More on the Kielland forceps

A study of 103 deliveries with Kielland forceps has been presented. Mother's age, parity, presentation, height of the head, anaesthesia, weight of the child, failures, puerperium, indications, injuries to the mother, conditions of the child, maternal and children mortality are discussed. Kielland instrument still maintains its position as a usefull specialized forceps for deep transverse arrest and also for obliqually placed fetal head.     

Kielland产钳在持续性枕后位中的应用

目的 评估Ｋｉｅｌｌａｎｄ产钳对持续性枕后位进行反置上钳旋转胎头的安全性及可行性。方法 对１００例胎头双顶径已达或已过坐骨棘水平的持续性枕后位产妇,用Ｋｉｅｌｌａｎｄ产钳进行反置上钳旋转胎头产钳术。结果 成功率１００％,母体软产道损伤１７％,新生儿损伤１２％,无会阴Ⅲ度裂伤,无后穹窿,宫颈,膀胱损伤及子宫破裂,无新生儿颅内出血及死亡等严重并发症,结论 Ｋｉｅｌｌａｎｄ产钳反置上钳旋转胎头术用于双顶     

Kielland vs. nonrotational forceps for the second stage of labor.

OBJECTIVE: To examine and compare maternal and neonatal morbidity after use of two types of obstetric forceps used in the management of the second stage of labor. STUDY DESIGN: This retrospective investigation was conducted from January 1993 to December 1995 and included 55 infants delivered with Kielland forceps as compared to 213 infants delivered with nonrotational forceps. The maternal and neonatal charts were reviewed for data collection. Maternal complications compared included blood loss, vaginal lacerations, postpartum hemorrhage, and third- and fourth-degree perineal lacerations. Infant data collected compared fetal lacerations, nerve palsies, shoulder dystocias, blood gas values and admissions to the neonatal intensive care unit. Statistical analysis was performed by Fisher's exact, chi 2 and Student's t test. RESULTS: Women in both groups were similar with respect to age, gravidity, parity and estimated gestational age at delivery. Infants were similar in both groups with respect to fetal weight, admissions to the neonatal intensive care unit, nerve compromise, scalp lacerations and facial bruising. The Kielland group had statistically significantly longer labor, 671 +/- 285.8 vs. 614 +/- 226.5 minutes (P < .05) and longer second stage of labor 184 +/- 74.71 vs. 161 +/- 65.79 minutes (P < .05). The Kielland group also had a statistically higher percentage of one-minute Apgar scores < 6, 18.2% vs. 4.7% (P < .05), and meconium present at delivery, 14.5% vs. 5.6% (P < .05). CONCLUSION: Management of the second stage of labor can be accomplished safely with Kielland forceps and rotation of the fetal head. Supervision by an experienced operator will allow residents to be trained with respect to appropriate patient selection and application of these forceps.     

Have Kielland Forceps Reached Their ''Use By'' Date?

Kielland forceps have long been used in Australian hospitals for rotation and delivery from occipitolateral and occipitoposterior positions. We have studied the pattern and use of these forceps in our hospital, and conducted a statewide survey of obstetric trainees about their experience with Kielland forceps. We conclude that current obstetric training programmes are unlikely to provide registrars with sufficient skill in their safe use.     

Brachial plexus paresis associated with fetal neck compression from forceps

Instrumental vaginal deliveries have been associated with higher risks of brachial plexus injuries. The proposed mechanisms involve the indirect association of instrumental deliveries with shoulder dystocia and nerve stretch injuries secondary to rotations of 90 degrees or more. We present a brachial plexus paresis resulting from direct compression of the forceps blade in the fetal neck. A term infant was delivered by a low Kielland forceps rotation. No shoulder dystocia was noted. The immediate neonatal exam revealed an Erb's palsy and an ipsilateral bruise in the lateral aspect of the neck. The paresis resolved during the first day of life. Direct cervical compression of the fetal neck by forceps in procedures involving rotations of the presentation may result in brachial plexus injuries.     

The role of forceps in modern obstetrics.

The objective of this study was to assess the safety and devise criteria to minimise complications following forceps deliveries. A prospective analytical study was performed on 644 consecutive forceps deliveries in a Sri Lankan provincial hospital. The incidence of maternal and fetal complications was analysed. The incidence of both cervical and third degree perineal tears was commoner in face-to-pubis deliveries. When the number of traction efforts required to complete the delivery is more than three the incidence of third degree perineal tears and postpartum haemorrhage became significantly commoner. There were six cases of ruptured uterus and all were in multiparous patients following mid-cavity forceps deliveries. The maternal and fetal morbidity following rotational forceps deliveries was no different from non-rotational forceps deliveries. In addition to the standard criteria of head being fully engaged in the pelvis, cervix being fully dilated, the station of the head below the level of the ischeal spines and bladder being empty before attempting forceps delivery, we also recommend that the baby should be delivered occipito-anterior and the number of traction efforts used to be kept at three or less to minimise the maternal trauma.     

