What is the window hole for in obstetric forceps? Application of obstetric forceps - indications, contraindications and complications

OPERATION OF APPLYING OBSTETRIC FORCEPS

Obstetric forceps called an instrument designed to extract a live, full-term fetus by the head.

Application of obstetric forcepsis a delivery operation in which a live, full-term fetus is removed through the natural birth canal using obstetric forceps.

Obstetric forceps were invented by the Scottish physician Peter Chamberlain (died 1631) in late XVI centuries. For many years, obstetric forceps remained a family secret, passed down from generation to generation, as they were the object of profit for the inventor and his descendants. The secret was later sold for a very high price. 125 years later (1723), obstetric forceps were “reinvented” by the Geneva anatomist and surgeon I. Palfin (France) and immediately made public, so priority in the invention of obstetric forceps rightfully belongs to him. The tool and its application quickly became widespread. In Russia, obstetric forceps were first used in 1765 in Moscow by Moscow University professor I.F. Erasmus. However, the credit for introducing this operation into everyday practice inherently belongs to the founder of Russian scientific obstetrics, Nestor Maksimovich Maksimovich (Ambodik, 1744-1812). He outlined his personal experience in the book “The Art of Weaving, or the Science of Women’s Business” (1784-1786). According to his drawings, instrumental maker Vasily Kozhenkov (1782) made the first models of obstetric forceps in Russia. Subsequently, domestic obstetricians Anton Yakovlevich Krassovsky, Ivan Petrovich Lazarevich, Nikolai Nikolaevich Fenomenov made a great contribution to the development of the theory and practice of the operation of applying obstetric forceps.

DEVICE OF OBSTETRIC FORCEPS

Obstetric forceps consist of two symmetrical parts - branches, which may have differences in the structure of the left and right parts of the castle. One of the branches, which is grabbed with the left hand and inserted into the left half of the pelvis is called left branch. Another branch - right.

Each branch has three parts: spoon, lock element, handle .

Spoon is a curved plate with a wide cutout - window. The rounded edges of spoons are calledribs(top and bottom). The spoon has special shape, which is dictated by the shape and size of both the fetal head and the pelvis. The spoons of obstetric forceps do not have a pelvic curvature (straight Lazarevitz forceps). Some models of forceps also have a perineal curvature in the area where the spoons and handles connect (Kieland, Piper).Head curvature - this is the curvature of the spoons in the frontal plane of the forceps, reproducing the shape of the fetal head. Pelvic curvature - this is the curvature of the spoons in the sagittal plane of the forceps, corresponding in shape to the sacral cavity and to a certain extent to the wire axis of the pelvis.

Lock serves to connect the branches of the forceps. The design of the locks is not the same in different models of tongs. A distinctive characteristic is the degree of mobility of the branches connected by it:

Russian tongs (Lazarevich) - the lock is freely movable;

English tongs (Smellie) - the lock is moderately movable;

German tongs (Naegele) - the lock is almost motionless;

-French tongs (Levret) - the lock is motionless.

Lever serves for gripping the forceps and producingtractions. It has smooth internal surfaces, and therefore, when the branches are closed, they fit tightly to each other. The outer surfaces of the parts of the forceps handle have a corrugated surface, which prevents the surgeon’s hands from slipping when performing traction. The handle is made hollow to reduce the weight of the tool. At the top outer surface the handles have side projections calledbush hooks. When performing traction, they provide reliable support for the surgeon’s hand. In addition, Bush hooks make it possible to judge the incorrect application of obstetric forceps if, when closing, the branches of the hook are not located opposite each other. However, their symmetrical arrangement cannot be a criterion for the correct application of obstetric forceps. The plane in which the Bush hooks are located after inserting the spoons and closing the lock corresponds to the size in which the spoons themselves are located (transverse or one from the oblique dimensions of the pelvis).

In Russia, forceps are most often used Simpson-Fenomenov. N.N. Fenomenov made an important change to the Simpson design, making the lock more movable. The mass of this model of forceps is about 500 g. The distance between the most distant points of the head curvature of the spoons when closing the forceps is 8 cm, the distance between the tops of the spoons is 2.5 cm.

MECHANISM OF ACTION

The mechanism of action of obstetric forceps includes two moments of mechanical effect (compression and attraction). The purpose of the forceps is to tightly grasp the fetal head and replace the expelling force of the uterus and abdominals the attractive force of the doctor. Hence, obstetric forceps are only attractive instrument, but not a rotary or compression one. However, the known compression of the head during its extraction is nevertheless difficult to avoid, but this is a disadvantage of the forceps, and not their purpose. There is no doubt that during the process of traction, obstetric forceps perform rotational movements, but exclusively following the movement of the fetal head, without disturbing the natural mechanism of childbirth. Therefore, in the process of removing the head, the doctor should not interfere with the rotations that the fetal head will make, but, on the contrary, facilitate them. Forced rotational movements with forceps are unacceptable, since incorrect positions of the head in the pelvis are not created without reason. They arise either due to anomalies in the structure of the pelvis, or due to the special structure of the head. These causes are persistent, anatomical and cannot be eliminated by the use of obstetric forceps. The point is not at all that the head does not turn, but that there are conditions that exclude both the possibility and the necessity of turning at a given time. Forcible correction of the position of the head in this situation inevitably leads to to birth trauma of mother and fetus.

INDICATIONS

Indications for the operation of applying obstetric forceps arise in situations where conservative continuation of labor is impossible due to the danger of serious complications for both the mother and the fetus, up to fatal outcome. During the period of expulsion, if appropriate conditions are present, these situations can be completely or partially eliminated by surgical delivery by applying obstetric forceps. Indications for surgery can be divided into two groups: indications from the mother and indications from the fetus. And indications from the mother can be divided into indications related to pregnancy and childbirth ( obstetric indications) and indications related to extragenital diseases of a woman that require “switching off” pushing (somatic indications). A combination of the two is often observed.

Indications for the operation of applying obstetric forceps are as follows:

-Indications from the mother:

- obstetric indications:

severe forms of gestosis (preeclampsia, eclampsia, severe hypertension, refractory to conservative therapy) require the exclusion of pushing and straining of the woman in labor;
persistent weakness of labor and/or weakness of pushing, manifested by standing of the fetal head in one plane of the pelvis for more than 2 hours, with no effect from use medications. Prolonged standing of the head in one plane of the small pelvis leads to an increased risk of birth trauma for both the fetus (a combination of mechanical and hypoxic factors) and the mother (genitourinary and intestinal-genital fistulas);
bleeding in the second stage of labor, caused by premature detachment of a normally located placenta, rupture of the umbilical cord vessels during their membrane attachment;
endometritis during childbirth.

