The operation of applying obstetric forceps. Indications for use. Cavity Obstetric Forceps
Over the past three centuries, medical and public opinion about the use of obstetric forceps were opposite, but not as categorical as the points of view given. Nevertheless, if the use of obstetrical forceps is abolished, then 5-25% of women in labor who are delivered by this method would have two options: a caesarean section or, as before the invention of the forceps, the second stage of labor within 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 use Simpson tongs, as well as Neville-Barnes, Ferguson, Tucker-McLain tongs 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 details about the building various kinds forceps can be found in the literature listed 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 iliopubic eminence and the sacroiliac joint are the boundaries. 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 application of the 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 well established, such as anterior view occiput presentation, the first or second position, both branches of the forceps are taken in hand and folded in front of the patient's perineum in such a way as if they were applied to the head of the fetus. 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 " english castle”, 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 first or second position front view occipital 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 the 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 extension of the head, and it will pass through birth canal 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.
The sufficient grip force of the 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. Index and middle fingers are held together and the other hand is placed on the lock, which helps in the implementation of traction down (payot reception). 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 needs to be, but less 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 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.
When the head descends to the perineum, and the back of the head passes under pubic symphysis, the direction of traction should be gradually changed anteriorly and upwards at an angle of approximately 45°. 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 repeating in reverse order actions taken when they are applied. 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 swept seam is in the right or left oblique size, then after correct overlay spoons of forceps, 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 name itself will surely evoke associations with the distant Middle Ages for most readers. In a sense, they will be right: obstetric forceps were invented at the end of the sixteenth century. At that time it was a real advance in obstetrics. C-section then it was practically not used, and if some healer took up such dangerous operation, then only for the sake of saving the life of the child - the woman in labor did not have a single chance. Forceps helped the baby to be born, facilitated too difficult childbirth and saved the life of the mother.
The sight of this instrument will certainly not cause much confidence among the uninitiated: the third millennium and - some kind of tongs! In fact, this "outdated" and "backward" instrument, albeit in rare cases, is still indispensable. Of course, medical science and practice, compared with the 17th century, have risen to cosmic heights. Many methods quickly become obsolete, something is improved, something is abandoned altogether. But the imposition of forceps is used in the generic practice of experienced obstetricians in all countries of the world to this day. Over the past three centuries, their design and indications for use have changed significantly, and the benefits disproportionately outweigh the risk of complications.
Application conditions
Receiving the application of obstetric forceps is possible only in the second stage of labor with the full opening of the cervix, when the fetal head is in the pelvic cavity or at the exit from it.
The operation of applying obstetric forceps is quite painful: the born head of the fetus will have big sizes because of the spoons of tongs imposed on it, therefore, it provides for mandatory anesthesia. Most often, short-term intravenous anesthesia is given, but if a woman is giving birth under epidural anesthesia, the anesthesiologist simply injects an additional amount of the pain medication used.
The use of forceps is often accompanied by an episiotomy - an operation to cut the perineum to expand the birth canal. This will prevent the formation of deep tears in the woman in labor.
The capture of the baby's head is carried out only when it is already almost at the exit from female pelvis which further increases the safety of the procedure. The shape of the tool is maximally adapted to gently and safely for the fetus, but securely grab the head of the newborn. With the help of practiced professional movements (the so-called traction) an experienced obstetrician helps a newborn baby to pass through the birth canal. In addition, a sterile towel is usually placed between the handles of the forceps, which reduces the risk of excessive squeezing of the fetal head to almost nothing. We repeat that this procedure is used only in case of serious difficulties in the natural passage of the child or the need to complete the birth process as soon as possible and it is impossible to use other methods of childbirth. However, the baby's head should correspond to the average size of the head of a full-term fetus. Obstetricians formulate this condition a little differently: it should not be too large or too small. This is due to the size of the forceps, which are designed for the average size of the head of a full-term fetus. The use of obstetric forceps without taking this condition into account can lead to too much injury for the baby and mother.
Forceps become a very dangerous tool even with a narrow pelvis, so their use is contraindicated. The operation of applying obstetric forceps is carried out only if all of the above conditions are present.
