they grasp and try to remove the fetal head located above or at the entrance to the pelvic cavity. Currently, high obstetric forceps are not used, since this operation is very difficult and traumatic for the mother and fetus. In cases where it is necessary to quickly complete childbirth with this position of the head, they resort to cesarean section (see) or vacuum extraction (see) of the fetus.
Technique for applying obstetric forceps with pelvic curvature(general rules). The technique of applying both typical and atypical obstetric forceps includes the following five points: 1) insertion of spoons; 2) closing the forceps; 3) test traction; 4) traction itself (pulling the head with forceps); 5) removing the forceps. Positive result The operation can only be guaranteed if a thorough study of the purpose, purpose and technique of each of these points is made.
The first moment of the operation. The left spoon is introduced first. When closing the tongs, it must lie under the right one, otherwise closing the tongs will be difficult, since a significant part of the lock (pin, pin, plate) is always on the left spoon. In order not to make a mistake when choosing a spoon, you should make it a rule to fold the forceps before insertion (Fig. 1) in order to clearly see which of the spoons is the left and which is the right. Then the obstetrician spreads the genital slit with his left hand and inserts four fingers of his right hand into the vagina along its left wall.
If the edges of the external os of the cervix are still preserved, then it is necessary to determine the gap between its edges and the head. Next, with the left hand, take (like a writing pen or like a bow) the left branch of the forceps by the handle and lift the handle anteriorly and to the right inguinal fold of the woman in labor so that the top of the spoon of the forceps enters the genital slit according to its longitudinal (antero-posterior) diameter. The lower edge of the spoon rests on the thumb of the right hand. The spoon is inserted into the genital slit, pushing its lower rib with the thumb of the right hand and under the control of the fingers inserted into the vagina (Fig. 2). The spoon should slide between your index and middle fingers. When inserted correctly, the spoon should lie so that the head curvature of the forceps does not capture the edge of the pharynx and fits well to the head; the insertion of the obstetrician's right hand is intended to control the advancement of the spoon. As the spoon moves into the birth canal, the handle of the forceps should approach the midline and descend posteriorly. The spoon must be inserted with great care, easily, smoothly, without any violence. ABOUT correct position spoons in the pelvis can be judged by the fact that the Bush hook is positioned strictly in the transverse dimension of the pelvic outlet (in the horizontal plane). The inserted left spoon must certainly go beyond the ends of the fingers, therefore, beyond the parietal tubercle, located in the temporo-parietal region of the head. If the spoon is inserted deep enough, the lock is close to the external genitalia. When the left spoon fits well on the head, its handle is handed over to the assistant. The right (second) spoon of the forceps is inserted in the same way as the left one (Fig. 3), right hand to the right side under the protection of the fingers of the left hand inserted into the vagina.
The second moment of the operation. To close the pliers, each handle is grabbed with the same hand so that thumbs were located on Bush's hooks. After this, the handles are brought together and the forceps are easily closed (Fig. 4). Correctly applied obstetric forceps tightly grasp the head along its large oblique size (in the direction from the back of the head through the ears to the chin) - biparietally. The sagittal suture occupies a mid-position between the spoons, the curved tops of which are directed anteriorly, the leading point of the head (posterior fontanel) is in the plane of the forceps (Fig. 5). The inner surfaces of the handles of the pliers should be close to each other (or almost close). A sterile napkin folded 2-4 times is placed between the handles; This ensures good alignment of the spoons of the forceps to the head and avoids the possibility of excessive compression in the forceps. Having closed the tongs, you should make thorough examination whether soft tissues are captured by them birth canal.
The third moment of the operation. Test traction allows you to once again verify the correct application of the forceps (whether the head follows the forceps). To do this, the obstetrician grabs the handles of the forceps with his right hand from above so that the index and middle fingers lie on the Bush hooks. Simultaneously left hand he places it on the back surface of the right one, with the end of the extended index or middle finger touching the head (Fig. 6). If the forceps are applied correctly, then during the attraction process the fingertip will always be in contact with the head. Otherwise, it slowly moves away from the head, the distance between the lock of the tongs and the head increases, and their handles diverge: the tongs begin to slip and they must be immediately repositioned.