Indications for vaginal delivery with forceps application

The aim of the study was to establish indications for operative vaginal delivery by extraction of the fetus with forceps in modern obstetrics. Material and methods: This is a retro- and prospective study which includes 672 forceps deliveries in the period of 1994-2008 in Maternity hospital Sofia. Simpson and Kielland were used for extractions subject to appropriate indications and conditions, regardless of the gestational week of pregnancy. Results: The most frequent indication for forceps application is fetal asphyxia (78.1%) and considering the frequency for 15 years it is the permanent, leading indication for forceps in modern obstetrics. Arrest of the head in the same plane of the pelvis was the indication in 23.6% of the cases it varies and is rarely primary through the 15 year period. Ineffective uterine contractions and/or pushes (16.7%) tends to decrease its frequency. Avoiding maternal efforts in the second stage of labor (8.5%) and in 50% of the cases was indicated for women with cardiovascular diseases. Malpositions (7.7%) increases through the years probably secondary to epidural analgesia. Indication preeclampsia-eclampsia is described in 1.3% of cases, followed by genital bleeding by 1.9% and prolapse of the umbilical cord by 0.6% and they are more incidentally reasons for application of forceps. Conclusion: Asphyxia of the fetus is the most common and a leading indication for extraction of the fetus with forceps. Ineffective uterine contractions and the arrest of the head in the same plane of the pelvis are consistent in their occurrence and lead to prolonged labor. In certain critical conditions (genital bleeding, prolapse of the umbilical cord and eclampsia) extraction of the fetus with forceps remains the only way for fast vaginal delivery.     

The relation between ease of forceps delivery and speed of cervical dilatation.

An attempt has been made to predict a difficult forceps delivery. The duration of the 7 to 10 cm cervical dilatation interval was measured from the completed cervimetric chart in 952 consecutive patients who delivered spontaneously between December 1973 and September 1974. The 7 to 10 cm cervical dilatation intervals of this group were compared with those of 378 consecutive patients in whom forceps were applied with the fetal head in the occipito-anterior position and 83 consecutive patients where Kielland's forceps rotation from the occipito-tranverse or occipito-posterior position was performed. The forceps deliveries were graded as 'easy', 'moderately difficult', or 'difficult'. In only 5% of the spontaneous delivery group did the 7 to 10 cm cervical dilatation interval exceed two hours. In the occipito-anterior and Kielland's forceps groups an 'easy' delivery could be expected if the 7 to 10 cm cervical dilatation interval was less than two hours. The greater this interval increased beyond two hours, the greater was the proportion of 'moderately difficult' and 'difficult' forceps deliveries.     

产后尿潴留高危因素及盆底康复技术对其疗效的分析

目的：研究产后尿潴留（PUR）发生的高危因素,并探讨盆底康复技术治疗PUR的效果。方法：随机选取2012年4月至9月在大连市妇幼保健院（妇产医院）经阴分娩的393例产妇,其中发生PUR并给予开放式导尿治疗的产妇193例（病例组）,未发生PUR的产妇200例（正常组）,收集并比较两组患者的临床资料。根据入组标准,最终纳入186例PUR患者,根据治疗方法分为低频脉冲电治疗组（实验组,86例）和常规物理治疗组（对照组,100例）,比较两组患者的顽固性PUR发生率、膀胱残余尿量、住院天数、住院费用等。结果：单因素分析显示,无痛分娩、产钳助产术、胎头吸引术、手转胎头、第一产程时间、第二产程时间是PUR发生的相关危险因素。Logistic逐步回归分析显示,PUR的独立危险因素按风险度大小依次为产钳助产术、胎头吸引术、无痛分娩、手转胎头及年龄。撤除导尿管后,实验组的残余尿量、顽固性PUR人数、住院天数均显著少于对照组（P≤0．05）。结论：无痛分娩、产钳助产术、胎头吸引术、手转胎头、第一产程时间、第二产程时间显著增加PUR的风险。年龄、手转胎头、无痛分娩、产钳助产术、胎头吸引术是PUR的独立危险因素。低频脉冲电对PUR有显著的治疗作用。     

Intervention during labor: risk factors associated with complete tear of the anal sphincter.

