Obstetric forceps. Tool structure, types
The operation of applying obstetric forceps. Indications, conditions.
Obstetric forceps is a tool 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 a strict secret, and it did not become the property of obstetric practice. The priority in the invention of obstetric forceps rightfully belongs to the French surgeon Palfin, who in 1723 published his message. The tool and its application quickly became widespread. In Russia, tongs were first used in 1765 in Moscow by Professor Erasmus. Later, 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. Forceps consist of two branches (or spoons) - right and left. Each branch consists of 3 parts: the spoon itself, the castle part and the handle. The spoon itself is made fenestrated, and the handle is hollow to reduce the weight of the forceps, which is about 500 g. The total length of the tool is 35 cm, the length of the handle with a lock is 15 cm, the spoon is 20 cm. The spoon has the so-called head curvature and pelvic. The head 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 the Simpson-Phenomenov forceps, the distance between the most distant points of the head curvature of the spoons when the forceps are closed 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 (Lazarevich's straight forceps).
The lock serves 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 castle in the Simpson-Fenomenov tongs has a simple structure: on the left branch there is a notch into which the right branch is inserted. This structure of the castle provides 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 the outside of the tongs there are side protrusions called Bushy hooks. When the forceps are folded, they should lie symmetrically in the same plane. After inserting the spoons and locking 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 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, with closed branches, they fit snugly against each other. The branches of the tongs differ in the following ways: 1) on the left branch, the lock and the plate of the lock are on top, on the right - on the bottom; 2) Bush's hook and the ribbed surface of the handle (if the tongs are on the table) on the left branch are turned 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 turned to the left hand, and the handle of the right branch is turned to the right hand of the surgeon. The left branch is always inserted with the left hand into the left half of the pelvis, the right branch with the right hand into the right half of the pelvis.
Other well-known forceps models include: 1) Lazarevich forceps (Russian model), having one head curvature and non-crossing spoons; 2) Levre tongs (French model) - long tongs with two curvatures, crossed handles and a screw lock that is tightly screwed; 3) German Negele tongs, combining the main qualities of the Simpson-Fenomenov tongs (English tongs) and Levre models.
Indications for the imposition of obstetric forceps. The imposition of forceps is used in cases where an urgent end of labor is required in the period of exile and there are conditions for performing this operation. There are 2 groups of indications: those related to the condition of the fetus and the condition of the mother. Often there are combinations of them.
The indication for the application of forceps in benefit of the fetus is hypoxia, which has developed due to various reasons (premature detachment of a normally located placenta, prolapse of the umbilical cord, weakness of labor, late preeclampsia, 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 choice of adequate tactics for managing the woman in labor, including determining the method of delivery.
AT interests of the woman in labor forceps are applied according to the following indications: 1) secondary weakness of labor activity, accompanied by a stop in the forward movement of the fetus at the end of the exile period; 2) severe manifestations of late preeclampsia (preeclampsia, eclampsia, severe hypertension, not amenable to conservative therapy); 3) bleeding in the second stage of labor, due to premature detachment of a normally located placenta, rupture of blood vessels during sheath attachment of the umbilical cord; 4) diseases of the cardiovascular system in the stage of decompensation; 5) respiratory disorders due to lung diseases, requiring the exclusion of attempts; 6) diseases of a general nature, acute and chronic infections, high temperature in a woman in labor. The imposition of obstetric forceps may be required for women in labor who underwent surgical intervention on the abdominal organs on the eve of childbirth due to the inability of the abdominal muscles to provide full-fledged attempts. The use of obstetric forceps in some cases can be indicated for tuberculosis, diseases of the nervous system, kidneys, organs of vision (the most common indication for applying forceps is high myopia).
Thus, the indications for the imposition of obstetric forceps in the interests of the woman in labor may be due to the need for an urgent end of labor or the need to exclude attempts. The listed indications in many cases are combined, requiring an emergency end of childbirth in the interests of not only the mother, but also the fetus. Indications for the imposition of obstetric forceps are not specific to this operation, they may be indications for other operations (caesarean section, vacuum extraction of the fetus, fruit-destroying operations). The choice of a delivery operation largely depends on the presence of certain conditions that allow a particular operation to be performed. These conditions have significant differences, therefore, in each case, their careful assessment is necessary for the correct choice of the method of delivery.
When applying forceps, the following conditions are necessary:
Living fruit. In case of fetal death and there are indications for emergency delivery, fruit-destroying operations are performed, in rare extreme cases, a caesarean section. Obstetric forceps in the presence of a dead fetus are contraindicated.
Full disclosure of the uterine pharynx. Deviation from this condition will inevitably lead to rupture of the cervix and the lower segment of the uterus.
2. Absence of the amniotic sac. This condition follows from the previous one, since with the correct management of childbirth, when the uterine os is fully opened, the fetal bladder must be opened.
The fetal head should be in the narrow cavity of the cavity or at the exit from the small pelvis. With other options for the position of the head, the use of obstetric forceps is contraindicated. An accurate determination of the position of the head in the small pelvis is possible only with a vaginal examination, which must be performed before applying the obstetric forceps. If the lower pole of the head is determined between the plane of the narrow part of the small pelvis and the plane of exit, then this means that the head is located in the narrow part of the cavity of the small pelvis. From the point of view of the biomechanism of labor, 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., to the exit from the small pelvis. With the head located in the 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 the direct size of the exit from the small pelvis, the entire cavity of the small pelvis is made by the head, its departments are not accessible for palpation. At the same time, the head has completed the internal rotation, then the next moment of the biomechanism of labor follows - extension of the head (if there is an anterior view of the occipital insertion).
The head of the fetus should correspond to the average size of the head of a full-term fetus i.e. not too large (hydrocephalus, large or giant fetus) or too small (premature fetus). This is due to the size of the forceps, which are suitable only for the head of a medium-sized full-term fetus, otherwise their use becomes traumatic for the fetus and for the mother.
Sufficient size of the pelvis, allowing the head to be removed by forceps. With a narrow pelvis, forceps are a very dangerous tool, so their use is contraindicated.
The operation of applying obstetric forceps requires the presence of all of the above conditions. When embarking on forceps delivery, the obstetrician must have a clear understanding of the biomechanism of childbirth, which will have to be artificially imitated. It is necessary to be guided in what moments of the biomechanism of childbirth the head has already managed to do and what it will have to do with the help of forceps. Forceps are a pulling tool that replaces the missing force of attempts. The use of forceps for other purposes (correction of incorrect head insertions, rear view of the occipital insertion) as a corrective and rotational instrument has long been ruled out.
Preparation for the imposition of obstetric forceps. The forceps are applied in the position of the woman in labor on the operating table (or on the Rakhmanov bed) on her back, with her legs bent at the knee and hip joints. Before the operation, the intestines and bladder should be emptied, and the external genitalia should be disinfected. Before the operation, a thorough vaginal examination is performed to confirm the conditions for the application of forceps. Depending on the position of the head, it is determined which variant of the operation will be used: abdominal obstetric forceps with the head located in the narrow part of the pelvic cavity, or exit obstetric forceps if the head has sunk to the pelvic floor, i.e. into the exit from the small pelvis.
The use of anesthesia when applying obstetric forceps is desirable, and in many cases mandatory. In multiparous (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 small pelvis, is a difficult moment of the operation, especially with the resistance of the pelvic floor muscles, which is eliminated by anesthesia. In addition, in many cases, the use of obstetric forceps is due to the need to exclude straining activity in the parturient woman, which can only be achieved with adequate anesthesia. Anesthesia is also required for anesthesia of 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 removing the fetal head in forceps, the risk of perineal rupture increases, the imposition of obstetric forceps is usually combined with perineotomy.
