The imposition of obstetric forceps - indications, contraindications and complications. The operation of imposing obstetric forceps Obstetric forceps - types and technique of imposition

OBLIGATION FORCE OPERATION

obstetric forceps called a tool designed to extract a live full-term fetus by the head.

Application of obstetrical forceps- This is 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) at the end of the 16th century. For many years, obstetric forceps remained a family secret, inherited, as they were the subject of profit of the inventor and his descendants. The secret was later sold for a very high price. After 125 years (1723), obstetric forceps were "secondarily" invented by the Genevan anatomist and surgeon I. Palfin (France) and immediately made public, so the 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 Professor of Moscow University I.F. Erasmus. However, the merit of introducing this operation into everyday practice inalienably 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 master Vasily Kozhenkov (1782) made the first models of obstetric forceps in Russia. Subsequently, domestic obstetricians Anton Yakovlevich Krassovsky, Ivan Petrovich Lazarevich, and 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 that is grasped 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 .

The spoon is a curved plate with a wide cut - window. The rounded edges of spoons are calledribs(top and bottom). The spoon has a special shape, which is dictated by the shape and size of both the fetal head and the small pelvis. Spoons of obstetric forceps do not have pelvic curvature (straight forceps Lazarevitz). Some models of tongs additionally have perineal curvature in the area of ​​the spoon and handle junction (Kielland, 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, the wire axis of the pelvis.

Lock serves to connect the branches of forceps. The device of 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 castle is moderately mobile;

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

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

Lever serves to grip forceps and producetraction. It has smooth inner surfaces, and therefore, with closed branches, they fit snugly against each other. The outer surfaces of the forceps handle parts have a corrugated surface, which prevents the surgeon's hands from slipping during traction. The handle is made hollow to reduce the weight of the tool. In the upper part of the outer surface of the handle there are lateral protrusions, which are calledcrochet bush. During traction, they provide a reliable support for the surgeon's hand. In addition, Bush's hooks make it possible to judge the incorrect application of obstetric forceps if, when the branches of the hook are closed, they are not located against 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 the introduction of the spoons and the closing of the lock corresponds to the size in which the spoons themselves are located (transverse or one from oblique dimensions of the pelvis).

In Russia, forceps are most often used Simpson-Fenomenov. N.N. Phenomenov made an important change to the Simpson tongs, making the lock more mobile. The mass of this forceps model 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 points of mechanical effect (compression and attraction). The purpose of the forceps is to tightly grasp the head of the fetus and replace the expelling force of the uterus and abdominals with the pulling force of the doctor. Hence, forceps are only enticing tool, but not rotary and not compression. However, the known compression of the head during its removal is nevertheless difficult to avoid, but this is a disadvantage of the forceps and not their purpose. There is no doubt that in the process of traction, obstetric forceps make rotational movements, but only following the movement of the fetal head, without violating the natural mechanism of childbirth. Therefore, the doctor in the process of extracting the head should not interfere with the turns that the fetal head will make, but, on the contrary, contribute to them. Violent rotational movements with forceps are unacceptable, since incorrect positions of the head in the pelvis are not created without a 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 action 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 maternal and fetal birth trauma.

INDICATIONS

Indications for the operation of applying obstetric forceps arise in situations where conservative continuation of labor is impossible due to the risk of serious complications for both the mother and the fetus, up to death. During the period of exile, under appropriate conditions, these situations can be completely or partially eliminated by operative delivery by applying obstetric forceps. Indications for surgery can be divided into two groups: indications from the mother and indications from the fetus. And the indications from the mother's side can be divided into indications associated with pregnancy and childbirth (obstetric indications) and indications associated with extragenital diseases of a woman that require "turning off" attempts (somatic indications). Often there is a combination of them.

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

-Mother's testimony:

- obstetric indications:

severe forms of preeclampsia (preeclampsia, eclampsia, severe hypertension, resistant to conservative therapy) require the exclusion of attempts and stress of the woman in labor;
persistent weakness of labor and / or weakness of attempts, manifested by the standing of the fetal head in one plane of the pelvis for more than 2 hours, in the absence of the effect of the use of medications. Prolonged standing of the head in one plane of the small pelvis leads to an increased risk of birth traumatism of 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, due to premature detachment of a normally located placenta, rupture of the umbilical cord vessels during their membrane attachment;
endometritis in childbirth.

Somatic indications:

diseases of the cardiovascular 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.
-Fetal indications:

fetal hypoxia, which develops due to various reasons in the second stage of labor (premature detachment of a normally located placenta, weakness of labor, late preeclampsia, short umbilical cord, entanglement of the umbilical cord around the neck, etc.).
The imposition of obstetric forceps may be required for women in labor who underwent surgical intervention on the abdominal organs on the eve of childbirth (the inability of the abdominal muscles to provide full-fledged attempts).

Once again, I would like to emphasize that in most cases there is a combination of the above indications that require an emergency end of childbirth. Indications for the operation of applying obstetric forceps are not specific to this operation, they may be an indication for other delivery operations (caesarean section, vacuum extraction of the fetus). The choice of a delivery operation depends entirely on the presence of certain conditions that allow a particular operation to be performed, therefore, in each case, they must be carefully assessed in order to choose the right 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 the operation is contraindicated.



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

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

-Absence of a fetal bladder. If the fetal bladder is intact, it must be opened.

-The head of the fetus should correspond to the average size of the head of a full-term fetus. Obstetricians formulate this condition a little 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. Decrease - 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 into account this condition becomes traumatic for the fetus and for the mother.

-Correspondence between the size of the pelvis of the mother and the head of the fetus. With a narrow pelvis, forceps are a very dangerous tool, so their use is contraindicated.

-The fetal head should be located at the exit from the small pelvis with an arrow-shaped suture in a direct size or in the cavity of the small pelvis with an arrow-shaped suture in one of the oblique sizes. An accurate determination of the position of the fetal head in the small 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 . The forceps applied to the head, which is a large segment in the plane of the exit of the small pelvis (on the pelvic floor), are called output, while the sagittal suture is located in a direct size.

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

Tall forceps ((Forceps alta)imposed on the head of the fetus, which stood in a large segment at the entrance to the small pelvis. The imposition of high forceps was a technically difficult and dangerous operation, often leading to severe birth trauma to the mother and fetus. Currently not applicable.

The operation of imposing obstetric forceps can be carried out only if all of the listed conditions are present. An obstetrician, starting to apply obstetric forceps, must have a clear idea of ​​​​the biomechanism of childbirth, which will have to be artificially imitated. It is necessary to clearly understand what moments of the biomechanism of labor the fetal head has already done, and what it will have to do during traction.

PREPARATION FOR OPERATION

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

The choice of method of anesthesia determined by the condition of the woman and the indications for the operation. In cases where the active participation of a woman in childbirth seems appropriate (weak 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 in somatically healthy women, it is advisable to use anesthesia, since the application of spoons to the head located in the pelvic cavity is a difficult moment of the operation, requiring the elimination of the resistance of the pelvic floor muscles.

In women in labor, for whom attempts are contraindicated, the operation is performed under anesthesia. With initial arterial hypertension, the use of anesthesia with nitrous oxide with oxygen with the addition of halothane vapors at a concentration of not more than 1.5 vol.% is indicated. Halothane 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 the removal of 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. The bladder must be emptied before the operation. The external genitalia and inner thighs are treated with a disinfectant solution. The hands of obstetricians are treated as for surgical operations.

Immediately before applying the forceps, it is necessary to perform a thorough vaginal examination (with a half-hand) in order to confirm the conditions for the operation and determine the position of the head in relation to the planes of the small pelvis. Depending on the position of the head, it is determined which variant of the operation will be applied (cavitary or output obstetric forceps). Due to the fact that when removing the fetal head in forceps, the risk of perineal rupture increases, the application of obstetric forceps should be combined with an episiotomy.

