Application of obstetric forceps. Obstetric forceps Indications for use

The application of forceps is used in cases where urgent completion of labor during the expulsion period is required and there are conditions for performing this operation. There are 2 groups of indications: indications related to the condition of the fetus and the condition of the mother. Combinations of these are often observed.

The indication for applying forceps in the interests of the fetus is hypoxia, which has developed due to various reasons (premature abruption of a normally located placenta, prolapse of the umbilical cord, weakness of labor, late gestosis, short umbilical cord, entanglement of the umbilical cord around the neck, etc.). The obstetrician leading the birth is responsible for the timely diagnosis of fetal hypoxia and the selection of adequate management tactics for the woman in labor, including determining the method of delivery.

In the interests of the woman in labor, forceps are applied for the following indications: 1) secondary weakness of labor, accompanied by a stop in the forward movement of the fetus at the end of the expulsion period; 2) severe manifestations of late gestosis (preeclampsia, eclampsia, severe hypertension, refractory to conservative therapy); 3) bleeding in the second stage of labor, caused by premature detachment of a normally located placenta, rupture of blood vessels during the membrane attachment of the umbilical cord; 4) diseases of the cardiovascular system in the stage of decompensation; 5) breathing disorders due to lung diseases, requiring the exclusion of pushing; 6) general diseases, acute and chronic infections, high fever in a woman in labor. The application of obstetric forceps may be required for women in labor who have undergone surgical intervention on the abdominal organs on the eve of childbirth (the inability of the abdominal muscles to provide full pushing). The use of obstetric forceps in some cases may be indicated for tuberculosis, diseases of the nervous system, kidneys, and organs of vision (most

A common indication for forceps is high myopia).

Thus, the indications for the application of obstetric forceps in the interests of the woman in labor may be due to the need to urgently end labor or the need to eliminate pushing. The listed indications in many cases are combined, requiring emergency termination of labor in the interests of not only the mother, but also the fetus. Indications for the application of obstetric forceps are not specific to this operation; they may also be indications for other operations (cesarean section, vacuum extraction of the fetus, fetal destruction operations). The choice of delivery operation largely depends on the presence of certain conditions that allow a specific operation to be performed. These conditions differ significantly, so careful assessment is necessary in each case to correctly select the method of delivery.

Conditions for applying obstetric forceps. When applying forceps, the following conditions are necessary:

1. Live fruit. In case of fetal death and there are indications for emergency delivery, fetal destruction operations are performed, and in rare extreme cases - caesarean section. Obstetric forceps are contraindicated in the presence of a dead fetus.

2. Full opening of the uterine os. Deviation from this condition will inevitably lead to rupture of the cervix and lower segment of the uterus.

3. Absence of amniotic sac. This condition follows from the previous one, since with proper management of labor, when the uterine os is fully dilated, the amniotic sac must be opened.

4. The fetal head should be in the narrow part of the cavity or at the outlet of the small pelvis. For other head position options, the use of obstetric forceps is contraindicated. Accurate determination of the position of the head in the pelvis is possible only during a vaginal examination, which must be performed before applying obstetric forceps. If the lower pole of the head is determined between the plane of the narrow part of the pelvis and the exit plane, then this means that the head is located in the narrow part of the pelvic cavity. From the point of view of the biomechanism of childbirth, this position of the head corresponds to the internal rotation of the head, which will be completed when the head descends to the pelvic floor, i.e., into the outlet of the small pelvis. When the head is located in a narrow part of the pelvic cavity, the sagittal (sagittal) suture is located in one of the oblique dimensions of the pelvis. After the head descends to the pelvic floor, during a vaginal examination, the sagittal suture is determined in the direct size of the outlet from the pelvis, the entire pelvic cavity is filled with the head, its parts are not accessible for palpation. In this case, the head has completed the internal rotation, then the next moment of the biomechanism of childbirth follows - extension of the head (if there is an anterior view of the occipital insertion).

5. The fetal head should correspond to the average size of the head of a full-term fetus, i.e., not be too large (hydrocephalus, large or giant fetus) or too small (premature fetus). This is due to the size of the forceps, which are only suitable for the head of a medium-sized full-term fetus; otherwise, their use becomes traumatic for the fetus and the mother.

6. Sufficient dimensions of the pelvis to allow passage of the head removed with forceps. With a narrow pelvis, forceps are a very dangerous instrument, so their use is contraindicated.