Somatic indications:

illnesses of cardio-vascular system in the stage of decompensation;
breathing disorders due to lung disease;
high myopia;
acute infectious diseases;
severe forms of neuropsychiatric disorders;
intoxication or poisoning.
-Indications from the fetus:

fetal hypoxia, developing as a result various reasons in the second stage of labor (premature abruption of a normally located placenta, weakness of labor, late gestosis, short umbilical cord, entanglement of the umbilical cord around the neck, etc.).
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).

Once again, I would like to emphasize that in most cases there is a combination of the listed indications that require emergency termination of labor. Indications for the operation of applying obstetric forceps are not specific to this operation; they may also be an indication for other delivery operations ( C-section, vacuum extraction of the fetus). The choice of delivery operation fully depends on the presence of certain conditions that allow a specific operation to be performed, therefore, in each case, their careful assessment is necessary to the right choice method of delivery.

To perform the operation of applying obstetric forceps, certain conditions are necessary to ensure the most favorable outcome for both the woman in labor and the fetus. If one of these conditions is not present, then surgery is contraindicated.



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

-Full opening of the uterine os. Failure to comply with this condition will inevitably lead to rupture of the cervix and lower segment uterus.

-Absence of amniotic sac. If the amniotic sac is intact, it should be opened.

-The fetal head should correspond to the average size of the head of a full-term fetus. Obstetricians formulate this condition somewhat differently: the fetal head should not be too large or too small. An increase in this parameter occurs with hydrocephalus, a large or giant fetus. Decreased in a premature fetus. This is due to the size of the forceps, which are calculated for the average size of the head of a full-term fetus. The use of obstetric forceps without taking this condition into account becomes traumatic for the fetus and the mother.

-Correspondence between the sizes of the mother's pelvis and the fetal head. With a narrow pelvis, forceps are a very dangerous instrument, so their use is contraindicated.

-The fetal head should be located at the outlet of the small pelvis with a sagittal suture in a straight dimension or in the pelvic cavity with a sagittal suture in one of the oblique dimensions. Accurate determination of the position of the fetal head in the pelvis is possible only with a vaginal examination, which must be performed before applying obstetric forceps.

Depending on the position of the head, there are:

Exit forceps (Forceps minor) - typical . Outlets are called forceps applied to the head, which stands as a large segment in the plane of the outlet of the small pelvis (on the pelvic floor), while the sagittal suture is located in a straight dimension.

Abdominal obstetric forceps (Forceps major) - atypical. Cavity forceps are called forceps applied to the head located in the pelvic cavity (in its wide or narrow part), while the arrow-shaped suture is located in one of the oblique dimensions.

High obstetric forceps ((Forceps alta)placed on the fetal head, which stood as a large segment at the entrance to the pelvis. Application of high forceps was technically difficult and dangerous operation, often leading to severe birth trauma for mother and fetus. Currently not used.

The operation of applying obstetric forceps can be performed only if all of the above conditions are present. An obstetrician, when starting to apply obstetric forceps, must have a clear understanding of the biomechanism of childbirth, which will have to be artificially imitated. It is necessary to clearly understand which moments of the biomechanism of labor the fetal head has already completed, and which it will have to accomplish during traction.

PREPARATION FOR OPERATION

Preparation for the operation of applying obstetric forceps includes several points (choosing a method of anesthesia, preparing the woman in labor, preparing the obstetrician, vaginal examination, checking the forceps).

Choosing a pain relief method determined by the woman’s condition and indications for surgery. In cases where the woman's active participation in childbirth seems appropriate (weakness of labor and/or intrauterine fetal hypoxia in a somatically healthy woman), the operation can be performed using long-term epidural anesthesia (DPA), pudendal anesthesia or inhalation of nitrous oxide with oxygen. However, when applying abdominal obstetric forceps to somatically healthy women It is advisable to use anesthesia, since placing spoons on the head located in the pelvic cavity is a difficult moment of the operation, requiring the elimination of resistance of the pelvic floor muscles.

In women in labor for whom pushing is contraindicated, the operation is performed under anesthesia. At initial arterial hypertension The use of anesthesia with nitrous oxide and oxygen with the addition of fluorothane vapor in a concentration not exceeding 1.5 vol.% is indicated. Ftorotan inhalation is stopped when the fetal head is removed to the parietal tubercles. In a woman in labor with initial arterial hypo- and normotension, anesthesia with seduxen in combination with ketalar at a dose of 1 mg/kg is indicated.

Anesthesia should not be terminated after removing the child, since even with exit forceps, the operation of applying obstetric forceps is always accompanied by a control manual examination of the walls of the uterine cavity.

The operation of applying obstetric forceps is carried out in the position of the woman in labor on her back, with her legs bent at the knee and hip joints. Before surgery bladder must be emptied. The external genitalia and inner thighs are treated with a disinfectant solution. Obstetricians treat their hands as for surgical operations.

Immediately before applying forceps, it is necessary to carry out a thorough vaginal examination (half-handed) in order to confirm the presence of conditions for the operation and determine the location of the head in relation to the planes of the pelvis. Depending on the position of the head, it is determined which type of operation will be used (abdominal or exit obstetric forceps). Due to the fact that when removing the fetal head using forceps, the risk of perineal rupture increases, the application of obstetric forceps should be combined with episiotomy.

OPERATIONAL TECHNIQUE

The technique of applying obstetric forceps includes the following points.

Insertion of spoons

When inserting spoons of obstetric forceps, the doctor should follow the first "triple" rule (rule of three “lefts” and three “rights”): left spoon left inserted by hand into left side of the pelvis, similarly, right spoon right hand in right side of the pelvis. The handle of the tongs is grabbed in a special way: by type writing pen(the index and middle fingers are placed at the end of the handle opposite the thumb) or by type bow(opposite the thumb along the handle there are four others widely spaced). Special view gripping the spoons with forceps allows you to avoid the application of force during its insertion.