Output obstetric forceps. Output obstetric forceps is an operation in which the forceps are applied to the head of the fetus, located in the outlet of the small pelvis .; At the same time, the head has completed the internal rotation, and the last moment of the biomechanism of childbirth before its birth is carried out with the help of forceps. In the anterior view of the occipital insertion of the head, this moment is the extension of the head, and in the posterior view, it is flexion followed by extension of the head. Output obstetric forceps are also called typical, in contrast to abdominal, atypical, forceps.
The technique of applying both typical and atypical forceps includes the following points: 1) the introduction of spoons, which is always carried out in accordance with the following rules: first, the left spoon is inserted with the left hand to the left side ("three left"), the second - the right spoon with the right hand in right side ("three right"); 2) forceps closing; 3) trial traction, which allows you to make sure that the forceps are correctly applied and that there is no threat of their slipping; 4) actual traction - 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 second - the left spoon with the left hand.
Technique of imposing output obstetric forceps in the anterior view of the occipital insertion. The first point is the introduction of spoons. The folded tongs are placed on the table to pinpoint the left and right spoons. The left spoon is inserted first, since when the forceps are closed, it must lie under the right one, otherwise the closure will be difficult. The obstetrician takes the left spoon in his left hand, grabbing it like a writing pen or a bow. Before inserting the left hand into the vagina, four fingers of the right hand are inserted into 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 palmar surface of the head and inserted between the head and the side wall of the pelvis. The thumb remains outside and is retracted to the side. The handle of the left spoon before its introduction is set almost parallel to the right inguinal fold, while the top of the spoon is located at the genital slit in the longitudinal (anteroposterior) direction. The lower edge of the spoon rests on the first finger of the right hand. The spoon is introduced into the genital slit carefully, without violence, by pushing the lower rib I with the finger of the right hand, and only partially the introduction of the spoon is facilitated by the easy advancement of the handle. As the spoon penetrates deep into the handle, it gradually descends down to the crotch. With the fingers of the right hand, the obstetrician helps to guide the spoon so that it lies on the head on the side 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 the transverse dimension of the 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 forceps spoon to the assistant, who must hold it without moving it. After that, the obstetrician spreads the genital gap with his right hand and inserts 4 fingers of his left hand into the vagina along its right wall. The second is inserted the right spoon of forceps with the right hand into the right half of the pelvis (Fig. 109, b). The right spoon of tongs should always lie on the left. Properly applied forceps capture the head through the zygomaticotemporal 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 capture the head in its largest diameter, the line of the handles of the tongs is facing the wire point of the head. The second point is the closing of the tongs. Separately introduced spoons must be closed so that the forceps can act as a tool for capturing and extracting the head. Each of the handles is taken with the same hand, while the thumbs are located on Bush's hooks, and the remaining 4 clasp the handles themselves. After that, you need to bring the handles 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 placed on the head not in the same plane, as a result of which the locking parts of the tool do not match. This difficulty is usually easily removed by pressing the side hooks with the thumbs; 2) the lock does not close, as one of the spoons is inserted above the other. The deep 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 are applied incorrectly, they must be removed and applied again; 3) the lock is closed, but the handles of the tongs diverge. This is due to the fact that the size of the head slightly exceeds the distance between the spoons in the head curvature. The convergence of the handles in this case will cause compression of the head, which can be avoided by laying a folded towel or diaper between them.
Having closed the forceps, a vaginal examination should be performed and make sure that the forceps do not capture soft tissues, the forceps lie correctly and the wire point of the head is in the plane of the forceps.
The third point is trial traction (Fig. 111). This is a necessary test to ensure that the forceps are correctly applied and that there is no danger of them slipping. The technique of trial traction is as follows: the right hand clasps the forceps handles from above so that the index and middle fingers lie on the side hooks; the left hand rests on top of the right, and its index finger is extended and in contact with the head in the region of the wire point. The right hand carefully makes the first traction. Traction should be followed by the forceps, the left hand on top with the index finger extended, and the head. If the distance between the index finger and the head increases during traction, this indicates that the forceps are applied incorrectly and eventually they will slip off.
Fourth moment- extraction of the head with forceps (actual traction). During traction (Fig. 112), the forceps are usually grasped as follows: with the right hand they cover the lock from above, putting (with Simpson-Fenomenov forceps) the III finger in the gap between the spoons above the lock, and the II and IV fingers on the side hooks. The left hand grasps the handles of the tongs from below. The main force of traction is developed by the right hand. There are other ways to grab the forceps. N. A. Tsovyanov proposed a method of capturing forceps, which allows simultaneous traction and abduction of the head into the sacral cavity (Fig. 113). With this method, II and III fingers of both hands of the obstetrician, bent with a hook, capture 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 are on the upper surface, and the nail phalanxes - on the upper surface of the handle of the opposite spoon of forceps. IV and V fingers, also slightly bent, grab the parallel branches of the forceps extending from the lock from above and move as high as possible, closer to the head. The thumbs, being under the handles, rest against the middle third of the lower surface of the handles. The main work with this grip of forceps falls on the IV and V fingers of both hands, especially on the nail phalanges. With the pressure of 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 produce pressure on the lower surface of the handles, directing them upward.
When extracting 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 which part of the pelvis the head is located in and what moments of the biomechanism of labor must be reproduced when the head is removed with forceps.
In the anterior view of the occipital insertion, the extraction of the head with the 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 that, the tractions are given an upward direction (the obstetrician directs the ends of the handles to his face) in order for the head to be extended. Tractions should be made in one direction.
Rocking, rotational, pendulum movements are unacceptable. Traction must be completed in the direction in which it was started. The duration of a separate traction_corresponds to the duration of the effort, the tractions are repeated at intervals of 30-60 s. After 4-5_tractions, the forceps are opened to reduce the compression of the head. According to the strength of tractions, they imitate a fight: each traction begins slowly, with increasing strength and, having reached a maximum, gradually fading away, goes into a pause.
Traction is performed by the doctor while standing (rarely sitting), the elbows of the obstetrician should be pressed to the body, which prevents the development of excessive force when removing the head.
The fifth moment is the opening and removal of the tongs. The fetal head is removed with forceps or by manual means after removing the forceps, which in the latter case is carried out after the eruption of the largest circumference of the head. To remove the forceps, each handle is taken with the same hand, the spoons are opened, then they are moved apart and after that the spoons are removed in the same way as they were applied, but in the reverse order: the right spoon is removed first 1, while the handle is retracted to the left inguinal fold, the second is removed spoon, its handle is retracted to the right inguinal fold.
Cavity obstetric forceps. Abdominal 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 forceps and perform extension (with anterior view of the occipital insertion). Due to the incompleteness of the internal rotation, the sagittal (sagittal) suture is in one of the oblique dimensions. Obstetric forceps are applied in the opposite oblique size so that the spoons capture the head in the region of the parietal tubercles. The imposition of forceps in the oblique size of the pelvis presents certain difficulties. More complex than the output obstetric forceps are traction, in which the internal rotation of the head is completed by 45 ° or more, and only then the head is extended.
The technique of applying abdominal obstetric forceps in the 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 captured 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 introducing spoons is preserved: the first spoon is inserted with the left hand into the left half of the pelvis, the second is 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 pelvis and immediately placed in the region of the left parietal tubercle of the head; the handle of the forceps is passed 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, as this is prevented by the pubic arch. This obstacle is overcome by the movement ("wandering") of 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 forward) until it is established in the region of the right parietal tubercle. The movement of the spoon is carried out by carefully pressing the II yalz of the left hand on its lower edge, the handle of the tongs is shifted somewhat backwards and in a clockwise direction.
The second moment - the closure of the tongs - is performed when the forceps lie on the head bipari-etally and are in the left oblique size of the pelvis.
