Overview of Forceps Delivery
In the last thirty years, the use of forceps during childbirth has become less popular among doctors. These days, forceps are used in approximately 1.1% of all vaginal deliveries (based on a study of over 22 million vaginal deliveries from 2005-2013). The use of a procedure called vacuum extraction is also less common, but still used more often than forceps. This might be because vacuum extraction is easier to perform than a forceps delivery. However, forceps are more likely to result in a successful vaginal delivery than vacuum extraction.
Even though forceps can be more effective than a vacuum, their use is still decreasing. Some people believe this is due to concerns about legal action related to complications from forceps delivery. These complications can include tearing in the area between the vagina and anus (perineal laceration) and injuries to the baby. Some people believe that fewer doctors are being trained to use forceps, which could also explain why they are less commonly used now.
However, forceps can be beneficial when used correctly during the right part of labor. Forceps can help avoid the need for a C-section, which is a more invasive surgery that carries higher risks of complications. For example, C-sections can lead to a higher chance of infection after childbirth. There are also long-term risks associated with C-sections, such as an increased chance of needing another C-section in the future, abnormal placement of the placenta, and tearing of the uterus (uterine rupture). Therefore, avoiding these complications is beneficial for the patient, and as such, many doctors believe it would be advantageous to bring back the use of forceps during vaginal delivery.
Anatomy and Physiology of Forceps Delivery
Knowing how the female pelvis is structured is key for doctors when using forceps to help deliver a baby. This is because, once the forceps are in the pelvis, the doctor can’t see very well. So, they have to rely on their understanding of how the mother’s pelvis is shaped.
Before the doctor uses forceps to deliver the baby, they must first make sure that the mother’s pelvis is large enough compared to the baby’s head. This is known as ruling out cephalopelvic disproportion and it involves understanding the shape of the mother’s pelvis (pelvimetry). There are four main types of pelvic shapes, which include Anthropoid, Android, Gynaecoid, and Platypelloid.
The most common pelvic shape is the Gynaecoid. Mothers with a Gynaecoid or Anthropoid shaped pelvis are likely to have an easier vaginal delivery. On the other hand, mothers with an Android or Platypelloid shaped pelvis may find vaginal delivery more difficult. Doctors can determine the type of pelvis through an x-ray. They can also tell if the mother’s pelvis is wide enough for a successful vaginal delivery by measuring the diameter between the ischial spines (bottom part of the pelvis) before labor starts.
Understanding the baby’s anatomy also plays a part in delivering the baby. The baby’s position in the womb (fetal station) can be determined by feeling the baby’s head and using a measure referred to as the bipyramidal distance. This measure helps the doctor determine the baby’s progress towards birth. If the baby’s head is above a specific point in the pelvis called the ischial spines, it is considered to be in a “negative” position. If the baby’s head is below this point, it is in a “positive” position. This position can be divided into thirds above and below, giving a numerical system from -3 to +3. Alternatively, doctors can also use a measurement system that involves centimeters, ranging from -5 to +5.
The position of the baby should ideally be determined at the same time as the baby’s station. This helps the doctor plan for any extra steps if the baby is not in the right position for birth (occiput anterior position). The right position for birth is when the front of the baby’s head (marked by a “diamond” shaped suture) is towards the mother’s back. Any position other than this may make it more challenging for the doctor to deliver the baby using forceps, as they may need to turn the baby’s head.
Why do People Need Forceps Delivery
Operative vaginal delivery, which involves the use of tools like forceps or a vacuum to help deliver a baby, might be recommended by doctors in certain situations. Both the health of the mom and baby are taken into account when making this decision and there isn’t any one rule that applies to every case.
For the baby, the main reason this method might be suggested is if doctors notice signs of distress when the baby’s head is low down in the birth canal. This could make delivering through a cesarean section (a surgery to deliver the baby) difficult. For the mother, operative vaginal delivery might be recommended if she is very tired or if she has been in the second stage of labor for a long time. Specifically, the second stage is when the cervix is fully dilated and the mother is pushing, but the baby is not coming out. The specific amount of time considered “too long” varies, but generally speaking, for first-time moms it’s about 3-4 hours and for moms who’ve had babies before it’s about 2-3 hours.