The left spoon of the forceps is inserted first. Standing, the doctor inserts four fingers of the right hand (half-hand) into the vagina into the left half of the pelvis, separating the fetal head from the soft tissues of the birth canal. The thumb remains outside. Taking the left branch of the forceps with your left hand, the handle is retracted to right side, placing it almost parallel to the right groin fold. The top of the spoon is pressed against the palmar surface inserted into the vagina of the hand, so that the lower edge of the spoon is located on the fourth finger and rests on the abducted thumb. Then, carefully, without any effort, the spoon is moved between the palm and the fetal head deep into the birth canal, placing the lower edge between the third and fourth fingers of the right hand and resting on the bent thumb. In this case, the trajectory of movement of the end of the handle should be an arc. Advancement of the spoon into the depths of the birth canal should be accomplished due to the instrument’s own gravity and by pushing the lower edge of the spoon with 1 right finger hands. Half hand located in birth canal, is a guide hand and controls the correct direction and position of the spoon. With its help, the obstetrician makes sure that the top of the spoon is not directed into the fornix, onto the side wall of the vagina and does not capture the edge of the cervix. After inserting the left spoon, it is handed over to the assistant to avoid displacement. Next, under the control of the left hand, the obstetrician inserts the right branch into the right half of the pelvis with the right hand in the same way as the left branch.

Correctly applied spoons are located on the fetal head according to "second" triple rule . The length of the spoons is on the fetal head along a large oblique size (diameter mento-occipitalis) from the back of the head to the chin; the spoons grasp the head in the greatest transverse dimension in such a way that the parietal tubercles are located in the windows of the spoons of the forceps; the line of the forceps handles faces the leading point of the fetal head.

Closing the forceps

To close the pliers, each handle is grabbed with the same hand so that the first fingers of the hands are located on the Bush hooks. After this, the handles are brought together and the tongs are easily closed. Correctly applied forceps lie across the sagittal suture, which occupies a mid-position between the spoons. The lock elements and bush hooks should be located at the same level. When closing correctly applied forceps, it is not always possible to bring the handles together; this depends on the size of the fetal head, which is often more than 8 cm (the greatest distance between the spoons in the area of ​​the cephalic curvature). In such cases, a sterile diaper folded 2-4 times is placed between the handles. This prevents excessive compression of the head and a good fit of the spoons to it. If the spoons are not symmetrically positioned and a certain force is required to close them, it means that the spoons are not applied correctly, they need to be removed and reapplied.

Test traction

This necessary moment allows you to ensure that the forceps are applied correctly and that there is no risk of them slipping. It requires a special positioning of the obstetrician's hands. To do this, the doctor covers the handles of the forceps from above with his right hand so that the index and middle fingers lie on the hooks. He places his left hand on the back surface of his right, with an outstretched middle finger should touch the fetal head in the area of ​​the leading point. If the forceps are positioned correctly on the fetal head, then during test traction the fingertip will always be in contact with the fetal head. Otherwise, it moves away from the head, which indicates that the forceps are not applied correctly and, in the end, they will slip off. In this case, the forceps must be applied again.

Traction proper (extraction of the head)

After trial traction, making sure that the forceps are applied correctly, they begin their own traction. For this, the index finger and ring fingers the right hand is placed on top of the Bush hooks, the middle one is between the diverging branches of the forceps, the thumb and little finger cover the handle on the sides. With your left hand, grab the end of the handle from below. There are other ways to grab the forceps: by Tsovyanov, attraction to Osiander(Osiander).

When removing the head with forceps, it is necessary to take into account the nature, strength and direction of traction. Traction of the fetal head with forceps should imitate natural contractions. To do this you should:

Imitate a contraction by force: start tractions not sharply, but with a weak pull, gradually strengthening them and weakening them again towards the end of the contraction;

When performing traction, do not develop excessive force by tilting your torso back or resting your foot on the edge of the table. The obstetrician's elbows should be pressed to the body, which prevents the development of excessive force when removing the head;

Between tractions it is necessary to pause for 0.5-1 minutes. After 4-5 tractions, the forceps are opened for 1-2 minutes to reduce the pressure on the head;

Try to perform traction simultaneously with contractions, thus strengthening the natural expulsion forces. If the operation is performed without anesthesia, the woman in labor must be forced to push during traction.

Rocking, rotating, pendulum-like movements are unacceptable. It should be remembered that forceps are a drag tool; traction should be performed smoothly in one direction.

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. The direction of traction is determined third "triple" rule - it is fully applicable when applying forceps to the head located in the wide part of the pelvic cavity (cavitary forceps);

The first direction of traction (from the wide part of the pelvic cavity to the narrow) - down and back , according to the wire axis of the pelvis*;

The second direction of traction (from the narrow part of the pelvic cavity to the outlet) - downwards and anteriorly ;

- third direction of traction (extraction of the head in forceps) - anteriorly .

*Attention! The direction of traction is indicated relative to an upright woman.

Removing the forceps

The fetal head can be removed using forceps or manually after removing the forceps, which is carried out after cutting through the largest circumference of the head. To remove the tongs, take each handle with the same hand, open the spoons and remove them in reverse order: first - right spoon, while the handle is taken to the inguinal fold, the second is the left spoon, its handle is taken to the right inguinal fold. You can remove the head without removing the forceps as follows. The obstetrician stands to the left of the woman in labor and grabs the forceps with his right hand in the lock area; The left hand is placed on the perineum to protect it. Traction is directed more and more anteriorly as the head extends and cuts through the vulvar ring. When the head is completely removed from the birth canal, open the lock and remove the forceps.

DIFFICULTIES ARISING WHEN APPLYING OBSTETRIC FORCEPS

Difficulties in inserting spoons may be associated with the narrowness of the vagina and rigidity of the pelvic floor, which requires dissection of the perineum. If it is not possible to insert the guide hand deeply enough, then in such cases the hand must be inserted somewhat posteriorly, closer to the sacral cavity. In the same direction, insert the spoon with forceps; in order to position the spoon in the transverse dimension of the pelvis, it must be moved using a guide hand, acting on the posterior edge of the inserted spoon. Sometimes the spoon of the forceps encounters an obstacle and does not move deeper, which may be due to the top of the spoon getting into the fold of the vagina or (which is more dangerous) into its fornix. The spoon must be removed and then reinserted with careful control of the fingers of the guide hand.

Difficulties may also occur when closing the forceps. The lock will not close if the spoons of the tongs are not placed on the head in the same plane or one spoon is inserted higher than the other. In this situation, it is necessary to insert your hand into the vagina and correct the position of the spoons. Sometimes, when the lock is closed, the handles of the forceps diverge greatly; this may be due to insufficient depth of insertion of the spoons, poor coverage of the head in an unfavorable direction, or excessive size of the head. In case of insufficient insertion depth spoons, their tops put pressure on the head and when trying to squeeze the spoons, severe damage fetus up to a fracture of the skull bones. Difficulties in closing the spoons also arise in cases where the forceps are applied not transversely, but in an oblique and even fronto-occipital direction. Incorrect position of the spoons is associated with errors in diagnosing the location of the head in the small pelvis and the location of the sutures and fontanelles on the head, so repeated vaginal examination and insertion of spoons is necessary.