The third moment - trial traction -
The fourth moment is the extraction of the head(actual traction). Completing the internal turn, the head simultaneously makes two movements: it moves more and more downward and at the same time turns the back of the head forward. The head reaches the pelvic floor after a counterclockwise rotation of approximately 45° and is positioned with a sagittal suture in the direct dimension of the exit from the pelvis. To imitate the natural biomechanism, traction is performed first down and somewhat backwards. As it advances, the head, together with the forceps, will rotate counterclockwise until it reaches the pelvic floor, where the spoons are located in a transverse dimension. In this case, only extraction should be active, while the rotation of the forceps is due to the independent rotation of the head as it moves along the birth canal. After the head has reached the pelvic floor, further tractions are performed in the same way as with the exit obstetric forceps: first horizontally until the suboccipital fossa appears from under the pubic arch, then anteriorly upwards so that the head is extended.
Fifth moment - opening and removing the tongs - performed in the same way as with exit obstetric forceps.
Operation technique in the second position of the fetus. In the second position, the sagittal suture is in the left oblique dimension, the forceps should be applied in the opposite pelvic dimension, i.e., in the right oblique.
First moment - the introduction of spoons is carried out in the usual sequence, i.e. the left spoon is introduced first, the second - the right one. 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 introduction 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 size.
Second and third moments operations are performed normally.
Fourth moment - actually traction - are produced in the same way as in the first position. The differences lie in the fact that as you advance, the head, together with the forceps, will turn not, against, but clockwise by 45 °.
Fifth moment performed typically.
Difficulties encountered when applying obstetric forceps. Difficulties in inserting spoons may be due to the narrowness of the vagina and the resistance of the pelvic floor, which requires incision of the perineum. Sometimes the forceps spoon encounters an obstacle and does not move deeper, which may be due to the tip of the spoon getting into the fold of the vagina or (more dangerously) into its fornix. The spoon must be withdrawn and then re-introduced under careful finger control of the guide hand. Sometimes difficulties in the introduction of spoons are caused by a sharp configuration of the head when the head curvature of the spoon does not correspond to the changed shape of the head. Carefully overcoming this difficulty, it is possible to correctly insert and apply the spoon.
In some cases, difficulties may also be encountered when closing the spoons, usually arising if the spoons do not lie in the same plane. In such cases, the handles of the forceps should be lowered backwards towards the perineum and an attempt should be made to close the forceps. If this fails, then under the control of the fingers inserted into the vagina, the spoons move until they are in the same plane. If this technique does not lead to the goal, it is necessary to remove the forceps and apply again. If the forceps handles diverge when attempting to close them, this may be due to insufficient depth of insertion of the spoons, poor grip on the head in an unfavorable direction, or excessive size of the head. With insufficient depth of insertion of the spoons, their tops press on the head, and when trying to compress the spoons, severe damage to the fetus can occur, up to a fracture of the skull bones. Difficulties in closing the spoons also arise in cases where the forceps are applied not in the transverse, 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 small pelvis and the location of the sutures and fontanelles on the head, therefore, to eliminate it, a second vaginal examination and appropriate movement or re-insertion of the spoons is necessary.
Obstetric forceps - are designed to extract a live 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's forceps - used for traction in anterior occipital presentation; b) Tooker-McLean forceps - used to rotate from the rear view of the occipital presentation to the anterior view of the occipital presentation and extraction of the fetus; c) Keelland and Barton forceps - with a transverse arrangement of the sagittal suture for turning into an anterior view of the occipital presentation; d) Piper forceps - designed to extract the head in breech presentation.
The device of obstetric forceps. The forceps have 2 spoons (branches), each of which consists of three parts - the spoon itself (which captures the head of the fetus, it is fenestrated, the length of the window is 11 cm, the width is 5 cm); castle part; handle (hollow, the outer side of the handle is wavy). On the outer side of the forceps, near the lock, there are protrusions, Bush hooks, which, when the forceps are folded, should be turned in different directions, i.e. laterally, and lie in the same plane. Most models of forceps have two curvatures - head (calculated for the circumference of the head) and pelvic (goes along the edge of the spoon, curvature along the plane of the pelvis). The ends of the spoons when folded do not touch each other, the distance between them is 2-2.5 cm. The head curvature in the folded forceps is 8 cm, the pelvic curvature is 7.5 cm; the largest width of the spoons is not more than 4-4.5 cm; length - up to 40 cm; weight - up to 750 g.
Indications for the imposition of obstetric forceps:
1. Indications on the part of the woman in labor: weakness of labor activity not amenable to drug therapy, fatigue; weakness of attempts; bleeding from the uterus at the end of I and II periods of labor; contraindications for exertive activity (severe gestosis; extragenital pathology - cardiovascular, renal, high myopia, etc.; feverish conditions and intoxication); severe forms of neuropsychiatric disorders; chorioamnionitis in childbirth, if the end of labor is not expected within the next 1-2 hours.
2. Indications from the fetus: acute intrauterine fetal hypoxia; prolapse of umbilical cord loops; threat of birth trauma.
Contraindications for the imposition of obstetric forceps: dead fetus; hydrocephalus or microcephaly; anatomically (II - III degree of narrowing) and clinically narrow pelvis; deeply premature fetus; incomplete opening of the uterine os; frontal presentation and front view of facial presentation; pressing the head or positioning the head with a small or large segment at the entrance to the pelvis; threatening or beginning uterine rupture; pelvic presentation of the fetus.
Conditions for applying obstetric forceps:
1. Full disclosure of the uterine pharynx.
2. Opened fetal bladder.
3. Empty bladder.
4. Head presentation and finding the head in the cavity or at the exit from the small pelvis.
5. Correspondence of the size of the fetal head with the size of the pelvis of the woman in labor.
6. Average head sizes.
7. Living fetus.
Complications after applying obstetric forceps:
1. For the mother: damage to the soft birth canal; rupture of the pubic joint; damage to the roots of the sciatic nerve, followed by paralysis of the lower extremities; 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, damage to the eyes; bone damage - depression, fractures, separation of the occipital bone from the base of the skull; brain compression; hemorrhages in the cranial cavity.
3. Postpartum infectious complications.
Three triple rules for applying obstetric forceps:
1. About the sequence of insertion of forceps spoons:
the left spoon is inserted with the left hand into the left half of the pelvis of the woman in labor ("three from 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 on the right").
2. Orientation of the spoons on the fetal head with forceps applied:
the tops of the spoons of the tongs should be facing the wire point;
forceps should capture the parietal tubercles of the fetus;
the wire point of the head must lie in the plane of the forceps.
in the plane of the entrance - obliquely down, to the socks of the seated obstetrician;
in the pelvic cavity - horizontally, on the knees of a seated obstetrician;
in the exit plane - from the bottom up, on the face of the seated obstetrician.
Moments of the operation of applying obstetric forceps:
1. Introduction of tongs spoons. Produced after a vaginal examination. The left spoon of tongs is introduced 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 the left hand, the handle is taken to the right side, setting 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 retracted thumb. Then, carefully, without any effort, the spoon is advanced between the palm and the head of the fetus deep into the birth canal, placing the lower edge between the III and IV fingers of the right hand and leaning on the bent thumb. In this case, the trajectory of movement of the end of the handle should be an arc. The promotion of the spoon into the depths of the birth canal should be carried out due to the gravity of the instrument and by pushing the lower edge of the spoon 1 with the finger of the right hand. The half-hand, located in the birth canal, is a guide hand and controls the correct direction and location of the spoon. With its help, the obstetrician makes sure that the top of the spoon does not go into the vault, onto the side wall of the vagina and does not capture the edge of the cervix. After the introduction of the left spoon, in order to avoid displacement, it is passed to the assistant. Further, 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 lock of the tongs. To close the tongs, each handle is grasped with the same hand so that the first fingers of the hands are located on Bush's hooks. After that, the handles are brought together, and the tongs close easily. Properly applied forceps lie across the swept seam, which occupies a median position between the spoons. The elements of the lock and Bush hooks should be located on the same level.