OPERATIONAL TECHNIQUE

The technique of the operation of applying obstetric forceps includes the following points.

Introduction of spoons

When introducing spoons of obstetric forceps, the doctor should follow the first "triple" rule (rule of three "lefts" and three "rights"): left the spoon left inserted by hand into left side of the pelvis, similarly, right the spoon right hand in right side of the pelvis. The handle of the tongs is grasped in a special way: by type writing pen(at the end of the handle, the index and middle fingers are placed opposite the thumb) or by type bow(opposite the thumb, four others are widely spaced along the handle). The special type of gripping forceps spoons avoids the application of force during its introduction.

The left spoon of tongs is introduced 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 the left hand, the handle is taken to the right side, setting 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 retracted thumb. Then, carefully, without any effort, the spoon is advanced between the palm and the head of the fetus deep into the birth canal, placing the lower edge between the III and IV fingers of the right hand and leaning on the bent thumb. In this case, the trajectory of movement of the end of the handle should be an arc. The promotion of the spoon into the depths of the birth canal should be carried out by virtue of the own gravity of the instrument and by pushing the lower edge of the spoon with 1 finger of the right arms. The half-hand, located in the birth canal, is a guide hand and controls the correct direction and location of the spoon. With its help, the obstetrician makes sure that the top of the spoon does not go into the vault, onto the side wall of the vagina and does not capture the edge of the cervix. After the introduction of the left spoon, in order to avoid displacement, it is passed to the assistant. Further, 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.

Properly placed spoons are placed on the head of the fetus according to "second" triple rule . Length of spoons - on the head of the fetus along a large oblique size (diameter mento-occipitalis) from the back of the head to the chin; spoons capture the head in the largest transverse dimension in such a way that the parietal tubercles are in the windows of the forceps spoons; the line of forceps handles faces the leading point of the fetal head.

Closing forceps

To close the tongs, each handle is grasped with the same hand so that the first fingers of the hands are located on Bush's hooks. After that, the handles are brought together, and the tongs close easily. Properly applied forceps lie across the swept seam, which occupies a median position between the spoons. The elements of the lock and Bush hooks should be located on the same level. When closing correctly applied forceps, it is not always possible to bring the handles closer together, this depends on the size of the fetal head, which is often more than 8 cm (the largest distance between the spoons in the region of the head curvature). In such cases, a sterile diaper folded 2-4 times is inserted between the handles. This prevents excessive compression of the head and a good fit of spoons to it. If the spoons are not arranged symmetrically and a certain force is required to close them, it means that the spoons are placed incorrectly, they must be removed and applied again.

trial traction

This necessary moment allows you to make sure that the forceps are applied correctly and that there is no danger of them slipping. It requires a special position of the hands of the obstetrician. For this, the doctor's right hand covers the handles of the forceps from above so that the index and middle fingers lie on the hooks. He puts his left hand on the back surface of the right, and the extended middle finger should touch the head of the fetus in the region of the leading point. If the forceps are correctly positioned on the fetal head, the tip of the finger is in constant contact with the head during trial traction. 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.

Actually traction (removing the head)

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

When extracting 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 mimic natural contractions. For this you should:

Simulate a fight by strength: start traction not abruptly, but with weak sipping, gradually strengthening and again weakening them by the end of the fight;

When performing traction, do not develop excessive force by leaning your torso back or resting your foot on the edge of the table. The elbows of the obstetrician 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 min. After 4-5 tractions, the forceps are opened for 1-2 minutes to reduce the pressure on the head;

Try to produce traction simultaneously with contractions, thus strengthening the natural expelling forces. If the operation is performed without anesthesia, it is necessary to force the woman in labor to push during traction.

Rocking, rotational, pendulum movements are not allowed. It should be remembered that tongs are a drawing instrument; traction should be done smoothly in one direction.

The direction of traction depends on which part of the pelvis the head is located in and what moments of the biomechanism of labor must be reproduced when the head is removed with forceps. The direction of traction is determined the third "triple" rule - it is fully applicable when forceps are applied to the head located in a wide part of the pelvic cavity (abdominal forceps);

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

The second direction of traction (from the narrow part of the pelvic cavity to the exit) - down and forward ;

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

*Attention! The direction of traction is indicated relative to the vertically standing woman.

Removing forceps

The fetal head can be brought out with forceps or by manual means after removal of the forceps, which is carried out after the eruption of the largest circumference of the head. To remove the tongs, each handle is taken with the same hand, the spoons are opened and removed in the reverse order: the first is the right one. spoon, while the handle is taken to the inguinal fold, the second - 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, grabs the forceps with her right hand in the area of ​​​​the castle; the left hand is placed on the crotch to protect it. Traction directs more and more anteriorly as the head is extended and erupted through the vulvar ring. When the head is completely removed from the birth canal, open the lock and remove the forceps.

DIFFICULTIES ARISING IN THE APPLICATION OF FORCEPS

Difficulties in the introduction of spoons may be associated with the narrowness of the vagina and the rigidity of the pelvic floor, which requires dissection of the perineum. If it is not possible to insert the guide arm deep enough, then in such cases the arm must be inserted somewhat backwards, closer to the sacral cavity. In the same direction, insert the forceps spoon in order to position the spoon in the transverse dimension of the pelvis, it must be moved with the help of a guide hand, acting on the back edge of the inserted spoon. Sometimes the forceps spoon encounters an obstacle and does not move deeper, which may be due to the tip of the spoon getting into the fold of the vagina or (more dangerously) into its fornix. The spoon must be removed and then re-introduced with careful control of the fingers of the guide hand.

Difficulties can 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 above the other. In this situation, it is necessary to insert a hand into the vagina and correct the position of the spoons. Sometimes, when the lock is closed, the handles of the tongs diverge greatly, this may be due to insufficient insertion depth of the spoons, poor coverage of the head in an unfavorable direction, or excessive head size. Insufficient insertion depth Spoons of their tops press on the head and when trying to squeeze the spoons, severe damage to the fetus can occur, up to a fracture of the bones of the skull. Difficulties in closing the spoons also arise in cases where the forceps are applied not in the transverse, but in an oblique and even fronto-occipital direction. The 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 a repeated vaginal examination and the introduction of spoons are necessary.

The lack of advancement of the head 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 labor.

Traction can cause slipping forceps - vertical(through the head out) or horizontal(front or back). Causes of forceps slipping are incorrect gripping of the head, improper closing of the forceps, inappropriate dimensions of the fetal head. Sliding 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 sign of slipping of the forceps (an increase in the distance between the lock and the head of the fetus, the divergence of the handles of the forceps), it is necessary to stop traction, remove the forceps and apply them again if there are no contraindications for this.

EXIT FORCEPS

Anterior view of the 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 size of the exit of the small pelvis, the small fontanel is located in front of the womb, the sacral cavity is completely filled with the head of the fetus, the ischial spines do not reach. Forceps are applied in the transverse dimension of the pelvis. The handles of the tongs are horizontal. In the downward direction, posteriorly, traction is performed until the occipital protuberance is born from under the womb, then the head is unbent and removed.

Posterior view of the occipital presentation. The internal rotation of the head is completed. The fetal head is located on the pelvic floor. Arrow-shaped seam - in the direct size of the exit, the small fontanel is located at the coccyx, the rear corner of the large fontanel is under the bosom; the small fontanel is located below the large one. Forceps are applied in the transverse dimension of the pelvis. Tractions are performed in a horizontal direction (downward) until the front edge of the large fontanel comes into contact with the lower edge of the pubic symphysis (the first fixation point). Then traction is done anteriorly until the region of the suboccipital fossa is fixed at the top of the coccyx (the second point of fixation). After that, the handles of the forceps are lowered backwards, the head is extended and birth is from under the pubic articulation of the forehead, face and chin of the fetus.