Lack of head advancement during traction may depend on their incorrect direction. Traction should always correspond to the direction of the wire axis of the pelvis and the biomechanism of childbirth.

With traction it can happen slipping of the forceps - vertical(through the head outwards) or horizontal(forward or backward). The reasons for the forceps slipping are improper grip of the head, improper closure of the forceps, and inappropriate dimensions of the fetal head. Slipping of the forceps is dangerous due to the occurrence of serious damage to the birth canal: ruptures of the perineum, vagina, clitoris, rectum, bladder. Therefore, at the first signs of the forceps slipping (increasing the distance between the lock and the fetal head, divergence of the forceps handles), it is necessary to stop traction and remove the forceps and apply them again if there are no contraindications for this.

OUTPUT OBSTETRIC FORCEPS

Anterior view of occipital presentation. The internal rotation of the head is completed. The fetal head is located on the pelvic floor. The sagittal suture is located in the direct dimension of the pelvic outlet, the small fontanel is located in front of the womb, the sacral cavity is completely filled with the fetal head, the ischial spines do not reach. The forceps are applied in the transverse dimension of the pelvis. The handles of the tongs are located horizontally. Traction is applied in a downward-posterior direction until the occipital protuberance emerges from under the pubis, then the head is extended and removed.

Posterior view of occipital presentation. The internal rotation of the head is completed. The fetal head is located on the pelvic floor. The sagittal suture is in the direct size of the exit, the small fontanel is located at the coccyx, the posterior corner of the large fontanel is under the pubis; The small fontanel is located below the large one. The forceps are applied in the transverse dimension of the pelvis. Traction is performed in the horizontal direction (downwards) until the anterior edge of the greater fontanelle comes into contact with the lower edge of the symphysis pubis (the first point of fixation). Then traction is performed anteriorly until the area of ​​the suboccipital fossa is fixed at the apex of the coccyx (second point of fixation). After this, the handles of the forceps are lowered posteriorly, the head is extended and the fetus is born from under the pubic symphysis of the forehead, face and chin.

CAVITY OBSTETRIC FORCEPS

The fetal head is located in the pelvic cavity (in its wide or narrow part). The head will have to complete the internal rotation in the forceps and perform extension (in the anterior view of the occipital presentation) or additional flexion and extension (in the posterior view of the occipital presentation). Due to the incompleteness of the internal rotation, the swept seam is in one of the oblique dimensions. Obstetric forceps are applied in the opposite oblique size so that the spoons grasp the head in the area of ​​the parietal tuberosities. Applying forceps obliquely presents certain difficulties. More complex than exit obstetric forceps are traction, which completes the internal rotation of the head by 45° and more, and only then does extension of the head follow.

First position, anterior view of the occipital presentation. The fetal head is in the pelvic cavity, the sagittal suture is in the right oblique size, the small fontanel is located on the left and in front, the large one is on the right and behind, the ischial spines are reached (the fetal head in the wide part of the pelvic cavity) or are reached with difficulty (the fetal head in the narrow parts of the pelvic cavity). In order to the fetal head was grasped biparietally, forceps must be applied in the left oblique direction.

When applying abdominal obstetric forceps, the order of insertion of the spoons is maintained. The left spoon is inserted under the control of the right hand into posterolateral section of the pelvis and is immediately located in the region of the left parietal tubercle of the head. The right spoon should lie on the head on the opposite side, in the anterolateral part of the pelvis, where it cannot be inserted immediately, since this is prevented by the pubic arch. This obstacle is overcome by moving (“wandering”) the spoon. The right spoon is inserted in the usual way into the right half of the pelvis, then, under the control of the left hand inserted into the vagina, the spoon is moved anteriorly until it is positioned in the area of ​​the right parietal tubercle. The spoon is moved by carefully pressing the second finger of the left hand on its lower edge. In this situation, the right spoon is called - "wandering", and the left one - "fixed". Traction is performed downwards and backwards, the head makes an internal rotation, the sagittal suture gradually turns into the straight size of the pelvic outlet. Next, traction is directed first downwards until the occipital protuberance emerges from under the pubis, then forwards until the head is extended.

Second position, anterior view of occipital presentation. The fetal head is in the pelvic cavity, the sagittal suture is in the left oblique size, the small fontanel is located on the right and in front, the large one is on the left and behind, the ischial spines are reached (the fetal head in the wide part of the pelvic cavity) or are reached with difficulty (the fetal head in the narrow parts of the pelvic cavity).In order for the fetal head to be grasped biparietally, the forceps must be applied in the right oblique direction. In this situation, the “wandering” spoon will be the left spoon, which is applied first. Traction is performed, as in the first position, in the anterior view of the occipital presentation.

COMPLICATIONS

The use of obstetric forceps, subject to the conditions and technique, usually does not cause any complications for the mother and fetus. In some cases, this operation may cause complications.

Damage to the birth canal. These include ruptures of the vagina and perineum, less often - the cervix. Severe complications include ruptures of the lower segment of the uterus and injuries pelvic organs: bladder and rectum, usually occurring when the conditions for surgery and the rules of technique are violated. Rare complications include damage to the bone birth canal - rupture of the pubic symphysis, damage to the sacrococcygeal joint.

Complications for the fetus. After surgery on the soft tissues of the fetal head, there is usually swelling and cyanosis. With strong compression of the head, hematomas can occur. Strong pressure from a spoon on the facial nerve can cause paresis. Severe complications are damage to the bones of the fetal skull, which can be of varying degrees - from bone depression to fractures. Brain hemorrhages pose a great danger to the life of the fetus.

Postpartum infectious complications. Delivery using obstetric forceps is not a cause of postpartum infectious diseases, however, it increases the risk of their development, and therefore requires adequate prevention of infectious complications in the postpartum period.

VACUUM EXTRACTION OF FRUIT

Vacuum extraction of the fruit - a delivery operation in which the fetus is artificially removed through the natural birth canal using a vacuum extractor.

The first attempts to use the power of vacuum to extract a fetus through the vaginal birth canal were made in the middle of the last century. Simpson's invention of the aerotractor dates back to 1849. The first modern model of a vacuum extractor was designed by the Yugoslav obstetrician Finderle in 1954. However, the design of the vacuum extractor proposed in 1956 Maelstrom(Malstrom), is most widely used. In the same year, a model invented by domestic obstetricians was proposed K. V. Chachava And P. D. Vashakidze .