Mechanism of action
The purpose of the forceps is to tightly grasp the fetal head and replace the expelling force of the uterus and abdominals the driving force of the physician. The process of "pulling out" the baby can not be called violent: traction are applied almost effortlessly, no artificial turns or any displacement of the fetal head are made. The movements of the obstetrician diligently copy the movements of the head and shoulders of the child, which he would produce in the process of natural childbirth.
In the process traction the doctor can also perform rotational movements, but only following the natural movement of the fetal head. In this case, the doctor does not prevent the head from turning, but, on the contrary, contributes to them.
Indications for use
There are several indications for this procedure. Firstly, the state of health of the woman in labor, which requires the maximum shortening of the period of expulsion of the fetus, the exclusion of attempts and stress of the woman in labor: diseases of the cardiovascular and broncho-pulmonary systems, kidneys, heart failure, very severe late toxicosis. Secondly, obstetrical forceps are superimposed with weak attempts or weakness labor activity. In this case, the fetal head stays in the same plane of the pelvis for more than 2 hours, which can lead to excessive fatigue of the woman in labor and very serious obstetric complications. In the second stage of labor, the fetal head passes through a rather narrow bone ring - the pelvic cavity. Difficulty in advancing the fetal head is fraught with backfire both for the child and for the mother: the pelvic bones squeeze the head of the fetus, the bones of the skull, in turn, put pressure on soft tissues birth canal of a woman, which leads to various injuries. Therefore, if medications, for example, intravenous administration oxytocin, which causes the uterus to contract, does not help the birth of a child, you have to resort to using forceps. Thirdly, bleeding in the second stage of labor, due to premature detachment of a normally located placenta, rupture of the umbilical cord vessels during their shell attachment. Fourth, with acute intrauterine hypoxia ( oxygen starvation) of the fetus, when the delay in childbirth will inevitably lead to the death of the child and the count goes literally for minutes (with a short umbilical cord, its entanglement around the child's neck).
Preparation and conduct of the operation
Based on the well-known truth “forewarned is forearmed”, and, I would add, “calm down”, I will try to describe in detail what awaits you during the preparation for the operation and its implementation.
Preparation for the operation of applying obstetric forceps includes several points: choosing the method of anesthesia, preparing the woman in labor, examining the vagina and determining the position of the fetus, checking the forceps.
During the operation of applying obstetric forceps, the woman in labor lies on her back, with her legs bent at the hips and knees. Before the operation bladder must be emptied. The external genitalia and inner thighs are treated with a disinfectant solution.
We repeat once again that due to the fact that when removing the fetal head with forceps, the risk of perineal rupture increases, the application of obstetric forceps is combined with an episiotomy. When introducing spoons, the obstetrician grabs the handle of the forceps in a special way: special kind capture avoids the application of force when it is introduced.
The left spoon of tongs is introduced first. Standing, the doctor inserts four fingers of the right 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 spoon with the left hand, the handle is retracted to right side, setting it almost parallel to the right inguinal fold. Then, carefully, without any effort, the spoon is advanced between the palm and the head of the fetus deep into the birth canal. In this case, the trajectory of movement of the end of the handle, as it were, describes an arc. The advancement of the entire branch into the depths of the birth canal is carried out practically due to the instrument's own gravity. The hand located in the birth canal is a guide hand and controls the correct direction and location of the branch. 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. Further, under the control of the left hand, the obstetrician introduces the right branch with the right hand into the right half of the pelvis in the same way as the left one.
Spoons capture the baby's head in the widest place in such a way that the parietal tubercles are in the windows of the forceps spoons, and the line of forceps handles faces the leading point of the fetal head. traction they try to carry out simultaneously with contractions, thus strengthening the natural expelling forces.
Possible Complications
We emphasize once again that timely and correctly applied forceps do not negative influence on the health status of women and children.