The operation of applying obstetric forceps requires the presence of all the listed conditions. When starting delivery with forceps, the obstetrician must have a clear understanding of the biomechanism of childbirth, which will have to be artificially imitated. It is necessary to understand which moments of the biomechanism of labor the head has already completed and which it has to accomplish with the help of forceps. Forceps are a pulling tool that replaces the missing force of pushing. The use of forceps for other purposes (correction of incorrect head insertions, posterior view of the occipital insertion, as a corrective and rotational instrument) has long been excluded.

Preparation for application of obstetric forceps. The forceps are applied in the position of the woman in labor on the operating table (or on the Rakhmanov bed) on her back, with her legs bent at the knee and hip joints. Before the operation, the intestines and bladder must be emptied, and the external genitalia must be disinfected. Before the operation, a thorough vaginal examination is performed to confirm the availability of conditions for applying forceps. Depending on the position of the head, it is determined which version of the operation will be used: abdominal obstetric forceps for the head located in the narrow part of the pelvic cavity, or exit obstetric forceps if the head has dropped to the pelvic floor, i.e., into the outlet of the small pelvis.

The use of anesthesia when applying obstetric forceps is desirable, and in many cases mandatory. In addition, in many cases, the use of obstetric forceps is due to the need to eliminate pushing activity in the woman in labor, which can only be achieved with adequate anesthesia. Anesthesia is also required to relieve pain from this operation, which in itself is very important. When applying forceps, inhalation, intravenous anesthesia or pudendal anesthesia is used.

Due to the fact that when extracting the fetal head using forceps, the risk of perineal rupture increases, the application of obstetric forceps is usually combined with perineotomy.

Exit obstetric forceps. Exit obstetric forceps is an operation in which forceps are applied to the fetal head located at the pelvic outlet. At the same time, the head has completed its internal rotation, and the last moment of the biomechanism of childbirth before its birth is carried out using forceps. In the anterior view of the occipital insertion of the head, this moment is extension of the head, and in the posterior view, flexion followed by extension of the head. Exit obstetric forceps are also called typical in contrast to cavity, atypical, forceps.

The technique of applying both typical and atypical forceps includes the following points: 1) insertion of spoons, which is always carried out in accordance with the following rules: first, the left spoon is inserted with the left hand into the left side (“three left”), the second is the right spoon with the right hand into right side (“three right”); 2) closing the forceps; 3) test traction to ensure that the forceps are applied correctly and that there is no risk of them slipping; 4) traction itself - extraction of the head with forceps in accordance with the natural biomechanism of childbirth; 5) withdrawal

forceps in the reverse order of their application: the right spoon is removed first with the right hand, the left spoon is removed second with the left hand.

Technique for applying exit obstetric forceps with anterior view of the occipital insertion.

The first point is the introduction of spoons. Folded tongs are placed on the table to accurately identify the left and right spoons. The left spoon is inserted first, since when closing the forceps it must lie under the right one, otherwise closing will be difficult. The obstetrician takes the left spoon in his left hand, grasping it like a pen or bow. Before inserting the left hand into the vagina, four fingers of the right hand are inserted on the left side to control the position of the spoon and protect the soft tissues of the birth canal. The hand should be facing the head with the palmar surface and inserted between the head and the side wall of the pelvis. The thumb remains outside and is moved to the side. Before its insertion, the handle of the left spoon is installed almost parallel to the right inguinal fold, the top of the spoon is located at the genital slit in the longitudinal (antero-posterior) direction. The lower edge of the spoon rests on the first finger of the right hand. The spoon is inserted into the genital opening carefully, without violence, by pushing the lower rib I with the finger of the right hand, and only partly the insertion of the spoon is facilitated by the slight advancement of the handle. As the spoon penetrates deeper, its handle gradually moves down towards the perineum. Using the fingers of his right hand, the obstetrician helps guide the spoon so that it rests on the side of the head in the plane of the transverse dimension of the pelvic outlet. The correct position of the spoon in the pelvis can be judged by the fact that the Bush hook is positioned strictly in the transverse dimension of the exit from the pelvis (in the horizontal plane). When the left spoon is correctly placed on the head, the obstetrician removes the inner hand from the vagina and passes the handle of the left spoon of the forceps to the assistant, who must hold it without moving it. After this, the obstetrician spreads the genital slit with his right hand and inserts 4 fingers of his left hand into the vagina along its right wall. The second one inserts the right spoon of forceps with the right hand into the right half of the pelvis. The right spoon of the tongs should always lie on the left. Correctly applied forceps grasp the head through the zygomatic-parietal plane, the spoons lie slightly in front of the ears in the direction from the back of the head through the ears to the chin. With this placement, the spoons grasp the head in its largest diameter, the line of the tongs handles faces the wire point of the head.