The principle of operation of the device is to create negative pressure between the inner surface of the cups and the fetal head. The main elements of the apparatus for vacuum extraction are: a sealed buffer container and an associated pressure gauge, manual suction to create negative pressure, a set of applicators (in the Maelstrom model - a set of metal cups from 4 to 7 numbers with a diameter of 15 to 80 mm, in the Maelström model - a set of metal cups from 4 to 7 numbers with a diameter of 15 to 80 mm, in E.V. Chachava and P.D. Vashakidze - rubber cap). IN modern obstetrics vacuum extraction of the fetus has extremely limited use due to adverse consequences for the fetus. Vacuum extraction is used only in cases where there are no conditions for performing other delivery operations.

Unlike the operation of applying obstetric forceps, vacuum extraction of the fetus requires the active participation of the woman in labor during traction of the fetus by the head, so the list of indications is very limited.

INDICATIONS

weakness of labor, with ineffective conservative therapy;
the onset of fetal hypoxia.
CONTRAINDICATIONS

diseases that require “switching off” pushing (severe forms of gestosis, decompensated heart defects, high myopia, hypertension), since during vacuum extraction of the fetus active pushing activity of the woman in labor is required;
discrepancy between the sizes of the fetal head and the mother’s pelvis;
extension presentation of the fetal head;
fetal prematurity (less than 36 weeks).
The last two contraindications are associated with the peculiarity of the physical action of the vacuum extractor, so placing the cups on the head of a premature fetus or in the area of ​​the large fontanel is fraught with serious complications.

CONDITIONS FOR THE OPERATION

- Live fruit.

Complete opening of the uterine os.

Absence of amniotic sac.

Correspondence between the sizes of the mother's pelvis and the fetal head.

The fetal head should be in the pelvic cavity with a large segment at the entrance to the small pelvis.

-Occipital insert .

OPERATIONAL TECHNIQUE

The technique of vacuum extraction of the fetus consists of the following points:

Inserting the cup and placing it on the head

The vacuum extractor cup can be inserted in two ways: under hand control or under vision control (using mirrors). Most often in practice, the cup is inserted under hand control. To do this, under the control of the left guide hand, the cup is inserted into the vagina with the lateral surface in the direct size of the pelvis with the right hand. Then it is turned and the working surface is pressed against the fetal head, as close as possible to the small fontanel.

Creating negative pressure

The cup is attached to the apparatus and a negative pressure of up to 0.7-0.8 amt is created within 3-4 minutes. (500 mmHg).

Attraction of the fetus by the head

Tractions are performed synchronously with pushing in the direction corresponding to the biomechanism of childbirth. During the pauses between attempts, attraction is not produced. A mandatory step is to perform a test traction.

Removing the cup

When cutting through the vulvar ring of the parietal tubercles, the calyx is removed by breaking the seal in the apparatus, after which the head is removed manually.

COMPLICATIONS

The most common complication is the cup slipping from the fetal head, which occurs when the tightness in the apparatus is broken. Cephalohematomas often occur on the fetal head, and brain symptoms are observed.

The operation of applying obstetric forceps (applicatio forcipes obstet-riciae) is aimed at artificially extracting the fetus by the head (rarely by the buttocks) in case of urgent need to complete the second stage of labor. The instruments used for this are called obstetric forceps (forceps obstetriciae). They were invented in early XVII century by Chamberlain (Fig. 250). Rice. 250. Chamberlain obstetric forceps (a). Palfin's obstetric forceps (“iron hands”) - manus ferreae Palfynianae (b). However, he did not make his invention public and the honor of opening the forceps (1723) rightly belongs to I. Palfin. Subsequently, several hundred models of obstetric forceps were proposed.

Device of forceps

Almost all proposed models of forceps can be divided into four types, and their design reflects the fundamental attitude of certain obstetricians to this operation. The main types of forceps: 1) Russian, 2) English, 3) French, 4) German. Russian Lazarevich forceps ( Fig. 251), Gumilevsky (Fig. 252) do not have a pelvic curvature, they are straight. In contrast, the other three types of forceps have two curvatures: head and pelvic; the branches intersect. The main model of forceps used in our country to this day is Simpson's forceps (Fig. 253) modified by Fenomenov.

The forceps consist of two branches - right and left. Each branch (ramus) has three parts: a spoon (cochlear), a lock (pars juncturae), and a handle (manubrium). The total length of the instrument is 35 cm; the length of the handle with a lock is 15 cm, the length of the spoon is 20 cm. The spoon of the tongs is fenestrated, the window is oval; its length is 11 cm, width 5 cm, it is bordered by an edge (upper and lower when the instrument is positioned on the table). The spoon has a so-called head curvature and a pelvic curvature (curvature along the plane). The tops of the spoons when closing the tongs are at a distance of 2.5 cm; the distance between the most distant points of the head curvature of the spoons when closing the forceps is 8 cm (the large transverse size of the head up to its configuration is 9 cm).

The lock in the Simpson-Fenomenov tongs is very simple; on the left branch there is a notch into which the right branch is inserted. The handles of the pliers are straight, inner surface they are smooth, flat, and the outer one is ribbed and wavy, which prevents the surgeon’s hands from slipping. On the outer surface of the handles near the lock there are so-called Bush hooks. The weight of the instrument is about 500 g. The branches of the forceps are distinguished by the following signs: 1) on the left branch there is a lock and a lock plate on top, on the right - on the bottom; 2) the Bush hook and the ribbed surface of the handle (if you put the tongs on the table) on the left branch face to the left, on the right – to the right; 3) the left branch is taken in the left hand and inserted into the left half of the pelvis; the right branch is taken in the right hand and inserted into the right half of the pelvis. Action of forceps. From the definition of the operation of applying forceps it follows that their main action is attraction.

The force required for the operation of applying forceps cannot be precisely determined, but it should be assumed that it is the force that can be applied by one person; the use of excessive force, especially by two people, is very dangerous and should be categorically rejected. Selecting a forceps model. Of the huge number of models of forceps, it is enough to have two: 1) domestic straight forceps by Lazarevich (model 1887) or Gumilevsky, 2) English Simpson forceps, modified by N. N. Fenomenov. Indications for the application of forceps can be combined into the following main groups: 1) indications from the fetus (asphyxia, threat of birth injury); 2) indications from the parturient: a) insufficiency of labor, b) diseases of the cardiovascular system, c) diseases of the respiratory tract, kidneys, d) severe nephropathy, eclampsia.

If a woman’s efforts are not enough for a successful delivery, then use alternative ways: caesarean section, delivery with forceps or vacuum extractor. Most expectant mothers have little knowledge of the devices used in obstetrics and are therefore afraid of using them. But tools are used in cases where it is justified and ignoring the problem can lead to undesirable consequences for both mother and child.