Complications in the baby. Most often, the consequences of using obstetric forceps are expressed in reddish loop-shaped traces that remain on the head and face of the baby. Usually these marks disappear within the first month without any medical intervention. Due too strong pressure spoons of forceps on the presenting part of the fetus, hematomas may occur, damage is possible skin or facial nerve. exceptional cases babies have eye injuries, nerve damage brachial plexus(manifested by a “hanging” handle in a child). The use of forceps can also cause damage to the uterus, bladder, or sciatic nerve roots.
Mom's complications. These include possible ruptures of the vagina and perineum, less often - the cervix. Severe complications can be ruptures of the lower segment of the uterus and damage pelvic organs: bladder and rectum. But such things can happen only if the conditions for the operation and the rules of its technique are violated, which is basically impossible in modern maternity hospitals.
But still!...
Of course, the application of obstetric forceps is an unpleasant procedure, it, like, in fact, any operation, has dangerous moments. I assure women that just like that, with a "preventive" purpose, no one will resort to this procedure. It is produced only when absolutely necessary, when there is no other way out and we are talking really about saving a baby's life. But if you happen to experience the techniques of ancient obstetrics in modern conditions- do not panic, but perceive it simply as a conscious need to help your long-awaited baby see the light.
Obstetric forceps were invented by the Scottish physician William Chamberlain in 1569.For many years, this instrument remained a family secret, passed down only by inheritance: the doctor's family and his descendants made considerable wealth from this invention. As it happened with many scientific discoveries, 125 years later, in 1723, obstetric forceps were again "invented" by the Dutch surgeon I. Palfin. These were already more enlightened times, so the surgeon immediately published his invention and submitted it for testing to the Paris Academy of Sciences, for which he was rewarded: the priority in the invention of obstetric forceps belongs to him. Although it is believed that these forceps are less perfect than Chamberlain's instrument. 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 belongs to another outstanding doctor, the founder of the Russian scientific obstetrics Nestor Maksimovich Maksimovich-Ambodik. Mine personal experience he described in the book The Art of Weaving, or the Science of Womanhood, published in 1786. According to his drawings, the Russian "instrumental" master Vasily Kozhenkov in 1782 made the first models of obstetric forceps in Russia. Later, 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.
Obstetric forceps are a tool that replaces the missing or missing force of uterine contractions during childbirth. Obstetric forceps serve as a continuation of the obstetrician's hands (the "iron hands" of the obstetrician).
The imposition of obstetric forceps is one of the most important and responsible operations in the practice of an obstetrician. According to the technical difficulty, the operation occupies one of the first places in operative obstetrics. When applying obstetric forceps, various injuries and complications are possible.
The device of obstetric forceps - see Obstetric and gynecological instruments. The most common model in the USSR is the English obstetric Simpson forceps in the modification of N. N. Fenomenov. In some obstetric institutions, Russian obstetric forceps of IP Lazarevich are used - without pelvic curvature (straight forceps) and with non-crossing spoons (forceps with parallel spoons); Kylland's obstetric forceps (a model widely used abroad) are built according to the type of I. P. Lazarevich's forceps.
The main action of obstetric forceps is purely mechanical in nature: compression of the head, its straightening and extraction. The compression of the head, which is inevitable during the application of forceps, should be minimal, in any case not exceed that observed in childbirth with the natural configuration of the head. Otherwise, the bones, vessels and nerves of the fetal head will inevitably suffer. Obstetrical forceps are only a gripping and enticing tool, but by no means correcting incorrect presentations and insertion of the head.
Indications and contraindications. Previously, obstetric forceps were applied at the personal discretion of the obstetrician, certain indications for their imposition have now been developed. Obstetric forceps are applied in cases where it is necessary to quickly end the birth in the interests of the mother, fetus, or both together: with eclampsia, premature detachment placenta, prolapse of the umbilical cord, incipient asphyxia of the fetus, maternal diseases that complicate the course of the exile period (heart defects, nephritis), fever, etc. In case of secondary weakness of labor, obstetric forceps are used in cases where the period of exile in primiparas lasts more than 2 hour. (3-4 hours), and for multiparous - more than an hour.