The second point is the closure of the forceps. Separately inserted spoons must be closed so that the forceps can serve as a tool for grasping and removing the head. Each of the handles is taken with the same hand, while the thumbs are located on the Bush hooks, and the remaining 4 fingers clasp the handles themselves. After this, you need to bring the handles closer together and close the tongs. For proper closure, a strictly symmetrical arrangement of both spoons is required.

When closing the spoons, the following difficulties may occur: 1) the lock does not close, since the spoons are not placed on the head in the same plane, as a result of which the locking parts of the tool do not coincide. This difficulty is usually easily eliminated by pressing with the thumbs on the side hooks; 2) the lock does not close because one of the spoons is inserted higher than the other. The deeper spoon is moved slightly outward so that the Bush hooks coincide with each other. If, despite this, the tongs do not close, it means that the spoons have been applied incorrectly and must be removed and reapplied; 3) the lock is closed, but the handles of the tongs diverge. This is due to the fact that the size of the head is slightly greater than the distance between the spoons in the head curvature. Bringing the arms together in this case will cause compression of the head, which can be avoided by placing a folded towel or diaper between them.

Having closed the forceps, you should perform a vaginal examination and make sure that the forceps do not capture soft tissue, the forceps are positioned correctly and the wire point of the head is in the plane of the forceps.

The third point is test traction. This is a necessary check to ensure that the forceps are applied correctly and that there is no risk of them slipping. The test traction technique is as follows: the right hand clasps the handles of the forceps from above so that the index and middle fingers lie on the side hooks; The left hand lies on top of the right, and its index finger is extended and touches the head in the area of the wire point. The right hand carefully makes the first traction. Traction should be followed by forceps, the left hand on top with the index finger extended, and the head. If during traction the distance between the index finger and the head increases, this indicates that the forceps are not applied correctly and will eventually slip off.

The fourth point is removing the head with forceps (actually traction). During traction, the forceps are usually grasped in the following way: with the right hand, they grasp the lock from above, placing (with Simpson-Fenomenov forceps) the third finger in the gap between the spoons above the lock, and the second and fourth fingers on the side hooks. With your left hand, grasp the handles of the tongs from below. The main traction force is developed by the right hand. There are other ways to grasp the forceps. N. A. Tsovyanov proposed a method for gripping forceps, allowing simultaneous traction and abduction

heads into the sacral cavity. With this method, the II and III fingers of both hands of the obstetrician, bent with a hook, grasp the outer and upper surface of the instrument at the level of the side hooks, and the main phalanges of these fingers with Bush hooks passing between them are located on the outer surface of the handles, the middle phalanges of the same fingers - on the upper surface, and the nail phalanges are on the upper surface of the handle of the opposite spoon of the forceps. The fourth and fifth fingers, also slightly bent, grasp the parallel branches of the forceps extending from the lock from above and move as high as possible, closer to the head. The thumbs, being under the handles, rest against the middle third of the lower surface of the handles with the flesh of the nail phalanges. The main work with this grip of the forceps falls on the IV and V fingers of both hands, especially on the nail phalanges. By pressing these fingers on the upper surface of the branches of the forceps, the head is retracted from the pubic joint. This is also facilitated by the thumbs, which exert pressure on the lower surface of the handles, directing them upward.

When removing the head with forceps, it is necessary to take into account the direction of traction, their nature and strength. The direction of traction depends on in which part of the pelvis the head is located and what aspects of the biomechanism of labor need to be reproduced when removing the head with forceps. In the anterior view of the occipital insertion, extraction of the head with exit obstetric forceps occurs due to its extension around the fixation point - the suboccipital fossa. The first tractions are performed horizontally until the suboccipital fossa appears from under the pubic arch. After this, the tractions are given an upward direction (the ends of the handles are directed by the obstetrician towards his face) so that the head is extended. Tractions must be performed in one direction. Rocking, rotating, pendulum-like movements are unacceptable. Traction must be completed in the direction in which it was started. The duration of an individual traction corresponds to the duration of an attempt; tractions are repeated with breaks of 30-60 s. After 4-5 tractions, the forceps are opened to reduce compression of the head. The strength of the tractions imitates a contraction: each traction begins slowly, with increasing strength and, having reached a maximum, gradually fades away and goes into a pause.