CAVITY 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 forceps and perform extension (with anterior occipital presentation) or additional flexion and extension (with posterior 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 capture the head in the region of the parietal tubercles. The imposition of forceps in an oblique size presents certain difficulties. More complex than exit obstetrical forceps are tractions, in which the internal rotation of the head is completed by 45° and more, and only then follows the extension of the head.

First position, anterior 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 fontanel is located on the right and behind, the ischial spines are reached (the fetal head is in the wide part of the pelvic cavity) or is reached with difficulty (the fetal head is in the narrow part of the pelvic cavity). In order to The fetal head was grasped biparietally, forceps should be applied in the left oblique dimension.

When applying abdominal obstetric forceps, the order of insertion of spoons is preserved. The left spoon is inserted under the control of the right hand into posterolateral 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, as this is prevented by the pubic arch. This obstacle is overcome by moving ("wandering") of 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 established in the region of the right parietal tubercle. The spoon is moved by careful pressure of the second finger of the left hand on its lower edge. In this situation, the right spoon is called - "wandering", and the left "fixed". Tractions are performed downwards and backwards, the head makes an internal turn, the sagittal suture gradually turns into a straight size of the pelvic outlet. Next, the traction is directed first down to the exit of the occipital protuberance from under the womb, then anteriorly until the head is extended.

Second position, anterior 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 fontanel is located on the left and behind, the ischial spines are reached (the fetal head is in the wide part of the pelvic cavity) or is reached with difficulty (the fetal head is in the narrow part of the pelvic cavity).In order for the fetal head to be captured biparietally, forceps must be applied in the right oblique size. In this situation, the "wandering" will be the left spoon, which is applied first. Tractions are produced, as in the first position, in the anterior form of the occipital presentation.

COMPLICATIONS

The use of obstetrical forceps in compliance with the conditions and technique usually does not cause any complications for the mother and fetus. In some cases, this operation can cause complications.

Damage to the birth canal. These include ruptures of the vagina and perineum, less often - the cervix. Severe complications are ruptures of the lower segment of the uterus and damage to the pelvic organs: the bladder and rectum, which usually occur when the conditions for the operation and the rules of technology 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, usually - swelling, cyanosis. With a strong compression of the head, hematomas may occur. The strong pressure of the 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. Hemorrhages in the brain are a great danger to the life of the fetus.

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

VACUUM EXTRACTION OF THE FETUS

Vacuum extraction of the fetus - 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 the fetus through the natural birth canal were made in the middle of the last century. The invention of the "aerotractor" by Simpson is dated 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 the 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 a negative pressure between the inner surface of the cups and the head of the fetus. 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 E.V. Chachava and P.D. Vashakidze - rubber cap). In modern obstetrics, vacuum extraction of the fetus is of extremely limited use due to adverse effects on 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 activity, with ineffective conservative therapy;
incipient fetal hypoxia.
CONTRAINDICATIONS

diseases that require "turning off" attempts (severe forms of preeclampsia, decompensated heart defects, high myopia, hypertension), since during vacuum extraction of the fetus, active laboring activity of the woman in labor is required;
discrepancy between the size of the fetal head and the mother's pelvis;
extensor presentation of the fetal head;
prematurity of the fetus (less than 36 weeks).
The last two contraindications are associated with the peculiarity of the physical action of the vacuum extractor, so the placement of cups on the head of a premature fetus or in the region of a large fontanel is fraught with serious complications.

CONDITIONS FOR THE OPERATION

- Living fruit.

Full opening of the uterine os.

Absence of a fetal bladder.

Correspondence between the size of the pelvis of the mother and the head of the fetus.

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

-Occipital insertion .

OPERATIONAL TECHNIQUE

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

Cup insertion and placement on the glans

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

Creating negative pressure

The cup is attached to the device and negative pressure up to 0.7-0.8 amt is created within 3-4 minutes. (500 mm Hg).

Fetal attraction by the head

Tractions are performed synchronously with attempts in the direction corresponding to the biomechanism of childbirth. In the pauses between attempts, attraction is not produced. The obligatory moment is to perform a trial traction.

Removing the cup

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

COMPLICATIONS

The most common complication is slipping of the calyx from the fetal head, which occurs when there is a leak in the device. Cephalohematomas often occur on the fetal head, cerebral symptoms are observed.

The imposition of obstetric forceps is a delivery operation, during which the fetus is removed from the mother's birth canal using special tools.

Obstetrical forceps are intended only for removing the fetus by the head, but not for changing the position of the fetal head. The purpose of the operation of applying obstetric forceps is to replace the generic expelling forces with the entraining force of the obstetrician.

Obstetric forceps have two branches, interconnected with a lock, each branch consists of a spoon, a lock and a handle. The forceps spoons have a pelvic and head curvature and are designed to actually capture the head, the handle is used for traction. Depending on the device of the lock, several modifications of obstetric forceps are distinguished; in Russia, obstetric forceps of Simpson-Fenomenov are used, the lock of which is characterized by simplicity of the device and considerable mobility.

CLASSIFICATION

Depending on the position of the fetal head in the small pelvis, the technique of the operation varies. When the fetal head is located in the wide plane of the small pelvis, cavity or atypical forceps are applied. Forceps applied to the head, located in the narrow part of the pelvic cavity (the sagittal suture is almost in a straight size), are called low abdominal (typical).

The most favorable variant of the operation, associated with the least number of complications, both for the mother and the fetus, is the imposition of typical obstetric forceps. In connection with the expansion of indications for CS surgery in modern obstetrics, forceps are used only as a method of emergency delivery, if the opportunity to perform CS is missed.

INDICATIONS

Severe gestosis, not amenable to conservative therapy and requiring the exclusion of attempts.
Persistent secondary weakness of labor activity or weakness of attempts, not amenable to medical correction, accompanied by prolonged standing of the head in one plane.
PONRP in the second stage of labor.
The presence of extragenital diseases in a woman in labor, requiring the exclusion of attempts (diseases of the cardiovascular system, high myopia, etc.).
Acute fetal hypoxia.

CONTRAINDICATIONS

Relative contraindications - prematurity and large fetus.

CONDITIONS FOR THE OPERATION

Live fruit.
Full opening of the uterine os.
Absence of a fetal bladder.
The location of the fetal head in the narrow part of the pelvic cavity.
Correspondence of the size of the fetal head and the mother's pelvis.

PREPARATION FOR OPERATION

It is necessary to consult an anesthesiologist and choose the method of anesthesia. The woman in labor is in the supine position with legs bent at the knee and hip joints. The bladder is emptied, the external genital organs and the inner surface of the thighs of the woman in labor are treated with disinfectant solutions. Conduct a vaginal examination to clarify the position of the fetal head in the pelvis. The forceps are checked, the hands of the obstetrician are treated as if for a surgical operation.

PAIN RELIEF METHODS

The method of anesthesia is chosen depending on the condition of the woman and the fetus and the nature of the indications for surgery. In a healthy woman (if it is advisable to participate in the process of childbirth) with weakness of labor activity or acute fetal hypoxia, epidural anesthesia or inhalation of a mixture of nitrous oxide with oxygen can be used. If it is necessary to turn off the attempts, the operation is performed under anesthesia.