It is necessary to strictly consider contraindications to the use of obstetric forceps. They stem from following conditions, in which this operation can be applied: sufficient dimensions of the pelvis to allow the head to pass - the true conjugate must be at least 8 cm; the fetal head should be neither excessively large (hydrocephalus, pronounced post-term pregnancy), nor too small (forceps cannot be applied to the fetal head less than 7 months old); the head should stand in the pelvis in a position convenient for applying obstetric forceps (the movable head is a contraindication); the cervix should be smoothed, the uterine os is fully opened, its edges should go beyond the head; the fetal bladder must be broken; the fetus must be alive.
Among these conditions, the height of the head in the pelvis is especially important. For practical work, you can use following scheme determining the location of the head. 1. The head stands above the entrance to the small pelvis (Fig. 1), easily moves with a push, returning back (balloting). Forceps are contraindicated. 2. The head entered the pelvis as a small segment (Fig. 2). Its largest circumference (biparietal diameter) is located above the entrance to the pelvis. The cervical-occipital sulcus stands three transverse fingers above the symphysis; the head is limitedly mobile, slightly fixed. During vaginal examination, the cape is accessible to the examining finger; swept seam - in the transverse or slightly oblique size of the pelvis. Forceps cannot be applied either. 3. Head at the entrance to the pelvis with a large segment (Fig. 3); with a biparietal diameter, it passed the entrance to the pelvis, motionless; the cervical-occipital sulcus stands two fingers above the symphysis. With a vaginal examination, the cape cannot be reached; the head is occupied in front - upper edge and the upper third of the posterior surface of the pubic joint, behind - the cape and inner surface first sacral vertebra. Swept seam - in one of the oblique dimensions, sometimes closer to the transverse. Wired dot almost reaches the line main plane passing through the lower edge of the symphysis. It is not recommended to apply forceps, especially for a novice obstetrician (high forceps). 4. Head in a wide part of the pelvic cavity (Fig. 4); with its largest circumference, it passed the plane of the wide part of the cavity, the cervical-occipital groove - about one finger above the symphysis. On vaginal examination ischial spines achievable, the sacral cavity is almost completed, the cape cannot be reached. The wire point almost reaches the spinal line, the sagittal suture is in an oblique size. Freely palpable III and IV sacral vertebrae and coccyx. Forceps are allowed (atypical forceps, difficult operation). 5. Head in the narrow part of the pelvic cavity (Fig. 5); above the entrance to the pelvis, it is not defined (cervical-occipital groove flush with the height of the symphysis). During vaginal examination, the ischial spines are not determined, the sacrococcygeal articulation is free. Head close to pelvic floor, its biparietal size occupies the plane of the narrow part of the pelvic cavity. Small fontanel (wire point) - below the spinal line; the head has not yet completely completed rotation, the sagittal suture is in one of the oblique dimensions of the pelvis, closer to a straight one. Forceps may be applied. 6. Head in the outlet of the small pelvis (Fig. 6). She and her cervical-occipital sulcus over the entrance to the pelvis are not defined. head finished inner turn(rotation), swept seam - in direct size pelvic outlet. favorable conditions for applying forceps (typical forceps).
"Obstetric forceps" is the code name for the operation of extracting the fetus by applying special forceps to the presenting part.
In the Soviet Union, the Simpson-Fenomenov forceps model was the most common (see).
Indications. Forceps are indicated when required quick ending childbirth in the interests of the mother or fetus, more often both of them (threatening, weakness of labor during the period of exile, turning off attempts during, etc. Conditions for the operation: sufficient pelvic dimensions (true conjugate of at least 8 cm); full disclosure uterine pharynx; fixed, standing in a convenient for the imposition of obstetric forceps head; sufficient size of the head (should not be too large or too small); torn ; alive (the latter conditionally).
Preparation for the operation. Obstetric forceps are applied in the position of a woman on her back on or on a Rakhmanov bed; the legs should be brought to the stomach, they are held by an assistant (or they are held with the help of a leg holder). Before surgery, a woman needs to empty her bladder, intestines ( cleansing enema). Spend the toilet of the external genitalia. Impose obstetrical forceps, as a rule, under anesthesia.