Tractions are performed by the doctor standing (less often sitting), the obstetrician’s elbows should be pressed to the body, which prevents the development of excessive force when removing the head.

The fifth point is opening and removing the tongs. The fetal head is brought out using forceps or manually after removing the forceps, which in the latter case is carried out after the largest circumference of the head has erupted. To remove the forceps, take each handle with the same hand, open the spoons, then move them apart and after that the spoons are removed in the same way as they were applied, but in the reverse order: the right spoon is removed first, while the handle is moved to the left groin fold, the left spoon is removed second , its handle is retracted to the right groin fold.

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Output tongs

1. Preparation:

placing the woman in labor on a “transverse” bed;
treatment of the hands of the operator and assistant (the method is the fastest possible under these conditions);
treatment of the surgical field (external genitalia, inner thighs, perineum) with an antiseptic solution;
bladder catheterization;
anesthesia (preferably general anesthesia, pudendal anesthesia - with exit forceps);
collecting the tongs and laying the branches on the work table (Figure 1);
internal examination with a “half-hand” or two fingers to clarify the condition of the birth canal, presentation, type, position, position, sagittal suture and determine the level of the head.

Rice. 1. Collecting the tongs and laying the branches on the work table

2. Operation technique:

insertion and placement of forceps spoons. Four fingers of the right hand are inserted into the left half of the pelvis in the direction of the sacroiliac joint (Fig. 2). With the left hand, the left spoon of the forceps is grasped by the handle in the form of a bow or with three fingers, its top is placed in the groove between the index and middle fingers, and the handle is deflected towards the opposite groin. Under the control of the hand inserted into the vagina, the thumb moves along the lower branch, without violence the spoon itself is placed on the head along its greatest curvature, and the parietal tubercle is grabbed. The handle of the left spoon is easily lowered. The spoon is passed to the assistant, who holds it in the given position. The right spoon is also inserted under the control of the left hand (Fig. 3).

Rice. 2. Placement of the left spoon of forceps

Rice. 3. Insertion of the right spoon with forceps

closing the forceps: the right spoon, when correctly applied to the head, easily fits into the lock of the left one: Bush hooks are at the same level for shock absorption, a diaper is placed between the jaws (Fig. 4),

Rice. 4. Closing the forceps

control of the correct application of the forceps: with two fingers of the right hand, check whether the cervix is captured between the jaws of the forceps and the head. The left hand supports the pliers by the handles,
test traction (Fig. 5). We place the right hand on top of the handle of the forceps - the left one overlaps the right one, the middle finger touches the head. Light traction is applied. If this does not increase the distance between the head and the finger - therefore the forceps do not slip - they are applied correctly. If the distance increases, the forceps are applied incorrectly; they must be removed by removing the spoons in the reverse order, first the right one, tilting the handle of the forceps to the left groin of the woman in labor, and then the left one;

Rice. 5. Test traction

traction itself. Hand position: 1) classic - the right hand grabs the handles in such a way that the index and middle fingers rest on the hooks (Fig. 6). The left hand repeats the position of the right, or also grabs the handles of the tongs from below. 2) according to Tsovyanov - after inserting the spoons and closing the forceps, the second and third fingers of both hands, bent with a hook, grasp the outer and upper surfaces of the instrument at the level of the Bush hooks. The main phalanges of the index fingers are located on the outer surface of the handles, with the Bush hooks passing between the main phalanges of the index and middle fingers. The fourth and fifth fingers grasp parallel forceps. The thumbs are under the handles of the tongs.

Rice. 6. Traction itself

Tractions are performed along the axis of the birth canal, taking into account the biomechanism of labor and the nature of the operation (abdominal or exit). Tractions are performed in a horizontal direction and upward (in 2 positions). The amount of traction depends on the position of the head in the cavity or at the pelvic outlet.

Removing the head before the parietal tubercles erupt, the spoons of the forceps are removed using the method described above in the reverse order (Figure 7 a, b).

“Obstetric forceps” is the conventional name for the operation of extracting the fetus by applying special forceps to the presenting part.

In the Soviet Union, the Simpson-Fenomenov model of forceps was most common (see).

Indications. The application of obstetric forceps is indicated when a quick end to labor is required in the interests of the mother or the fetus, more often than both of them (threatening labor, weakness of labor during the expulsion period, switching off pushing, etc. Conditions for the operation: sufficient pelvic size (true conjugate at least 8 cm) ; full opening of the uterine pharynx; motionless head, standing in a place convenient for application of obstetric forceps; sufficient size of the head (should not be too large or too small); torn; alive (the latter is conditional).