OPERATIONAL TECHNIQUE

General surgical technique

The general technique of the operation of applying obstetric forceps includes the rules for applying obstetric forceps, which are observed regardless of the plane of the pelvis in which the fetal head is located. The operation of applying obstetric forceps necessarily includes five stages: the introduction of spoons and their placement on the fetal head, the closing of the forceps branches, trial traction, removal of the head, and removal of the forceps.

Rules for the introduction of spoons

The left spoon is held with the left hand and inserted into the left side of the mother's pelvis under the control of the right hand, the left spoon is inserted first, as it has a lock.

· The right spoon is held with the right hand and inserted into the right side of the mother's pelvis over the left spoon.
To control the position of the spoon, all the fingers of the obstetrician's hand are inserted into the vagina, except for the thumb, which remains outside and is set aside. Then, like a writing pen or a bow, they take the handle of the tongs, while the top of the spoon should be facing forward, and the handle of the tongs should be parallel to the opposite inguinal fold. The spoon is inserted slowly and carefully with the help of pushing movements of the thumb. As the spoon moves, the handle of the tongs is moved to a horizontal position and lowered down. After inserting the left spoon, the obstetrician removes the hand from the vagina and passes the handle of the inserted spoon to the assistant, who prevents the spoon from moving. Then a second spoon is introduced. Spoons of forceps lie on the head of the fetus in its transverse size. After the introduction of the spoons, the handles of the tongs are brought together and they try to close the lock. In this case, difficulties may arise:

The lock does not close because the spoons of the tongs are placed on the head not in the same plane - the position of the right spoon is corrected by shifting the branch of the tongs with sliding movements along the head;

One spoon is located above the other and the lock does not close - under the control of the fingers inserted into the vagina, the overlying spoon is shifted downward;

The branches are closed, but the handles of the forceps diverge strongly, which indicates that the spoons of the forceps do not overlap the transverse size of the head, but obliquely, the large size of the head or the location of the spoons on the head of the fetus is too high, when the tops of the spoons rest against the head and the head curvature of the forceps does not fits her - it is advisable to remove the spoons, conduct a second vaginal examination and repeat the attempt to apply forceps;

The inner surfaces of the handles of the forceps do not fit tightly to each other, which, as a rule, occurs if the transverse size of the fetal head is more than 8 cm - a diaper folded in four is inserted between the handles of the forceps, which prevents excessive pressure on the fetal head.

After closing the branches of the forceps, it should be checked whether the soft tissues of the birth canal are captured by the forceps. Then a trial traction is carried out: the handles of the forceps are grasped with the right hand, they are fixed with the left hand, the forefinger of the left hand is in contact with the head of the fetus (if during traction it does not move away from the head, then the forceps are applied correctly).

Next, the actual traction is carried out, the purpose of which is to remove the fetal head. The direction of traction is determined by the position of the fetal head in the pelvic cavity. When the head is in the wide part of the small pelvic cavity, the traction is directed downward and backward, with traction from the narrow part of the small pelvic cavity, the attraction is carried out downward, and when the head is standing in the exit of the small pelvis, downward, towards itself and forward.

Traction should imitate contractions in intensity: gradually begin, intensify and weaken, a pause of 1–2 minutes is necessary between tractions. Usually 3-5 tractions are enough to extract the fetus.

The fetal head can be brought out in forceps or they are removed after bringing the head down to the exit of the small pelvis and vulvar ring. When passing through the vulvar ring, the perineum is usually cut (obliquely or longitudinally).

When removing the head, serious complications can occur, such as the lack of advancement of the head and slipping of the spoons from the fetal head, the prevention of which consists in clarifying the position of the head in the small pelvis and correcting the position of the spoons.

If the forceps are removed before the eruption of the head, then first the handles of the forceps are spread and the lock is opened, then the spoons of the forceps are removed in the reverse order of insertion - first the right, then the left, deviating the handles towards the opposite thigh of the woman in labor. When removing the fetal head in forceps, traction is carried out with the right hand in an anterior direction, and the perineum is supported with the left hand. After the birth of the head, the lock of the forceps is opened and the forceps are removed.

Typical obstetrical forceps

The most favorable variant of the operation. The head is located in the narrow part of the small pelvis: two-thirds of the sacral cavity and the entire inner surface of the pubic joint are occupied. With vaginal examination, the ischial spines are difficult to reach. The sagittal suture is located in a straight or almost straight size of the pelvis. The small fontanel is located below the large one and anterior or posterior to it, depending on the type (anterior or posterior).

The forceps are applied in the transverse size of the pelvis, the spoons of the forceps are placed on the lateral surfaces of the head, the pelvic curvature of the instrument is compared with the pelvic axis. In the anterior view, traction is carried out downward and anteriorly until the moment of fixation of the suboccipital fossa at the lower edge of the symphysis, then anteriorly until the eruption of the head.

In the posterior view of the occipital presentation, traction is carried out first horizontally until the first fixation point is formed (the anterior edge of the large fontanel is the lower edge of the pubic symphysis), and then anteriorly until the suboccipital fossa is fixed at the top of the coccyx (the second fixation point) and the handles of the forceps are lowered posteriorly, as a result of which extension occurs heads and the birth of the forehead, face and chin of the fetus.

Cavity Obstetric Forceps

The fetal head is located in the wide part of the pelvic cavity, fulfilling the sacral cavity in the upper part, the occiput has not yet turned anteriorly, the sagittal suture is located in one of the oblique dimensions. At the first position of the fetus, forceps are applied in the left oblique size - the left spoon is behind, and the right spoon "wanders"; in the second position, on the contrary - the left spoon “wanders”, and the right spoon remains behind. Traction is carried out in the direction downwards and backwards until the head passes into the plane of the exit of the pelvis, then the head is released by manual techniques.

COMPLICATIONS

Damage to the soft birth canal (ruptures of the vagina, perineum, rarely the cervix).
Rupture of the lower segment of the uterus (during the operation of applying abdominal obstetric forceps).
Damage to the pelvic organs: the bladder and rectum.
· Damage to the pubic joint: from symphysitis to rupture.
· Damage to the sacrococcygeal joint.
Postpartum purulent-septic diseases.
· Traumatic injuries of the fetus: cephalohematomas, paresis of the facial nerve, injuries of the soft tissues of the face, damage to the bones of the skull, intracranial hemorrhages.

FEATURES OF THE POSTOPERATIVE PERIOD

In the early postoperative period, after the application of abdominal obstetric forceps, a control manual examination of the postpartum uterus is carried out to establish its integrity.
· It is necessary to control the function of the pelvic organs.
In the postpartum period, it is necessary to prevent inflammatory complications.

The operation of applying obstetric forceps refers to delivery. Delivery operations are called operations with the help of which childbirth is completed. Delivery operations through the natural birth canal include: extraction of the fetus with the help of obstetric forceps, by vacuum extraction, extraction of the fetus by the pelvic horses, fruit-destroying operations.

The operation of applying forceps is extremely important in obstetrics. Domestic obstetricians have done a lot for the development and improvement of this operation, in particular, the indications for it and the definition of the conditions for its implementation have been developed in detail, their own varieties of the instrument have been created, and the immediate and long-term outcomes of the operation for the mother and child have been studied. The role of the obstetrician in providing prompt assistance to women in labor in cases of complicated childbirth is great and responsible. It is especially great during the operation of applying obstetric forceps. Therefore, among the few, but very responsible obstetric operations (not counting the light ones), the operation of applying obstetric forceps undoubtedly occupies a special place both in terms of the relative frequency of its use compared to other obstetric operations, and in terms of the beneficial results that this operation can give with timely, skillful and careful application.