3. Trial traction. This necessary moment allows you to make sure that the forceps are applied correctly and that there is no danger of them slipping. It requires a special position of the hands of the obstetrician. For this, the doctor's right hand covers the handles of the forceps from above so that the index and middle fingers lie on the hooks. He puts his left hand on the back surface of the right, and the extended middle finger should touch the head of the fetus in the region of the leading point. If the forceps are correctly positioned on the fetal head, the tip of the finger is in constant contact with the head during trial traction. 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. Actually traction for the extraction of the fetus. After a trial traction, after making sure that the forceps are correctly applied, they begin their own traction. Traction of the fetal head with forceps should mimic natural contractions. For this you should:
imitate a fight by strength: start traction not abruptly, but with weak sipping, gradually strengthening and again weakening them by the end of the fight;
when producing traction, do not develop excessive strength by leaning back the torso or resting your foot on the edge of the table. The elbows of the obstetrician 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 min. After 4-5 tractions, the forceps are opened for 1-2 minutes to reduce the pressure on the head;
try to produce traction simultaneously with contractions, thus strengthening the natural expelling forces. If the operation is performed without anesthesia, it is necessary to force the woman in labor to push during traction.
Rocking, rotational, pendulum movements are not allowed
5. Removing the forceps. To remove the tongs, each handle is taken with the same hand, the spoons are opened and removed in the reverse order: the first is the right spoon, while the handle is taken to the inguinal fold, the second is the left spoon, its handle is taken to the right inguinal fold.
1. The head is movable above the entrance to the small pelvis; during external examination, it ballots.
2. The head is slightly pressed against the entrance to the small pelvis - this means that during external examination it is motionless, and during vaginal examination it is repelled.
3. The head is pressed into the small pelvis - this is the norm in the absence of childbirth in primiparas.
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 positions of the fetus. Causes, diagnosis, obstetric tactics.
Transverse position - a clinical situation in which the axis of the fetus intersects the axis of the uterus at a right angle.
Oblique position - 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 cavities of the large pelvis. The oblique position is a transitional state: during childbirth, it turns either into a longitudinal or transverse position.
Etiological factors:
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.
b) Limited fetal mobility: with oligohydramnios; large fruit; multiple pregnancy; in the presence of uterine fibroids, deforming the uterine cavity; with increased tone of the uterus with the threat of abortion, in the presence of a short umbilical cord.
c) Obstacle to the insertion of the head: placenta previa, narrow pelvis, the presence of uterine fibroids in the region of the lower uterine segment.
d) Anomalies in the development of the uterus: bicornuate uterus, saddle uterus, septum in the uterus.
e) Anomalies in the development of the fetus: hydrocephalus, anencephaly.
Diagnostics.
1. Examination of the abdomen. The shape of the uterus is elongated in transverse size. The circumference of the abdomen always exceeds the norm for the gestational age 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 bottom of the uterus, large parts are found in the lateral sections of the uterus (on the one hand, round dense, on the other, soft), the presenting part is not determined. The fetal heartbeat is best heard at the navel.
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 view of the fetus, as usual, is recognized by the back: the back is facing anteriorly - anterior view, the back is posteriorly - posterior.
3. Vaginal examination. At the beginning of labor with a whole fetal bladder, it is not very informative, it only confirms the absence of the presenting part. After the outflow of amniotic fluid with sufficient opening of the pharynx (4-5 cm), it is possible to determine the shoulder, shoulder blade, spinous processes of the vertebrae, axillary cavity. By the location of the spinous processes and the scapula, the type of fetus is determined, by the armpit - the position: if the cavity is facing to the right, then the position is the first, in the second position, the armpit is open to the left.
The course of pregnancy and childbirth.
Most often, pregnancy in transverse positions proceeds without complications. Sometimes, with increased fetal mobility, an unstable position is observed - a frequent change in position (longitudinal - transverse - longitudinal).
Complications of pregnancy in the 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; infection of the fetus; the formation of a neglected transverse position of the fetus - loss of fetal mobility with intensive early discharge of amniotic fluid; loss of small parts of the fetus; hypoxia; overstretching and rupture of the lower segment of the uterus.
When limbs fall out, it is necessary to clarify what fell into the vagina: a pen or a leg. The handle, lying inside the birth canal, can be distinguished from the leg by the greater length of the fingers and by the absence of the calcaneal tubercle. The hand is connected to the forearm in a straight line. The fingers are spread apart, the thumb is especially taken away. It is also important to determine which handle fell out - right or left. To do this, it is as if they “hello” with the right hand with a dropped handle; if this succeeds, the right handle falls out; if it fails, the left handle falls out. By the dropped handle, the recognition of the position, position and type of the fetus is facilitated. The handle does not interfere with the internal rotation of the fetus on the stem, its reduction is an error that makes it difficult to rotate the fetus or embryotomy. A dropped handle increases the risk of ascending infection during childbirth and is an indication for faster delivery.
Prolapse of the umbilical cord. If, during a vaginal examination, loops of the umbilical cord are felt through the fetal bladder, they speak of its presentation. Determination of loops of the umbilical cord in the vagina with a ruptured fetal bladder is called prolapse of the umbilical cord. The umbilical cord usually falls out during the passage of water. Therefore, for the timely detection of such a complication, a vaginal examination should be performed immediately. Prolapse of the umbilical cord in the 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 live fetus, urgent help is needed. With a transverse position, full opening of the cervix of the uterus and a moving fetus, such help is the rotation of the fetus on the leg and its subsequent extraction. With incomplete opening of the pharynx, a caesarean section is performed.
exit forceps
1. Preparation:
- laying a woman in labor on a "transverse" bed;
- processing the hands of the operator and assistant (the method is the fastest possible under these conditions);
- treatment of the surgical field (external genitalia, inner thighs, perineum) with an antiseptic solution;
- bladder catheterization;
- anesthesia (preferably - general anesthesia, pudendal anesthesia - with exit forceps);
- picking up tongs and laying branches on the work table (Fig. 1);
- internal examination with a "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 tongs and stacking 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 tongs is taken by the handle in the form of a bow or with three fingers, its tip is set in the groove between the index and middle fingers, and the handle deviates to 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 captured. The handle of the left spoon is easily lowered. The spoon is passed to the assistant, who holds it in a given position. The right spoon is also introduced under the control of the left hand (Fig. 3).
Rice. 2. Placing the left spoon of the tongs
Rice. 3. Introduction of the right spoon forceps
- forceps closure: the right spoon, when properly applied to the head, easily enters the lock of the left one: Bush hooks are at the same level for cushioning, a diaper is laid between the branches (Fig. 4),
Rice. 4. Closing the forceps
- control of the correct application of the forceps: with two fingers of the right hand, it is checked whether the cervix is captured between the jaws of the forceps and the head. The left hand supports the tongs by the handles,
- trial traction (Fig. 5). We place the right hand from above on the handle of the tongs - the left hand is superimposed on the right, the middle finger touches the head. Light traction is produced. If this does not increase the distance between the head and the finger - therefore the forceps do not slip off - they are applied correctly. If the distance increases - the forceps are applied incorrectly, it is necessary to remove them, removing the spoons in reverse order, first the right one, deflecting the handle of the forceps to the left groin of the woman in labor, and then the left one;
Rice. 5. Trial traction
- actual traction. 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 the introduction of the spoons and the closing of the tongs, the second and third fingers of both hands, bent with a hook, capture the outer and upper surfaces of the instrument at the level of Bush's hooks. The main phalanges of the index fingers are located on the outer surface of the handles, with Bush's hooks passing between the main phalanges of the index and middle fingers. The fourth and fifth fingers grasp the parallel forceps. The thumbs are under the handles of the tongs.