That said, there are certain criteria, suggested by the American College of Obstetricians and Gynecologists, that need to be met before doctors can use these methods:
- The cervix is completely open (fully dilated)
- The protective sac around the baby (membranes) have broken
- The baby’s head has moved down into the birth canal (vertex presentation)
- Doctors have estimated the weight of the baby
- Doctors believe the mother’s pelvis is wide enough for vaginal delivery
- The mother has been given pain medicine (anesthesia)
- The mother’s bladder is empty
- The mother agrees to the procedure and understands its pros and cons
- Doctors have a backup plan in case the initial method doesn’t work
Specific medical conditions, like heart or nerve diseases, might also make operative vaginal delivery a good option if these prevent the mother from being able to push effectively.
When a Person Should Avoid Forceps Delivery
There are certain situations when a doctor should not use tools like forceps or a vacuum to help with a baby’s delivery, because it can be risky for the mother and the baby. These situations are called “contraindications”.
For mothers, delivering a baby with the help of tools is not advised if:
- The cervix, which is the lower part of the womb that opens during childbirth, is not fully open
- The protective sac around the baby (known as the membranes) has not yet broken
- The baby’s head has not moved down into the right place for birth
- The position of the baby inside the womb is not known
- The baby’s head is too large to pass through the mother’s pelvic bones, a condition known as “cephalopelvic disproportion”.
Furthermore, a woman might not be a good candidate for such procedure if the baby is not positioned correctly (unless a breech extraction – the baby coming out bottom first – is planned), or if she has a connective tissue disorder.
For babies, it’s not safe to use delivery tools if they have a bleeding disorder like hemophilia, thrombocytopenia (low platelet count, which help with clotting), or von Willebrand disease, or a bone condition like osteogenesis imperfecta, which makes their bones very fragile.
It is also potentially unsafe if the baby is very premature or very big – though doctors have not agreed on the exact weight limits for safely using forceps in delivery.
Equipment used for Forceps Delivery
Forceps are a type of tool used by doctors, possibly during childbirth. The “blades” or ends of the forceps can be smooth or have small openings, known as fenestrations. The ones with these small openings are examples of Simpson and Elliot forceps. Both have crossed branches, but are used differently: the Simpson forceps have parallel separate arms and are used with a long shaped head, while the Elliot forceps have overlapping arms and are used with an unshaped head. There’s another type called the Tucker McLane forceps, which have a smooth blade without openings and are useful when the baby’s head is round.
All forceps are made up of four necessary parts: a handle to hold, a lock to secure, a shank or arm, and the blade or end. The blade is shaped in a specific way to accommodate the baby’s head and fit the shape of the mother’s pelvis.
Simpson, Elliot, and Tucker McLane forceps all have an English lock, which prevents them from fully rotating. There’s another kind called the Keilland forceps that have a sliding lock and a minor pelvic curve that allows it to disconnect and fully rotate. However, these types of rotating forceps, such as the Keilland model, have higher chances of causing complications for both the mother (like vaginal tears or bleeding) and the baby (like shoulder issues or cuts from the blades).
Piper forceps are generally the preferred choice when a baby is being delivered feet first, also known as a breech position, as they have a longer arm and a pelvic curve to protect the baby’s head when it’s leaning forward.
Who is needed to perform Forceps Delivery?
A successful childbirth using special instruments calls for a highly-skilled and experienced childbirth doctor, or obstetrician. To avoid or handle any complications for the mother or the baby, the doctor might have to perform hundreds of deliveries using an instrument called forceps. It’s also important that a children’s doctor, or pediatrician, is there at the time of the birth.
Preparing for Forceps Delivery
Before a forceps delivery, it’s important that the patient understands everything that might happen. This includes understanding the advantages and disadvantages of forceps delivery, as well as other possible methods like vacuum-assisted delivery and cesarean section, which is a surgery to deliver the baby. As a precaution, it’s recommended for the doctor to get approval for a cesarean section in case the forceps delivery isn’t successful. The team in the operating room is alerted to step in if an emergency cesarean section is needed, especially when there are signs the baby is in distress.
In preparation, the doctor needs to ensure the right forceps are ready for use and are in working condition. There might also be a need for a backup instrument. It’s not advisable to use vacuum extraction if forceps delivery fails, as this can increase the risk of complications for the baby. As cuts and tears in the vaginal and perineal (area around the vagina and anus) region are common during a forceps delivery, equipment and stitches for repairing these tears should be ready on the table used for delivery.