The fourth moment of the operation. After making sure that the forceps are applied correctly, they begin to extract the fetus with forceps (traction itself). For this, the index finger and ring fingers the right hand is placed on the Bush hooks, the middle one is placed between the diverging branches of the forceps, and the thumb and little finger cover the handles on the sides. The left hand clasps the handles from below (Fig. 7). The main traction force is developed by the right hand. When extracting a fetus using obstetric forceps, it is necessary to carry out all manipulations in accordance with the mechanism of its birth in each individual case and take into account three points: the direction of traction, the strength, and the nature of the traction. According to the direction, traction is divided posteriorly (with a horizontal position of the woman in labor - from top to bottom), towards itself (parallel to the horizon) and anteriorly (from bottom to top). These directions are determined by the desire to imitate the natural mechanism of birth and advancement of the fetal head along the wire axis of the birth canal when applying obstetric forceps. The direction of traction must strictly correspond to the position of the head in the birth canal: the higher the head is in the pelvic cavity, the more posterior the direction of traction should be. When the head is positioned at the outlet of the pelvis, traction during its eruption is performed in the third position, from bottom to top. Due to the fact that in obstetric forceps with pelvic curvature the direction of movement of the handles does not coincide with the direction of movement of the spoons, N. A. Tsovyanov proposed the following method of grasping (Fig. 8) and traction with forceps: the bent II and III fingers of both hands of the obstetrician grasp from under the handles obstetric forceps at the level of Bush hooks, their outer and top surface, and the main phalanges of the indicated fingers with Bush hooks passing between them are located on the outer surface of the handles, the middle phalanges of the same fingers are on the upper surface; nail phalanges are also located on the upper surface of the handle, but only on the other (opposite) spoon of obstetric forceps; The fourth and fifth fingers, also slightly bent, grasp the parallel branches of the forceps extending from the lock from above and move as high as possible, closer to the head. The thumbs, being under the handles, rest against the flesh of the nail phalanges middle third the bottom surface of the handles. The main work when extracting the head falls on the nail phalanges of the IV and V fingers of both hands. By pressing your fingers on the upper surface of the parallel branches of the forceps extending from the lock, the head is moved away from the symphysis pubis. This prevents its inevitable friction against the back surface of the womb and ensures correct movement along the pelvic axis towards the sacral cavity. The same movement is facilitated by the thumbs, which exert pressure on the lower surface of the handles, directing them upward (anteriorly). The action of the main phalanges of the II and III fingers of both hands, squeezing the outer surface of the handles at the level of the Bush hooks, is reduced to capturing and holding the head under a certain and constant pressure throughout the entire operation. Thus, the obstetrician’s fingers, located above and below the forceps, acting simultaneously in different directions, ensure the production of traction and advancement of the head along the axis of the birth canal. The force of traction should be commensurate with the strength of the obstetrician and the available resistance. The pulling force should not be excessive.
It is not allowed to perform traction with four hands (two obstetricians at once or one after the other). If 8-10 tractions are unsuccessful, further use of obstetric forceps should be abandoned. During traction, the obstetrician strives to complete the unfinished stages of the birth mechanism. The extraction of the fetus with obstetric forceps should not occur continuously, but with intervals of 30-60 seconds. The duration of an individual traction corresponds to the duration of pushing; it should begin, like an effort, slowly, gradually increase in strength and, having reached a maximum, go into a pause, gradually fading away. After 4-5 tractions, open the forceps and take a break for 1-2 minutes. No rocking, rotating, pendulum-like or other movements should be made during traction. Rotating the head with forceps is unacceptable; the tongs should turn along with the head due to its rotation; during traction, imitating the natural mechanism of fetal birth, the head is rotated in forceps.
Fifth moment of the operation. Obstetric forceps are removed either after the head is removed, or when it is still erupting. In the latter case, the forceps are carefully opened, both spoons are moved apart, each spoon is taken in the corresponding hand of the same name and removed in the same way as they were applied, but in the reverse order, that is, the right spoon, describing an arc, is taken to the left groin fold, the left - to the right (Fig. 9). The spoons should slide smoothly, without jerking. It is necessary to consistently focus on both the pelvic and cephalic curvature. After the birth of the head, the fetal body is removed according to general rules.
Technique for applying direct obstetric forceps
The first moment of the operation. When applying straight parallel Lazarevich forceps, it does not matter which spoon is inserted first, since this is not prevented by the locking device. When applying straight but crossing forceps, the left (with the lock) branch is inserted first. When inserting a spoon with straight forceps, each branch is held horizontally and the spoon is inserted under control inner hand, describing an arc corresponding to the circumference of the fetal head. The design of straight obstetric forceps allows them to be applied to the presenting part of the fetus not only transversely and obliquely, but also straight size small pelvis. However last option unsafe (possibility of injury to the urethra, bladder, rectum).
Second and third moments of the operation- closing the forceps and testing traction - have no features compared to the operation of applying obstetric forceps with pelvic curvature.
The fourth moment of the operation- traction itself. When using straight forceps, you can more accurately control and direct the movements of the head, since the direction of movement of the handles of straight forceps coincides with the direction of movement of the fetal head. When removing the head using straight obstetric forceps, you should never lift the handles of the forceps high (as when using forceps with pelvic curvature), as this will lead to significant trauma to the perineum and vagina.
Fifth moment of the operation- opening the lock and removing straight forceps is also done after the birth of the head or during its eruption. If the forceps are removed during the process of eruption of the head, then (unlike obstetric forceps with pelvic curvature) it does not matter which branch is removed first - the forceps are removed when the handle is moved to the side, and each branch of the forceps describes an arc corresponding to the circumference of the head. In the crust, straight forceps (more convenient when applied to a high head) due to the refusal to use high obstetric forceps are used much less frequently than forceps with pelvic curvature.
Typical (exit) obstetric forceps with the anterior view of the occipital presentation, it is used most often. On palpation through the anterior abdominal wall the head is not defined above the entrance to the pelvis. At vaginal examination the sagittal suture of the head is located in the direct size of the pelvic outlet, the leading point is the small (posterior) fontanel, in relation to the large (anterior) fontanel it is located downward and anteriorly, under the pubis; the sacral cavity is completed, the ischial spines are not reached. The forceps should be applied in the transverse dimension of the pelvic outlet, that is, biparietally on the head. If the head has approached the lower edge of the pubic fusion with the occipital protuberance, then traction is performed along a horizontal line until the occipital protuberance comes out from under the pubis. Then the head is brought out, slowly and carefully lifting the handles of the forceps anteriorly, and the movement characteristic of this moment of childbirth should occur - extension of the head around the point of fixation, that is, the area of the occipital bone. The perineum is supported by hand, preventing rapid eruption of the frontal tubercles.
