INSTRUMENTAL DELIVERY
FORCEPS
 Parts of forceps
 Handles – to grip the forceps
 Lock – holds the two blades together
– English lock /French lock /Sliding lock
 Shank – connects handle and blade
 Blades – toe and heel
 Shape – solid, semifenestrated and fenestrated
 Diameter – widest distance between the two blades 7.5cms
 Two curves – cephalic (fits the shape of fetal head) and pelvic ( follows direction of
birth canal
Indications:
 Maternal exhaustion
 Prolonged second stage of labor
– >3hr with and> than 2hr without regional analgesia in primi
– >2hr with and >1hr without regional analgesia in multi
 Fetal distress
 Prophylactic indication
Contraindications:
 Fetal bleeding disorders
Classification(American College of Obstetrics and Gynaecology)
Two important factors are taken into consideration:
1. Station of the head
2. Rotation of the head
Procedure
Outlet forceps
Low forceps
Midforceps
Criteria
1. Scalp is visible at the introitus without separating the labia
2. Fetal skull has reached pelvic floor
3. Sagittal suture is in anteroposterior diameter, right, or left occiput
anterior or posterior position
4. Fetal head is at or on perineum
5. Rotation does not exceed 45 degrees
Leading point of fetal skull is at station ≥ +2, and not on the pelvic floor.
1. Rotation is 45 degrees or less(left or right occiput anterior to occiput
anterior, or left or right occiput posterior to occiput posterior)
2. Rotation is greater than 45 degrees.*
Station above +2but*head is engaged.
High
Not included in classification.
 *To be decided and done only by consultant
Prerequisites
 Good uterine contractions
 Station of head +2 or more
 Presentation must be suitable Vertex, face (chin anterior), after coming head
 Cervix completely dilated
 Sagittal suture in antero posterior diameter
 Membranes should be absent
 Suitably anaesthetised
 Bladder/ bowel empty
Application of forceps
Outlet forceps application
 Cephalic application (always)
 Axis of traction is Biparietal-Bimalar
Technique
 Identification of blades –
“Ghosting” or “Phantom” application
The instrument should be placed in front of the pelvis with the tip pointing upwards and
pelvic curve forwards
 First the left blade should be applied guided by the right hand & then the right blade
guided with the left hand
Application of left blade –

Hold the handle of left blade by pen grip vertically near right groin of the mother
 Pelvic curve is directed downward and cephalic curve inward toward the vulva with
plane of shank perpendicular to the floor
 Fingers of right hand are placed in the vagina between fetal head and left vaginal wall
 Left blade is inserted at 5 o’clock positon between head and fingers. The handle is
lowered slowly to the horizontal and moved up by the vaginal finger giving an
occipitomental position
 Middle & index finger of the right hand guide the toe of blade along the side of head
 Right thumb is placed on heel of blade & provides the necessary force for guiding
into vagina & not the left hand at handle which merely guides the handle over an arc
from right thigh towards midline
 Application of right blade Hold the right blade in right hand and apply similarly except that toe is guided more
anteriorly to avoid the brow which if caught would displace the head and make it
LOT thus good application of first blade is lost making it brow mastoid application
 When right blade is in place, handles are locked
 After handles are locked satisfactorily the application is checked
 When forceps is applied correctly locking is easy.

 Preextraction examination:
 FHS auscultation
 Vaginal examination to rule out cord, membrane or cervical entrapment
 Episiotomy must be given when perineum is overstretched (in low forceps)
 Check the application
 Danforths criteria:
 Posterior fontanellae should be located midway between the sides of blades & one
finger breadth above the plane of shanks
 The Sagittal suture should be perpendicular to the plane of shanks throughout its
length
 Fenestrations of blade felt should be equal and not more than finger tip on either
side
Traction
 Extraction of fetal head:
 Operator should sit on a stool and grasp forceps with one hand on the handle and
other on the shank
 Traction given during the uterine contractions
 Forceps need not be unlocked in between contractions
 Use flexors of the arm (at the level of wrist joint)
 Direction of traction must follow birth canal. First outwards and posteriorly until
the occiput comes under the symphysis pubis and neck pivots in the subpubic
angle, then the direction is changed to outward and anteriorly to promote
extension of the head.
 Not more than 3 attempts provided there is descent with first attempt
 Birth of the head:
 Traction is continued with extension of the head, forehead, face and chin are born
 Removal of forceps:
 After the birth of head forceps is removed in reverse process as application
 Examination of vagina, cervix and uterus for lacerations and repaired .