Preparing for surgery. Obstetric forceps are applied with the woman in the supine position on or on the Rakhmanov bed; The legs should be brought to the stomach, held by an assistant (or they are held with a leg holder). Before the operation, the woman needs to empty her bladder and bowels (cleansing enema). Toilet the external genitalia. Obstetric forceps are applied, usually under anesthesia.

Types of obstetric forceps. Depending on where in the pelvis (in the inlet, cavity or outlet) the fetal head is located, exit or typical obstetric forceps are distinguished [the head, having completed rotation (internal rotation), is located at the bottom of the pelvis, it is better if it is at the exit]; cavity, or atypical (the head in the pelvic cavity with incomplete rotation), and the so-called high (the height of atypicality) obstetric forceps (the head, with the help of forceps, must go through the entire mechanism of childbirth). The application of high forceps is not performed in routine obstetric practice.

Technique for applying output (typical) obstetric forceps. The exit obstetric forceps are applied by an obstetrician. Before applying obstetric forceps, it is necessary to first perform a thorough vaginal examination of the woman in labor (to determine the degree of opening of the uterine pharynx, the condition of the amniotic sac, the position of the sagittal suture and fontanelles). If you have insufficient knowledge of the technique, it is necessary to perform a vaginal examination with a half-hand (thumb outside the genital opening).

The exit forceps are placed on the head, which has performed all the rotating movements: the small fontanel is located under the symphysis, the sagittal suture is in the direct size of the pelvic outlet, the head is on the bottom of the pelvis, performing the entire sacral cavity. Output (typical) forceps are applied in the transverse dimension of the pelvis and on the transverse (biparietal) dimension of the head.

Introduction of spoons. The left spoon is always inserted first. When closing the forceps, it should lie under the right one (otherwise closing will be difficult). In order not to make a mistake in choosing a spoon, before insertion you should fold the forceps and, holding the handles with both hands, place them in front of you so that both spoons are next to each other: the left one is on the left, the right one is on the right (Fig. 1). The spoon is taken with the left hand, held like a pen or bow (you cannot grab the spoon with your entire hand, as this can develop great force and cause injury to the mother and fetus). Before inserting the left tray, four (not two) fingers of the right hand (control hand) are inserted to control and protect the soft tissues. The fingers of the control hand must be inserted so that they extend beyond the parietal tubercles of the fetal head.

Rice. 1. Tongs and folded.

Grasping the handle of the left spoon with your left hand, place its lower edge in the groove between the middle and index fingers. The back of the lower edge of the spoon rests on the extended thumb. The end of the spoon (its top) should be directed forward, towards the mother. The handle of the spoon should be held in an elevated, close to vertical position, parallel to the right inguinal fold of the woman in labor.

The forward movement of the spoon of the tongs should be carried out mainly due to the force of its gravity; Progress can be partly helped by placing the thumb of the control right hand on the outside (lightly pushing on the lower edge of the spoon) and the same light and careful pushing of the handle. With the remaining fingers of the right (control) hand, inserted inside, direct the spoon of the forceps forward so that it rests on the head from the side, in the plane of the transverse dimension of the pelvic outlet. The correct position of the inserted spoon in the pelvis can be judged by Busch hooks: they must stand strictly in the transverse dimension of the pelvic outlet.

The spoon must certainly go beyond the ends of the fingers of the control hand, that is, beyond the parietal tubercle. The spoon must be inserted with great care, easily, without any force.

The handle of the inserted spoon is passed to an assistant, who must hold it in this position. Any use of a spoon can lead to complications in the future.

The right spoon of obstetric forceps is inserted in the same way as the left one: with the right hand - to the right side, under the protection of the fingers inserted into the left hand. The right spoon of the tongs should always lie above the left. It is more difficult to insert the right spoon than the left one. This is often explained by the fact that the handle of the left spoon is not lowered down enough, towards the perineum. [The expressions “anterior”, “posterior”, “right”, “left” are applied to the vertical (“standing”) position of a woman: “anterior” - to the symphysis, “posterior” - to the sacrum, “right”, “left” - to the side of the woman in labor, regardless of the position of the doctor.]
Closing (closing) obstetric forceps. Before closing the obstetric forceps, you need to check whether the skin of the perineum or the vaginal mucosa is caught in the lock. For proper closure, the handles of the pliers must lie in the same plane and parallel.

