Rotational Forceps Delivery Research Articles

Kjelland's forceps in the new millennium. Maternal and neonatal outcomes of attempted rotational forceps delivery

The use of Kjelland's forceps is now uncommon, and published maternal and neonatal outcome data are from deliveries conducted more than a decade ago. The role of Kjelland's rotational delivery in the 'modern era' of high caesarean section rates is unclear. To compare the results of attempted Kjelland's forceps rotational delivery with other methods of instrumental delivery in a tertiary hospital. Retrospective review of all instrumental deliveries for singleton pregnancies 34 or more weeks gestation in a four-year birth cohort, with reference to adverse maternal and neonatal outcomes. The outcomes of 1067 attempted instrumental deliveries were analysed. Kjelland's forceps were successful in 95% of attempts. Kjelland's forceps deliveries had a rate of adverse maternal outcomes indistinguishable from non-rotational ventouse, and lower than all other forms of instrumental delivery. Kjelland's forceps also had a lower rate of adverse neonatal outcomes than all other forms of instrumental delivery. Prudent use of Kjelland's forceps by experienced operators is associated with a very low rate of adverse maternal and neonatal outcomes. Training in this important obstetric skill should be reconsidered urgently, before it is lost forever.

Tisseel for management of traumatic postpartum haemorrhage

Following the introduction of haemostatic agents, new opportunities are available when facing problematic bleeding. We report the first case of traumatic postpartum hemorrhage successfully controlled with a fibrin sealant. 26-year nulliparous patient had a rotational forceps delivery and developed multiple vaginal lacerations. Haemostasis could not be achieved after suturing, vaginal packing and IV tranaxemic acid. She lost approx. 3,500 ml blood and received 4 U transfusion. Tisseel was used as a thin layer on vaginal wall and bleeding settled. She had good recovery and perineum healed well. Tisseel consists of a two-component fibrin biomatrix to stop diffuse bleeding. When the tissues are very oedematous, it can be difficult to insert sutures. We tried this innovative option with very effective results. The absence of long-term complications is reassuring and we recommend its use in similarly extreme situations.

Upper cervical spinal cord injury in neonates: The use of magnetic resonance imaging

Neonatal upper cervical spinal cord injury is associated with rotational forceps delivery and presents with quadriparesis and diaphragmatic paralysis. The underlying pathology determines neurologic outcome but is difficult to assess clinically or with simple radiographic techniques. We report 4 cases in which early magnetic resonance imaging demonstrated the extent and severity of the injury and guided management. (J Pediatr 2001;138:105-8)

Preliminary experience with twenty perineal repairs using Indermil tissue adhesive

Objective: To assess the use of Indermil tissue adhesive for perineal repair. Setting: Leeds General Infirmary, a teaching hospital with 4500 deliveries annually. Method: Over a period of five months, 20 women who sustained either a second degree tear or who had an episiotomy at vaginal delivery had their perineal skin repaired with Indermil tissue adhesive. They were followed up prior to discharge and then by telephone once discharged. Results: Ten repairs followed normal vaginal deliveries, six were after ventouse deliveries, three after midcavity forceps delivery and one after a rotational forceps delivery. Three women noticed a burning sensation during application of adhesive. At follow up, 13 women were completely without problems, two complained of a sharp sensation from excess adhesive, one had silver nitrate applied at the six week check, two had small defects in the skin which healed well and in two women the skin edges broke down completely but did not need resuturing. Conclusion: Indermil tissue adhesive appears to be a safe and effective method of skin closure for episiotomies and second degree tears. The skin closure is quick and painless.

Rotational versus nonrotational forceps: Maternal and neonatal outcomes

Objective: Our purpose was to evaluate maternal and neonatal morbidity associated with rotations performed with Leff forceps in comparison with nonrotational forceps deliveries. Study Design: A review of 267 rotational and nonrotational forceps deliveries from August 1996 through February 1998 was performed. Multiple maternal and neonatal outcome measures were compared and results were analyzed by χ 2 with the Fisher exact test and the Student t test. Results: One hundred sixty-three traditional low-forceps or outlet forceps deliveries were compared with 104 rotational forceps deliveries performed with Leff forceps. There were no significant differences between the 2 groups in maternal age, gestational age, gravidity, parity, total labor duration, birth weight, and Apgar scores. There were significantly lower rates of episiotomy, third- and fourth-degree lacerations, and sulcus lacerations in the rotation group, and the second stage of labor was also shorter. The neonatal intensive care unit admission rate was higher in the rotation group; however, none of the admissions were directly related to the mode of delivery. Conclusion: Rotational deliveries performed with Leff forceps are associated with less maternal morbidity and shorter second stage of labor than are deliveries performed with traditional forceps. Leff forceps are a safe option for rotation of the persistent occipitoposterior fetal position. (Am J Obstet Gynecol 1999;181:1185-7.)