In what cases are forceps or a vacuum extractor used?

These medical instruments are justified in using if the cervix is ​​fully dilated and the widest part of the child’s head has already passed into the area under the pubic bone. This placement of the fetus indicates that it will successfully pass through the pelvic bones, and forceps or a vacuum extractor should be used in order to stretch it without unnecessary injury. soft fabrics crotch.
If the child's skull has not yet reached the mother's pelvis, then instrumental intervention is not justified and can cause harm - a head injury is possible. With this location and weak labor activity, a caesarean section is more often used.

In case of long 2nd stage of labor or fetal distress, 2 types of auxiliary instruments for delivery are used: a vacuum extractor and obstetric forceps.

Vacuum extractor: mechanism of action of the tool. Consequences of use and features of use

The tool consists of a bowl, a flexible hose and a mechanism that provides pressure (up to 0.8 kg/cm2).

There are several types of vacuum extractor: with a metal cup (Mahlstrom extractor), with a hard polyethylene cup and a soft silicone cup (disposable). Bowls with front and rear tube fixation have also been developed. This allows you to create a vacuum acentrically and successfully apply them depending on the position of the child's head.

WITH modern medicine Disposable flexible silicone cups are predominantly used.

How is a vacuum extractor used?

The procedure is carried out in stages:

● the cup is inserted into the vagina of the woman in labor;
● a vacuum is created using a tool;
● traction on the child’s head;
● removing the cup from the newborn's head.

The vacuum extractor cup is inserted in a vertical-lateral position and fixed on the child’s head. The instrument is then positioned correctly: the cup is attached closer to the leading point on the baby's head, avoiding the fontanelles. By making sure the bowl is in the correct position, negative pressure is created.

The fixation stage must be carried out with extreme care: it is unacceptable to attach the cup to the soft tissues of the woman in labor.

When choosing a direction, it is important to take into account the biomechanism of childbirth: the wire point of the child’s head moves along the wire axis of the mother’s pelvis. If you deviate from this trajectory, the bowl may warp and the instrument may come off the surface of the fetal head.

Tractions should be performed synchronously with pushing and not exceed 4 times; if the cup slips, it can be reapplied again, but no more - the risk of injury to the fetus increases.

During the procedure, an episiotomy is used. If the newborn is successfully extracted, the cup is removed, gradually reducing the pressure.

If the attempt at vacuum extraction fails, then conditions arise for delivery with obstetric forceps.

Complications after vacuum extraction in mother and child

During childbirth using a vacuum extractor, there is a risk for the mother of rupture of the soft tissues of the labia minora, labia majora, vagina, perineum, and clitoris.
The child may experience the following complications:
● cephalohematomas;
● injury to the soft tissues of the head;
● hemorrhages.
The silicone bowl of the vacuum extractor is the safest for use of all existing types.

Contraindications to the use of a vacuum extractor. When is a tool prohibited from use?

There are a number of contraindications, in the presence of which delivery using this instrument is unacceptable. These include:
● dead fetus;
● high straight standing of the child’s head;
● frontal or facial insertion of the head;
● incomplete dilatation of the cervix;
● pelvic (low) presentation;
● miscarriage (birth before 30 weeks);
● extragenital or obstetric pathology, which involves excluding the 2nd stage of labor.

Indications for vacuum extraction and prerequisites for performing the procedure

Indications for the procedure can be from the part of the mother and from the fetus.

For the expectant mother, a prerequisite for the procedure may be pregnancy pathologies that require a reduction in the 2nd stage of labor:

● septic, infectious diseases accompanied by high temperature;
● weakness of labor in the 2nd stage of labor.

A vacuum extractor should be used if there is fetal distress (in the 2nd stage of labor) and it is not possible to perform a caesarean section.

Conditions for performing the vacuum extraction procedure:

● living child;
● full dilatation of the cervix;
● absence of amniotic sac;
● anatomical correspondence in the size of the birth canal and the child’s head;
● the head should be in the pelvis of the woman in labor.

Obstetric forceps. Tool structure, types

Obstetric forceps - medical instrument, made of metal, shaped like tweezers. They consist of 2 parts, each of them includes a spoon, a handle and a lock. Spoons are designed with curvature in mind to fit around the head; the handle is designed for traction. Depending on the type of lock, there are several types of pliers. In the Russian Federation, the Simpson-Fenomenov instrument is used.
Classification of the instruments used depending on the location of the fetus: there are low cavity (typical) forceps - for applying to the child’s head, located in the narrow part of the pelvic cavity, and atypical - when located in the wide part.

Why are forceps used during childbirth?

In modern obstetrics, the instrument is used for delivery if:
● time for caesarean section was missed;
● diagnosed with severe gestosis that cannot be treated;
● weak attempts, labor cannot be corrected with medication;
● the woman in labor has extragenital pathologies that require pushing to be excluded;
● acute fetal hypoxia is observed.
Large fetuses and prematurity are considered contraindications for forceps delivery.

Indications for the use of obstetric forceps

The use of forceps during childbirth is used if:

● the fruit is alive;
● the cervix is ​​fully dilated;
● amniotic sac is absent;
● the dimensions of the child’s head and the woman’s birth canal correspond;
● the fetal head is located in a narrow part of the pelvic cavity of the woman in labor.

Complications and postoperative rehabilitation after childbirth using forceps

During the rehabilitation period the following is carried out:

● control examination of the uterus to ensure its integrity;
● monitoring the functioning of the pelvic organs;
● prevention of inflammatory processes.

Which is better: a vacuum extractor or forceps?

There are many stories about how the fetus was damaged by pulling it with forceps during childbirth. The fears of a woman who worries about her child are quite natural. If pregnancy proceeds with pathologies, then concern increases: will such instruments be used and how dangerous is it?

The safety of using an extractor and forceps largely depends on the experience and skills of the doctor.
For a child, cupping can result in hematoma and tissue swelling, and the use of forceps can result in cuts.
Vacuum extraction involves less pain relief for the woman in labor, soft tissue ruptures occur less frequently and rehabilitation is easier.
The effectiveness for accelerating labor is approximately the same.

If there are indications for the use of forceps or a vacuum extractor, you should carefully select the specialist who will deliver the child, because the choice and success of using the instruments depends on his skills, experience and knowledge.