In the posterior view of the occipital presentation, the position of the head in the pelvic outlet is characterized by the fact that the occiput has completed a posterior rotation, the sagittal suture is located in the direct size of the outlet, the leading point is the posterior (small) fontanelle, in relation to the anterior (large) fontanel it is located downward and posteriorly. The posterior view of the occipital presentation is a variant of the normal mechanism of fetal birth, therefore the head must be removed in the posterior view. When applying forceps in the posterior view, you should remember all the details of the mechanism for cutting the head, trying to imitate it when removing it with obstetric forceps. Apply forceps and perform traction in the same way as with the anterior view of the occipital presentation. When cutting through the head, you must remember about two points of fixation of the head: one to enhance flexion and the other to extend. As soon as, with horizontal traction, the area of the border of the scalp of the forehead appears under the symphysis (the anterior point of fixation), you should proceed to extracting the head in the direction along the anterior arc (Fig. 10). At the same time, the head is bent even more to allow the occiput and both parietal tubercles to emerge ( Special attention perineal protection!). After the birth of the occiput, they begin to straighten the head around another fixation point (occipital bone), which is fixed in front of the coccyx. To do this, the handles of the forceps are lowered posteriorly towards the perineum.
In case of anterior cephalic presentation, typical obstetric forceps are applied to the head when its sagittal suture is in the direct size of the pelvic outlet, the anterior (large) fontanel is located anteriorly, the posterior (small) fontanel is posterior and is difficult to reach. The anterior (large) fontanel lies below, the small one - above. The insertion of spoons is carried out, as usual, in the transverse dimension of the pelvis. Closing is done with the handles relatively raised. To avoid further extension, the first spoon is held by an assistant with the handle raised anteriorly. Ideal grip through the parietal region is impossible; spoons are applied according to the vertical size of the head. The first tractions are done with relatively raised handles, and later - in horizontal direction until the area of the bridge of the nose (anterior fixation point) appears under the symphysis. Then the head is flexed by traction anteriorly (Fig. 11), until the occipital region is born above the perineum (remember the possibility of rupture of the perineum!). After this, the handles of the forceps are lowered posteriorly, and the head is extended around occipital protuberance(posterior fixation point), and the face is released from under the pubis. The lock is opened and the spoons are removed only after the head has been removed. Correction of anterior cephalic presentation with obstetric forceps (translation into a more physiological one - occipital or facial) is currently not used.
In case of facial presentation, typical obstetric forceps are rarely used. The technique of applying forceps for facial presentations is much more complicated than for occipital presentations. Only an experienced obstetrician can perform the operation, with a strict assessment of the indications. The application of forceps is permissible only in cases where the head is on the pelvic floor and the chin is facing anteriorly. If the chin is turned posteriorly, childbirth is impossible (if there are no conditions for cesarean section, a craniotomy is performed). Forceps are applied in the transverse dimension of the pelvis with the handles raised anteriorly, since in these presentations the wire point (chin) is always located at the pubic symphysis, and the bulk of the head lies in the recess of the sacral bone. The spoons are placed perpendicular to the vertical dimension (Fig. 12). After closing the spoons and testing traction, traction is done somewhat posteriorly in order to bring the chin out from under the pubis; then the handles of the forceps are raised anteriorly, the head is bent around the hyoid bone (fixation point) and the forehead, parietal tubercles and occiput are brought above the perineum.
Atypical (cavitary) obstetric forceps
If with typical exit forceps, when removing the head, the process of cutting, cutting and birth of the head is reproduced, then with cavity forceps, an internal rotation of the head in the forceps is also performed during traction. This is due to the fact; that the fetal head standing in the pelvic cavity has not completed the internal rotation, and its sagittal suture may be in one of the oblique or transverse dimensions of the pelvic cavity. The peculiarities of the technique concern only the first moment (insertion of spoons) and the fourth (traction).
In the first position of the fetus, occipital presentation, anterior view, atypical obstetric forceps are applied in biparietal size head, that is, in the left oblique size of the pelvic cavity (Fig. 13). The left spoon is inserted first (as with typical forceps), but somewhat posteriorly - so that the spoon rests on the head in the area of the left parietal tubercle. The right spoon of the forceps is also first inserted from behind, then, together with the fingers of the control hand, it is carefully raised (the handle of the forceps is lowered at this time) to the right parietal tubercle (the spoon “wanders”), after which the forceps are closed and a test traction is performed. The direction of traction is first done downwards and somewhat posteriorly. At the same time, feeling the rotation of the head (with the posterior fontanelle counterclockwise - to the right and anteriorly), they contribute to this movement. When the rotation of the head is complete (posterior fontanel at the pubis, sagittal suture in the direct size of the pelvic outlet), traction is performed horizontally until the birth of the occipital protuberance from under the pubis, and then anteriorly - extension and birth of the head.
Atypical obstetric forceps for the second position of the fetus, occipital presentation, anterior view are also applied in the biparietal size of the head, but in the right oblique size of the pelvic cavity (Fig. 14). To do this, insert the left spoon into left half pelvis, and then it is moved anteriorly and to the right until it lies on the left parietal tubercle. The right spoon is inserted so that it rests on the right parietal tubercle. Traction is done slightly backwards and downwards; when the head begins to descend, it is rotated in the forceps by the posterior (small) fontanel anteriorly and to the left, that is, clockwise by 45°. Next, traction is performed as with typical obstetric forceps: horizontally and anteriorly.
Atypical obstetric forceps for the first position of the fetus, occipital presentation, posterior view are applied in the right oblique dimension of the pelvic cavity so that they cover the head biparietally. The insertion of spoons is carried out in the same way as in the second position, anterior view. With traction downward (towards oneself) and somewhat posteriorly, the head is rotated by the posterior (small) fontanelle posteriorly (very rarely anteriorly, in these cases the spoons of the forceps are shifted accordingly). Then the direction, strength and nature of traction are determined by the same rules as with typical obstetric forceps.
