Kielland's Rotational Forceps Research Articles

Maternal and Neonatal Complications Following Kielland's Rotational Forceps Delivery: A Systematic Review and Meta-analysis

(Abstracted from BJOG 2023;130:856–864) Fetal malposition as labor advances can contribute to many risks and adverse outcomes. One method of management is Kielland rotational forceps delivery (KRFD); previous research has yielded conflicting evidence about the safety and effectiveness of KRFD compared with other delivery methods.

Maternal and neonatal complications following Kielland's rotational forceps delivery: A systematic review and meta-analysis.

There is conflicting evidence regarding the safety of Kielland's rotational forceps delivery (KRFD) in comparison with other modes of delivery for the management of persistent fetal malposition in the second stage of labour. To derive estimates of risks of maternal and neonatal complications following KRFD, compared with rotational ventouse delivery (RVD), non-rotational forceps delivery (NRFD) or a second-stage caesarean section (CS), from a systematic review and meta-analysis of the literature. Standard search methodology, as recommended by the Cochrane Handbook for Systematic Reviews of Interventions. Case series, prospective or retrospective cohort studies and population-based studies. A meta-analysis using a random-effects model was used to derive weighted pooled estimates of maternal and neonatal complications. Thirteen studies were included. For postpartum haemorrhage there was no significant difference between Kielland's and ventouse delivery; the rate was lower in Kielland's delivery compared with non-rotational forceps (RR0.79, 95%CI 0.65-0.95) and second-stage CS (RR0.45, 95%CI 0.36-0.58). There were no differences in the rates of anal sphincter injuries or admission to neonatal intensive care. Rates of shoulder dystocia were higher with Kielland's delivery compared with ventouse delivery (RR1.79, 95%CI 1.08-2.98), but rates of neonatal birth trauma were lower (RR0.49, 95%CI 0.26-0.91). There were no differences seen in the rates of 5-min APGAR score < 7 between Kielland's delivery and other instrumental births, but they were lower when compared with second-stage CS (RR0.47, 95%CI 0.23-0.97). Kielland's rotational forceps delivery is a safe option for the management of fetal malposition in the second stage of labour.

Rotational forceps: a retrospective study evaluating anatomical and functional consequences for the pelvic floor.

The use of Kielland's rotational forceps is considered to involve greater technical difficulty and may be associated with a higher rate of pelvic floor trauma. Our main objective was to evaluate the association between avulsion of the levator muscle and rotational and non-rotational forceps. This was an observational study carried out at a tertiary hospital that recruited singleton cephalic vaginally primiparous women with previous Kielland's forceps delivery between March 2012 and May 2017. Patients were retrieved from a local database, contacted consecutively and blinded to all clinical data. Power calculations determined a sample of n = 160 patients. All women underwent a urogynecological interview, clinical examination and 4D translabial ultrasound (TLUS). The 4D TLUS volumes were stored and analyzed offline by an experienced ultrasound examiner who was blinded to all clinical data. A total of 165 patients were available for analysis. Rotational forceps accounted for 27.3% (45 out of 165) of the study sample. Avulsion was present in 41.8% (69 out of 165) of all forceps deliveries. On multivariate analysis, rotational forceps was associated with avulsion, with an adjusted odds ratio (OR) of 2.57 (CI 95% 1.20-5.62, p = 0.016). Body mass index at the beginning of gestation was found to be a protective factor, with an adjusted OR of 0.918 (CI 95% 0.847-0.986, p = 0.025). Rotational forceps is associated with a higher avulsion rate than non-rotational forceps, with an adjusted OR of over 2.5. Obstetricians need to consider the potential long-term consequences of performing a rotational forceps for mothers.