Types of obstetric forceps. Depending on where in the pelvis (at the entrance, cavity or exit) the fetal head is located, there are output, or typical, obstetric forceps [the head, having rotated (internal turn), is located at the bottom of the pelvis, it is better if it has exit]; cavity, or atypical (head in the pelvic cavity with incomplete rotation), and the so-called high (top of atypicality) obstetric forceps (the head with the help of forceps must do the entire mechanism of childbirth). The imposition of high forceps in normal obstetric practice is not performed.
Technique of imposing output (typical) obstetric forceps. Weekend obstetric forceps imposes an obstetrician. Before applying obstetrical forceps, it is necessary to carefully vaginal examination women in labor (determine the degree of opening of the uterine os, the condition amniotic sac, the position of the sagittal suture and fontanelles). With insufficient knowledge of the technique, it is necessary to perform a vaginal examination with a half-hand (thumb outside the genital slit).
The exit forceps are placed on the head, which has done all the rotational movements: the small fontanelle stands under the symphysis, the sagittal suture is in the direct size of the pelvic outlet, the head is at the bottom of the pelvis, fills the entire sacral cavity. Output (typical) forceps are applied in the transverse size of the pelvis and on the transverse (biparietal) size of the head.
Introduction of spoons. The left spoon is always introduced first. When closing the forceps, it should lie under the right one (otherwise the closure will be difficult). In order not to make a mistake in choosing a spoon, you should fold the tongs before insertion and, holding the handles with both hands, place them in front of you so that both spoons are side by side: left - on the left, right - on the right (Fig. 1). They take the spoon with their left hand, hold it like a writing pen or a bow (you can’t grab the spoon with the whole brush, so you can develop great power and cause injury to the mother and fetus). Before insertion of the left spoon, four (not two) fingers of the right hand (control hand) are inserted to control and protect the soft tissues. The fingers of the control hand should be inserted so that they go beyond the parietal tubercles of the fetal head.
Rice. 1. Tongs and folded.
Grabbing the handle of the left spoon with your left hand, put lower rib into the groove between the middle and index fingers. The back of the lower edge of the spoon lies on an outstretched thumb. The end of the spoon (its tip) should be directed forward, towards the mother. The handle of the spoon should be held in an elevated, close to vertical position, parallel to the right inguinal fold of the woman in labor.
The translational movement of the tongs spoon should be carried out mainly due to its gravity; some progress can be helped by those outside thumb control right hand (with a slight push on the lower edge of the spoon) and the same light and accurate pushing of the handle. With the remaining fingers of the right (control) hand, inserted inside, direct the spoon of forceps forward so that it lies on the head from the side, in the plane of the transverse dimension of the pelvic outlet. The correct position of the inserted spoon in the pelvis can be judged by Bush's hooks: they must be strictly in the transverse dimension of the pelvic outlet.
The spoon must certainly go beyond the ends of the fingers of the control hand, that is, beyond the parietal tubercle. It is necessary to introduce a spoon with great care, easily, without any violence.
The handle of the inserted spoon is passed to the assistant, who must hold it in this position. Any Noah spoons in the future can lead to complications.
The right spoon of obstetric forceps is inserted in the same way as the left one: with the right hand - to the right side, under the protection of the fingers of the left hand inserted into the fingers. The right spoon of tongs should always lie above the left. Inserting the right spoon is more difficult than the left one. Often this is due to the fact that the handle of the left spoon is not sufficiently lowered down, towards the perineum. [The expressions "anterior", "posterior", "right", "left" apply to the vertical ("standing") position of a woman: "anterior" - to the symphysis, "posterior" - to the sacrum, "right", "left" - to the side of the woman in labor, regardless of the position of the doctor.]
Closure (closure) of obstetric forceps. Before closing the obstetric forceps, it is necessary to check whether the skin of the perineum or the mucous membrane of the vagina has got into the lock. For proper closure, the handles of the pliers must lie in the same plane and parallel.
Trial traction. To make sure that the imposition of traction is correct. To do this, the left hand should be placed on top of the right; her outstretched index finger should be in contact with the head of the fetus in the region of the small fontanel (Fig. 2). During traction, the head should follow the forceps and behind index finger left hand.
