3. Instrumental Delivery

4. Forceps Delivery indications A. Indicated : 1.Anesthesia 2.Heart disease 3.Pulmonary disease 4.Fetal distress 5.After coming head 6.In cesarean section

5. B. Selected : 1. Poor cintractions 2. Fatigue 3. Op position 4. Prevention of cystocele and rectocele ? 5. Prevention of hemorrohid?

6. Contraindications Extreme prematurity (< 34 weeks) Extreme prematurity (< 34 weeks) Suspected bleeding disorder Suspected bleeding disorder Macrosomia, suspected or USG established Macrosomia, suspected or USG established

7. Prerequisitions for forceps 1. Full dilatation 2. Engagement 3. Empty bladder 4. Known position (of the fetal head) 5. Ruptured membranes 6. Adequate anesthesia 7. Episiotomy 8. R/O C.P.D 9. Skilled operator

8. Parts of Equipment 1. Cup size 40, 50, 60 mm. 2. Types of cup Malestorm Malestorm Bird Bird Siliastic (Mety-vac) Siliastic (Mety-vac) M-cup. M-cup. 3. Vacuum tubing. 4. Traction chain. 5. Suction apparatus — which has capacity to produce 0.8 kg/cm2 negative suction @ 550-600 mm Hg.

9. 6. Traction force max @ 22.7 kg required before detachment or pop-off takes place. This is the safetyend point. 7. Application distance: is 3 cm from post edge of anterior fontanelle of fetal sclap till the anterior outer edge of traction cup.

10. 8. Site of applications a- Flexing median a- Flexing median b. Hexing paramedian Result in b. Hexing paramedian Result in c. Deflexing median Asyncilitism c. Deflexing median Asyncilitism d. Deflexing paramedian d. Deflexing paramedian Failure for Failure for correct correct traction traction

11. Parts of Forcep's Has two crossing blade branches Has two crossing blade branches Each branch blade has four components Each branch blade has four components 1. The blade 1. The blade 2. Shank 2. Shank 3. Lock — English and/or sliding type 3. Lock — English and/or sliding type 4. Handle 4. Handle Each blade has two curves Each blade has two curves a. Cephalic-coniorms to shape of fetal head a. Cephalic-coniorms to shape of fetal head b. Pelvic-confoims to pelvic curvature b. Pelvic-confoims to pelvic curvature

12. Common Types of Forceps in Use 1. Wringly's outlet forceps 2. Simpson's 3. Tucker-McIane 4. Kielland forceps 5. Piper's forceps 6. Hay's forceps

13. Classification of Forceps Delivery (Instrumental Delivery) (ACOG 2000) Procedure Criteria Outlet forceps 1. Sclap visible and at 1. Sclap visible and at interoitus without interoitus without separating labia separating labia 2. Fetal skull at pelvic floor 2. Fetal skull at pelvic floor 3. Sagittal suture in AF dia or 3. Sagittal suture in AF dia or LOA or ROA position LOA or ROA position 4. Fetal head is or at pelvic 4. Fetal head is or at pelvic perineum (leading pole) perineum (leading pole) 5. Rotation needed does not 5. Rotation needed does not exceed 45° exceed 45°

14. Low forceps Low forceps Leading point ^ +2 station and Leading point ^ +2 station and not on pelvic floor not on pelvic floor Rotation is 45° or less. LOA/ Rotation is 45° or less. LOA/ ROA to occiput ant and/or ROA to occiput ant and/or LOP/POP with occiput pos- LOP/POP with occiput pos- terior terior Rotation is > 45° Rotation is > 45° Mid forceps Mid forceps Station above +2 cm but head Station above +2 cm but head is Engaged (Abdomen palpable is Engaged (Abdomen palpable vertex is I/5th only) vertex is I/5th only) High forceps High forceps Not included in this classification Not included in this classification

15. Function of Forceps Used as traction, rotation or both, Used as traction, rotation or both, by and large used as a tractor by and large used as a tractor Possible Max Force Used Possible Max Force Used Upto 60 kg max after which fetal skull damage is assured. Generally with forceps at elbow along side body leads to force of 22-27 kgs per tractor pull. Upto 60 kg max after which fetal skull damage is assured. Generally with forceps at elbow along side body leads to force of 22-27 kgs per tractor pull.

16. Preparation of Forcep Application 1. Pudendal block or regional anesthesia 2. Lithotomy position 3. Bladder assured empty 4. Perineum cleaned and draped 5. Forceps are constructed outside as to be applied 6. Precise knowledge of exact position of fetal head either by suture direction or by locating posterior ear 7. Application as for biparital or bi malar position, is only safe application of forceps.

33. Indications A. Maternal Exhausation Exhausation Poor/absent maternal expulsive efforts Poor/absent maternal expulsive efforts Need to avoid maternal expensive effort, Need to avoid maternal expensive effort, cardiac disease/CVA cardiac disease/CVA Lack of effort Lack of effort

34. B. Fetal Nonreassuring fetal CTG test Nonreassuring fetal CTG test C. Prolonged 2nd stage Primi > 2 hr without regional anesthesia Primi > 2 hr without regional anesthesia Multi > 1 hr anesthesia (for with RA addl hr) Multi > 1 hr anesthesia (for with RA addl hr) Desired selective shortening of 2nd stage Desired selective shortening of 2nd stage

35. Prerequisites A. Maternal Lithotomy position Lithotomy position Reassurance Reassurance Consent Consent Adequate analgesia Adequate analgesia Empty bladder Empty bladder Adequate assessed pelvis. Adequate assessed pelvis.

36. B. Fetal B. Fetal Cephalic presentation Cephalic presentation Membranes ruptured Membranes ruptured Engaged fetal head Engaged fetal head Position of head-known Position of head-known Station +2 Station +2 Flexed attitude Flexed attitude Moulding of head +1 only. Moulding of head +1 only.

37. C. Others C. Others Cervix fully dilated Cervix fully dilated No placenta praevia No placenta praevia Experienced operator Experienced operator Ability to do less, with facilities Ability to do less, with facilities existing prtoi to attempting. existing prtoi to attempting.

38. Indications Maternal Maternal Heart disease Heart disease Pulmonary injury or severe COFD Pulmonary injury or severe COFD Severe intrapartum infection Severe intrapartum infection Neurological conditions such as cord injury or neuromuscular diseases Neurological conditions such as cord injury or neuromuscular diseases Prolonged 2nd stage. Prolonged 2nd stage.

39. Fetal Indications Fetal Indications Prolapse of umbilical cord Prolapse of umbilical cord Premature separation of placenta Premature separation of placenta Non-assuring CTG tracing, persistant. Non-assuring CTG tracing, persistant. Others Others Lack of maternal expulsive effort Lack of maternal expulsive effort Elective shortening of 2nd stage Elective shortening of 2nd stage (prophylactive) or social need. (prophylactive) or social need.

40. Prerequisites 1. Vertex presentation or face with chin out (mento-anterior) 2. Head must be engaged 3. Position of fetal head well known 4. Cervix fully dilated 5. Bladder completely empty 6. Membranes ruptured 7. No CPD assessed 8. Informed mother's consent.