Intrapartum ultrasound during rotational forceps delivery: a novel tool for safety, quality control, and teaching

Operative vaginal delivery and, in particular, rotational forceps delivery require extensive training, specific skills, and dexterity. Performed correctly, it can reduce the need for difficult late second-stage cesarean delivery and its associated complications. When rotation to occiput anterior position is achieved, pelvic trauma and anal sphincter injury commonly associated with direct delivery from occiput posterior positions may be avoided. We report the original and novel use of real-time intrapartum ultrasound simultaneously during Kielland's rotational forceps delivery to monitor correct execution and increase maternal safety. This is a prospective observational study performed at the Charité University Hospital in Berlin between 2013 and 2018. Simultaneous, real-time, intrapartum suprapubic ultrasound during Kielland's rotational forceps deliveries were performed in a series of laboring women with normal fetuses and arrest of labor in the late second stage and with a fetal head malposition, requiring operative vaginal delivery. In addition to vaginal palpation for head station, rotation, and asynclitism, intrapartum ultrasound was also used to objectively determine head station, head direction, and midline angle. The operator was not blinded to the ultrasound findings. The delivering obstetrician examined the woman and performed the delivery. An assistant, trained in intrapartum ultrasound, placed a curved-array transducer transversely in the midline just above the pubic bone to display the forceps blades being applied and the rotation of the fetal head in occiput anterior position. In all 32 laboring women included in the study, the blades were applied correctly and the fetal heads successfully rotated to an occiput anterior position with direct ultrasound confirmation, and vaginal delivery was achieved. There were no cases of difficult application, repeat application, slippage of the blades, or rotation of the fetal head in the wrong direction. Maternal outcomes showed no vaginal tears, cervical tears, or postpartum hemorrhage >500 mL. There was 1 case of third-degree perineal tear (3a). Neonatal outcomes included mild hyperbilirubinemia (n=1), small cephalohematoma conservatively managed (n=1), and early-onset group B streptococcus sepsis secondary to maternal colonization (n=1). There were no neonatal deaths. Ultrasound guidance during Kielland's rotational forceps delivery is an original and novel approach. We describe the use of intrapartum ultrasound in assessing fetal head station and position and also to simultaneously and objectively monitor performance of rotational forceps delivery. Intrapartum ultrasound enhances operator confidence and, possibly, patient safety. It is a valuable adjunct to obstetrical training and can improve learning efficiency. Real-time ultrasound guidance of fetal head rotation to occiput anterior position with Kielland's forceps may also protect the perineum and reduce anal sphincter injury. This novel approach can lead to a renaissance in the safe use of Kielland's forceps.

The correlation between the type of forceps application and the rate of levator ani muscle avulsion: A prospective cohort study.

The association between the use of forceps and levator ani muscle (LAM) avulsion seems to be clear-cut. However, whether the lesion is due to the mechanical trauma yielded by the instrument or to the intrinsic complexity of this type of delivery, is yet to be determined. This study aims at determining the difference in LAM avulsion rate between Kielland rotational forceps and non-rotational forceps. Prospective observational study with 94 nulliparous women with forceps-assisted deliveries (FD) between July 2015 and January 2016. 3D-TpUS was performed 6 months after every patient's delivery, during which LAM avulsion, and levator hiatus area and anteroposterior and transverse diameters were assessed. A total of 89 nulliparous were studied, comprising 27 rotational-FD, and 62 non-rotational-FD. No differences in obstetric, intrapartum, or neonatal characteristics were observed between study groups. There were no statistically significant differences in the presence of avulsion between cases of rotational forceps (44.4% vs 35.5%, OR: 1.5 [0.6-3.6]), correction of asinclitism of the fetal head (34.4% vs. 40.4% OR: 0.8 [0.3-1.9]) or station (midforceps: 32.8% vs low forceps: 50.0% OR: 2.0 [0.8-5.1]). We have not observed differences in the LAM-avulsion rate between rotational forceps and non-rotational forceps performed by highly experienced personnel in instrumental deliveries.

Kielland's forceps: does it increase the risk of anal sphincter injuries? An observational study.