Purpose and action of obstetric forceps

The following questions are most frequently discussed in the literature:

1. whether obstetric forceps are intended only for the head (including the subsequent one) or can they be applied to the buttocks of the fetus;
2. is it possible to use forceps to overcome the discrepancy between the size of the pelvis of the woman in labor and the head of the fetus, using force and, in particular, the force of attraction or compression of the head with spoons;
3. what is the nature of the extracting force of forceps;
4. whether it is permissible to rotate the head with tongs around its vertical or horizontal axis;
5. whether forceps have dynamic action;
6. whether the forceps should stretch the soft tissues of the birth canal, preparing them for the eruption of the fetal head.

The first question - about the admissibility of applying forceps to the buttocks - was resolved positively in domestic obstetrics. Almost all guidelines allow the application of forceps to the buttocks, provided that the latter are already firmly inserted into the pelvic inlet and it is impossible to put a finger behind the inguinal fold to extract the fetus. Traction should be performed carefully due to the ease of slipping of the forceps.

On the second question - about overcoming the discrepancy between the head of the fetus and the pelvis of the woman in labor with the help of forceps, domestic obstetricians have a unanimous opinion. Forceps are not designed to bridge the mismatch, and a narrow pelvis by itself is never an indication for surgery. It should be noted that compression of the head with forceps during the operation is inevitable and represents an inevitable disadvantage of the instrument. Back in 1901, in the dissertation work of A. L. Gelfer on the corpses of newborns, the change in intracranial pressure was studied when the head was passed with forceps through a narrow pelvis. The author came to the conclusion that when the head was passed with forceps through the normal pelvis, intracranial pressure increased by 72-94 mm Hg. Art. Only 1/3 of the cases of pressure increase depends on the compressive action of the forceps, and 1/3 - on the compressive action of the pelvic walls. With a true conjugate of 10 cm, intracranial pressure increased to 150 mm, of which 1/3 occurs when forceps were used, with a conjugate of 9 cm, intracranial pressure reached 200 mm, and at 8 cm - even 260 mm Hg. Art.

The most complete substantiation of the view regarding the nature of the extracting force and the possibility of using various types of rotational movements was given by N. N. Fenomenov. Currently, there is a clear provision that forceps are intended only for removing the fetus, and not for artificially changing the position of the head. In this case, the obstetrician follows the movements of the head and contributes to them, combining the translational and rotational movement of the head, as occurs in spontaneous childbirth. The dynamic action of forceps is expressed in increased labor activity with the introduction of forceps spoons, but this is not significant.

Indications for the imposition of obstetric forceps

Indications for forceps surgery are usually divided into maternal and fetal indications. In modern guidelines, the indications for the operation of applying obstetric forceps are as follows: acute distress (suffering) of the fetus and shortening of the II period. There is a significant difference in the frequency of individual indications for surgery. A. V. Lankovits in his monograph "The operation of applying obstetric forceps" (1956) indicates that this difference remains large, even if you do not adhere to the details of the division, and combine the indications into groups: indications from the mother, from the fetus and mixed. So, the testimony from the mother accounts for from 27.9 to 86.5%, and including mixed, from 63.5 to 96.6%. Indications from the fetus range from 0 to 68.6%, and including mixed, from 12.7 to 72.1%. Many authors do not indicate mixed indications at all. It should be noted that the general formulation of the testimony given by N. N. Fenomenov (1907) expresses the general that underlies the individual testimony and covers the whole variety of particular moments. So, N. N. Fenomenov gave the following general definition of indications for surgery: “The application of forceps is indicated in all those cases in which, if the necessary conditions for their use are present, the expelling forces are insufficient to end the birth act at the moment. And further: “If during childbirth any circumstances arise that threaten the danger of the mother or the fetus, or both together, and if this danger can be eliminated by the speedy end of childbirth with the help of forceps, then the forceps are indicated.” The indications for the application of forceps are the threatening condition of the woman in labor and the fetus, which, as in the operation of extracting the fetus, requires an urgent end of the birth act.

These are: decompensated heart disease, severe lung and kidney disease, eclampsia, acute infection accompanied by a rise in body temperature, fetal asphyxia. In addition to these general and other obstetric operations, there are special indications for forceps.

1. Weakness of labor activity. The frequency of this indication is significant. The appearance of signs of compression of the soft tissues of the birth canal or the fetus makes it necessary to resort to surgery, regardless of the time during which the head was standing in the birth canal. However, even without obvious signs of compression of the fetal head and soft tissues of the woman in labor, the obstetrician, if conditions are present, may resort to surgery after an average of 2 hours.
2. Narrow pelvis. For an obstetrician in the management of childbirth, it is not the narrow pelvis itself that is important, but the ratio between the size and shape of the pelvis of the woman in labor and the head of the fetus. It should be mentioned that for a long time the purpose and effect of forceps was seen in the compression of the head, which facilitates its passage through a narrow pelvis. Subsequently, thanks to the work of domestic authors, especially N. N. Fenomenov, this view of the action of forceps was abandoned. The author wrote: “Speaking on these grounds in the most categorical way against the doctrine that considers a narrow (flat) pelvis as an indication for forceps, I understand very well, of course, that the imposition of forceps will and should nevertheless take place with a narrow pelvis, but not for the sake of narrowing, but due to general indications (weakening of labor, etc.), if the conditions necessary for the forceps are present. After nature, with the help of an expedient configuration of the head, has eliminated or almost eliminated the initial existing discrepancy between the pelvis and the birth object, and when the head has already completely or almost completely passed the narrowed place and for the final birth needs only an increase in (weakened) straining activity, which can be replaced artificially, the operation of applying forceps in this case is quite an expedient benefit. Between this view of the forceps and the narrow pelvis and the above, the difference is vast and quite obvious. Thus, in my opinion, a narrow pelvis by itself can never be considered an indication for forceps surgery. After all, the indication for obstetric operations in general is always the same - it is the impossibility of an arbitrary end of childbirth without danger to the mother and fetus.
3. The narrowness and inflexibility of the soft tissues of the birth canal and their infringement - these indications are extremely rare.
4. Unusual head inserts. Unusual insertion of the head cannot serve as an indication for surgery if it is a manifestation of a discrepancy between the pelvis and the head and this discrepancy has not been overcome. Forceps should not be used to correct the position of the head.
5. Threatened and accomplished uterine rupture. Currently, only N. A. Tsovyanov considers overstretching of the lower segment of the uterus among the indications for the imposition of forceps. A.V. Lankovits (1956) believes that if the head is in the pelvic cavity, or even more so in its outlet, then in such cases a caesarean section is not feasible, and the spoons of the forceps cannot have direct contact with the uterus, since the neck has already moved beyond the head . The author believes that in such a situation and the threat of uterine rupture, there is reason to consider the operation of applying abdominal and output forceps as indicated. It is quite obvious that the refusal of vaginal delivery in case of diagnosed uterine rupture during childbirth is the only correct position of the doctor.
6. Bleeding during childbirth is only in exceptional cases an indication for a forceps operation.
7. Eclampsia is an indication for forceps surgery quite often, from 2.8 to 46%.
8. Endometritis in childbirth. A.V. Lankovits, based on the observation of 1000 births complicated by endometritis, believes that only if attempts are unsuccessful to speed up the course of childbirth with conservative measures or if any other serious indications appear on the part of the mother or fetus, surgery is acceptable.
9. Diseases of the cardiovascular system - the issue should be resolved individually, taking into account the clinic of extragenital disease, together with the therapist.
10. Respiratory diseases - a functional assessment of the state of the woman in labor is taken into account with the determination of indications of the function of external respiration.
11. Intrauterine fetal asphyxia. If there are signs of onset asphyxia that is not amenable to conservative treatment, immediate delivery is indicated.