VECTIS
 A single blade to extract baby during caesarean section
 It is used as a lever or a tractor or an artificial right hand.
 Also called the lever or extractor
VENTOUSE
 Types
 Metal cups : Stainless steel -Malmstrom’s
 Bird’s cup- Ant. & posterior
 Soft cups : Silastic & Plastic –Kobayashi, Mityvac
 Kiwi-Omni – for LSCS
 Parts
 Vaccum cup
Rigid cups – stainless steel
Flexible cups – polyethylene silastic
 Traction tubings
 Vaccum generator
 Prerequisites
Similar to that of forceps except that
 it can be used even when the head is 45 degrees short of rotation
 when head is at or below ‘0’ station
 Application
 Insertion -cup is lubricated, collapsed and introduced
 Largest cup to be placed on the fetal head with knob pointing towards the
occiput and the centre of the cup at the flexion point which is 1-2cms anterior to
posterior fontanelle,it is a point through which mentovertical diameter passes
(clinically it should be applied more posteriorly)
 Application distance means distance between anterior margin of cup
&ant.fontanelle, should be 3 cm or more
 Paramedian Centre of the cup is < 1cm away from sagittal suture
 How will you create the vacuum ?
 Pressure is slowly raised from 0.2 to 0.8kg/cm2 (600mmhg) for metal cup but
rapidly in case of silastic cup i.e over 2 minutes.
 Check for proper application & see that no maternal tissues are included
 Rapid ventouse (LSCS)
 Principles of traction
 Two handed technique – three finger grip
 Should be synchronous with uterine contraction & maternal bearing down
efforts
 Should be in the direction of pelvic axis & perpendicular to cup
 Traction force-Average 8 to15 kgs
 Episiotomy may or may not be given depending on the operator’s individual
judgement.
 As the development of vacuum progresses, artificial caput succedaneum called
chignon develops (metal cup)
 Once the head is delivered ,the suction pressure is released & vacuum cup removed
 When should the operative vaginal deliveries be abandoned?
 No evidence of progressive descent with each pull
 When delivery is not imminent following 3 pulls
 3 Cup detachments (pop-off)
 Time limit of 30 min
 Application of vacuum cup during Caesarean section
 Deeply engaged head-elevated from below-then apply ventouse
 High floating head-fundal pressure-fetal head comes to incision site-apply
ventouse
 Soft cups are best suited for this application
 Antibiotics
 There are insufficient data to justify the use of prophylactic antibiotics in operative
vaginal delivery. Good standards of hygiene and aseptic techniques are
recommended.
Analgesia after delivery
 Regular paracetamol and diclofenac should be offered after an operative vaginal
delivery in the absence of contraindications.
 Documentation
Same as that of forceps delivery
FORCEPS
A Anesthesia
assistance
Adequate pain relief
Neonatal support
FORCEPS DELIVERY
B
Bladder
Bladder empty
C
Cervix
Fully dilated , membranes ruptured
D
Determine
Position , station , pelvic adequacy think possible shoulder dystocia
E
Equipment
F
Forceps
Phantom application left blade, left hand , maternal left side ,
pencil grip and vertical insertion , with right thumb in the vagina ,
directing the blade .Right blade , right hand ,maternal right side,
pencil grip and vertical insertion with left thumb directing the
blade. Lock blades and support-check application .Post fontanelle
1cm above the plane of the shanks .Fenestration not > finger
breadth between it and scalp. Sagittal suture perpendicular to the
plane of the shanks with occipital sutures 1cm above respective
blades
G
Gentle
traction
Applied with contraction/expulsive effort
H
Handle
elevated
Traction in axis of birth canal, do not elevate handle too early
I
Incision
Consider episiotomy
VACUUM DELIVERY
A
B
C
D
Anesthesia assistance
Bladder
Cervix
Determine
E
F
Equipment
Fontanelle
G
Gentle traction
H
Handle elevated
I
J
Incision
Jaw
Adequate pain relief Neonatal support
Bladder empty
Fully dilated , membranes ruptured
Position , station , pelvic adequacy. Think of possible
shoulder dystocia
Inspect vacuum cup , pump,tubing and check pressure
Position the centre of the cup 1-2cm anterior to the posterior
fontanelle.Sweep finger around the cup to clear maternal
tissue
100mmhg initially , pull with contractions only :as
contractions begin increase pressure to 600mmhg .Prompt
mother for good expulsive effort .Traction in the axis of birth
canal
Traction in axis of birth canal, do not elevate handle too
early
Consider episiotomy
Remove forceps when jaw is reachable or delivery assured