Test traction. To ensure that traction is applied correctly. To do this, the left hand should be placed on top of the right; her extended index finger should be in contact with the fetal head in the area of the small fontanelle (Fig. 2). During traction, the head should follow the forceps and the index finger of the left hand.

The head is removed using obstetric forceps (traction itself) while standing. With the right hand, located on the handle and in the area of the Bush hooks, energetic attraction (traction) is applied. The left hand should be placed on top, with the index finger in the recess located near the lock. In this position, it provides energetic assistance to the right during traction. The forceps together with the head should move along the wire line of the pelvis, that is, change direction, gradually moving forward and upward (along an arc). Traction is performed along an arc until the back of the head and the suboccipital fossa appear. It is not allowed to do joint traction with four hands (two at once or in shifts, one after the other). If 8-10 tractions do not give success, further tractions should be abandoned. When removing the head with forceps, you need to imitate natural contractions, alternating traction with pauses. Each traction begins slowly, gradually increasing its strength and, having reached a maximum, goes into a pause, reducing the strength of traction. Pauses should be long enough.

Rice. 2. Test traction.

When extracting the head using forceps, you should not make any rocking, rotating, or pendulum-like movements - in which direction the traction began, it should be completed. To prevent unnecessary, sometimes excessive squeezing of the head, it is recommended to place a towel folded in several layers between the handles of the spoons of the tongs.

Passing the head under the symphysis and removing it. The head is passed under the pubic arch so that it rolls over the suboccipital fossa (rotation point). In this case, the head moves from a bent position to an extension position (Fig. 3). Traction is done in a horizontal direction until the back of the head appears and the suboccipital fossa reaches the lower edge of the symphysis. At this moment, they begin to remove the head. To do this, stand on the right side of the woman in labor, grab the forceps with your left hand, and protect the perineum with your right while the head is cutting through. Carefully, slowly, centimeter by centimeter, slightly pulling the head with tongs, lift the handle of the tongs upward.

Rice. 3. Removal of the head.

Removing the forceps (opening). The forceps are removed after the head is outside the genital slit (birth of the head). They are carefully opened by pushing both spoons apart. Each spoon is taken in the same hand and removed in the same way as they were applied, but in the reverse order, that is, the right spoon, describing an arc, is taken to the left groin fold, the left - to the right. The spoons should slide smoothly, without jerking. After removing the head, the fetal body is removed according to the general rules (see).

Cavity forceps, or atypical ones, can only be applied by an obstetrician. In these cases, forceps are applied to the head, which is located almost at the bottom of the pelvis. In the forceps, the head must complete internal rotation (rotation), cutting and cutting. When the head is positioned in an oblique size of the pelvis, forceps are applied only in an oblique size. When applying them, the same rules apply as when applying exit forceps; it is only important to accurately determine which of the oblique dimensions of the pelvis (right or left) the fetus is located in. On the head, standing with an arrow-shaped suture in one of the oblique dimensions, forceps are applied in the opposite oblique dimension. The second feature of applying forceps to the head, which is located in the oblique size of the pelvis, concerns the technique of inserting spoons. One spoon is inserted behind the head and left here - this is the back, or fixed, spoon. Another spoon is first inserted from behind, and then a 90° arc is made to reach the parietal tubercle lying in front. This is the so-called wandering spoon. Depending on the position of the arrow-shaped seam, either the right or the left spoon will be fixed (back): in the first (left) position (arrow-shaped seam in the right oblique size), the left spoon will be fixed, in the second (right) position (arrow-shaped seam in the left oblique size ) - right. The spoons should be placed so that their ends are always facing the wire point (forward).

Management of the postpartum mother and newborn after applying forceps. After the application of obstetric forceps, injuries and ruptures of the cervix, vagina, perineum, etc. often occur, so after childbirth it is necessary to carefully examine the soft birth canal. Tears must be sewn up.

Currently, a new delivery device has been introduced into obstetric practice - a vacuum extractor (see), which is more gentle and gentle than obstetric forceps.

After childbirth, a woman must follow a regimen as after an obstetric operation (see). A child sent to the nursery should receive the same care as children born after a difficult birth or surgery receive (see).

Obstetric forceps are an instrument that replaces the missing or missing force of uterine contractions during childbirth. Obstetric forceps serve as an extension of the obstetrician’s hands (“iron hands” of the obstetrician).

The application of obstetric forceps is one of the most important and responsible operations in the practice of an obstetrician. In terms of technical difficulty, the operation occupies one of the first places in operative obstetrics. When applying obstetric forceps, various injuries and complications are possible.