Among 41,200 consecutive deliveries there were 152 cases of complete tear of the anal sphincter (complete tear). In a case-control design, the association between interventions during labor (forceps, vacuum extraction, use of oxytocin and prostaglandins and mediolateral episiotomy) and complete tear, were evaluated by confounder control using multiple logistic regression analysis. Controls chosen were the patients delivering just before and after the index patient with complete tear. Use of Kielland forceps, mediolateral episiotomy, shoulder dystocia and nulliparity were significantly associated with complete tear. Maternal age, presentation in labor, duration of second stage of labor and the indication for instrumental deliveries and episiotomy had no significant association with complete tear.     

Obstetrical vacuum: a modern instrument]

Contrary to the forceps, the vacuum extractor has clearly progressed in the last years. The use of the vacuum extractor increases in every developed countries, certainly because of an easier learning than forceps. Furthermore, maternal after-effects of the delivery like sphincters injuries and anal incontinence seem to be less frequent with vacuum extractor than with forceps. For these reasons the American College of Gynecologists and Obstetricians (ACOG) recommend a large use and a priority teaching of this fetal extraction instrument. The technical aspects of use of the vacuum extractor are developed in this article, and personnel results are added as commentaries.     

Indications and technic of operative vaginal delivery in vertex presentation

In operative vaginal delivery in vertex presentation we pay attention to a separation in the indication for using a forceps or using a vacuumextractor. A delivery with a vacuumextractor is recommendable only in a flexion of the fetal head, in a low obstetrical resistance and with slow tractions. A delivery with a forceps is recommendable even in a deflexion of the fetal head, in a high obstetrical resistance and in fetal distress situations. A comparison in 2 collectives, each of a time period of 5 years, shows an interesting difference. In collective 1 (1963 to 1967) the frequency of forceps deliveries was 2.2% and of vacuumdeliveries was 3.2%. In collective 2 (1978 to 1982) the frequency of forcepsdeliveries was 4.1% and of vacuumdeliveries was 0.4%. Caused by a separation of the indication and by a consequent fetal monitoring there was an improvement in fetal and maternal morbidity and mortality. Using a handle in forceps delivery the procedure is more easy and less harmful for the baby.     

The use of forceps delivery in own analysis

OBJECTIVES: The clinical analysis of deliveries ended by forceps over the period of ten years. DESIGN: Review of perinatal outcome and indications to use outlet and low forceps or midforceps. MATERIALS AND METHODS: Author analysed 137 forceps deliveries in comparison to control group of 250 normal, vaginal labours. Obstetrical history, indications to use vaginal operation, duration of labour, hospitalisation time, newborns state in Apgar score or arterial cord pH, PaO2, and fetal or maternal injures were statistically analysed. The American College of Obstetricians and Gynecologists (ACOG) 1988 forceps classification be adopted for deliveries. Using outlet, low forceps and midforceps concerned with vaginal operation. RESULTS: The common indications to use outlet or low forceps were prolonged second stage of labour. The most frequent indication for the midforceps was a risk of fetal asphyxia and neonatal hypoxia. A major fetal injury occurred in midforceps, particularly with fetal head rotations. Furthermore, midforceps delivery increased incidence of maternal perineal trauma. The outlet or low forceps was safe for fetal outcome and trauma of the birth canal in comparison to normal vaginal delivery. CONCLUSIONS: The prophylactic use of outlet or low forceps has beneficial impact on the neonate because it shortens second stage of labour and decreased the incidence of neonatal hypoxia. The midforceps delivery increased a perinatal disorders and using cesarean section are better for child and mother.     

Twin dystocia: about one case of compaction

We report a case of twin dystocia during the evacuation of full-term fetus both in cephalic presentation. A low-outlet forceps for second-phase arrest was performed for the first twin but the head remained stuck to maternal perineum, mimicking a shoulder dystocia. Digital examination found a twin compaction, that is the presence of the second twin's fetal head at the level of the first twin's chest. The discrepancy between fetal weights and the use of forceps could favor this rare complication. Various maneuvers were described previously attempted to solve the problem. Forcing back the second head may help to achieve delivery of the first twin.     

Experience with the Bamberg obstetrical forceps

The design and use of a divergent obstetrical forceps, which was developed at the Staatliche Frauenklinik und Hebammenschule in Bamberg by Sipli and Krone are presented. The major advantage associated with the use of this instrument is that it permits the exertion of a limited constant application force (max 300 g) on the fetal head. Thus, compression injuries are effectively prevented and slippage of the forceps with resultant trauma is precluded. The Bamberg forceps was evaluated at the Frauenklinik und Poliklinik der Technischen Universit?t München and at the Staatliche Frauenklinik und Hebammenschule Bamberg, Federal Republic of Germany. An evaluation of 483 cases where this forceps was used is presented. No serious complications directly attributable to the use of this instrument could be documented.     