Rice. 6. Actually traction
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 weekend). Tractions are made in the horizontal direction and upwards (in 2 positions). The amount of traction depends on the position of the head in the cavity or at the exit of the pelvis.
2) If the wire point is facing 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, but a pulling instrument, during traction, the head makes an internal turn, and the forceps follow the head. After turning the head and establishing the swept seam in a straight size, the head is removed by the method described above with exit forceps.
During the eruption of the parietal tubercles, an episiotomy is performed on one or both sides.
Ed. K.V. Voronin
Obstetric forceps are a tool that replaces the missing or missing force of uterine contractions during childbirth. Obstetric forceps serve as a continuation of the obstetrician's hands (the "iron hands" of the obstetrician).
The imposition of obstetric forceps is one of the most important and responsible operations in the practice of an obstetrician. According to the technical difficulty, the operation occupies one of the first places in operative obstetrics. When applying obstetric forceps, various injuries and complications are possible.
The device of obstetric forceps - see Obstetric and gynecological instruments. The most common model in the USSR is the English obstetric Simpson forceps in the modification of N. N. Fenomenov. In some obstetric institutions, Russian obstetric forceps of IP Lazarevich are used - without pelvic curvature (straight forceps) and with non-crossing spoons (forceps with parallel spoons); Kylland's obstetric forceps (a model widely used abroad) are built according to the type of I. P. Lazarevich's forceps.
The main action of obstetric forceps is purely mechanical in nature: compression of the head, its straightening and removal. The compression of the head, which is inevitable during the application of forceps, should be minimal, in any case not exceed that observed in childbirth with the natural configuration of the head. Otherwise, the bones, vessels and nerves of the fetal head will inevitably suffer. Obstetrical forceps are only a gripping and enticing tool, but by no means correcting incorrect presentations and insertion of the head.
Indications and contraindications. Previously, obstetric forceps were applied at the personal discretion of the obstetrician, certain indications for their imposition have now been developed. Obstetric forceps are applied in cases where it is necessary to quickly end the birth in the interests of the mother, the fetus, or both together: with eclampsia, premature detachment of the placenta, prolapse of the umbilical cord, incipient asphyxia of the fetus, maternal diseases that complicate the course of the exile period (heart defects, nephritis), febrile condition, etc. With secondary weakness of labor, obstetric forceps are used in cases where the period of exile in primiparas lasts more than 2 hours. (3-4 hours), and for multiparous - more than an hour.
It is necessary to strictly consider contraindications to the use of obstetric forceps. They arise from the following conditions under which this operation can be applied: sufficient dimensions of the pelvis to allow the head to pass - the true conjugate must be at least 8 cm; the fetal head should be neither excessively large (hydrocephalus, pronounced post-term pregnancy), nor too small (forceps cannot be applied to the fetal head less than 7 months old); the head should stand in the pelvis in a position convenient for applying obstetric forceps (the movable head is a contraindication); the cervix should be smoothed, the uterine os is fully opened, its edges should go beyond the head; the fetal bladder must be broken; the fetus must be alive.
Among these conditions, the height of the head in the pelvis is especially important. For practical work, you can use the following scheme for determining the location of the head. 1. The head stands above the entrance to the small pelvis (Fig. 1), easily moves with a push, returning back (balloting). Forceps are 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 cervical-occipital sulcus stands three transverse fingers above the symphysis; the head is limitedly mobile, slightly fixed. During vaginal examination, the cape is accessible to the examining finger; swept seam - in the transverse or slightly oblique size of the pelvis. Forceps cannot be applied either. 3. Head 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 cervical-occipital sulcus stands two fingers above the symphysis. With a vaginal examination, the cape cannot be reached; the head is occupied in front - the upper edge and the upper third of the posterior surface of the pubic articulation, behind - the promontory and the inner surface of the first sacral vertebra. Swept seam - in one of the oblique dimensions, sometimes closer to the transverse. The wire point almost reaches the line of the main plane passing through the lower edge of the symphysis. It is not recommended to apply forceps, especially for a novice obstetrician (high forceps). 4. Head in a wide part of the pelvic cavity (Fig. 4); with its largest circumference, it passed the plane of the wide part of the cavity, the cervical-occipital groove - about one finger above the symphysis. With vaginal examination, the ischial spines are achievable, the sacral cavity is almost completed, the promontory cannot be reached. The wire point almost reaches the spinal line, the sagittal suture is in an oblique size. III and IV sacral vertebrae and coccyx are freely palpable. Forceps are allowed (atypical forceps, difficult operation). 5. Head in the narrow part of the pelvic cavity (Fig. 5); above the entrance to the pelvis, it is not defined (cervical-occipital groove flush with the height of the symphysis). During vaginal examination, the ischial spines are not determined, the sacrococcygeal articulation is free. The head comes close to the pelvic floor, its biparietal size occupies the plane of the narrow part of the pelvic cavity. Small fontanel (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 a straight one. Forceps may be applied. 6. The head in the outlet of the small pelvis (Fig. 6). She and her cervical-occipital sulcus over the entrance to the pelvis are not defined. The head has completed the 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 such 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 is an instrument used to remove a live full-term fetus by the head through the natural birth canal. They are designed to-
to tightly grasp the head and replace the expelling forces with the dragging force of the doctor. The forceps are only a pulling tool, not a rotary or compression tool. Depending on the location of the head in the small pelvis, there are weekend forceps (forceps minor) and abdominal forceps (forceps major).
What is 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. A spoon has a cutout (window), rounded ribs - upper and lower. 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 head curvature. The ribs of the hips are also curved to match the shape of the pelvis, and this curvature 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, do not have a pelvic curvature (Lazarevich, Pravosud, Gumilevsky). An analogue of straight forceps abroad is the Killand model (Fig. 23.11).
Lock connects the branches of forceps. According to the device of the lock, several models, or types, of tongs are distinguished: a) Russian tongs (Lazarevich) - the lock is freely movable; b) English-
Rice. 23.10. Piper obstetrical forceps
sky tongs (Simpson) - the castle is moderately mobile; c) German tongs (Negele) - the castle is almost motionless; d) French tongs (Levre) - the lock is motionless (Fig. 23.1 2).
Lever serves to grasp the forceps and produce traction. The inner surface of the handles is smooth for better
Rice. 23.11. Kyland's obstetrical forceps
of their fit to each other, the outer one is embossed with side hooks for better gripping by hands.
Rice. 23.12. Obstetric forceps:
a - Lazarevich; b - Simpson;
in - Negele; G - Levre;
What tongs more often Total enjoy in Russia and what is
them device?
In Russia, Simpson-Fenomenov forceps are most often used (Fig. 23.13). N. N. Fenomenov (a Russian obstetrician) made an important change to the forceps of Simpson's design, making the lock more mobile. These forceps are 35 cm long, their branches cross almost in the middle; the lock is simple and allows 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 the 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 testimony for overlays obstetric forceps?
The indication for the operation of applying obstetric forceps is the danger to the mother or fetus during the period of exile, which can be completely or partially eliminated by rapid delivery. Indications for surgery can be divided into two groups: indications from the mother and indications from the fetus. Indications on the part of the mother can be divided into: those associated with pregnancy and childbirth (obstetric indications) and those associated with extragenital diseases of a woman that require “turning off” attempts (somatic indications). Often there is a combination of them.
