Obstetric forceps. Indications for vacuum extraction and prerequisites for the procedure. Contraindications to the use of a vacuum extractor. When the tool is prohibited for use

The imposition of forceps is used in cases where an urgent end of labor is required in the period of exile and there are conditions for performing this operation. There are 2 groups of indications: indications related to the condition of the fetus and the condition of the mother. Often there are combinations of them.

An indication for the application of forceps in the interests of the fetus is hypoxia, which has developed as a result of various reasons(premature abruption of a normally located placenta, prolapse of the umbilical cord, weakness labor activity, late preeclampsia, short umbilical cord, entanglement of the umbilical cord around the neck, etc.). The obstetrician leading the birth is responsible for the timely diagnosis of fetal hypoxia and the choice of adequate tactics for managing the woman in labor, including determining the method of delivery.

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

frequent indication forceps is high myopia).

Thus, the indications for the imposition of obstetric forceps in the interests of the woman in labor may be due to the need for an urgent end of labor or the need to exclude attempts. The listed indications in many cases are combined, requiring an emergency end of childbirth in the interests of not only the mother, but also the fetus. Indications for the imposition of obstetric forceps are not specific to this operation, they may be indications for other operations (caesarean section, vacuum extraction of the fetus, fruit-destroying operations). The choice of delivery operation largely depends on the presence of certain conditions to perform a specific operation. These conditions differ significantly, so they must be carefully assessed in each case in order to right choice method of delivery.

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

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

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

3. Absence amniotic sac. This condition follows from the previous one, since with the correct management of childbirth, when the uterine os is fully opened, the fetal bladder must be opened.

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

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

6. Sufficient pelvis dimensions allowing the head to be removed by forceps. With a narrow pelvis, forceps are a very dangerous tool, so their use is contraindicated.

The operation of applying obstetric forceps requires the presence of all of the above conditions. When embarking on forceps delivery, the obstetrician must have a clear understanding of the biomechanism of childbirth, which will have to be artificially imitated. It is necessary to be guided in what moments of the biomechanism of childbirth the head has already managed to do and what it will have to do with the help of forceps. Forceps are a pulling tool that replaces the missing force of attempts. The use of forceps for other purposes (correction of incorrect head insertions, posterior view of the occipital insertion, as a corrective and rotational instrument) has long been ruled out.

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

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

Due to the fact that when removing the fetal head in forceps, the risk of perineal rupture increases, the imposition of obstetric forceps is usually combined with perineotomy.

Output obstetric forceps. Output obstetric forceps is an operation in which the forceps are applied to the head of the fetus, located in the outlet of the small pelvis. At the same time, the head has completed the internal rotation, and the last moment of the biomechanism of childbirth before its birth is carried out with the help of forceps. At front view occipital insertion of the head, this moment is the extension of the head, and in the posterior view - flexion followed by extension of the head. Output obstetric forceps are also called typical, in contrast to abdominal, atypical, forceps.

The technique of applying both typical and atypical forceps includes the following points: 1) the introduction of spoons, which is always carried out in accordance with the following rules: the left spoon is inserted first with the left hand into left side("three left"), the second - the right spoon right hand to the right side ("three right"); 2) forceps closing; 3) trial traction, which allows you to make sure that correct overlay tongs and the absence of the threat of their slipping; 4) actual traction - extraction of the head with forceps in accordance with the natural biomechanism of childbirth; 5) withdrawal

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

Technique of imposing output obstetric forceps in the anterior view of the occipital insertion.

The first point is the introduction of spoons. The folded tongs are placed on the table to pinpoint the left and right spoons. The left spoon is inserted first, since when the forceps are closed, it must lie under the right one, otherwise the closure will be difficult. The obstetrician takes the left spoon in his left hand, grabbing it like a writing pen or a bow. Before inserting the left hand into the vagina, four fingers of the right hand are inserted into the left side to control the position of the spoon and protect the soft tissues birth canal. The hand should be facing the palmar surface of the head and inserted between the head and the side wall of the pelvis. The thumb remains outside and is retracted to the side. The handle of the left spoon before its introduction is set almost parallel to the right inguinal fold, while the tip of the spoon is located at the genital slit in the longitudinal (anteroposterior) direction. Bottom rib spoon rests on the first finger of the right hand. The spoon will be inserted into the genital slit carefully, without violence, by pushing the lower rib I with the finger of the right hand, and only partially the introduction of the spoon is facilitated by the easy advancement of the handle. As the spoon penetrates deep into the handle, it gradually descends down to the crotch. With the fingers of the right hand, the obstetrician helps to guide the spoon so that it lies on the head on the side in the plane of the transverse dimension of the pelvic outlet. The correct position of the spoon in the pelvis can be judged by the fact that the Bush hook is strictly in the transverse dimension of the exit from the pelvis (in the horizontal plane). When the left spoon is correctly placed on the head, the obstetrician removes inner arm from the vagina and passes the handle of the left forceps spoon to the assistant, who must hold it without shifting. After that, the obstetrician spreads the genital gap with his right hand and inserts 4 fingers of his left hand into the vagina along its right wall. The second one is inserted with the right spoon of forceps with the right hand into the right half of the pelvis. The right spoon of tongs should always lie on the left. Properly applied forceps capture the head through the zygomaticotemporal plane, the spoons lie slightly in front of the ears in the direction from the back of the head through the ears to the chin. With this placement, the spoons capture the head in its largest diameter, the line of the handles of the tongs is facing the wire point of the head.

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

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

Having closed the forceps, a vaginal examination should be performed and make sure that the forceps do not capture soft tissues, the forceps lie correctly and the wire point of the head is in the plane of the forceps.