Conditions necessary for the imposition of obstetric forceps

To perform the operation of applying forceps, a number of conditions are necessary to ensure a favorable outcome for both the woman in labor and the fetus:

1. Finding the head in the cavity or outlet of the pelvis. In the presence of the specified condition, all the others, as a rule, are present. The operation of applying forceps with a high-standing head belongs to the so-called high forceps and is not currently used. However, obstetricians still mean completely different operations by high forceps. Some under high forceps mean the operation of applying them to the head, which has been established as a large segment at the entrance to the small pelvis, but has not yet passed the terminal plane, others, when the head is pressed to the entrance, and still others, when the head is movable. By high forceps is meant such an imposition of them when the largest segment of the head, being tightly fixed at the entrance to the small pelvis, has not yet had time to pass the terminal plane. In addition, he quite rightly notes that determining the height of the head in the pelvis is not as simple as it might seem at first glance. None of the proposed methods for determining the height of the head in the pelvis (the implementation of the sacral cavity, the back surface of the womb, the reach of the cape, etc.) can claim to be accurate, since various factors can affect this determination, namely: the size of the head, degree and the shape of its configuration, the height and deformation of the pelvis, and a number of other circumstances that are not always accountable.

Therefore, it is not the head in general that is important, but its largest circumference. In this case, the largest circumference of the head does not always pass in the same section of the head, but is associated with the insertion feature. So, with an occipital insertion, the largest circle will pass through a small oblique size, with a parietal (anterocephalic) - through a straight line, with a frontal - through a large oblique and with a facial - through a sheer one. However, with all these varieties of insertion of the head, it will be practically correct to assume that its largest circumference passes at the level of the ears. By holding the semi-hand high enough (all fingers except the thumb) during vaginal examination, one can easily find both the ear and the innominate line, which forms the border of the entrance to the pelvis. Therefore, it is recommended to conduct a study before the operation with a half-hand, and not with two fingers, in order to reach the ear and determine exactly in which plane of the pelvis the largest circumference of the head is located and how it was inserted.

Below are the options for the location of the head in relation to the planes of the small pelvis (Martius scheme), which should be considered when applying obstetric forceps:

• option 1 - the head of the fetus is above the entrance to the small pelvis, the application of forceps is impossible;
• option 2 - the head of the fetus with a small segment at the entrance to the small pelvis, the application of forceps is contraindicated;
• option 3 - the head of the fetus with a large segment at the entrance to the small pelvis, the application of forceps corresponds to the technique of high forceps. Currently, this technique is not used, since other methods of delivery (vacuum extraction of the fetus, caesarean section) give more favorable results for the fetus;
• option 4 - the head of the fetus in a wide part of the pelvic cavity, cavity forceps could be applied, however, the operation technique is very complicated and requires a highly qualified obstetrician;
• option 5 - the head of the fetus in the narrow part of the pelvic cavity, abdominal forceps can be applied;
• option 6 - fetal head in the plane of exit from the small pelvis, the best position for applying obstetric forceps using the exit forceps technique.

A completely secondary role is played by the question of where the lower pole of the head is located, because with a different insertion, the lower pole of the head will be located at a different height, with the configuration of the head the lower pole will be lower. Of great importance is the mobility or immobility of the fetal head. Complete immobility of the head usually occurs only when its largest circumference coincides or almost coincides with the plane of entry.

1. Correspondence of the size of the pelvis of the woman in labor and the head of the fetus.
2. The average size of the head, i.e. the head of the fetus should not be too large or too small.
3. Typical insertion of the head - forceps are used to remove the fetus, and therefore should not be used to change the position of the head.
4. Full disclosure of the uterine pharynx, when the edges of the pharynx moved beyond the head everywhere.
5. A ruptured fetal bladder is an absolutely necessary condition.
6. Living fruit.
7. Accurate knowledge of finding the presenting part, position, including the degree of asynclitism.
8. The lower pole of the head at the level of the ischial spines. It should be noted that a pronounced birth tumor can mask the true position of the head.
9. Sufficient dimensions of the outlet of the pelvis - lin. intertubero more than 8 cm.
10. Sufficient episiotomy.
11. Adequate anesthesia (pudendal paracervical, etc.).
12. Emptying the bladder.

Without dwelling on the technique of applying obstetric forceps, which is covered in all manuals, one should dwell on the positive and negative aspects of applying forceps for both the mother and the fetus. At present, however, isolated works have appeared on a comparative assessment of the use of obstetric forceps and a vacuum extractor.

Forceps Models

Forceps - an obstetric instrument with which a live full-term or almost full-term fetus is removed from the birth canal by the head.

There are over 600 different models of obstetric forceps (French, English, German, Russian). They differ mainly in the structure of the spoons of the tongs and the lock. Forceps Levre (French) have crossed long branches, a hard lock. Negele tongs (German) - short crossed branches, the lock resembles scissors: on the left spoon there is a rod in the form of a hat, on the right there is a notch that fits the rod. Lazarevich forceps (Russian) have non-crossing (parallel) spoons with only a head curvature and a movable lock.

Recently, most obstetricians use forceps of the Simpson-Fenomenov model (English): crossed spoons have two curvatures - head and pelvic, the lock is semi-movable, there are side protrusions on the handle of the forceps - Bush hooks.

General rules for applying obstetric forceps

To perform the operation, the woman in labor is placed on the Rakhmanov bed in the position for vaginal operations. Before the operation, bladder catheterization and treatment of the external genital organs are performed. The operation of applying obstetric forceps is performed under general anesthesia or epidural anesthesia. An episiotomy is usually performed before the operation.

The main points of the operation of applying obstetric forceps are the introduction of forceps spoons, closing the forceps, performing tractions (trial and working), removing the forceps.

The main fundamental points that should be observed when applying obstetric forceps are dictated by triple rules.

1. The first triple catch concerns the insertion of the jaws (spoons) of the forceps. They are introduced into the genital tract separately: first, the left spoon is inserted with the left hand into the left half of the pelvis (“three from the left”) under the control of the right hand, the second, the right spoon is inserted with the right hand into the right half of the pelvis (“three from the right”) under the control of the left hand.
2. The second triple rule is that when closing the forceps, the axis of the forceps, the axis of the head and the wire axis of the pelvis must coincide (“three axes”). To do this, forceps should be applied so that the tops of the spoons are turned towards the wire point of the fetal head, capture the head along the largest circumference, and the wire point of the head is in the plane of the forceps axis. When the forceps are correctly applied, the auricles of the fetus are located between the spoons of the forceps.
3. The third triple rule reflects the direction of traction when removing the head in forceps, depending on the position of the head (“three positions - three tractions”). In the first position, the fetal head is located as a large segment in the plane of the entrance to the small pelvis, while the traction is directed from top to bottom (on the toes of the shoes of the seated obstetrician). Extraction of the fetal head located at the entrance to the small pelvis, using obstetric forceps (high forceps) is currently not used. In the second position, the fetal head is in the pelvic cavity (abdominal forceps), while traction is performed parallel to the horizontal line (in the direction of the knees of the seated obstetrician). In the third position, the head is in the plane of the exit from the small pelvis (exit forceps), traction is directed from the bottom up (to the face, and at the last moment - in the direction of the forehead of the seated obstetrician).

Obstetric forceps technique

The exit forceps are applied to the fetal head, located in the plane of the exit from the small pelvis. In this case, the swept seam is located in the direct dimension of the exit plane, the forceps are applied in the transverse dimension of this plane.

The insertion of the forceps spoons is carried out according to the first triple rule, the closing of the forceps according to the second triple rule. Spoon tongs close only if they lay down correctly. If the spoons do not lie in the same plane, then by pressing on the Bush hooks, the spoons must be turned out into one plane and closed. If it is impossible to close the forceps, the spoons should be removed and the forceps should be reapplied.