Along with these preparations, the anesthetic and pediatric teams should also be informed well ahead of the procedure so they can get ready for their part in the delivery. Typically, forceps delivery requires regional anesthesia like an epidural or pudendal block (types of anesthesia to numb the lower half of the body), as well as local anesthesia for the perineal area because a cut, known as episiotomy, is usually made to create more space and prevent tears. There should also be arrangements to test the baby’s umbilical cord blood to measure its acid and base levels, which is a common procedure in complicated deliveries.
Before using the forceps, the doctor will usually empty the patient’s bladder. This allows the baby’s head to move down more freely and is also useful if an emergency cesarean section becomes necessary.
There is ongoing debate about the use of antibiotics to prevent infection during forceps delivery. Current evidence suggests that they don’t significantly reduce rates of post-delivery infection in the mother or shorten the mother’s hospital stay.
How is Forceps Delivery performed
Forceps are a kind of medical tool used during a vaginal birth when a baby gets stuck or the mother becomes exhausted. They look similar to two large spoons, and they are used to gently grab the baby’s head and help guide it out of the birth canal.
Depending on how far the baby’s head is in the birth canal, different types of forceps are used:
- Outlet Forceps: These are used when the baby’s head is really close to being out. The scalp is even visible if you gently spread the mother’s labia, and the baby’s skull is at the level of the pelvic floor muscles. The baby is facing forward or slightly turned to the right or left, and less than halfway rotated.
- Low Forceps: These are used when the baby’s head has descended more than halfway into the birth canal but isn’t as close as it would be for the outlet forceps. Again, the baby is facing forward or slightly to the right or left, and less than halfway rotated.
- Mid Forceps: These are used when the baby’s head is engaged in the mother’s pelvis but it hasn’t descended as far as it would need to for low forceps.
- High Forceps: These aren’t classified within the standard criteria but are used when the baby’s head hasn’t yet descended to the mid-pelvis.
When doctors apply the forceps, they have to be very careful to avoid hurting the baby or the mother. They position the forceps so that they lie over the baby’s cheeks with the back of the baby’s head (where the soft spot is) situated just above the forceps. The doctor will make sure that no tissue from the mother is accidentally grasped by the forceps.
The idea behind using forceps is to help pull the baby out gently during contractions, without squeezing the baby’s head too much. If needed, the forceps can be used to rotate the baby’s head to a better position between contractions. The pulling is done while the doctor is sitting and using their forearms, not their chest, for strength. To keep things smooth and steady, the doctor pulls along the curve of the mother’s pelvis without swinging back and forth.
In order to make more space for the baby and to prevent any tears in the mother’s vagina, the doctor will make a small cut in the perineum (the area between the vagina and anus) before they start using the forceps. This is called an episiotomy and is usually done on the right side to lessen the chance of an injury to the rectum. When the widest part of the baby’s head (between ear and ear) passes the opening of the vagina, the forceps are then removed following the reverse order they were put on. In most cases, the baby is delivered within three or four pulls.
Possible Complications of Forceps Delivery
Figuring out what complications might happen after certain medical procedures can be challenging because there aren’t always enough quality studies to guide us.
For mothers undergoing certain procedures, some possible complications could include tears in the skin around their genital area and bruises, injuries to the muscles that help in bowel movements, and a long-term issue where the pelvic organs drop down into a lower position than normal.
For babies, potential risks could include cuts on the face, nerve damage, eye injuries, fractures in the skull, bleeding inside the head, bruises under the scalp, higher levels of a substance called bilirubin in the blood, and sadly, death in some cases.
What Else Should I Know About Forceps Delivery?
Forceps can be a good option when a baby needs help to be born, like if labor isn’t progressing, the baby’s heart rate isn’t stable, the mom is exhausted, or if the mom has a health condition that prevents her from pushing. This method can be a suitable alternative to using a vacuum device or having a cesarean section (C-section), which is a type of surgery.
The advantages of using forceps over a vacuum are numerous:
- They’re less likely to detach from the baby’s head during delivery
- Can be safely used even for premature babies
- Can help rotate the baby’s head in the right direction
- Causes less bleeding on the baby’s scalp
- Lowers the chance of the baby suffering from encephalopathy, a type of brain disease
Generally, a vacuum is a safer tool for the mom. However, forceps are usually safer for the baby.