Rotational instrumental deliveries are thought to carry additional risks compared with non-rotational instrumental deliveries, including trauma to maternal tissues, and require specific expertise and training. We conducted a retrospective study to investigate the association between the type of forceps delivery and maternal perineal trauma, and in particular to investigate if Kielland's rotational forceps delivery increases obstetric anal sphincter injuries (OASIS). This is a retrospective observational study of 1,515 women who attended a tertiary maternity unit over a period of 5 years and had operative vaginal deliveries primarily or completed by forceps. Data were obtained through the hospital's maternity reporting system. The severity of maternal perineal trauma, particularly third and fourth-degree tears in relation to the type of forceps delivery was explored. Multinomial logistic regression models were used to estimate the crude and the adjusted relative risks (RR) of sustaining third-degree tears compared with other types of vaginal tears. Univariate analyses explored the crude associations between relative risks and age, ethnicity, birth weight, type of instrumental delivery and operator's experience. A multivariate multinomial logistic regression model estimated the adjusted relative risks and included all the previous variables as independent covariates. Of the 1,492 women included in the study, 150 women (77 %) had sustained category 1 tears, 63 women (4 %) had sustained category 2 tears and 279 women (19 %) had sustained third-degree tears. There was no statistically significant association between the severity of maternal perineal trauma and the type of forceps delivery (failed ventouse vs Kielland's forceps RR 1.52, p = 0.159 CI 0.84-2.72, Wrigleys vs Kielland's RR 0.59, p = 0.249, CI 0.24-1.43; Andersons vs Kielland's RR 1.16, p = 0.603, CI 0.65-2.05) after adjusting for age, birth weight, BMI, ethnicity and operator experience (full list of covariates not included). The incidence of third- and fourth-degree tears following rotational Kielland's forceps delivery and other non-rotational forceps deliveries is comparable.

Forceps: towards obsolescence or revival?

Cesarean section rates have become a political issue, attracting the attention of governments, health bureaucrats and professional organizations. In some instances this has led to a renewed interest in forceps delivery, even Kielland's rotational forceps. It is suggested that calls for a greater use of forceps, especially rotational forceps, are ill-advised and commonly based on ignorance of recent urogynecological and imaging literature. Forceps use is associated with a much higher likelihood of major maternal trauma, especially to the anal sphincter and levator ani muscles, which may result in substantial future morbidity. Hence, its use should be avoided whenever possible. This is particularly obvious for rotational forceps.

Kielland's forceps. From controversy to consensus?

Kielland's rotational forceps are designed to overcome malposition of the fetal head in the second stage of labor. After a decline in their use because of reported adverse outcomes and fear of litigation, recent evidence suggests that they may be safe and effective in trained hands and significantly more successful at achieving operative vaginal delivery than either rotational ventouse or manual rotation. This is important because of the increased short and long-term morbidity related to cesarean section compared with the reduced morbidity of subsequent pregnancy after operative vaginal delivery. Kielland's forceps are therefore re-emerging as a useful instrument in the armamentarium of modern obstetrics. Limitations to wider use of Kielland's forceps are the lack of training opportunities as well as that contemporary evidence remains underpowered to detect rare adverse outcomes.

Maternal and Neonatal Outcomes of Successful Kiellandʼs Rotational Forceps Delivery

OBJECTIVE To estimate the rates of early neonatal and maternal complications in a consecutive series of successful Kielland's rotational forceps deliveries. METHODS This was a retrospective cohort study of consecutive cases of successful rotational forceps deliveries performed in singleton pregnancies at 36 weeks of gestation or more in a tertiary referral center in Scotland, UK, from 2001 to 2008 (n=873). We also compared outcomes associated with successful rotational forceps deliveries in 2008 (n=150) with those of nonrotational forceps delivery (n=873), ventouse delivery (n=159), spontaneous vertex delivery (n=3,494), and emergency cesarean delivery (n=947). RESULTS There was one stillbirth associated with a rotational forceps delivery. This was diagnosed before application of forceps. After rotational forceps deliveries, 58 of 872 (6.7%) of live-born neonates were admitted to the neonatal unit. Twenty-seven of 872 (3.1%) neonates had one or more complications that could be attributable to traumatic delivery and seven neonates (0.8%) had a diagnosis of neonatal encephalopathy. When compared with alternative methods of delivery over a single year, neonatal admission rates after delivery by rotational forceps deliveries (5 of 150 [3.3%]) were not significantly different from spontaneous vertex delivery (128 of 3,494 [3.7%; P=1.00]) or ventouse delivery (6 of 159 [3.8%; P=1.00]) and lower than emergency cesarean delivery (106 of 947 [11.2%; P=.002). Postpartum hemorrhage rates after rotational forceps deliveries (8 of 150 [5.3%; P=.008]) were lower than those associated with emergency cesarean delivery (142 of 947 [15.0%; P=.008]). CONCLUSION Rates of short-term neonatal and maternal complications after successful rotational forceps deliveries are low. LEVEL OF EVIDENCE II.