After closing the spikes, traction is performed. First, to check the correct application of forceps, I perform! trial traction. To do this, with the right hand, cover the handle of the tongs from above so that the index and middle fingers of the right hand lie on the Bush hooks. The left hand is placed on top of the right so that the index finger touches the head of the fetus. If the forceps are applied correctly, then during the trial traction the head moves behind the forceps.

If the forceps are applied incorrectly, the index finger moves away from the fetal head along with the forceps (forceps slip). Distinguish between vertical and horizontal slipping. In the case of vertical slipping, the tops of the forceps spoons diverge, slide along the head and go out of the genital tract. When horizontal slipping, the forceps slide from the head up (to the womb) or back (to the sacrum). Such slippage is only possible with a high-positioned head. At the first sign of slipping of the forceps, the operation should be stopped immediately, the spoons of the forceps should be removed and reinserted.

Working tractions (actual tractions) are performed after they are convinced of the success of the trial traction. The right hand remains on the forceps, and the handles of the forceps from below cover the left hand. The direction of traction corresponds to the third triple rule - first on the face, then on the forehead of the seated obstetrician. The strength of traction resembles attempts - it gradually increases and gradually weakens. Like sweating, traction is performed with pauses, during which it is useful to relax the forceps to avoid excessive squeezing of the head.

After the appearance of the nape of the fetus above the perineum, the obstetrician should stand on the side of the woman in labor, grab the handles of the forceps with his hands and direct the traction upwards. After the eruption of the head, traction is carried out with one hand up, and the perineum is supported with the other.

After removing the largest perimeter of the fetal head, the forceps are removed in reverse order (first the right spoon, then the left). After that, the head and shoulders of the fetus are removed by hand.

Technique for imposing output (typical) obstetric forceps in posterior occipital presentation

In the posterior view of the occiput presentation, forceps are applied in the same way as in the anterior view, however, the nature of the traction in this case is different. The first tractions are directed steeply down until the region of the large fontanel is brought under the pubic symphysis, then the crown is brought out by traction upwards.

After the appearance of the back of the head above the perineum, the handles of the forceps are lowered down, the fetal head unbends and its front part appears in the genital slit.

Technique for applying abdominal (atypical) obstetric forceps

Abdominal forceps are applied to the fetal head located in the pelvic cavity. In this case, the swept suture is located in one of the oblique dimensions (right or left) of the pelvis, the forceps are applied in the opposite oblique dimension of this plane. In the first position (arrow-shaped seam in the right oblique size), forceps are applied in the left oblique size, in the second position (arrow-shaped seam in the left oblique size) - in the right oblique size (Fig. 109).

The introduction of forceps spoons is carried out according to the first triple rule (“three on the left, three on the right”), but in order for the forceps spoons to lie in an oblique size of the pelvis, one of the spoons must be shifted upward (towards the womb). That spoon, which, after being introduced into the pelvic cavity, does not move, is called fixed. Spoon, shifted to the bosom, is called wandering. In each individual case, depending on the location of the swept seam, either the right or the left spoon will be fixed. In the first position (arrow-shaped seam in the right oblique size), the fixed spoon will be the left one, in the second position (arrow-shaped seam in the left oblique size) - the right one.

Closing forceps, trial and working traction is carried out according to the rules described above.

In addition to the complications associated with the incorrect technique of the operation, ruptures of the perineum, vagina, large and small labia, and the clitoris can be observed. Possible violations of the act of urination and defecation in the postpartum period.

The operation can also be traumatic for the fetus: damage to the soft tissues of the head, cephalohematoma, retinal hemorrhage, cerebrovascular accident, trauma to the skull bones.

The operation of applying obstetric forceps to the present time remains a rather traumatic method of operative delivery through the natural birth canal. The outcome of childbirth for the fetus largely depends on the weight of his body, the height of the head, the position of the head, the duration of the operation, the qualifications of the doctor, the condition of the fetus at the beginning of the operation, and the quality of neonatal care.

Complications of applying obstetric forceps

In domestic and foreign literature, attention is paid to a number of complications in the mother and fetus during the operation of applying obstetric forceps. Particular attention is paid to an increase in the number of cephalohematomas by 3-4 times when applying obstetric forceps. An analysis of 5,000 births revealed that in spontaneous births, cephalohematoma is observed in 1.7% versus 3.5% during the operation of applying exit obstetric forceps and in 32.7% - with abdominal obstetric forceps. Despite the fact that no pathological electroencephalograms or skull injuries were found in these observations, cephalohemagomas were found in 25% of studies, and the authors attribute skull injuries to the use of obstetric forceps. Although cephalohemagomas resolve rapidly, it should be noted that neonatal complications are not uncommon, including complications of this neonatal period such as anemia, hyperbilirubinemia, calcification, septicemia, and meningitis. Thus, the immediate outcomes of the forceps operation for a child can be considered by dividing all complications into the following types:

• soft tissue damage;
• hemorrhages in the brain and cranial cavity;
• asphyxia;
• rare injuries to the bones of the skull, eyes, nerves, collarbone, etc.

With the output obstetric forceps, no increase in perinatal morbidity and mortality was detected. With regard to abdominal forceps, the issue remains not entirely clear to this day. Some authors believe that the reduction in perinatal morbidity and mortality is due to the increased use of caesarean section, and obstetrical forceps are offered only for difficult births.

In conclusion, we can say with good reason that even Russian-type tongs - the most advanced of all types of this instrument - do not represent a completely safe tool and should not be used without good reason.

An obstetrician can go this only right way only if obstetric care is well organized, creative development of the heritage of the Russian obstetric school, continuous improvement of his knowledge and experience, thoughtful clinical assessment of the whole organism of a woman giving birth. The difficulties of such a path are not small, but quite surmountable.

Over the past three centuries, medical and public opinions on the use of obstetric forceps have been opposite, but not as categorical as the points of view given. However, if the use of obstetrical forceps was abolished, then 5-25% of women in labor who were delivered by this method would have two options: a caesarean section or, as before the invention of the forceps, a second stage of labor over long hours or even days.

Over the past three centuries, more than 700 species have been proposed, and new ones continue to be invented. Usually in clinical practice, Simpson forceps are used, as well as Neville-Barnes, Ferguson, Tucker-McLain forceps similar to them with spoons in the form of a plate. The tongs consist of two branches, right and left, each of which includes a spoon, a lock and a handle. The head curvature of the spoon, concave on the inside and convex on the outside, corresponds to the shape of the fetal head, and the pelvic curvature is expressed in the curvature of the spoons in the form of an arc, which corresponds to the curvature of the birth canal of the mother. The branches of the tongs are closed in the area of ​​the lock and handles. Forceps designed for rotation (most often these are Killand's forceps) are distinguished by a pronounced head curvature and a slightly pronounced pelvic curvature of the spoons. Such a device allows rotation in the pelvic cavity and reduces the risk of injury to the mother's tissues, because. reduces the arc of rotation due to the narrowing of the tips of the spoons. When applying rotational forceps, asynchronous insertion is often encountered, therefore, such forceps have a sliding lock. Each obstetrician prefers a different style of forceps based on skill and awareness. In clinical practice, the obstetrician needs to be familiar with two of their types - the classic Simpson forceps and the Keelland rotary forceps. More detailed information about the structure of various types of forceps can be found in the literature, a list of which is presented at the end of this chapter.

