Forceps-Aided Delivery

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Chapter 244 Forceps-Aided Delivery

DESCRIPTION

Forceps-aided delivery is a method of assisting or expediting vaginal vertex delivery through the application of obstetric forceps. (Discussion here is limited to low or outlet forceps with the fetus presenting within 45 degrees of directly occiput anterior.)

INDICATIONS

Fetal: nonreassuring fetal status, acute fetal distress. Maternal: fatigue, prolonged second stage of labor (nulliparous women: lack of continuing progress for 3 hours with regional anesthesia or 2 hours without regional anesthesia; multiparous women: lack of continuing progress for 2 hours with regional anesthesia or 1 hour without regional anesthesia), certain types of pulmonary, cardiac, or neurologic disease.

CONTRAINDICATIONS

Incompletely dilated cervix, significant fetal malpresentation, unengaged fetal head, intact fetal membranes, inability to assess fetal position or obtain maternal cooperation, distorted or contracted maternal pelvic anatomy, gestational age less than 34 weeks, fetal demineralization or clotting disorder.

REQUIRED EQUIPMENT

• Standard equipment for spontaneous vaginal delivery, including sterile gowns and gloves

• Fetal heart rate monitor

• Traction forceps (Simpson, Tucker-McLane or similar)

TECHNIQUE

Adequate maternal anesthesia or analgesia should be ensured in all but the most extreme circumstances. Whenever possible, the maternal bladder should be emptied (by catheter). The exact position of the fetal head must be ascertained by palpation of the sagittal suture and fontanels. All other preparations for vaginal delivery should be in place before forceps are applied.

Correct placement of forceps occurs only when the long axis of the blades corresponds to the occipitomental diameter, with the major portion of the blade lying over the face, the concave margins of the blades directed toward the sagittal suture (with the fetus in the occiput anterior position). To accomplish this, the left blade (both operator’s and patient’s left) is introduced into the vagina next to the fetal head using the operator’s right hand or fingers within the vaginal canal. The vaginal hand is used as a guide to accomplish the placement while the external hand provides only minimal support. The introduction is accomplished by starting with the handle perpendicular to the floor and the cephalic curve of the blade resting against the fetal head. The internal hand guides the blade inward, upward, and with a rotation that brings the forceps handle through a wide outward arc ending parallel to the floor. This arc is necessary to accommodate both the cephalic and pelvic curves of the device. A preliminary assessment of placement adequacy should be made before the right blade is placed. The right blade is placed in a similar arcing manner using the operator’s left hand as the internal hand, with the right providing simple support.

Before the two forceps blades are articulated, the position on the fetal head should be verified. A correct position will be evident by symmetry of the blades in comparison with the sagittal sutures and posterior fontanel. If necessary, one or both blades may be gently maneuvered (using fingers within the vagina) to accomplish optimal positioning. Removal and re-placement is sometimes necessary.

Traction is generally applied by the placement of the fingers on the upper surface of the handles or shanks and the thumbs below. Traction on the articulated forceps begins in a horizontal or slightly downward (axis of the maternal pelvic canal) manner. Traction should be intermittent and, when possible, coordinated with maternal expulsive efforts. To mimic the normal birth process, traction in the horizontal plane continues until the descending fetal head distends the vulva. (An episiotomy, if required, may be performed at this point.)

As the fetal head further distends the vulva, the axis of traction is gradually rotated upward, mimicking the normal extension process of the head as it rotates under the symphysis. Once the brow is palpable through the perineum, the blades may be removed and the fetal head delivered by pressure on the perineum (modified Ritgen maneuver). More often, the blades may be left in place until the fetal chin has cleared the perineum. The remainder of the delivery proceeds as with a spontaneous delivery.

COMPLICATIONS

It is difficult (if not impossible) to separate the effects of forceps-aided vaginal delivery from those of spontaneous vaginal delivery. Both randomized trials and meta-analysis studies have failed to show conclusive differences. Both forceps delivery and vacuum extraction have been associated with the development of maternal hematomas and possibly linked to pelvic floor injury. However, other factors associated with pelvic floor injury include normal spontaneous vaginal delivery, episiotomy, prolonged second stage of labor, and increased fetal size. Similarly, studies have failed to identify neonatal or fetal injuries or developmental abnormalities that can be directly linked to forceps delivery. (The morbidity that previously had been thought to be due to operative vaginal delivery actually may have resulted from the process of abnormal labor that led to the need for intervention.)

CPT CODE(S)

59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery

59409 Vaginal delivery only (with or without episiotomy and/or forceps);

59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care

59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps);

59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care

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