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.

Transverse arrest: a review of outcomes of rotational forceps and cesarean delivery at a single center

Objective: To assess whether Kielland forceps rotational delivery causes a significant increase in maternal or perinatal morbidity in comparison with cesarean delivery in the clinical situation of transverse arrest. Rotational forceps delivery has been reported to have unacceptably high maternal and neonatal complication rates when compared with either spontaneous vaginal delivery or non-rotational forceps delivery. Clinically, however, we considered the more relevant comparison between Kielland rotational forceps delivery and cesarean delivery as these are generally the two modes of delivery for the fetus in transverse arrest. Study Design: The charts of all the mothers delivered by Kielland forceps or cesarean delivery for the main indication of transverse arrest between July 1995 and June 1996 were reviewed. The following were evaluated: Apgar scores at 1 and 5 minutes, cord pH, birth weight, neonatal superficial facial laceration or bruising, bone or nerve injuries, maternal injuries, 3rd and 4th degree perineal or vaginal lacerations, post-partum fever. Statistical analysis was by χ 2 (for Apgar scores), two-tailed Fisher Exact test (for post-partum fever), and t test (for birth weight and cord pH). A P value < .05 was considered statistically significant. Results: Fifty-two Kielland forceps and 30 cesarean deliveries were performed. One-minute Apgar scores of less than or equal to 7 were noted in 11.5% and 6.7% of the forceps and cesarean section groups, respectively ( P = NS); mean arterial cord pH was 7.26 for both groups; no cases of post-partum fever were noted in the forceps versus 16% in the cesarean group ( P < .05); the mean weight was 3,316 and 3,569 g for the forceps and cesarean group, respectively ( P < .05). The Kielland group was also characterized by the following: 19 facial bruising and 2 temporary facial nerve injury (resolved by the time of discharge), 3 perineal lacerations, and 3 vaginal tears. No blood transfusions were required for either group. Conclusions: To our knowledge, this is the first study that compares rotational forceps delivery for transverse arrest with its true clinical alternative, cesarean delivery. No significant difference in cord pH and Apgar scores were noted between the two groups. The birth weight was greater and post-partum fever was more common in the cesarean section group. Neonatal facial bruising, temporary facial nerve palsy, and maternal perineal and vaginal lacerations were more common in the forceps groups. This study suggests that rotational forceps may be a reasonable alternative to cesarean delivery in the management of transverse arrest.

THE MANAGEMENT OF THE SECOND STAGE OF LABOUR IN PRIMIPARAE WITH EPIDURAL ANALGESIA

SUMMARYOne hundred and ninety‐four primiparae with lumbar epidural analgesia established during the first stage of labour were discouraged from pushing until the fetal head was visible at the perineum or until three hours had elapsed since full dilation of the cervix. The outcome in this group was compared with a similar group in whom pushing was commenced as soon as the second stage was diagnosed. The observed increase in spontaneous deliveries did not reach statistical significance. There was a reduction in non‐rotational forceps (p&lt;0.05), but no change occurred in the incidence of rotational forceps deliveries. The high rates of oxytocin augmentation in these primiparous labours may account for the failure of delayed pushing to increase the spontaneous delivery rate in our population.

Oxytocin Infusion During Second Stage of Labour in Primiparous Women using Epidural Analgesia

OBJECTIVE--To determine whether the high rate of forceps delivery associated with the use of epidural analgesia could be reduced through giving an intravenous infusion of oxytocin during the second stage of labour. DESIGN--A randomised, double blind, placebo controlled trial. SETTING--Delivery suites in three hospitals. SUBJECTS--226 Primiparous women with adequate epidural analgesia in whom full dilatation of the cervix had been achieved without prior stimulation with oxytocin. INTERVENTION--An infusion of oxytocin or placebo starting at the diagnosis of full cervical dilatation at an initial dose rate of 2 mU/min increasing to a maximum of 16 mU/min. MAIN OUTCOME MEASURES--The outcome of labour was assessed in terms of the duration of the second stage, mode of delivery, fetal condition at birth, postpartum blood loss, and the incidence of perineal trauma. RESULTS--Treatment with oxytocin was associated with a shorter second stage (p = 0.01), a reduction in the number of non-rotational forceps deliveries (p = 0.03), and less perineal trauma (p = 0.03) but was not associated with any reduction in the number of rotational forceps deliveries performed for malposition of the occiput. No adverse effects on fetal condition at birth or in the early puerperium were seen in association with the use of oxytocin. CONCLUSIONS--The use of an oxytocin infusion may reduce the high rate of operative delivery associated with epidural analgesia provided that the fetal occiput is in an anterior position at the onset of the second stage of labour but within the dose range studied does not seem to correct malposition of the fetal occiput.