Atypical obstetric forceps for the second position of the fetus, occipital presentation, posterior view are applied in the left oblique dimension of the pelvic cavity to the biparietal dimension of the head. The technique for inserting forceps is the same as for the anterior view of the occipital presentation of the first position. Only when the head is lowered during traction does its posterior fontanelle rotate posteriorly in the forceps. This is followed by additional flexion and extension of the head.
Rice. 15. Application of atypical forceps with a low transverse position of the head (bottom view). The arrows show the movement (wandering) of the right and left spoons (the initial position of the right and left spoons of the forceps is shaded): 1 - in the first position (the spoons of the forceps in the left oblique size); 2 - in the second position (spoon tongs in the right oblique size)
Atypical obstetric forceps with a low transverse position of the head is a very difficult operation. Obstetric forceps regular type(with pelvic curvature) are applied, like atypical ones, in the oblique size of the pelvic cavity, in accordance with the wire point (posterior fontanel): in the first position of the fetus - in the left oblique size of the pelvic cavity (Fig. 15, 1), and in the second position - in the right oblique size of the pelvic cavity (Fig. 15, 2). Among the features of the technique, we should mention the transfer of spoons of tongs. When the sagittal suture, after several tractions, becomes an oblique size, the forceps are removed and then applied again to the transverse dimensions of the head in the oblique size of the pelvis. In this position of the head, straight obstetric forceps are also used, which do not need to be repositioned, since they are placed on the biparietal size of the head and in the direct size of the pelvic cavity. First, a spoon is inserted, the edges should lie on the front side of the head. Take any spoon and insert it into the vagina towards the sacroiliac cavity closest to the face, then the spoon by transfer (“wandering”) is passed through the forehead and face to the front side of the head to the front end of the true conjugate. The posterior spoon is inserted through the same cavity as the first and advanced towards the posterior end of the conjugate.
In case of breech presentation, obstetric forceps are used very rarely and only if the buttocks are fixed in the cavity or are located at the bottom of the pelvis. Forceps are applied to the pelvic end of the fetus, if possible, only in a transverse dimension. When the buttocks are standing in the direct size of the pelvis, apply one spoon of forceps to the sacrum and the other to the back of the thighs. In this position of the buttocks, straight obstetric forceps are also used, applying them in the direct size of the pelvis.
Outcomes of the operation of applying obstetric forceps
Applied in a timely manner, technically correct, according to established indications, in compliance with the appropriate conditions, rules of asepsis and antisepsis and in the absence of contraindications, the operation of applying abdominal and exit obstetric forceps usually makes it possible to deliver a live fetus without compromising the health of the woman in labor. In some cases, this operation can cause a number of complications: damage to the birth canal (ruptures of the cervix, vaginal walls and perineum), injuries to the fetus (damage to the skin, depressions of the skull bones, paresis facial nerve, intracranial hemorrhages), postpartum diseases infectious origin. These complications may be due to non-compliance with the conditions and technical errors during the operation, but often they are the result of the pathological condition of the mother or fetus, which served as an indication for the application of obstetric forceps. Rare cases of genitourinary fistula (see) after the operation of the application of obstetric forceps should be explained by the excessive duration birth act and their belated imposition.
Postoperative period
Compliance with the strictest sanitary and hygienic regime. If there are sutures (staples) on the perineum, in addition to the usual thorough washing of the external genitalia, wiping the tissues in the area of the sutures with alcohol after each urination and defecation is recommended. Whenever infectious process appropriate treatment is carried out. Duration bed rest determined individually. Before discharge, the woman should be carefully examined for gynecological chair. After the application of obstetric forceps, postpartum leave for a woman in labor is extended to 70 days.
Bibliography: Lankowitz A. V. Operation of applying obstetric forceps, M., 1956, bibliogr.; Malinovsky M. S. Operative obstetrics, M., 1967; Practical obstetrics, ed. A. P. Nikolaeva, p. 321, Kyiv, 1968; Tsovyanov N. A. On the technique of applying obstetric forceps, M., 1944, bibliogr.
The operation of applying obstetric forceps (applicatio forcipes obstet-riciae) is aimed at artificially extracting the fetus by the head (rarely by the buttocks) in case of urgent need to complete the second stage of labor. The instruments used for this are called obstetric forceps (forceps obstetriciae). They were invented at the beginning of the 17th century by Chamberlain (Fig. 250). Rice. 250. Chamberlain obstetric forceps (a). Palfin's obstetric forceps (“iron hands”) - manus ferreae Palfynianae (b). However, he did not make his invention public and the honor of opening the forceps (1723) rightly belongs to I. Palfin. Subsequently, several hundred models of obstetric forceps were proposed.
Device of forceps
Almost all proposed models of forceps can be divided into four types, and their design reflects the fundamental attitude of certain obstetricians to this operation. The main types of forceps: 1) Russian, 2) English, 3) French, 4) German. Russian Lazarevich forceps ( Fig. 251), Gumilevsky (Fig. 252) do not have a pelvic curvature, they are straight. In contrast, the other three types of forceps have two curvatures: head and pelvis; the branches intersect. The main model of forceps used in our country to this day is Simpson's forceps (Fig. 253) modified by Fenomenov.