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 of preeclampsia (preeclampsia, eclampsia, severe hypertension, not amenable to conservative therapy) require "turning off" attempts;
Persistent weakness of labor and / or weakness of attempts, manifested by the standing of the fetal head in one plane of the pelvis for more than 2 hours, in the absence of the effect of the use of medications. Prolonged standing of the head in the same plane of the small pelvis leads to an increased risk of birth injury to both the fetus (a combination of mechanical and hypoxic factors) and the mother (genitourinary and enterogenital fistulas);
Bleeding in the second stage of labor, due to premature detachment of a normally located placenta, rupture of the umbilical cord vessels during their membrane attachment;
Endometritis in childbirth;
2) somatic indications:
Diseases of the cardiovascular system in the stage of decompensation;
Respiratory disorders due to lung diseases;
Myopia of a high degree;
Acute infectious diseases;
Severe forms of neuropsychiatric disorders;
Intoxication or poisoning.
The imposition of obstetric forceps may be required for women in labor who underwent surgical intervention on the abdominal organs on the eve of childbirth (the inability of the abdominal muscles to provide full-fledged attempts).
II. Fetal indications:
Fetal hypoxia, which developed due to various causes in the second stage of labor (premature detachment of a normally located placenta, weakness of labor, preeclampsia, short umbilical cord, entanglement of the umbilical cord around the neck, etc.).
What kind terms needed for overlays obstetric forceps?
For the imposition of obstetric forceps, the following conditions are necessary:
1) the presence of a live fetus;
2) full disclosure of the uterine os;
3) absence of a fetal bladder; if it is intact, then before the operation it must be opened;
4) the head of the fetus should be in the exit or in the cavity of the small pelvis, the swept seam - in a straight line or in one of the oblique dimensions;
5) the head should not be too small (prematurity, anencephaly) or too large (hydrocephalus, overmaturity);
"Obstetrics in questions and answers"
6) matching the size of the pelvis of the mother and the head of the fetus.
How held preparation to operations overlays obstetric forceps?
Preparation for the operation of applying obstetric forceps includes several points (selection of the method of anesthesia, preparation of the woman in labor, preparation of the obstetrician, vaginal examination, checking the forceps).
What kind methods anesthesia can apply?
The choice of the method of anesthesia is determined by the condition of the woman and the indications for the operation. In cases where the active participation of a woman in childbirth seems appropriate (weak labor and/or intrauterine fetal hypoxia in a somatically healthy woman), the operation can be performed using long-term epidural anesthesia (DPA) or inhalation of nitrous oxide with oxygen. However, when applying cavitary obstetric forceps in somatically healthy women, it is advisable to use anesthesia, since the application of spoons to the head located in the pelvic cavity is a difficult moment of the operation, requiring elimination of the resistance of the pelvic floor muscles. In women in labor, for whom attempts are contraindicated, the operation is performed under anesthesia.
Anesthesia should not end after the removal of the child, since the operation of applying abdominal obstetric forceps is accompanied by a control manual examination of the walls of the uterine cavity.
AT how is preparation women in labor and obstetrician
to operations overlays obstetric forceps?
The operation of applying obstetric forceps is performed in the position of the woman in labor on her back with her legs bent at the knees.
and hip joints. The bladder must be emptied before the operation. 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 training women in labor to operations?
Immediately before applying the forceps, it is necessary to perform a thorough vaginal examination (it is better to perform the examination with a half-hand, i.e., four fingers) in order to confirm the presence of conditions for the operation and determine the position of the head in relation to the planes of the small pelvis. Depending on the position of the head, it is determined which variant of the operation will be applied (cavitary or output obstetric forceps). From what major moments consists operation? The operation consists of five main points:
The first point is the introduction and placement of the spoons;
The second point is the closing of the tongs;
The third point is trial traction;
The fourth moment is the removal of the head;
The fifth moment is the removal of the tongs.
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 right hand of the obstetrician;
"Obstetrics in questions and answers"
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 introduced under the control of the left hand of the obstetrician.
How introduced in generic way right hand obstetrician, under control which superimposed left a spoon? To control the position of the left spoon, the obstetrician inserts a half-hand into the vagina, that is, four fingers (except the first) of the right hand. The half-hand should be turned with the palmar surface towards the head and inserted between the head and the left side wall of the pelvis. The right finger remains outside and is retracted to the side. After the introduction of the half-hand, they begin to apply the spoon.
How take handle forceps at administered spoons?
The handle of the tongs is grasped in a special way: by type writing pen(at the end of the handle, the index and middle fingers are placed opposite the thumb) or by the type of bow (opposite the thumb, four others are widely spaced along the handle). The special type of grip of the forceps spoon avoids the application of force during its introduction.
How have branch forceps before introduction spoons in generic way?
Before inserting the spoon into the birth canal, the forceps handle is moved to the side and placed parallel to the opposite inguinal fold, i.e., when the left spoon is inserted, parallel to the right inguinal fold, and vice versa. The top of the spoon is placed on the palmar surface of the semi-hand, located in the vagina. The back edge of the spoon is located on the lateral surface of the fourth finger and rests on the abducted thumb.
How introduce spoon?
The promotion of the spoon into the depths of the birth canal should be carried out by virtue of the own gravity of the instrument and by pushing the lower edge of the spoon with the finger of the right hand. In this case, the trajectory of the movement of the end of the handle should be an arc. The handle of the tongs, as the spoon is inserted, goes down and takes a horizontal position (Fig. 23.14).
What is appointment semi-hand located in generic ways?
The half-hand, located in the birth canal, is a guide hand and controls the correct direction and location of the spoon. With its help, the obstetrician makes sure that the top of the spoon does not go into the vault, onto the side wall of the vagina and does not capture the edge of the cervix. After the introduction of the left spoon, in order to avoid displacement, it is passed to the assistant. Further, under the control of the left hand, the obstetrician introduces the right branch with the right hand into the right half of the pelvis in the same way as the left one.
How introduce second (right) spoon?
The second (right) spoon is administered in the same manner 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-shoe.
Rice. 23.14. The position of the branch of the forceps when the spoon is inserted
How must be placed spoons on the head fetus? Spoons on the head of the fetus 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 size (diameter mento-occipitalis) (Fig. 23.15);
"Obstetrics in questions and answers"
2) at the same time, the spoons capture the head in the largest diameter so that the parietal tubercles are in the windows of the forceps spoons;
3) the line of forceps handles is turned to the leading point of the head.
Rice. 23.15. The location of the spoons in the occipital presentation
How produce closure forceps?
To close the forceps, 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 that, the handles bring together and close the tongs (Fig. 23.1 6).
Is always whether handles forceps adjacent friend to friend close?
The inner surfaces of the tongs handles 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 forceps
How enroll in such cases?
In such cases, a sterile napkin folded 2-4 times is inserted between the handles. This prevents excessive compression of the head and achieves a good fit of the forceps spoons to the head.
What order fulfillment third moment operations?
The third moment of the operation is trial traction.
This necessary moment allows you to make sure that the
proper application of the forceps and the absence of the threat of their slipping. It requires a special position of the hands of the obstetrician. How produce trial traction?
The obstetrician with his right hand clasps the forceps handles from above so that the index and middle fingers lie on the Bush hooks. He puts the left hand on the back surface of the right, stretches out the index or middle finger and touches the fetal head with it in the region of the leading point (Fig. 23.1 7). If the forceps are applied correctly, then during the trial traction, the tip of the finger is constantly in contact with the head. Otherwise, it moves away from the head, which indicates that the forceps are applied incorrectly and eventually they will slip off. In this case, the forceps must be repositioned.
How are located arms obstetrician when he produces extraction heads tongs?
After a trial traction proceed to the removal of the head. To do this, the index and ring fingers of the right hand are placed on Bush's hooks, the middle one - between divergent
passing with the branches of forceps, and the thumb and little finger cover the handles on the sides. The left hand grabs the end of the handle from below.
