Kielland-Barton-Laufe (K.B.L.) Forceps with Luikart Modification in the Management of Transverse and Posterior Positions of the Fetal Head

Disadvantages of Kielland and Barton forceps are described. A trial of K.B.L. forceps was undertaken in transverse and posterior positions of the fetal head. It was concluded that these forceps are easier to apply than Kielland forceps. Rotation of the head is easier, and they are the equal of Kiellands as tractors, with the advantage of causing less marking of the fetal head than either Kielland or Barton forceps.     

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     

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.     

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.     

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.     

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.     

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.     

Qualitative analysis by interviews and video recordings to establish the components of a skilled rotational forceps delivery

Objective

To define the skills of a mid-cavity rotational forceps delivery to facilitate transfer of skills from expert obstetricians to trainee obstetricians.

Study design

Qualitative interviews and video analysis carried out at maternity units of two university teaching hospitals (St. Michael's Hospital, Bristol, and Ninewells Hospital, Dundee). Ten obstetricians were identified as experts in conducting operative vaginal deliveries. Semi-structured interviews were carried out to identify key technical skills. The experts were also video recorded conducting mid-cavity rotational deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were individually coded by the three researchers and then compared for consistency of interpretation. The experts reviewed the data for respondent validation. The themes that emerged following the coding were used to formulate a taxonomy of skills.

Results

Rotational forceps were preferred by eight experts and two experts preferred manual rotation followed by direct traction forceps. The final taxonomy included detailed technical skills for Kielland rotational forceps delivery and manual rotation followed by direct traction forceps delivery.

Conclusion

This explicitly defined skills taxonomy could aid trainees’ understanding of the technique of rotational forceps delivery. This is an important potential contributor to safely reducing the rate of second-stage caesarean section.     

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.     

Is it Time to Rejuvenate the Forceps?

The obstetric forceps was designed to assist extraction of the foetal head and thereby accomplish delivery of the foetus in the second stage of labour. More than 700 types of obstetric forceps have been described. An understanding of the anatomy of the birth canal and the foetal head is a prerequisite to becoming a skilled and safe user of forceps. Operative vaginal delivery rates have remained stable at between 10 and 13 %. The last few decades has seen a rise in caesarean section, along with the introduction and safe use of the vacuum extractor. This has resulted in a decline both in the use of the obstetric forceps as well as in the training for the same. The forceps is less likely to fail when used as the primary instrument thereby reducing the need for the sequential use of two instruments which increase the morbidity of the neonate. Perineal trauma is more likely to occur with the use of the forceps but the evidence is that the maternal concern is less when compared to the ventouse. Simulation training is an important part of obstetric training. Application of forceps blades in the simulation setting can improve the skill level of obstetricians. The use of the forceps should not be decreasing and more senior involvement in training is necessary so that juniors develop the proper skills to perform forceps delivery in a competent and safe manner. It is vital that the art of the forceps is not lost to future generations of obstetricians and the women they care for.     

睾丸固定钳固定法在经皮附睾穿刺取精术中的应用价值

目的评价睾丸固定钳固定法在经皮附睾穿刺取精术(PESA)中的应用价值。方法选取初步诊断为梗阻性无精子症患者532例,将其随机分为三指固定法组(249例)和睾丸固定钳组(283例),比较两组PESA穿刺精子获取率差异。另根据经阴囊超声附睾头有无扩张以及扩张特征将病例分为附睾头细网状扩张亚组、附睾头管状/多囊管状扩张亚组和附睾头无扩张亚组,比较两种PESA方法对不同附睾头病变穿刺精子获取率的差异。结果三指固定法组穿刺精子获取率为60.64%(151/249),睾丸固定钳组为74.56%(211/283),显著高于三指固定法组(P0.05)。睾丸固定钳组穿刺精子获取率的优势主要由细网状扩张组贡献,该组三指固定法穿刺精子获取率为72.67%(125/172),而睾丸固定钳法为89.90%(178/198),显著高于三指固定法组(P0.05)。管状/多囊管状扩张亚组以及附睾头无扩张亚组2种PESA法穿刺精子获取率都偏低,差异无统计学意义(P0.05)。结论使用睾丸固定钳固定法对附睾头细网状扩张的患者进行PESA穿刺能提高精子获取率。     

Extractor instead of forceps

The extractor is an instrument shaped like a horn or like a bell which can be used in the second stage of labor to extract the child. This instrument is far less dangerous than forceps and much easier to handle. Instead of requiring deep insertion over the child's head or any part of his body, the extractor is simply applied to the part of the body nearest the operator. After applying the extractor and making a vacuumnin the instrument, the extraction of the child becomes easy. It can be done quickly by hand or slowly and evenly with the help of traction and a weight of about 6 pounds.In our department the extractor has been used successfully in 132 cases. There were no complications or accidents to mothers or delivered children.     

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.     

Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse.