Extraction of the head with obstetric forceps (actual traction) is performed while standing. Right hand, located on the handle and in the area of the Bush hooks, make an energetic attraction (traction). Left hand at the same time, it should be located on top, with the index finger in the recess near the lock. In this position, it provides energetic assistance to the right during traction. The forceps together with the head should move along the wire line of the pelvis, that is, change direction, gradually moving forward and upward (along the arc). Traction along the arc is done until the back of the head and the suboccipital fossa appear. It is not allowed to do joint tractions in four hands (two at once or in shifts, one after the other). If 8-10 tractions are not successful, further tractions should be abandoned. When removing the head with forceps, it is necessary to imitate natural contractions, alternating traction with pauses. Each traction begins slowly, gradually increasing its strength and, having reached a maximum, they pass, reducing the strength of traction, into a pause. Pauses should be long enough.
Rice. 2. Trial traction.
When removing the head in forceps, neither rocking, nor rotational, nor pendulum-like movements can be made - in which direction the traction is started, in that it should be completed. To prevent excessive, sometimes excessive squeezing of the head, it is recommended to lay a towel folded in several layers between the handles of the spoons of tongs.
Holding the head under the symphysis and removing it. The head is carried out under the pubic arch so that it rolls over with the suboccipital fossa (pivot point). In this case, the head moves from the bent position to the extension position (Fig. 3). Traction is done in a horizontal direction until the back of the head appears and the suboccipital fossa reaches the lower edge of the symphysis. At this point, proceed to the removal of the head. To do this, they stand on the right side of the woman in labor, grab the forceps with their left hand, protect the perineum with the right hand during the eruption of the head. Carefully, slowly, centimeter by centimeter, slightly pulling the head with tongs, raise the handle of the tongs up.
Rice. 3. Removing the head.
Removing the tongs (opening). The forceps are removed after the head is outside the genital gap (birth of the head). They are carefully opened, pushing both spoons apart. Each spoon is taken in the same hand and removed in the same way as they were superimposed, but in the reverse order, that is, the right spoon, describing the arc, is taken to the left inguinal fold, the left to the right. Spoons should slide smoothly, without jerking. After removing the head, the fetal body is removed along general rules(cm. ).
cavity forceps, or atypical, can only be imposed by an obstetrician. In these cases, forceps are applied to the head, which is located almost at the bottom of the pelvis. In forceps, the head must complete internal turning (rotation), cutting and cutting. When the head is standing in an oblique size of the pelvis, forceps are applied only in an oblique size. When applying them, the same rules apply as when applying output forceps, it is only important to determine exactly which of the oblique dimensions of the pelvis (right or left) is the fetus. On the head, standing with an arrow-shaped seam in one of the oblique dimensions, forceps are applied in the opposite oblique dimension. The second feature of applying forceps to the head, standing in an oblique size of the pelvis, concerns the technique of introducing spoons. One spoon is inserted behind the head and left here - this is the back, or fixed, spoon. Another spoon is first introduced also from behind, and then a turn is made along an arc of 90 ° to get to the parietal tubercle lying in front. This is the so-called wandering spoon. Depending on the position of the arrow-shaped seam, either the right or the left spoon will be fixed (back): in the first (left) position (arrow-shaped seam in the right oblique size), the left spoon will be fixed, in the second (right) position (arrow-shaped seam in the left oblique size ) - right. Spoons should be applied so that their ends are certainly turned towards the wire point (forward).
Maintenance of the puerperal and the newborn after the application of forceps. After the application of obstetrical forceps, injuries and ruptures of the cervix, vagina, perineum, etc. are often encountered, therefore, after childbirth, it is necessary to carefully examine the soft birth canal. Breaks must be sewn up.
At present, a new delivery device has been introduced into obstetric practice - a vacuum extractor (see), more gentle and gentle than obstetric forceps.
After childbirth, a woman must comply with the regime, as after an obstetric operation (see). A child referred to a nursery should receive the same care as children born after difficult childbirth or operations (see).