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 according to the following indications: 1) secondary weakness of labor, accompanied by stoppage forward movement 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, heat 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 nervous system, kidneys, 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 drops to pelvic floor, i.e. at the exit from 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: the left spoon is inserted first with the left hand into left side(“three lefts”), the second - the right spoon with the right hand to the right side (“three right ones”); 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 grasped with the same hand, while thumbs are located on Bush hooks, and the remaining 4 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 positioned on top with an outstretched index finger and 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 grasping 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 surfaces, and nail phalanges- on the upper surface of the handle of the opposite spoon of the tongs. 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.

Obstetric forceps - designed to extract a living fetus by the head in strict accordance with the natural biomechanism of childbirth.

The frequency of use of obstetric forceps in modern obstetrics is 1%.

The following types of obstetric forceps are distinguished: a) Simpson forceps - used for traction in anterior occipital presentation; b) Tooker-McLean forceps - used to rotate from the posterior view of the occipital presentation to the anterior view of the occipital presentation and extract the fetus; c) Kielland and Barton forceps - with a transverse arrangement of the sagittal suture for rotation to the anterior view of the occipital presentation; d) Piper forceps - designed to remove the head during breech presentation.

Device of obstetric forceps. The forceps have 2 spoons (branches), each of which consists of three parts - the spoon itself (which grasps the head of the fetus, it is fenestrated, window length 11 cm, width 5 cm); castle part; handle (hollow, the outer side of the handle is wavy). On the outer side of the tongs near the lock there are protrusions, Bush hooks, which, when folding the tongs, should be facing in different directions, i.e. laterally, and lie in the same plane. Most models of forceps have two curvatures - the head (calculated for the circumference of the head) and the pelvic (runs along the edge of the spoon, curvature along the plane of the pelvis). The ends of the folded spoons do not touch each other, the distance between them is 2-2.5 cm. The cephalic curvature in folded tongs is 8 cm, the pelvic curvature is 7.5 cm; the maximum width of the spoons is no more than 4-4.5 cm; length - up to 40 cm; weight - up to 750 g.

Indications for applying obstetric forceps:

1. Indications from the parturient: weakness of labor not amenable to drug therapy, fatigue; weakness of pushing; bleeding from the uterus at the end of the first and second stages of labor; contraindications for pushing (severe gestosis; extragenital pathology - cardiovascular, renal, high myopia, etc.; feverish conditions and intoxication); severe forms of neuropsychiatric disorders; chorioamnionitis during childbirth, if labor is not expected to end within the next 1 to 2 hours.

2. Indications from the fetus: acute intrauterine fetal hypoxia; loss of umbilical cord loops; threat of birth trauma.

Contraindications for applying obstetric forceps: dead fetus; hydrocephalus or microcephaly; anatomically (II - III degree of narrowing) and clinically narrow pelvis; very premature fetus; incomplete opening of the uterine os; frontal presentation and anterior type of facial presentation; pressing the head or positioning the head with a small or large segment at the entrance to the pelvis; threatening or incipient uterine rupture; breech presentation fetus

Conditions for applying obstetric forceps:

1. Full opening of the uterine os.

2. Opened amniotic sac.

3. Empty bladder.

4. Head presentation and the presence of the head in the cavity or in the outlet of the small pelvis.

5. Correspondence of the size of the fetal head to the size of the mother’s pelvis.

6. Average head sizes.

7. Live fruit.

Complications after applying obstetric forceps:

1. For the mother: damage to the soft birth canal; rupture of the symphysis pubis; root damage sciatic nerve followed by paralysis of the lower limbs; bleeding; uterine rupture; formation of a vaginal-vesical fistula.

2. For the fetus: damage to the soft parts of the head with the formation of hematomas, paresis of the facial nerve, eye damage; bone damage - depression, fractures, separation of the occipital bone from the base of the skull; compression of the brain; hemorrhages into the cranial cavity.

3. Postpartum infectious complications.

Three triple rules for applying obstetric forceps:

1. About the sequence of insertion of the forceps spoons:

the left spoon is inserted with the left hand into the left half of the pelvis of the woman in labor (“three on the left”), under the control of the right hand;

the right spoon is inserted with the right hand into the right half of the pelvis under the control of the left hand (“three to the right”).

2. Orientation of spoons on the fetal head with forceps applied:

the tops of the spoons of the tongs should be facing the wire point;

the forceps should grasp the parietal tubercles of the fetus;

the wire point of the head should lie in the plane of the forceps.

in the plane of entry - obliquely downwards, towards the toes of the sitting obstetrician;

in the pelvic cavity - horizontally, on the knees of a sitting obstetrician;

in the exit plane - from bottom to top, onto the face of a sitting obstetrician.

Moments of the operation of applying obstetric forceps:

1. Insertion of forceps spoons. Performed after a vaginal examination. The left spoon of the forceps is inserted first. Standing, the doctor inserts four fingers of the right hand (half-hand) into the vagina into the left half of the pelvis, separating the fetal head from the soft tissues of the birth canal. The thumb remains outside. Taking the left branch of the forceps with your left hand, the handle is moved to the right side, placing it almost parallel to the right inguinal fold. The top of the spoon is pressed against the palmar surface inserted into the vagina of the hand, so that the lower edge of the spoon is located on the fourth finger and rests on the abducted thumb. Then, carefully, without any effort, the spoon is moved between the palm and the fetal head deep into the birth canal, placing the lower edge between the third and fourth fingers of the right hand and resting on the bent thumb. In this case, the trajectory of movement of the end of the handle should be an arc. The advancement of the spoon into the depths of the birth canal should be done due to the instrument’s own gravity and by pushing the lower edge of the spoon with 1 finger of the right hand. The half-arm, located in the birth canal, is a guide hand and controls the correct direction and position of the spoon. With its help, the obstetrician makes sure that the top of the spoon is not directed into the fornix, onto the side wall of the vagina and does not capture the edge of the cervix. After inserting the left spoon, it is handed over to the assistant to avoid displacement. Next, under the control of the left hand, the obstetrician inserts the right branch into the right half of the pelvis with the right hand in the same way as the left branch.

2. Closing the pliers lock. To close the pliers, each handle is grabbed with the same hand so that the first fingers of the hands are located on the Bush hooks. After this, the handles are brought together and the tongs are easily closed. Correctly applied forceps lie across the sagittal suture, which occupies a mid-position between the spoons. The lock elements and bush hooks should be located at the same level.

3. Test traction. This necessary moment allows you to ensure that the forceps are applied correctly and that there is no risk of them slipping. It requires a special positioning of the obstetrician's hands. To do this, the doctor covers the handles of the forceps from above with his right hand so that the index and middle fingers lie on the hooks. He places his left hand on the back surface of his right, and the extended middle finger should touch the fetal head in the area of ​​the leading point. If the forceps are positioned correctly on the fetal head, then during test traction the fingertip will always be in contact with the fetal head. Otherwise, it moves away from the head, which indicates that the forceps are not applied correctly and, in the end, they will slip off. In this case, the forceps must be applied again.