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The forceps consist of two branches - right and left. Each branch (ramus) has three parts: a spoon (cochlear), a lock (pars juncturae), and a handle (manubrium). total length tool 35 cm; the length of the handle with a lock is 15 cm, the length of the spoon is 20 cm. The spoon of the tongs is windowed, window oval shape; its length is 11 cm, width 5 cm, it is bordered by an edge (upper and lower when the instrument is positioned on the table). The spoon has a so-called head curvature and a pelvic curvature (curvature along the plane). The tops of the spoons when closing the tongs are at a distance of 2.5 cm; the distance between the most distant points of the head curvature of the spoons when closing the forceps is 8 cm (the large transverse size of the head up to its configuration is 9 cm). |
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The lock in the Simpson-Fenomenov tongs is very simple; on the left branch there is a notch into which the right branch is inserted. The handles of the forceps are straight, their inner surface is smooth, flat, and their outer surface is ribbed and wavy, which prevents the surgeon’s hands from slipping. On the outer surface of the handles near the lock there are so-called Bush hooks. The weight of the instrument is about 500 g. The branches of the forceps are distinguished by the following signs: 1) on the left branch there is a lock and a lock plate on top, on the right - on the bottom; 2) the Bush hook and the ribbed surface of the handle (if you put the tongs on the table) on the left branch face to the left, on the right - to the right; 3) the left branch is taken into left hand and inserted into the left half of the pelvis; the right branch is taken in the right hand and inserted into right half pelvis Action of forceps. From the definition of the operation of applying forceps it follows that their main action is attraction. |
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The force required for the operation of applying forceps cannot be precisely determined, but it should be assumed that it is the force that can be applied by one person; the use of excessive force, especially by two people, is very dangerous and should be categorically rejected. Selecting a forceps model. Of the huge number of models of forceps, it is enough to have two: 1) domestic straight forceps by Lazarevich (model 1887) or Gumilevsky, 2) English Simpson forceps, modified by N. N. Fenomenov. Indications for the application of forceps can be combined into the following main groups: 1) indications from the fetus (asphyxia, threat of birth injury); 2) indications from the parturient: a) insufficiency of labor, b) diseases of cardio-vascular system, c) diseases respiratory tract, kidneys, d) severe nephropathy, eclampsia. |
The application of obstetric forceps is a delivery operation during which the fetus is removed from the mother's birth canal using special instruments.
Obstetric forceps are intended only for removing the fetus by the head, but not for changing the position of the fetal head. The purpose of the operation of applying obstetric forceps is to replace the labor expulsion forces with the attractive force of the obstetrician.
Obstetric forceps have two branches connected to each other using a lock; each branch consists of a spoon, a lock and a handle. The spoons of the forceps have a pelvic and cephalic curvature and are designed specifically for grasping the head; the handle is used for traction. Depending on the design of the lock, there are several modifications of obstetric forceps; in Russia, Simpson-Fenomenov obstetric forceps are used, the lock of which is characterized by a simple design and significant mobility.
CLASSIFICATION
Depending on the position of the fetal head in the small pelvis, the surgical technique varies. When the fetal head is located in the wide plane of the small pelvis, cavity or atypical forceps are applied. Forceps applied to the head, located in the narrow part of the pelvic cavity (the sagittal suture is almost straight), are called low abdominal (typical).
The most favorable option for the operation, associated with the least number of complications for both the mother and the fetus, is the application of typical obstetric forceps. Due to the expansion of indications for CS surgery in modern obstetrics, forceps are used only as a method of emergency delivery if the opportunity to perform CS is missed.
INDICATIONS
· Preeclampsia severe course, not amenable conservative therapy and requiring exclusion of efforts.
· Persistent secondary weakness of labor or weakness of pushing, not amenable to drug correction, accompanied by prolonged standing of the head in one plane.
· PONRP in the second stage of labor.
· The presence of extragenital diseases in the woman in labor that require stopping pushing (diseases of the cardiovascular system, high myopia, etc.).
· Acute fetal hypoxia.
CONTRAINDICATIONS
Relative contraindications are prematurity and large fetuses.
CONDITIONS FOR THE OPERATION
· Live fruit.
· Complete opening of the uterine os.
· Absence amniotic sac.
· The location of the fetal head in the narrow part of the pelvic cavity.
· Correspondence between the sizes of the fetal head and the mother's pelvis.
PREPARATION FOR OPERATION
It is necessary to consult an anesthesiologist and choose a method of pain relief. The woman in labor is in a supine position with her knees bent and hip joints feet. The bladder is emptied and the external genitalia and inner thighs of the woman in labor are treated with disinfectant solutions. A vaginal examination is performed to clarify the position of the fetal head in the pelvis. The forceps are checked, and the obstetrician's hands are treated as for performing a surgical operation.
METHODS OF PAIN RELIEF
The method of pain relief is chosen depending on the condition of the woman and fetus and the nature of the indications for surgery. U healthy woman(if it is appropriate for its participation in the birth process) with weakness of labor or acute fetal hypoxia, you can use epidural anesthesia or inhalation of a mixture of nitrous oxide and oxygen. If it is necessary to turn off pushing, the operation is performed under anesthesia.
OPERATIONAL TECHNIQUE
General surgical technique
The general technique for applying obstetric forceps includes the rules for applying obstetric forceps, which are observed regardless of the plane of the pelvis in which the fetal head is located. The operation of applying obstetric forceps necessarily includes five stages: inserting spoons and placing them on the fetal head, closing the branches of the forceps, test traction, removing the head, removing the forceps.
Rules for introducing spoons
· The left spoon is held with the left hand and inserted into left side mother's pelvis under the control of the right hand, the left spoon is inserted first, as it has a lock.