Device of obstetric forceps - see Obstetric and gynecological instruments. The most common model in the USSR is the English Simpson obstetric forceps modified by N. N. Fenomenov. In some obstetric institutions, Russian obstetric forceps by I.P. Lazarevich are used - without pelvic curvature (straight forceps) and with non-crossing spoons (forceps with parallel spoons); Kielland obstetric forceps (a widely used model abroad) are built according to the type of forceps of I.P. Lazarevich.

The main action of obstetric forceps is purely mechanical: compression of the head, straightening and extraction. Compression of the head, inevitable when applying forceps, should be minimal, in any case not exceed that observed during childbirth with the natural configuration of the head. Otherwise, the bones, blood vessels and nerves of the fetal head will inevitably suffer. Obstetric forceps are only a grasping and attracting instrument, but in no way correct incorrect presentation and insertion of the head.

Indications and contraindications. Previously, obstetric forceps were applied at the personal discretion of the obstetrician, but now certain indications for their application have been developed. Obstetric forceps are applied in cases where it is necessary to quickly complete childbirth in the interests of the mother, the fetus, or both together: with eclampsia, premature placental abruption, umbilical cord prolapse, incipient fetal asphyxia, maternal diseases complicating the course of the expulsion period (heart defects, nephritis), febrile condition, etc. In case of secondary weakness of labor, obstetric forceps are used in cases where the period of expulsion in first-time mothers lasts more than 2 hours. (3-4 hours), and for multiparous women - more than an hour.

It is necessary to strictly take into account contraindications to the use of obstetric forceps. They arise from the following conditions under which this operation can be used: the pelvis is sufficiently large to allow the head to pass through - the true conjugate must be at least 8 cm; the fetal head should be neither excessively large (hydrocephalus, severe post-term pregnancy) nor too small (forceps should not be applied to the head of a fetus less than 7 months old); the head should stand in the pelvis in a position convenient for applying obstetric forceps (a movable head is a contraindication); the cervix should be smoothed, the uterine os should be fully open, its edges should extend beyond the head; the amniotic sac must be ruptured; the fetus must be alive.

Among the listed conditions, the height of the head in the pelvis is especially important. For practical work, you can use the following diagram for determining the location of the head. 1. The head stands above the entrance to the small pelvis (Fig. 1), easily moves when pushed, returning back (balloting). Application of forceps is contraindicated. 2. The head entered the pelvis as a small segment (Fig. 2). Its largest circumference (biparietal diameter) is located above the entrance to the pelvis. The cervico-occipital groove stands three transverse fingers above the symphysis; the head has limited mobility, slightly fixed. During vaginal examination, the promontory is accessible to the examining finger; sagittal suture - in the transverse or slightly oblique size of the pelvis. Forceps should also not be used. 3. The head is at the entrance to the pelvis with a large segment (Fig. 3); with a biparietal diameter it passed the entrance to the pelvis, motionless; The cervico-occipital groove stands two fingers above the symphysis. During vaginal examination, the promontory cannot be reached; the head is occupied in front - the upper edge and the upper third of the posterior surface of the pubic symphysis, in the back - the promontory and the inner surface of the first sacral vertebra. The arrow-shaped seam is in one of the oblique sizes, sometimes closer to the transverse one. The wire point almost reaches the line of the main plane passing through the lower edge of the symphysis. It is not recommended to use forceps, especially for a novice obstetrician (high forceps). 4. The head is in the wide part of the pelvic cavity (Fig. 4); its greatest circumference passed the plane of the wide part of the cavity, the cervico-occipital groove - approximately one finger above the symphysis. During vaginal examination, the ischial spines are reachable, the sacral cavity is almost complete, the promontory cannot be reached. The wire point almost reaches the spinal line, the sagittal suture is oblique. The III and IV sacral vertebrae and coccyx can be easily palpated. Application of forceps is permitted (atypical forceps, difficult operation). 5. The head is in the narrow part of the pelvic cavity (Fig. 5); It is not defined above the entrance to the pelvis (the cervico-occipital groove is level with the height of the symphysis). During vaginal examination, the ischial spines are not identified, the sacrococcygeal joint is free. The head comes close to the pelvic floor, its biparietal size occupies the plane of the narrow part of the pelvic cavity. Small fontanelle (wire point) - below the spinal line; the head has not yet completely completed rotation, the sagittal suture is in one of the oblique dimensions of the pelvis, closer to the straight one. Forceps may be applied. 6. Head at the pelvic outlet (Fig. 6). It and its cervico-occipital groove above the entrance to the pelvis are not defined. The head has completed internal rotation (rotation), the sagittal suture is in the direct size of the pelvic outlet. Favorable conditions for applying forceps (typical forceps).