4. The actual traction for extracting the fetus. After trial traction, making sure that the forceps are applied correctly, they begin their own traction. Traction of the fetal head with forceps should imitate natural contractions. To do this you should:

imitate a contraction in terms of strength: start tractions not sharply, but with a weak pull, gradually strengthening them and weakening them again towards the end of the contraction;

When performing traction, do not develop excessive force by tilting your torso back or resting your foot on the edge of the table. The obstetrician's elbows should be pressed to the body, which prevents the development of excessive force when removing the head;

Between tractions it is necessary to pause for 0.5-1 minutes. After 4-5 tractions, the forceps are opened for 1-2 minutes to reduce the pressure on the head;

try to perform traction simultaneously with contractions, thus strengthening the natural expulsion forces. If the operation is performed without anesthesia, the woman in labor must be forced to push during traction.

Rocking, rotating, pendulum-like movements are unacceptable

5. Removing the forceps. To remove the forceps, each handle is taken with the same hand, the spoons are opened and removed in the reverse order: the first is the right spoon, with the handle taken to the groin fold, the second is the left spoon, its handle is taken to the right groin fold.

1. The head is movable above the entrance to the pelvis; during external examination it moves.

2. The head is slightly pressed against the entrance to the small pelvis - this means that during an external examination it is motionless, but during a vaginal examination it is pushed away.

3. The head is pressed into the small pelvis - this is the norm in the absence of labor in first-time mothers.

4. The head is a small segment at the entrance to the small pelvis, the smaller part of the head has passed the plane of the entrance.

5. The head is a large segment at the entrance to the small pelvis, most of the heads passed the entrance plane.

6. Head in the pelvic cavity:

a) in the wide part of the pelvic cavity b) in the narrow part of the pelvic cavity.

7. Head in the exit cavity.

Transverse and oblique position of the fetus. Causes, diagnosis, obstetric tactics.

Transverse position is a clinical situation in which the axis of the fetus intersects the axis of the uterus at a right angle.

Oblique position is a clinical situation in which the axis of the fetus intersects the axis of the uterus at an acute angle. In this case, the lower part of the fetus is located in one of the iliac fossa of the large pelvis. The oblique position is a transitional state: during childbirth it turns into either longitudinal or transverse.

Etiological factors:

a) Excessive fetal mobility: with polyhydramnios, multiple pregnancy(second fetus), with malnutrition or premature fetus, with flabbiness of the anterior muscles abdominal wall in multiparous women.

b) Limited fetal mobility: with oligohydramnios; large fruit; multiple births; in the presence of uterine fibroids, deforming the uterine cavity; with increased uterine tone, with the threat of miscarriage, in the presence of a short umbilical cord.

c) Obstruction to insertion of the head: placenta previa, narrow pelvis, presence of uterine fibroids in the lower segment of the uterus.

d) Anomalies of the uterus: bicornuate uterus, saddle uterus, septum in the uterus.

e) Fetal developmental anomalies: hydrocephalus, anencephaly.

Diagnostics.

1. Examination of the abdomen. The shape of the uterus is elongated in transverse size. The abdominal circumference always exceeds the norm for the period of pregnancy at which the examination is carried out, and the height of the uterine fundus is always less than the norm.

2. Palpation. There is no large part in the fundus of the uterus, large parts are found in the lateral parts of the uterus (round dense on one side, soft on the other), the presenting part is not determined. The fetal heartbeat is best heard in the navel area.

The position of the fetus is determined by the head: in the first position the head is palpated on the left, in the second - on the right. The type of fetus, as usual, is recognized by the back: the back is facing anteriorly - anterior view, the back is backward - posterior.

3. Vaginal examination. At the beginning of labor, with a whole amniotic sac, it is not very informative; it only confirms the absence of the presenting part. After the discharge of amniotic fluid, with sufficient opening of the pharynx (4-5 cm), the shoulder, scapula, spinous processes of the vertebrae, and axilla can be identified. The type of fetus is determined by the location of the spinous processes and scapula, and the position is determined by the armpit: if the cavity is facing to the right, then the position is the first, in the second position axilla open to the left.

The course of pregnancy and childbirth.

Most often, pregnancy in transverse positions proceeds without complications. Sometimes when increased mobility The fetus has an unstable position - frequent changes in position (longitudinal - transverse - longitudinal).

Complications of pregnancy with a transverse position of the fetus: premature birth with prenatal rupture of amniotic fluid, which is accompanied by loss of small parts of the fetus; hypoxia and infection of the fetus; bleeding with placenta previa.

Complications of childbirth: early rupture of amniotic fluid; fetal infection; the formation of an advanced transverse position of the fetus - loss of fetal mobility with intense early rupture of amniotic fluid; loss of small parts of the fetus; hypoxia; overstretching and rupture of the lower segment of the uterus.

In case of limb loss, it is necessary to clarify what fell into the vagina: an arm or a leg. The handle, lying inside the birth canal, can be distinguished from the stem by the longer length of the fingers and the absence of a calcaneal tubercle. The hand is connected to the forearm in a straight line. The fingers are separated, especially the thumb is abducted. It is also important to determine which handle fell out - right or left. To do this, it’s like “hello” right hand with a dropped handle; if this succeeds, the right handle falls out, if it fails, the left one falls out. The dropped handle makes it easier to recognize the position, position and type of the fetus. The handle does not interfere with internal rotation of the fetus onto the stem; its reduction is an error that complicates fetal rotation or embryotomy. A prolapsed arm increases the risk of ascending infection during childbirth and serves as an indication for faster delivery.

Umbilical cord prolapse. If, during a vaginal examination, loops of the umbilical cord are felt through the amniotic sac, they speak of its presentation. The detection of umbilical cord loops in the vagina with a ruptured amniotic sac is called umbilical cord prolapse. The umbilical cord usually falls out when your water breaks. Therefore, to detect such a complication in a timely manner, a vaginal examination should be performed immediately. Prolapse of the umbilical cord with a transverse (oblique) position of the fetus can lead to infection and, to a lesser extent, to fetal hypoxia. However, in all cases of umbilical cord prolapse with a living fetus, urgent assistance is necessary. In a transverse position, full opening of the uterine pharynx and a mobile fetus, such help is to turn the fetus onto its stem and then remove it. If the pharynx is not fully dilated, a caesarean section is performed.