· The right spoon is held with the right hand and inserted into the right side of the mother's pelvis on top of the left spoon.
To control the position of the spoon, all fingers of the obstetrician’s hand are inserted into the vagina, except for the thumb, which remains outside and is moved to the side. Then, like a pen or bow, take the handle of the tongs, with the top of the spoon facing forward and the handle of the tongs parallel to the opposite one. inguinal fold. The spoon is inserted slowly and carefully using pushing movements thumb. As the spoon moves, the handle of the tongs is moved to horizontal position and lower it down. After inserting the left spoon, the obstetrician removes his hand from the vagina and passes the handle of the inserted spoon to the assistant, who prevents the spoon from moving. Then the second spoon is introduced. The spoons of the forceps rest on the fetal head in its transverse dimension. After inserting the spoons, the handles of the tongs are brought together and an attempt is made to close the lock. This may cause difficulties:
· the lock does not close because the spoons of the forceps are not placed on the head in the same plane - the position of the right spoon is corrected by displacing the branch of the forceps with sliding movements along the head;
· one spoon is located higher than the other and the lock does not close - under the control of fingers inserted into the vagina, the overlying spoon is shifted downwards;
· the branches are closed, but the handles of the forceps diverge greatly, which indicates that the spoons of the forceps are placed not on the transverse size of the head, but on the oblique one, about the large size of the head or the position of the spoons on the head of the fetus is too high, when the tops of the spoons rest against the head and the head curvature of the forceps is not fits it tightly - it is advisable to remove the spoons, conduct a repeated vaginal examination and repeat the attempt to apply forceps;
· the internal surfaces of the handles of the forceps do not fit tightly to each other, which usually occurs if the transverse size of the fetal head is more than 8 cm - a diaper folded in four is placed between the handles of the forceps, which prevents excessive pressure on the fetal head.
After closing the branches of the forceps, you should check whether the soft tissues of the birth canal are captured by the forceps. Then a test traction is carried out: the handles of the forceps are grasped with the right hand, they are fixed with the left hand, and the index finger of the left hand is in contact with the head of the fetus (if during traction it does not move away from the head, then the forceps are applied correctly).
Next, the actual traction is carried out, the purpose of which is to extract the fetal head. The direction of traction is determined by the position of the fetal head in the pelvic cavity. When the head is in the wide part of the pelvic cavity, traction is directed downwards and backwards; when traction is from the narrow part of the pelvic cavity, the traction is directed downwards, and when the head is located at the outlet of the small pelvis, it is directed downwards, towards oneself and anteriorly.
Tractions should imitate contractions in intensity: gradually begin, intensify and weaken, a pause of 1–2 minutes is necessary between tractions. Usually 3–5 tractions are enough to extract the fetus.
The fetal head can be brought out in forceps or they are removed after bringing the head down to the exit of the small pelvis and vulvar ring. When passing the vulvar ring, the perineum is usually cut (obliquely or longitudinally).
When removing the head, serious complications may occur, such as lack of advancement of the head and slipping of the spoons from the fetal head, the prevention of which consists in clarifying the position of the head in the small pelvis and correcting the position of the spoons.
If the forceps are removed before the head erupts, then first move the handles of the forceps apart and unlock the lock, then remove the spoons of the forceps in order, reverse introduction, - first the right, then the left, deflecting the handles towards the opposite thigh of the woman in labor. When removing the fetal head in forceps, traction is carried out with the right hand in the anterior direction, and the perineum is supported with the left. After the head is born, the lock of the forceps is opened and the forceps are removed.
Typical obstetric forceps
The most favorable option for surgery. The head is located in a narrow part of the pelvis: two-thirds of the sacral cavity and the entire inner surface of the pubic symphysis are occupied. During vaginal examination, the ischial spines are difficult to reach. The sagittal suture is located in the straight or almost straight dimension of the pelvis. The small fontanel is located below the large one and anterior or posterior to it, depending on the type (anterior or posterior).
The forceps are applied in the transverse dimension of the pelvis, the spoons of the forceps are placed on the lateral surfaces of the head, the pelvic curvature of the instrument is compared with the pelvic axis. In the anterior view, traction is carried out downwards and anteriorly until the suboccipital fossa is fixed at the lower edge of the symphysis, then anteriorly until the head erupts.
In the posterior view of the occipital presentation, traction is carried out first horizontally until the first point of fixation is formed (the anterior edge of the greater fontanelle - the lower edge of the symphysis pubis), and then anteriorly until the suboccipital fossa is fixed at the apex of the coccyx (the second point of fixation) and the handles of the forceps are lowered posteriorly, resulting in extension head and birth of the forehead, face and chin of the fetus.
Abdominal forceps
The fetal head is located in the wide part of the pelvic cavity, filling the sacral cavity in the upper part, the anterior rotation of the occiput has not yet occurred, the sagittal suture is located in one of the oblique dimensions. At the first position of the fetus, the forceps are applied in a left oblique size - the left spoon is behind, and the right spoon “wanders”; in the second position, it’s the other way around - the left spoon “wanders”, and the right spoon remains behind. Traction is carried out downwards and backwards until the head passes into the plane of the pelvic outlet, then the head is released using manual techniques.
COMPLICATIONS
· Damage to the soft birth canal (ruptures of the vagina, perineum, and rarely the cervix).
· Rupture of the lower segment of the uterus (during the operation of applying abdominal obstetric forceps).
Damage pelvic organs: bladder and rectum.
· Damage to the symphysis pubis: from symphysitis to rupture.