Maternal and Neonatal Outcomes of Successful Kielland's Rotational Forceps Delivery

To estimate the rates of early neonatal and maternal complications in a consecutive series of successful Kielland's rotational forceps deliveries. This was a retrospective cohort study of consecutive cases of successful rotational forceps deliveries performed in singleton pregnancies at 36 weeks of gestation or more in a tertiary referral center in Scotland, UK, from 2001 to 2008 (n=873). We also compared outcomes associated with successful rotational forceps deliveries in 2008 (n=150) with those of nonrotational forceps delivery (n=873), ventouse delivery (n=159), spontaneous vertex delivery (n=3,494), and emergency cesarean delivery (n=947). There was one stillbirth associated with a rotational forceps delivery. This was diagnosed before application of forceps. After rotational forceps deliveries, 58 of 872 (6.7%) of live-born neonates were admitted to the neonatal unit. Twenty-seven of 872 (3.1%) neonates had one or more complications that could be attributable to traumatic delivery and seven neonates (0.8%) had a diagnosis of neonatal encephalopathy. When compared with alternative methods of delivery over a single year, neonatal admission rates after delivery by rotational forceps deliveries (5 of 150 [3.3%]) were not significantly different from spontaneous vertex delivery (128 of 3,494 [3.7%; P=1.00]) or ventouse delivery (6 of 159 [3.8%; P=1.00]) and lower than emergency cesarean delivery (106 of 947 [11.2%; P=.002). Postpartum hemorrhage rates after rotational forceps deliveries (8 of 150 [5.3%; P=.008]) were lower than those associated with emergency cesarean delivery (142 of 947 [15.0%; P=.008]). Rates of short-term neonatal and maternal complications after successful rotational forceps deliveries are low. II.

Use and Safety of Kiellandʼs Forceps in Current Obstetric Practice

We sought to evaluate the use and safety of Kielland's rotational forceps for delivery in current obstetric practice at a tertiary care obstetric unit. Data were obtained pertaining to all such attempted deliveries from 1997 through 2011. The outcomes analyzed included maternal obstetric features, induction and duration of labor, use of analgesia, fetal position and station, birth weight, seniority of the obstetrician, success and failure rates, and associated maternal and neonatal morbidity. There were 144 cases, of which 129 resulted in successful vaginal delivery (89.6%) and 15 were unsuccessful (10.4%). A senior obstetrician was present at all deliveries. The maternal morbidity was relatively low: third-degree or fourth-degree tear less than 1%, postpartum hemorrhage 12.4%, and urinary incontinence 7.8%. There were no cases of forceps-related neonatal trauma or hypoxic-ischemic encephalopathy. Contrary to earlier reports, in these circumstances, use of Kielland's forceps is associated with a high successful delivery rate and apparently low maternal and neonatal morbidity. III.

Maternal and neonatal outcomes following Kielland's rotational forceps delivery

BackgroundThere has been a decline in the use of Kielland's rotational forceps for malpositions, associated with reports that their use results in increased complications. However, most of these studies date...

Maternal and neonatal outcome with trial of operative vaginal delivery (TOVD) in theatre