Classic obstetrical forceps

After the indications for the application of obstetric forceps have been determined and preliminary preparation has been completed, the patient is placed in the lithotomy position with appropriate leg support. The forceps spoons are designed in such a way that when they are placed in the pelvic cavity in a transverse position, they maintain an amplitude of safe movement of 45 in each direction from the initial one: the boundaries are the iliopubic eminence and the sacroiliac joint. The imposition of forceps should be performed as follows: a spoon of forceps is applied to the child's head in the area between the eye sockets and ears. This arrangement of spoons is biparietal and bimalar, i.e. they are applied to the parietal and zygomatic bones, and the pressure on the head is distributed so that the most vulnerable parts of the skull do not experience it. If the imposition of forceps spoons is asymmetrical, for example, on the area of ​​​​the eyebrow and mastoid process, the subsequent pressure during traction is also distributed asymmetrically - pressure increases on the falciform processes of the cerebellum and the cerebellum, which leads to an increased risk of intracranial hematoma.

When the view and position of the fetal head is precisely established, for example, anterior occipital presentation, first or second position, both branches of the forceps are picked up and folded in front of the patient's perineum in such a way as if overlaying the fetal head. The left branch of the obstetric forceps is taken with the left hand, inserted from the left side and placed in front of the left ear of the fetus. During this action, the fingers of the right hand are inserted into the vagina, and the thumb of the left hand rests on the left branch of the forceps. The handle of the left branch of the tongs is held in the left hand, then it is rotated in an arcuate manner, with the fingers of the right hand directing the spoons of the tongs to the desired position. Then the hands are changed and the procedure for introducing the right spoon is carried out. Most classic forceps have an "English lock" in which the right branch enters the left. Thus, there is no need to manipulate the parts of the tongs separately from each other, as they are connected. For the first or second position in the anterior occiput presentation, the method of applying the forceps is the same, but the location of the head must be taken into account. The imposition of spoons of tongs on the head and the locking of the lock should be done without effort. If, however, when inserting spoons or when closing the branches of the forceps into the lock, any difficulties arise, you should stop and double-check the location of the fetal head.

If the branches of the tongs closed into a lock without difficulty, you should check the correct application of the spoons of the tongs in the following ways:

• the small fontanel should be in the middle of the distance between the spoons of the forceps, the lines of the lambdoid seam should be equidistant from the spoons of the forceps;
• the small fontanel should be at a distance equal to the width of one finger from the surface of the forceps in the lock area. If the small fontanel is located further from the indicated surface, then traction will lead to the extension of the head, and it will pass through the birth canal with its large size;
• the sagittal suture should be perpendicular to the locking surface of the forceps throughout its entire length. The location of the locking surface of the forceps obliquely with respect to the sagittal suture means that the spoons of the forceps are applied asymmetrically, closer to the areas of the eyebrow and mastoid process;
• palpable parts of the openings of the forceps spoons should be equal on both sides. With the correct application of the forceps, the holes in the spoons should almost not be palpated, more than one finger should not pass between them and the head.

If not all of these conditions are met, the overlay should be corrected or performed again.

Sufficient grip strength of tongs spoons is still one of the most important aspects. In this case, the required force of compression of the spoons is easier to achieve by placing the fingers as close as possible to the lock area of ​​the tongs, further from the end of the handles. The index and middle fingers are held together, and the other hand is placed on the lock, which helps in the implementation of traction down (Pajo's maneuver). It is necessary to ensure that such tractions correspond to the wire axis of the pelvis and do not exert pressure on the pubic bone.

Tractions should be carried out during the fight, combining them with attempts, and with their help to advance the head according to the wired axis of the pelvis - the curvature of Carus. During traction, the obstetrician can stand or sit, his arms should be bent at the elbows. It's hard to describe how strong the traction should be, but a less powerful effective traction is better. A recent study used isometric traction force determination. It has been shown that young obstetricians should be taught traction with an "ideal" force of 14-20 kg. Physically developed obstetricians of both sexes are able to apply significant and not always necessary forces when applying obstetric forceps. The basic principle is that traction should be of moderate strength and soft, in addition, it is necessary to evaluate their effectiveness. The result of traction together with attempts is the lowering and birth of the fetal head. In fact, after the first traction, it becomes clear whether it descends. In cases of mechanical obstruction to the passage of the head, a very definite sensation arises during the first traction, the presence of which means that further attempts to complete the birth with the help of obstetric forceps should be abandoned.

As the head descends toward the perineum and the occiput passes under the pubic symphysis, the direction of traction should gradually change anteriorly and upwards at approximately a 45° angle. When the fetal head is incised, the forceps are raised at an angle of 75°, one hand begins to hold the perineum or, if necessary, an episiotomy is performed. When the fetal head is almost born, the spoons of the forceps can be removed by reversing the steps performed when applying them. Usually, the right spoon of forceps is removed first. If too much force is needed to remove the trays, the head can be gently assisted with forceps placed on it.

If the sagittal suture is in the right or left oblique size, then after the correct application of the forceps spoons, it is necessary to gradually and accurately, without traction, turn the head 45 degrees towards the midline. This can be done by slightly lifting the handles of the forceps and slowly turning them in an arc, allowing the maternal soft tissues to adapt to the changing position of the fetal head. After turning the head, it is necessary to check again the correct application of the forceps spoons, because they could slip.

The natural process of childbirth is difficult and sometimes unpredictable. Often there are situations when, in order to save the life of the child and the mother, it is necessary to end the birth as soon as possible. In this case, the obstetrician-gynecologist urgently decides on the imposition of obstetric forceps.

Obstetric forceps - a little history

For the first time, obstetric forceps were created by P. Chamberlain, who kept the tool a secret and used it for personal enrichment.

Forceps, re-invented 125 years later by the surgeon Palfin, became public property. It was from this moment (1723) that obstetric forceps began to be used and improved first in European countries, and then in Russia and other post-Soviet republics.

Up to the moment when the caesarean section entered obstetric practice, obstetric forceps were the only means by which it was possible to save the lives of many babies and women in labor as well.

Obstetric forceps - types and overlay technique

To date, in total, there are more than 600 models of obstetric forceps, which differ in their structure and the nature of the imposition.

Depending on the location of the fetal head, forceps are classified:

1. Exit forceps (typical)- superimposed on the head, a large segment of which is located in the plane of the exit of the small pelvis. The imposition of exit obstetric forceps is rarely practiced, since in this position of the head, episiotomy can be dispensed with.
2. Cavity Obstetric Forceps (Atypical) required if the head is located directly in the pelvic cavity.
3. Tall forceps previously practiced when the head was at the entrance to the small pelvis. The imposition of high forceps is a dangerous and complicated procedure, leading to severe birth complications, which is why it is currently prohibited.

As a rule, classic models of tongs consist of two symmetrical spoons, a lock and a handle.

According to the degree of mobility of the lock - the connecting element, obstetric forceps can be divided into:

• Russians (the castle is quite mobile);
• German (the castle is almost motionless);
• English (moderate mobility);
• French (fixed lock).

In our country, the English obstetric Simpson forceps are most often used in the modification of the obstetrician Fenomenov, with the same name Simpson-Fenomenov. This model consists of two parts - the right and left spoons, which have two curvatures (head and pelvis), a movable lock, a ribbed handle with Bush hooks for fixing hands. The weight of the tongs is 500 grams, the length is about 35cm. The principles of applying obstetric forceps depend on the features of the instrument, and in particular on whether the output or cavity model.

Obstetric forceps - indications and consequences

The main indications for applying forceps are:

• diseases of the cardiovascular system, kidneys, heart of a woman, incompatible with the load of labor;
• weak generic activity;
• acute;
• prolapse of umbilical cord loops;
• premature detachment of the placenta and many others, at the discretion of the doctor.