· Damage to the sacrococcygeal joint.
· Postpartum purulent septic diseases.
· Traumatic injuries fetus: cephalohematomas, paresis of the facial nerve, injuries to the soft tissues of the face, damage to the bones of the skull, intracranial hemorrhages.
FEATURES OF MANAGEMENT IN THE POSTOPERATIVE PERIOD
· In the early postoperative period, after applying abdominal obstetric forceps, a control manual examination is carried out postpartum uterus to establish its integrity.
· It is necessary to monitor the function of the pelvic organs.
· In the postpartum period, it is necessary to prevent inflammatory complications.
Obstetric forceps (forceps obstetricia) is an instrument designed to extract a live full-term or almost full-term fetus by the head if it is necessary to urgently complete the second stage of labor.
Obstetric forceps were invented by P. Chamberlen (England) at the end of the 16th century (Fig. 1). The invention was kept strictly secret for a long time.
125 years later (1723), forceps were reinvented by J. Palfyn (France) and immediately published at the Paris Academy of Medicine, so Palfin is rightly considered the inventor of forceps. The tool and its application quickly became widespread (Fig. 2).
Rice. 1.
Rice. 2.
In Russia, forceps were first applied in Moscow by I.V. Erasmus in 1765. In everyday life obstetric practice The operation of applying obstetric forceps was introduced by the founder of Russian scientific obstetrics, Nestor Maksimovich-Ambo-dick. I.P. Lazarevich created an original type of Russian forceps, the main features of which are the simplicity of the device, the absence of pelvic curvature, the mobility of the branches of the lock).
N.N. Fenomenov made fundamental changes to one of the most common models of forceps - the English Simpson forceps: thanks to changes in the lock, greater mobility was imparted to the branches (Simpson-Fenomenov forceps).
Among delivery operations in the USA, England, France and Russia, the operation of applying obstetric forceps is in second place after cesarean section.
The main model of forceps used in our country is the Simpson-Fenomenov forceps.
The tongs are made up of two halves called branches. One of the branches, which is grasped with the left hand, is intended to be inserted into the left half of the pelvis - it is called the left branch; the second branch is called the right branch. Each branch has three parts: the spoon (cochlear), the lock (pars juncture) and the handle (manubrium). The forceps are 35 cm long and weigh about 500 g. medicine full-term fetus forceps
The spoon is a plate with a wide cutout in the middle - a window - and rounded ribs - upper and lower. The spoons are curved according to the curvature of the head. The inner surfaces of the spoons in closed forceps fit tightly to the fetal head due to the coincidence of the curvature of the head and spoons. The concave inside (and curved outside) curvature of the spoons is called the head curvature. The greatest distance between the inner surfaces of folded spoons is 8 cm, and between the tops of folded spoons is 2.5 cm. The ribs of the spoons are also curved in the form of an arc, with the upper edge being concave and the lower one being curved. This second curvature of the spoons is called the pelvic curvature, as it corresponds to the curvature of the pelvic axis.
The lock is used to connect the branches. The lock design is not the same various models forceps. The lock in the Simpson-Fenomenov forceps is very simple: on the left branch there is a notch into which the right branch is inserted, and the branches intersect. An essential feature is the degree of mobility of the branches connected by it: the lock can be freely movable (Russian tongs), moderately movable (English tongs), almost motionless (German tongs) and completely motionless (French tongs).
The movable lock allows you to position the spoons on the head in any plane of the pelvis and prevent excessive compression of the head.
The handles of the forceps are straight, their inner surface is smooth, flat, and their outer surface is ribbed and wavy, which prevents the surgeon’s hands from slipping. On the outer surface of the handles near the lock there are side Bush hooks, designed to support the fingers during movements. It is very important to distinguish the left branch (spoon) from the right, since it must be inserted first and when closing the forceps, it must lie under the right one, otherwise the forceps cannot be closed.
The purpose of the forceps is to tightly grasp the head and replace the expelling force of the uterus and abdominal press with the attracting force of the doctor. Therefore, the forceps are only a traction instrument and not a rotational or compression instrument. During the extraction process it is difficult to avoid a certain compression of the head, but this is a disadvantage of the forceps, and not their purpose.
Indications for the application of forceps can be from both the mother and the fetus (although this division is arbitrary).
Indications from the mother:
- Sh serious illnesses cardiovascular and respiratory systems, kidneys, visual organs, etc.;
- Ш severe nephropathy, eclampsia;
- Ш weakness of labor, not amenable to drug therapy, fatigue;
- III chorioamnionitis during childbirth, if labor is not expected to end within the next 1-2 hours.
Indications from the fetus:
- Ш acute fetal hypoxia;
- Ш loss of umbilical cord loops;
- Ш premature placental abruption.
Conditions for applying forceps. Exist following conditions for applying forceps:
- Ш presence of a living fetus;
- Ш full opening of the uterine os. In the case of incomplete opening of the pharynx, the cervix can be captured with forceps, and the cervix often ruptures and can move to the lower segment of the uterus;
- Ш absence of amniotic sac. Attraction to the membranes can cause premature placental abruption;
- The head should not be too small (severe prematurity) or too large, it should have normal density (otherwise the forceps may slip off the head during attraction);
- The head should be located in the narrow (sometimes in the wide) part of the pelvic cavity with an arrow-shaped suture in the straight and one of the oblique dimensions of the pelvis;
- Ш absence of disproportion between the pelvis and the head;
- Sh empty bladder.