Oxytocin infusion during second stage of labour in primiparous women using epidural analgesia: a randomised double blind placebo controlled trial.

To determine whether the high rate of forceps delivery associated with the use of epidural analgesia could be reduced through giving an intravenous infusion of oxytocin during the second stage of labour. A randomised, double blind, placebo controlled trial. Delivery suites in three hospitals. 226 Primiparous women with adequate epidural analgesia in whom full dilatation of the cervix had been achieved without prior stimulation with oxytocin. An infusion of oxytocin or placebo starting at the diagnosis of full cervical dilatation at an initial dose rate of 2 mU/min increasing to a maximum of 16 mU/min. The outcome of labour was assessed in terms of the duration of the second stage, mode of delivery, fetal condition at birth, postpartum blood loss, and the incidence of perineal trauma. Treatment with oxytocin was associated with a shorter second stage (p = 0.01), a reduction in the number of non-rotational forceps deliveries (p = 0.03), and less perineal trauma (p = 0.03) but was not associated with any reduction in the number of rotational forceps deliveries performed for malposition of the occiput. No adverse effects on fetal condition at birth or in the early puerperium were seen in association with the use of oxytocin. The use of an oxytocin infusion may reduce the high rate of operative delivery associated with epidural analgesia provided that the fetal occiput is in an anterior position at the onset of the second stage of labour but within the dose range studied does not seem to correct malposition of the fetal occiput.

Epidural analgesia implies a high forceps rate—can this be reduced?

SummaryAs the number of epidural anaesthetics for patients in labour increases in most obstetric units around the country the incidence of forceps and, in particular, rotational forceps delivery, also appears to increase. Prolonging the second stage of labour encourages spontaneous delivery and we describe a plan of management for such patients with epidural analgesia.

Epidural bupivacaine concentration and forceps delivery in primiparae

SummaryThis study of 383 consecutive primiparae given epidural analgesia in labour was conducted to examine the influence of the concentration of bupivacaine on the mode of delivery. The epidural technique and the management of labour were both standardised and the bupivacaine concentration was decided arbitrarily by the duty anaesthetist. Primiparae given 0·25 per cent bupivacaine throughout labour (n = 122) were less likely to require a forceps delivery than primiparae (n = 261) given more than 0.25 per cent bupivacaine at any stage during labour (P < 0·05). This was due mainly to a reduction in the incidence of rotational forceps deliveries and occurred despite a higher incidence (P < 0·05) of oxytocin augmentation of contractions during the second stage of labour in mothers receiving high concentration bupivacaine. Low concentration bupivacaine may not only reduce the incidence of forceps deliveries but may also have analgesic benefits if the number of mothers with forceps related pain in the puerperi...

Pudendal Block: An Obstetric Procedure That Needs Critical Evaluation

AbstractThe efficacy of pudendal block anaesthesia was evaluated in three centres by obstetric staff of different seniority. In one centre a Med‐E‐Jet which drives and disperses the drug at high velocity was used. The results obtained by objective testing of pain gave a complete bilateral block in 50% of cases. In 16.7% of the cases the block was adequate only on the left side with partial or no analgesia on the opposite side; the corresponding figure for the right side was 8.9%. The remaining 24.4% of cases needed additional local infiltration and was considered as failures.The seniority of the obstetric staff or the equipment used did not improve the results. The highest success rate was achieved by staff using the method routinely. Caution is expressed in performing trial of forceps or rotational forceps delivery under pudendal block anaesthesia without objectively testing for the results achieved by the block. Considering the success obtained in unilateral blockade there is room for improving the block achieved on both sides.

Which deliveries require paediatricians in attendance?

The mode of delivery and one minute Apgar score were taken from the neonatal records of 2086 full term infants born at one obstetric unit over 12 months. There were 1554 spontaneous vaginal vertex deliveries, 26 vaginal breech deliveries, and 506 operative or instrumental deliveries. The obstetric records of the operative deliveries were reviewed to determine whether fetal distress had been an indication for intervention, and the obstetric records of the spontaneous vaginal vertex deliveries were also reviewed for fetal distress detected antenatally. When fetal distress was present antenatally in spontaneous vaginal vertex deliveries the frequency of a one minute Apgar score below 7 was 10.2%. In operative and instrumental deliveries where fetal distress was the indication for intervention the frequency of one a minute Apgar score below 7 was 15.6% after non-rotational forceps delivery, 13.9% after rotational forceps delivery, and 45.8% after caesarean section. In the absence of fetal distress the frequency of an Apgar score below 7 was 2.4% after spontaneous deliveries, 7.1% after non-rotational forceps delivery, 13.2% after caesarean section, and 18.4% after rotational forceps delivery. The presence of fetal distress considerably increased the frequency of an Apgar score below 7 in each category except rotational forceps deliveries. Paediatric services to an obstetric unit may be organised rationally in the light of local staffing conditions with the help of these findings.