The objective of this study is to know the maternal and neonatal morbidity, along withcharacteristics affecting the success of trial of operative vaginal delivery (TOVD) intheatre. This is a retrospective study of TOVD in theatre. There were 196 cases ofTOVD in theatre out of 2945 deliveries during the period of study with a total failurerate of 25.5% for all instruments used. Caesarean section and sequential instrumentaldeliveries were associated with more major complications than Neville-Barnesforceps and Kiwi ventouse cup but none with Moolgaoker and Kielland rotationalforceps deliveries. However, the numbers may be small to make a conclusion that Moolgaoker and Kielland rotational forceps had the lowest failure rate (1/16 or 6%). Non-occipitoanterior positions significantly increased the incidence of TOVD (p 0.05, no significant difference). Table 2 illustrates the major complications in 89 parturient’s and 93 babies who had TOVD and in whom notes could be reviewed. Figure 2 Table 2: Illustrate major complications with various TOVDs ANOVA for four independent samples (Table 3) to compare different fetal blood sampling results between: Kiellands, Moolgaoker, sequential instrumental delivery and CS showed that no significant difference in umbilical cord arterial or venous pH between groups (Two tailed p value is 0.07) Figure 3 Table 3: Fetal blood samples for different modes of deliveries in the study: Kiellands, Moolgaoker, sequential instrumental delivery and CS. Moolgaoker and Kielland rotational forceps had lower failure rate (6%), compared to NBF (12.5%), Kiwi (39.2%), and Sequential instrumental delivery (29.3%). ANOVA analysis between the different means has shown significant longer hospital stay for sequential instrumental deliveries and CS (p = 0.017), with an average stay of 3.88 and 5.23 days respectively. DISCUSSION There are no absolute criteria for a TOVD in theatre [3] but the RCOG [1] has suggested that higher failure rates are associated with: 1. Maternal body mass index greater than 30 2. Estimated fetal weight greater than 4000 g or a clinically big baby 3. Occipito-posterior position 4. Mid-cavity delivery or when 1/5 head palpable per abdomen. It had been reported earlier that between 2% to 5% of all instrumental deliveries are undertaken in theatre with preparations made for immediate caesarean section [4, 5]. Patients need to be reassessed again in theatre under regional analgesia and a final decision made regarding the mode of delivery and the appropriate selection of instrument. Failure rates of OVD range from 16% to 20% cases [6, 7]. The failure rate in our study was at 25.5% and that the TOVD with Kiwi has had the lowest success rate between instruments (Failure rate of 39.2%). The experience of the surgeon affects the outcome of OVD, but it is difficult to compare the success rates for different Maternal and neonatal outcome with trial of operative vaginal delivery (TOVD) in theatre 3 of 4 surgeons as they use different instruments. Moreover, an experienced obstetrician is likely to have a higher success rate due to careful patient selection. A cautious less experienced operator may also have a high success rate by performing most of his/her OVD as trials in theatre [8]. In a recent prospective case-control study it has been shown that formal training and education was associated with improved safety of instrumental vaginal delivery for both the mother and the baby [6]. There is higher maternal and fetal morbidity after failed sequential instrumental delivery [9]. Although we found that CS and sequential instrumental deliveries were more associated with complications than with the NBF and Kiwi ventouse cup, this may be due to selection bias. Therefore, we cannot conclude with enough confidence that the latter statement is true. CONCLUSION A larger prospective study to compare the different instruments in TOVD is needed. Non-occipitoanterior positions significantly increased the incidence of TOVD Failure rate of 25.5% for all instruments used. References Maternal and neonatal outcome with trial of operative vaginal delivery (TOVD) in theatre 4 of 4 Author Information A Sayasneh Women’s Health Directorate, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, U. K. H Muppala Women’s Health Directorate, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, U. K. J Rafi Women’s Health Directorate, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, U. K. W Hassan Women’s Health Directorate, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, U. K. M Hanson Women’s Health Directorate, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, U. K.

Low dose bupivacaine/fentanyl epidural infusions in labour and mode of delivery

The aim of this study was to determine the effect on the instrumental delivery rate of two different concentrations of bupivacaine combined with fentanyl in epidural infusions during labour. Only primiparous women in whom a spontaneous vaginal delivery was anticipated, were included in the study. Those women receiving a higher concentration of bupivacaine and therefore a greater amount of local anaesthetic agent during labour were significantly more likely to have an instrumental delivery with Kielland's rotational forceps (p < 0.01). Those women receiving a lower concentration and smaller amount of bupivacaine were significantly more likely to have an instrumental delivery with Neville-Barnes forceps (p < 0.05). This provides evidence to support the theory that epidural analgesia may contribute to inadequate rotation of the presenting fetal part due to weakened pelvic floor muscles and that this is more likely to occur when higher concentrations of bupivacaine are used and a greater degree of motor block occurs.