In post-Soviet countries, obstetric forceps are prejudiced and considered to be a relic of the past. Typically, women are afraid of using forceps during childbirth, as they think that this leads to mental retardation and cerebral palsy (CP). But modern research has shown that forceps are not the cause of cerebral palsy.

Of course, the use of forceps during childbirth is a surgical intervention and it can be accompanied by a number of complications, but with the correct actions of the doctor, this rarely happens.

Obstetric forceps have been used for a long time; already in 1600, a child was born in England with their help. However, since then, forceps have changed a lot; more than 700 types of them have been created. The technique of applying forceps has also improved.

Today, several models of obstetric forceps are used: abdominal, exit, high, Simpson, Barton forceps and others. Models of tongs differ in the type of spoons and locking device.

If the fetus is already low enough, then special forceps are used, which are inserted nearby. When applying “low” forceps, the likelihood of injury and complications is much lower than if a standard instrument is used.

Method of using obstetric forceps.

To use forceps, certain conditions must be met (full opening of the cervix, absence of membranes, certain position of the fetus).

Before applying forceps, the size and position of the fetus and the degree of insertion of the head into the pelvis are determined. Anesthesia, local or epidural anesthesia is required. An episiotomy is often required - cutting the perineum. During the operation, the fetal heart rate is continuously recorded.

The mechanism of applying forceps is that the fetal head is tightly grasped and, with the help of practiced professional movements, is carried through the birth canal. The design of the spoons and the lock between them allow you not to squeeze the head too much so as not to harm the baby.

Indications for the use of forceps during childbirth.

First of all, forceps are used if it is necessary to quickly remove the child, for example, in case of oxygen starvation (hypoxia). Cm. "".

If you need to exclude or shorten the second period of pushing, for example, in case of cardiovascular diseases of the mother.

Using forceps, you can turn the fetus, which is in an awkward position, and gently remove the head during breech presentation.

Consequences of using forceps during childbirth.

The consequences of using forceps during childbirth for the mother can be complicated by bleeding, bruising, and rupture of the birth canal, but this also happens with a natural birth.

The consequences of using forceps during childbirth for a child depend on whether “low” or standard forceps are used, as well as on the qualifications and experience of the doctor. Although forceps sometimes injure a child, these injuries are very rarely serious.

In particular, there may be such consequences of using forceps.

Scratches, bruises and bruises on the child’s face and head.

Cephalohematomas are hemorrhages between the bones of the skull and the periosteum. If the cephalohematoma is small, it usually resolves on its own within 1-2 weeks. In some cases, a puncture (blood suction) is required.

Damage to the eyes of the facial nerve, brachial plexus, and skull fractures are extremely rare.

Research has shown that the use of forceps during childbirth is not a cause of cerebral palsy.

If the doctor has extensive experience in applying forceps, injury to the child is unlikely. Today, abdominal forceps are rarely used; mostly “low” or exit forceps are used, which are used only when the fetal head has already reached the exit from the birth canal. In this case, the likelihood of serious injury to the child is low.

In general, applying forceps is a complex manipulation that requires skills and sufficient experience from the doctor. In the West, forceps are still used quite often, and thanks to the improved technology of their use, complications are rare.

But since caesarean sections have become safer over the past twenty to thirty years, some modern doctors do not use forceps, but do caesarean sections. There are fewer and fewer specialists left who know how to work with forceps.

In post-Soviet countries, many doctors simply do not have sufficient experience in applying forceps, so they prefer to perform surgery. But cesarean section is not always safer than forceps. A cesarean section increases the risk of complications such as fever, blood clots, and bleeding.

Despite the fact that a caesarean section saves the lives of many babies, it is not a panacea and does not exclude injuries to the child. If obstetric forceps are used correctly and according to indications, then they are much safer than cesarean section.

As an alternative to forceps, the doctor can use a vacuum extractor to remove the baby from the birth canal. It is believed that vacuum extraction is less likely to cause injury to the mother, but is more likely to injure the child. Cm." " ".

In principle, the application of obstetric forceps and vacuum extraction of the fetus during childbirth are interchangeable procedures. The choice often depends on which technique the doctor is better at.