Contraindications to the application of obstetric forceps:
- 1) dead fetus;
- 2) incomplete opening of the uterine os;
- 3) hydrocephalus, anencephaly;
- 4) anatomically ( II--III degree narrowing) and clinically narrow pelvis;
- 5) very premature fetus;
- 6) high location fetal head (the head is pressed by a small or large segment at the entrance to the pelvis);
- 7) threatening or beginning uterine rupture.
Preparing for surgery. The woman in labor is placed on a Rakhmanov bed or operating table in position for vaginal operations. The legs are bent at the knee and hip joints and spread apart to provide free access to the perineal area. Before the operation, catheterization of the bladder and treatment of the external genitalia are performed. The sequence of treatment should be strictly observed: first the pubic area is treated, then the inner thighs, external genitalia and anal opening. To do this, use a 1% solution of iodonate or a 5% alcohol solution of iodine, octenisept, octeniderm, etc. Sterile shoe covers are put on the mother's legs, the external genitalia are covered with sterile underwear, leaving an opening for the entrance to the vagina.
When applying forceps, intravenous or, less commonly, inhalation anesthesia is used. Good results obtained from the use of bilateral pudendal anesthesia.
Depending on the height of the head in the pelvis, exit forceps and abdominal forceps are distinguished.
Output forceps are applied to the head, standing as a large segment at the pelvic outlet (station +3), with an arrow-shaped suture in the direct size of the pelvic outlet; in this case, the head is visible from the genital slit.
Such forceps are called elective, preventive abroad; they are applied quite often. In our country, they are used extremely rarely, because if the head is at the bottom of the pelvis, an episiotomy is sufficient to deliver the fetal head.
Cavity (typical) forceps are applied to the head, located as a large segment in the narrow part of the pelvic cavity (station +2), when the sagittal suture is in a straight or almost straight position, less often in the transverse (low transverse position of the head) dimension of the pelvis.
Principles of applying forceps. Before moving on to the technique of applying forceps, let's look at some general principles that apply to both typical and atypical forceps.
When applying forceps, the following threefold rules should be followed.
The first threefold rule. The left spoon is inserted first, which is inserted with the left hand into the left half of the pelvis (mother) (“three on the left”) under the control of the right hand; the right spoon is inserted with the right hand into the right side of the pelvis (“three to the right”) under the control of the left hand.
Second triple rule. The tops of the spoons should be facing the wire axis of the pelvis; The forceps should grasp the head along the large oblique dimension (mentooccipitalis) and biparietally so that the wire point of the head is in the plane of the forceps.
Third triple rule. With the head located in the wide part of the pelvic cavity, traction (relative to standing woman) are directed obliquely posteriorly, then downward and anteriorly, if the head is in the narrow part, downward and anteriorly, and if at the outlet of the pelvis, anteriorly.
The operation of applying obstetric forceps consists of 4 points:
- 1. Introduction and placement of spoons.
- 2. Closing the forceps and testing traction.
- 3. Traction or attraction (extraction) of the head.
- 4. Removing the forceps.
Complications during the operation of applying obstetric forceps
Slipping of the forceps.
Among the complications of applying obstetric forceps, there are two types of slipping: horizontal and vertical. The reasons for the slipping of the forceps are incorrect grip of the head, mismatch in the size of the head (excessively small or large head). A thorough vaginal examination usually reveals what the abnormal grip is (insufficient advancement of the forceps spoons or grip of the fetal head in an inappropriate size).
The diagnosis of the threat of forceps slipping is established on the basis of the extension of the spoons from the genital slit (although the fetal head does not advance) and an increase in the distance between the lock of the forceps and the head. In this case, you should abandon the attempt to prevent slipping by squeezing the handles more tightly; Such a technique threatens fatal injury to the fetus and does not prevent the danger of slipping. If there is a suspicion or threat of slipping of the forceps, it is necessary to stop traction and carry out a thorough examination to determine the cause of the slipping. Then you should remove the forceps and reapply them correctly.
Failed attempt to apply forceps. One of negative points when applying obstetric forceps, there is a failed attempt to apply them, which is observed in 1.2-6.7% of cases. The negative result is explained by insufficient consideration of the obstetric situation, non-compliance with conditions and incorrect technique of performing the operation.
If an attempt to apply forceps fails, the question of further delivery arises. If the head is located high enough, then a caesarean section is performed; If the fetus dies during the operation of applying obstetric forceps, then a fruit-destroying operation is performed.
Traumatic injuries of the birth canal and fetus. During the operation, ruptures of the perineum, vagina, labia majora and minora, clitoris, cervix, lower segment of the uterus, bladder and urethra, rupture of the symphysis and injury to the sacroiliac joint. A frequent complication is the continuation of a perineal rupture or episiotomy on the rectal sphincter.
Other complications. After applying forceps, increased blood loss during childbirth is noted, and the frequency of intrauterine interventions reaches 70%. The frequency of postpartum diseases is very high (13.5-96%) and is associated with prolonged labor and extensive trauma to the birth canal. The fetus is also subject to significant trauma. The range of these injuries varies - from minor injuries to the soft tissues of the head to deep wounds. Injuries to the fetal head include cephalohematomas, facial nerve paresis, skull fractures, and cerebral circulation, cerebral hemorrhages, etc.
A significant number of complications during the operation of applying obstetric forceps and not always favorable long-term results have somewhat reduced the frequency of use of this operation in modern obstetrics.
The operations of applying obstetric forceps and vacuum extraction of the fetus are not competing. Each of these operations has its own indications and conditions. Many obstetricians believe that obstetric forceps have more wide range indications than a vacuum extractor.