Plasma progesterone in the umbilical vessels at vaginal delivery of term infants.

The influence of stress and related factors on umbilical-cord vessel progesterone concentrations have been investigated in 150 vaginal deliveries. Cord vein progesterone levels were greater in breech deliveries than in forceps deliveries and in vaginal deliveries by maternal effort alone. Within the forceps group there was no difference in cord vessel progesterone concentrations between lift-out, mid-cavity or rotational forceps deliveries. Levels of progesterone were significantly greater in forceps deliveries where the infant was clinically distressed (P less than 0.01). Similarly, within the normal group progesterone levels were greater in a stressed group of infants, where cord vein pH, artery pH, Apgar score at 1 min or birthweight fell below the 10th centile for the study group. No differences in plasma progesterone concentration were found with labour commencing spontaneously or by induction, nor did the sex of the infant appear to influence this hormone. Progesterone levels were higher in samples from primiparae than in those from multiparae due to a small number of primiparae who had excessively long labours and high progesterone concentrations. There was, however, no strong statistical correlation between length of labour and progesterone concentrations.

EXTRADURAL ANALGESIA: THE INFLUENCE OF VOLUME AND CONCENTRATION OF BUPIVACAINE ON THE MODE OF DELIVERY, ANALGESIC EFFICACY AND MOTOR BLOCK

Five hundred and seventeen women in labour receiving extradural analgesia, using bupivacaine plain solution, were randomly allocated to one of three groups. Group A received 6-8ml of 0.5% solution, group B 10-14ml of 0.25% solution, and group C 6-8 ml of 0.25% solution. Spontaneous delivery occurred in 31.7% of patients in group A, 38.7% in group B and 53% in group C (P less than 0.001). The percentage of rotational forceps, ventouse and Caesarean section deliveries was similar in the three groups. Analgesia was most effective in group A, and at least in group C, both during labour and at delivery, although assessment by linear analogue score suggested that the differences between the three groups were slight. Motor block was most frequent and rapidly progressive in groups A, but was progressive in all groups, and after five or more top-up injections, was similar in the three groups. Difficulties with micturition following delivery were significantly more common in group A.

THE EFFECT OF LUMBAR EPIDURAL ANALGESIA ON THE RATE OF CERVICAL DILATATION AND THE OUTCOME OF LABOUR OF SPONTANEOUS ONSET

A study of 1055 spontaneous labours is presented relating progress and outcome to the presence of a lumbar epidural block in 282 of these patients and to the need for oxytocin augmentation in 427. Graphs for cervical dilatation starting at admission to hospital were constructed for normal and dysfunctional labours of spontaneous onset. Patients requiring augmentation of labour had a lesser cervical dilatation on admission to hospital, a longer first stage, more instrumental deliveries, more Caesarean sections and a greater number of babies with a low Apgar score. An epidural block had no effect on either the duration of first stage or the rate of cervical dilatation but was associated with a 20-fold increase in rotational forceps delivery and no increase in Caesarean section rate. With an epidural block there was no increase in the number of babies with cerebral irritation or low Apgar scores and there was a statistically significant improvement in the Apgar scores of babies of mothers in augmented dysfunctional labour who had an epidural block. The incidence of rotational forceps delivery in patients with an epidural block could be reduced with safety by allowing such patients to have a longer second stage before considering interference purely for delay.

Post-partum reactions to instrumental delivery.

A high proportion of women did not know that they had undergone an instrumental delivery at the time of giving birth. Fifty per cent of women were frightened or anxious about the forceps delivery, which suggests a lack of ante-natal preparation for such a delivery. Forceps application increased the pain in approximately 25%. This reflects inadequate anaesthesia, especially in those cases of rotational forceps delivery. A high proportion of women were disappointed at having an instrumental delivery, and this was unrelated to the indication for such a delivery. Only 15% preferred to have an Instrumental delivery again, which is less than those who were not disappointed at having an instrumental delivery at the time. These factors point to a generally negative outdated attitude towards forceps delivery. A more positive attitude towards instrumental delivery should be introduced by obstetricians, midwives, and physiotherapists, so that the procedure is considered more as a part of normal obstetrics.