再谈头位阴道助产术

头先露的阴道助产术包括产钳助产术和胎头负压吸引术。在第二产程中判断胎头位置及胎方位是阴道助产成功的关键。胎头最低位置于坐骨棘2 cm以下,胎方位为枕前位者,助产风险相对小。产科医生要严格把握阴道助产的手术指征,并与患者充分沟通。临床医生的判断能力,培训经历以及临床经验是助产成功的重要因素。     

Mid-Cavity Occipitoanterior Forceps Delivery — Laufe and Barnes Forceps Compared

Laufe forceps are divergent forceps designed to reduce compressive forces upon the fetal skull during delivery from the pelvic outlet. Here we have undertaken a retrospective matched analysis in which Laufe (N = 75) and Barnes (N = 75) forceps were used for occipitoanterior mid-cavity forceps delivery. Our aim was to compare fetal and maternal outcome following use of these 2 types of forceps in the mid-pelvis. Fetal morbidity, categorized by trauma, low Apgar score or jaundice, was present in 31 of 75 infants delivered by Laufe forceps and in 47 of 75 infants delivered by Barnes forceps (p less than 0.01). Overall, maternal morbidity was statistically similar between the 2 groups although perineal trauma was more frequent in the Laufe group (p less than 0.05). We concluded that there appeared to be an improved fetal outcome following occipitoanterior mid-cavity delivery using Laufe forceps compared with Barnes forceps. These initial findings imply that in situations of fetal compromise, where forceps delivery from an occipitoanterior position in the mid-cavity is indicated, that Laufe forceps might be chosen.     

Risk factors for forceps delivery in nulliparous patients

OBJECTIVE: To identify risk factors for forceps delivery during first pregnancy. MATERIALS AND METHODS: A retrospective case-control study was carried out in a tertiary maternity ward between January 2001 and December 2003. A total of 582 nulliparous women, with full-term (>37 weeks gestation), singleton, cephalic pregnancies, who delivered by the vaginal route with or without instrumental assistance were evaluated. RESULTS: The strongest risk factors for forceps delivery were birth weight greater than 4000 g (OR: 6.5; 95% CI: 1.6, 26.9), the occiput posterior position of the fetal head (OR: 5.8; 95% CI: 2.5, 13.8), and epidural analgesia (OR: 7.7; 95% CI: 4.1, 14.7). Other significant risk factors for forceps delivery were age over 35 years (OR: 2.4; 95% CI: 1.1, 5.1), induction of labor (OR: 2.1; 95% CI: 1.4, 3.1), first stage of labor longer than 420 min (OR: 2.3, 95% CI: 1.3,4.2), and a prolonged second stage of labor (OR: 1.6, 95% CI: 1.1, 2.4). CONCLUSION: Age over 35 years and induction of labor are risk factors for forceps delivery at admission. Epidural use, fetal head in occiput posterior position, and birth weight >4000 g are strong intrapartum risk factors for instrumental delivery in nulliparous women.     

Early and late intraventricular hemorrhage: the role of obstetric factors.

OBJECTIVE: To evaluate the influence of active phase labor and other obstetric factors on the development of periventricular-intraventricular hemorrhage in the neonate. METHODS: A total of 230 infants were studied. Antenatal enrollment was carried out when estimated fetal weight was 1750 g or less. Serial head ultrasound scans were performed to screen for periventricular-intraventricular hemorrhage, with the initial scan performed within minutes of birth. Scan findings and obstetric and neonatal variables collected prospectively at scheduled intervals were analyzed to determine the significant factors that predispose to intraventricular hemorrhage. RESULTS: In 47 infants (20%), intraventricular hemorrhage was detected within 1 hour of birth (early) and in another 49 (21%) at a later age (late). The overall incidence of hemorrhage was similar between vaginal and cesarean deliveries (41 and 44%, respectively). Early hemorrhage was more frequent in vaginal (28%) than cesarean deliveries (11%), whereas late hemorrhage was more frequent in cesarean deliveries. When the role of delivery mode and labor was analyzed by stepwise logistic regression, the odds ratios for development of early intraventricular hemorrhage increased in the following order: cesarean delivery with no labor, cesarean delivery with latent phase labor, vaginal delivery with forceps use, cesarean delivery with active phase labor, and vaginal delivery without forceps use. For late hemorrhage, the odds ratios increased in the following order: vaginal delivery with forceps, vaginal delivery without forceps, cesarean delivery with no labor, cesarean delivery with latent phase labor, and cesarean delivery with active phase labor. CONCLUSIONS: Active phase labor may predispose to early periventricular-intraventricular hemorrhage, but its influence may be attenuated by use of forceps or by abdominal delivery. The protective effect of forceps remains for late periventricular-intraventricular hemorrhage, but abdominal delivery does not seem to protect against late hemorrhage.