Which character must have traction?
When extracting 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. For this you should:
1) imitate a fight by strength: start traction not abruptly, but with weak sipping, gradually strengthen it and weaken it again;
2) when producing traction, do not develop excessive strength and do not increase it by tilting the body back or resting your foot on the edge of the table;
3) between individual tractions it is necessary to pause for 0.5-1 minutes;
"Obstetrics in questions and answers"
4) after 4-5 traction, open the forceps and rest the head for 1-2 minutes;
5) try to produce traction simultaneously with contractions, thus strengthening the natural expelling forces. If the operation is performed without anesthesia, it is necessary to force the woman in labor to push during traction.
Rocking, rotational pendulum movements are unacceptable. It should be remembered that tongs are a drawing instrument; traction should be performed smoothly in one direction.
AT what 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 a wide part of the pelvic cavity (cavitary forceps):
1) first direction traction (from wide parts cavities small pelvis to narrow) - down and back, respectively, the wire axis of the pelvis (Fig. 23.18) *;
2) second direction traction parts cavities small pelvis before plane exit) - down (Fig. 23.1 9);
3) third direction traction (removal heads in tongs) - anteriorly (Fig. 23.20).
What order fulfillment fourth moment operations -
withdrawals forceps?
The procedure for removing the forceps before eruption of the head is as follows:
1) take the right handle in the right hand, the left handle in the left hand and, spreading them apart, open the lock;
* All directions of traction are indicated in relation to the vertical position of the mother's body.
Rice. 23.17. trial traction
2) remove the spoons in the reverse order to the one in which they were introduced, i.e., first remove the right spoon, and then the left one; when removing the spoons, the handles should be deflected towards the opposite thigh of the woman in labor.
Can whether withdraw head, not taking off forceps, and how this is 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, embracing them in the area of the castle; put the left hand on the perineum as it is done when protecting it;
2) direct traction more and more anteriorly as the head unbends and cuts through the vulvar ring (Fig. 23.21);
3) to produce attraction with one right hand, with the left to support the perineum;
4) when the head is completely removed from the birth canal, open the lock and remove the forceps.
Rice. 23.21. Removal of the head in forceps
What kind difficulties may meet at administered spoons and
how them eliminate?
With the introduction of spoons, the following difficulties may occur:
1) the tip of the spoon rests against something and does not move deeper, which may be due to the tip of the spoon getting into the fold of the vagina or, more dangerously, into its fornix. In such cases, with the fingers of the hand-guide, you need to find what the top of the spoon rests on, and get around this obstacle; under no circumstances should an obstacle be overcome by force. To avoid this complication, the guide arm should be inserted in advance to a sufficient depth;
"Obstetrics in questions and answers"
2) it is impossible to pass the guide arm deep enough, since the space between the head and the side wall of the pelvis is excessively narrow.
In such cases, it is necessary to insert the guide hand somewhat backwards, closer to the sacral cavity, and insert a spoon of forceps in the same direction. To place the spoon in the transverse dimension of the pelvis, it must 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 right direction and at the required distance.
What kind difficulties may meet at circuit forceps
and how them eliminate?
When closing the tongs, the following difficulties may occur:
1) the lock does not close, since the spoons are not placed on the head in the same plane. It is necessary to insert fingers into the vagina and correct the position of the spoon;
2) the lock does not close, as one of the spoons is inserted above the other. It is necessary to introduce deeper the spoon that was not introduced deep enough; this movement should be made under the control of the semi-hand, which is inserted into the vagina for this purpose;
3) the lock is closed, but the handles of the tongs diverge greatly. This is due to the fact that the spoons did not lie on the diameter of the head, but captured it obliquely. To eliminate this, it is necessary to correct the position of the spoons on the head. Spoons should be removed, a vaginal examination should be repeated to accurately
but determine the position of the head, and again apply the forceps. 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 all the way. What kind difficulties may meet at extraction heads and how them eliminate?
When removing the head, the following difficulties may occur:
1) it is difficult to determine in which direction to produce traction. It is necessary to force the woman in labor to push: by the movement of the handles it will be clear where the attraction should be directed at the moment;
2) the head does not move along the birth canal, despite several tractions. This difficulty in removing the head can almost exclusively result from the wrong direction of traction. It is necessary to re-examine the position of the head in the pelvis and, if necessary, correct the location of the spoons. In the event that the advancement of the head still does not occur, brute force cannot be used;
3) spoons slide off the head. This is a very serious complication. If it is not noticed in time, the spoons can break off the head and cause severe damage to the woman in labor. In order to timely notice the slipping of the forceps from the head, in addition to the trial attraction, one should re-check the position of the head in the pelvis and the position of the spoons on the head. Sometimes slipping of forceps is indicated by the fact that their handles begin to diverge.
Weekends forceps
The output forceps are called, superimposed on the head, standing in the exit of the small pelvis with an arrow-shaped seam in the direct size of the latter.
"Obstetrics in questions and answers"
How situated head on 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, for-
nyata head, swept seam - in the direct size of the exit from the pelvic cavity. The small fontanel is defined below the large one (the head is bent - occipital insertion) and is located in front (front view) or behind (rear view).
How introduce spoons?
Spoons are introduced according to the rules described earlier: first, the left spoon - to the left side of the pelvis of the woman in labor, then the right spoon - to the right side. The left branch is held with the left hand, the right branch with the right. The right half-hand serves as a guide hand when introducing the left spoon and vice versa. Spoons are introduced in the transverse size of the pelvis. The handles of the forceps are located horizontally (Fig. 23.22).
How spoons capture head and how they on the her located?
Spoons grab the head across and are located in the direction from the back of the head through the ears to the chin. The line forming the mental continuation of the handles of the forceps rests on the leading point in the occipital presentation.
AT what direction produce attraction at front form
occipital presentation?
To imagine all the features of attraction, it is necessary
Rice. 23.22. Exit forceps. Occipital presentation, anterior view
remember the movements that the head makes, passing the exit of the pelvis in the anterior view of the occipital presentation (the biomechanism of childbirth).
The head moves somewhat downward and reaches the pelvic floor. The back of the head is more and more shown from the genital gap. The suboccipital fossa fits under the lower edge of the symphysis. After that, the head begins an extensor movement and the crown of the head is born first, then the forehead and face. It follows from this that attraction must first be produced downwards and anteriorly until the suboccipital fossa comes under the lower edge of the symphysis. Then the drives are directed more and more anteriorly, as a result of which the head unbends and is cut through by a circle passing through a small oblique dimension.
AT what direction produce attraction at rear form
occipital presentation?
Tractions are performed in a horizontal direction until the front edge of the large fontanelle comes into contact with the lower edge of the pubic symphysis (the first fixation point). Then traction is done anteriorly until the region of the suboccipital fossa is fixed at the top of the coccyx (the second point of fixation). After that, the handles of the forceps are lowered backwards - the head is extended and birth is from under the pubic articulation of the forehead, face and chin of the fetus.
cavity forceps
Forceps are called hollow, applied to the head, standing in the pelvic cavity (in its wide or narrow part) with an arrow-shaped suture in one of the oblique dimensions. The head will have to complete the internal rotation in forceps and perform extension (with anterior occipital presentation) or additional flexion and extension (with posterior 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 capture the head in the region of the parietal tubercles. The imposition of forceps in an oblique size presents certain difficulties.
"Obstetrics in questions and answers"
ness. More complex than exit obstetric forceps are tractions, in which the internal rotation of the head is completed by 45 ° or more, and only then the extension of the head follows, therefore, cavity forceps are atypical, since at this location 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 on data vaginal research?