OBJECTIVE: To undertake a five year follow up of a cohort of women and children delivered by forceps or vacuum extractor in a randomised controlled study. DESIGN: Follow up of a randomised controlled trial. SETTING: District general hospital in the West Midlands. POPULATION: Follow up questionnaires were sent to 306 of the 313 women originally recruited at the North Staffordshire Hospital to a randomised controlled study comparing forceps and vacuum extractor for assisted delivery. Two hundred and twenty-eight women responded (74.5%) and all were included in the study; forceps (n = 115) and vacuum extractor (n = 113). MAIN OUTCOME MEASURES: Bowel and urinary dysfunction, child vision assessment, and child development. RESULTS: Maternal adverse symptoms at long term follow up were relatively common. Urinary incontinence of various severity was reported by 47%, bowel habit urgency was reported by 44% (98/225), and loss of bowel control 'sometimes' or 'frequently' by 20% of women (46/226). No significant differences between instruments were found in terms of either bowel or urinary dysfunction. Overall, 13% (20/158) of children were noted to have visual problems. There was no significant difference in visual function between the two groups: ventouse 11/86 (12.8%), compared with forceps 9/72 (12.5%); odds ratio 0.97, 95% CI 0.38-2.50. Of the 20 children with visual problems, a family history was known in 18, and 17/18 (94%) had a positive family history for visual problems. No significant differences in child development were found between the two groups. CONCLUSIONS: There is no evidence to suggest that at five years after delivery use of the ventouse or forceps has specific maternal or child benefits or side effects.     

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 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.     

Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse

Objective To undertake a five year follow up of a cohort of women and children delivered by forceps or vacuum extractor in a randomised controlled study.
Design Follow up of a randomised controlled trial.
Setting District general hospital in the West Midlands.
Population Follow up questionnaires were sent to 306 of the 313 women originally recruited at the North Staffordshire Hospital to a randomised controlled study comparing forceps and vacuum extractor for assisted delivery. Two hundred and twenty-eight women responded (74.5%) and all were included in the study; forceps (   n = 115  ) and vacuum extractor (   n = 113  ).
Main outcome measures Bowel and urinary dysfunction, child vision assessment, and child development.
Results Maternal adverse symptoms at long term follow up were relatively common. Urinary incontinence of various severity was reported by 47%, bowel habit urgency was reported by 44% (98/225), and loss of bowel control 'sometimes' or 'frequently' by 20% of women (46/226). No significant differences between instruments were found in terms of either bowel or urinary dysfunction. Overall, 13% (20/158) of children were noted to have visual problems. There was no significant difference in visual function between the two groups: ventouse 11/86 (12.8%), compared with forceps 9/72 (12.5%); odds ratio 0.97,95% CI 0.38–2.50. Of the 20 children with visual problems, a family history was known in 18, and 17/18 (94%) had a positive family history for visual problems. No significant differences in child development were found between the two groups.
Conclusions There is no evidence to suggest that at five years after delivery use of the ventouse or forceps has specific maternal or child benefits or side effects.     

The prophylactic forceps operation

The time is not yet right for a general recommendation of the procedure to be described in this paper. As obstetric specialists, we must lead the way in improvements of our art, for this is still capable of improvement. The public is demanding with a voice that becomes louder and more insistent each year,relief from the dangers of childbirth for the childbearing woman. As regards the pain, the rapid spread of the twilight sleep craze will show the demand for “tokophobia” is spreading among women. If we study our cases carefully the conclusion is inevitable that while we have decidedly improved the maternal mortality and morbidity and have reduced the foetal deaths somewhat, labor is still painful and terrifying experience, still retains much morbidity that leaves permanent invalidism. The latter statement is also applicable to the child. Many efforts are being made to ease the travail of the woman and to better the lot of the infant. What follows is another such effort. Experience alone can decide whether it accomplishes its purpose. The “prophylactic forceps operation” is the routine delivery of the child in head presentation when the head has come to rest on the pelvic floor, and the early removal of the placenta. Primiparous labors and those in which the condition of the soft parts approximates a first labor, are treated by this method, which really compromises more than the actual delivery of the child. It is a rounded technic for the conduct of the whole labor, with the defined purpose of relieving pain, supplementing and anticipating the efforts of Nature, reducing the hemorrhage, and preventing and repairing damage.     

A comparison of different methods of instrumental delivery based on electronic measurements of compression and traction.

Electronic measurements of compression, using a hydrostatic technique, were made during 44 normal deliveries and compared with the values obtained during 32 deliveries using Kielland's forceps, 21 using Neville Barnes' forceps, 48 using Moolgaoker's adjustable forceps, and 26 using Malmstrom's vacuum extractor. Electronic recordings of traction, using strain gauges, were made simultaneously during all the instrumental deliveries except those with Kielland's forceps. By exercising suitable controls over most of the multiple factors operating at the time of any delivery the authors were able to compare objectively the efficiency of the different methods of instrumental delivery. Smaller forces of compression and traction were exerted and better Apgar scores were recorded in infants delivered with the adjustable forceps than in infants delivered with the other instruments. The superiority of the adjustable forceps was most noticeable during midcavity deliveries of the malrotated head.