The fetal head with its largest 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 size of the pelvis. The small fontanel is determined to the left (first position), anteriorly (anterior view) and below (the head is bent - occipital presentation) in relation to the large fontanel; ischial spines are reached easily (fetal head in the wide part of the pelvic cavity) or with difficulty (fetal head in the narrow part of the pelvic cavity).
How impose forceps?
In order for the head to be covered with spoons of forceps biparietally, they should be applied in the left oblique size of the pelvis, since the sagittal suture is in the right oblique size.
How introduced and placed first (left) spoon?
When applying abdominal obstetric forceps, the order of insertion of spoons is preserved. The left spoon is introduced under the control of the right guide hand to the left and somewhat backwards, i.e., into the back-side of the pelvis. The spoon is located on the region of the left parietal tubercle of the head. This spoon is called fixed, as it is immediately located in the right place after the introduction.
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, as this is prevented by the pubic arch. This obstacle is overcome by the movement ("wandering") of 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 established in the region of the right parietal tubercle. The spoon is moved by gentle pressure on its lower rib II with the finger of the left hand. In this situation, the right spoon is called "wandering".
Thus, the spoons lie opposite each other in the left oblique size 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".
AT what direction produce traction?
Tractions are performed downwards and backwards, the head makes an internal turn, the sagittal suture gradually turns into a straight size of the pelvic outlet. Next, the traction is directed first down to the exit of the occipital protuberance from under the womb, then anteriorly until the head is extended.
"Obstetrics in questions and answers"
Rice. 23.23. Hollow forceps. Occipital presentation, first position, anterior view
occipital presentation, second position, front view
How situated head?
The head is located in the same way as in the first position, only the swept seam is in the left oblique size; small fontanel is determined on the right (second position), kpe-
redi (front view) and below (occipital presentation) in relation to the large fontanel.
How impose forceps?
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 introduced first into the left half of the pelvis, and then it is moved anteriorly into the anterior-lateral pelvis (wandering spoon). The right, fixed spoon is immediately introduced into the right posterolateral pelvis. Thus, the spoons are placed in the right oblique size of the pelvis biparietally (Fig. 23.24).
AT what direction produce attraction?
The drives are produced in exactly the same way as in the front view of the first position, only the head, together with the forceps, as it moves forward, will make a turn not against, but clockwise.
Rice. 23.24. Hollow forceps. Occipital presentation, second position, anterior view
What are outcomes operations overlays obstetric forceps?
The use of obstetric forceps in compliance with the conditions and technique usually does not cause any complications for the mother and fetus. In some cases, this operation may cause some complications.
What kind may to be complications and on which reason?
When performing the operation of applying obstetric forceps, there may be the following complications.
Damage generic ways. These include ruptures of the vagina and perineum, less often - 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 technology are violated. Rare complications include damage to the bone birth canal - rupture of the pubic symphysis, damage to the sacrococcygeal joint.
Complications for fetus. After barely surgery on the soft tissues of the fetal head, swelling with a cyanotic color is usually observed. With a strong compression of the head, hematomas may occur. The strong pressure of the spoon on the facial nerve can cause paresis. Severe complications are damage to the bones of the fetal skull, which can be of varying degrees - from bone depression to fractures. Hemorrhages in the brain are a great danger to the life of the fetus.
Postpartum infectious complications. Delivery by the operation of applying obstetric forceps is not the cause of postpartum infectious diseases, however, it increases the risk of their development, and therefore requires adequate prevention of infectious complications in the postpartum period. Complications can be associated and depend on the pathological process or condition of the woman in labor, which was an indication for the imposition of obstetric forceps.
"Obstetrics in questions and answers"
vacuum extraction fetus
What called operation vacuum extraction fetus?
Vacuum extraction of the fetus is a delivery operation performed to extract the fetus by the head using a special apparatus - a vacuum extractor by creating negative pressure between the inner surface of the cup of the apparatus and the fetal head (Fig. 23.25).
What are testimony 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 cesarean sections already passed (endometritis), and for obstetric forceps more not has come."
Indications for vacuum extraction of the fetus:
Weakness of labor activity, not amenable to conservative therapy;
Beginning fetal hypoxia.
What are contraindications to operations vacuum extraction
fetus?
Contraindications to the use of vacuum extraction of the fetus are as follows:
1) discrepancy between the size of the pelvis and the head of the fetus;
2) preeclampsia (nephropathy, preeclampsia, eclampsia);
3) diseases of the woman in labor that require "turning off" attempts (decompensated heart defects, hypertension, lung diseases, a high degree of myopia, etc.);
4) extensor presentation of the head;
5) severe prematurity of the fetus (up to 36 weeks).
The last two contraindications are associated with the peculiarity of the physical action of the vacuum extractor, therefore, placing a cup on the head of a premature fetus or in the region of a large fontanel is fraught with serious complications.
What are terms for fulfillment operations vacuum extraction?
To perform the vacuum extraction operation, the following conditions are necessary:
1) the presence of a live fetus;
2) the location of the head in the small pelvis;
3) full disclosure of the uterine os;
4) absence of a fetal bladder;
5) correspondence between the sizes of the pelvis and the head of the fetus;
6) occipital presentation of the fetus.
What is preparation to operations?
Preparation for the operation corresponds to that when applying obstetric forceps (see "Obstetric forceps").
What are methods anesthesia?;
When performing a vacuum extraction operation, the active participation of the woman in labor is necessary, therefore anesthesia is not indicated. Epidural or pudendal anesthesia can be performed.
What need do directly before operation?
Immediately before the operation, it is necessary to perform a vaginal examination again to clarify the obstetric situation: the degree of opening of the uterine os, the height of the head, the nature of the insertion of the head.
From what moments develops technique operations vacuum extraction?
The technique of vacuum extraction of the fetus by the head consists of the following points:
"Obstetrics in questions and answers"
1) the introduction of the cup and placing it on the head;
2) creation of negative pressure;
3) attraction of the fetus by the head;
4) removing the cup.
How introduced cup vacuum extractor?
The vacuum extractor cup size #5 to #7 can be inserted in two ways:
Rice. 23.25. vacuum extractor
1) under the control of the hand;
2) by exposing the head with the help of mirrors (under visual control).
Most often in practice, a cup is introduced under the control of the hand. To do this, under the control of the left hand-guide, the cup is inserted into the vagina with the right hand, brought to the head and pressed against it (Fig. 23.26). We must try to put a cup closer to the small fontanel. You can not impose it on a large fontanel.
How create negative pressure?
To create a negative pressure, it is necessary to connect the hoses from the cup and the vacuum apparatus, create tightness in the system with a hand pump, gradually bringing the negative pressure to 500 mm Hg. Art. according to the pressure gauge connected to the system.
How produce traction?
With one hand, the obstetrician grabs the hose near the calyx or by a special device located at the junction of the hoses, and simultaneously with attempts produces tractions in the direction corresponding to the mechanism for the birth of the head, i.e., depending on the location of the head in the small pelvis (Fig. 23.27) . In the pauses between attempts, attraction is not produced. When cutting through the vulvar ring of the parietal tubercles, the calyx is removed by breaking the seal in the apparatus. In the future, the head is removed by providing manual assistance.
What kind may to be complications at implementation this operations?
The most common complication is slipping of the cup from the head, which occurs when the technique is violated, the force of attraction is increased, or the tightness in the device is broken. If the calyx slips, you can try to apply it again, but if the cup slips again, you cannot continue the operation and delivery by another method is necessary.
The fetus is sometimes traumatized: cephalohematomas are observed on the fetal head, brain symptoms, convulsions, etc. occur.
Rice. 23.26. Placement of the vacuum extractor cup
Rice. 23.27. Traction with a vacuum extractor
condition of the woman in labor, which served as an indication for the operation.