The third point is trial traction. This is a necessary test to ensure that the forceps are correctly applied and that there is no danger of them slipping. The trial traction technique is as follows: the right hand clasps the handles of the forceps from above so that the index and middle fingers lay on side hooks; the left hand rests on top of the right, and its index finger is extended and in contact with the head in the region of the wire point. The right hand carefully makes the first traction. Traction should be followed by forceps, left hand on top with outstretched index finger and head. If the distance between the index finger and the head increases during traction, this indicates that the forceps are applied incorrectly and eventually they will slip off.

The fourth point is the extraction of the head with forceps (actual traction). During traction, the forceps are usually grasped as follows: with the right hand they cover the lock from above, putting (with Simpson-Fenomenov forceps) the III finger in the gap between the spoons above the lock, and the II and IV fingers on the side hooks. The left hand grasps the handles of the tongs from below. The main force of traction is developed by the right hand. There are other ways to grab the forceps. N. A. Tsovyanov proposed a method for gripping forceps, which allows simultaneous traction and abduction

head into the sacrum. With this method, II and III fingers of both hands of the obstetrician, bent with a hook, capture the outer and upper surface of the instrument at the level of the side hooks, and the main phalanges of these fingers with the Bush hooks passing between them are located on outer surface handles, the middle phalanges of the same fingers - on the upper surface, and nail phalanges- on the upper surface of the handle of the opposite spoon of tongs. IV and V fingers, also slightly bent, grab the parallel branches of the forceps extending from the lock from above and move as high as possible, closer to the head. thumbs, being under the handles, the pulp of the nail phalanges rests on the middle third of the lower surface of the handles. The main work with this grip of forceps falls on the IV and V fingers of both hands, especially on the nail phalanges. With the pressure of these fingers on the upper surface of the branches of the forceps, the head is retracted from the pubic joint. This is also facilitated by the thumbs, which produce pressure on bottom surface handles pointing upwards.

When extracting the head with forceps, it is necessary to take into account the direction of traction, their nature and strength. The direction of traction depends on 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. In the anterior view of the occipital insertion, the extraction of the head with the exit obstetric forceps occurs due to its extension around the fixation point - the suboccipital fossa. The first tractions are performed horizontally until the suboccipital fossa appears from under the pubic arch. After that, the tractions are given an upward direction (the obstetrician directs the ends of the handles to his face) in order for the head to be extended. Tractions should be made in one direction. Rocking, rotational, pendulum movements are unacceptable. Traction must be completed in the direction in which it was started. The duration of individual tractions corresponds to the duration of the attempts, tractions are repeated with interruptions of 30-60 s. After 4-5 tractions, the forceps are opened to reduce head compression. According to the strength of tractions, they imitate a fight: each traction begins slowly, with increasing strength and, having reached a maximum, gradually fading away, goes into a pause.

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

The fifth moment is the opening and removal of the tongs. The fetal head is removed with forceps or by manual means after removing the forceps, which in the latter case 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, then they are pushed apart and after that the spoons are removed in the same way as they were superimposed, but in reverse order: the right spoon is removed first, while the handle is retracted to the left inguinal fold, the second is the left spoon is removed, its handle is retracted to the right inguinal fold.

The operation of applying obstetric forceps. Indications, conditions.

Obstetric forceps is a tool designed to extract the fetus by the head. The operation of applying obstetric forceps is a delivery operation in which the fetus is artificially removed through the natural birth canal using a special instrument.

Obstetric forceps were invented at the beginning of the 17th century by the Scottish physician Chamberlain, who kept his invention a strict secret, and it did not become the property of obstetric practice. The priority in the invention of obstetric forceps rightfully belongs to the French surgeon Palfin, who in 1723 published his message. The tool and its application quickly became widespread. In Russia, tongs were first used in 1765 in Moscow by Professor Erasmus. Later, domestic obstetricians N. M. Maskimovich-Ambodik, A. Ya. Krassovsky, I. P. Lazarevich, N. N. Fenomenov made a great contribution to the development of the theory and practice of the operation of applying obstetric forceps.

In modern obstetrics, despite the infrequent use of this operation, it is of great practical importance, since in some obstetric situations it is the operation of choice (Fig. 108).

The structure of obstetric forceps. The main model of forceps used in our country is the Simpson-Fenomenov forceps. Forceps consist of two branches (or spoons) - right and left. Each branch consists of 3 parts: the spoon itself, the castle part and the handle. The spoon itself is made fenestrated, and the handle is hollow to reduce the weight of the forceps, which is about 500 g. The total length of the tool is 35 cm, the length of the handle with a lock is 15 cm, the spoon is 20 cm. The spoon has the so-called head curvature and pelvic. The head curvature reproduces the circumference of the fetal head, and the pelvic curvature reproduces the sacral cavity, corresponding to a certain extent to the wire axis of the pelvis. In the Simpson-Phenomenov forceps, the distance between the most distant points of the head curvature of the spoons when the forceps are closed is 8 cm, the tops of the forceps are at a distance of 2.5 cm. There are models of forceps with only one head curvature (Lazarevich's straight forceps).

The lock serves to connect the branches. The structure of the locks is not the same in different models of tongs: the lock can be freely movable, moderately movable, motionless and completely motionless. The castle in the Simpson-Fenomenov tongs has a simple structure: on the left branch there is a notch into which the right branch is inserted. This structure of the castle provides moderate mobility of the branches - the spoons do not diverge up and down, but have mobility to the sides. Between lock and handle outside forceps have lateral protrusions called bushy hooks. When the forceps are folded, they should lie symmetrically in the same plane. After inserting the spoons and locking the lock, the plane in which the Bush hooks lie corresponds to the transverse or one of the oblique dimensions of the pelvis, in which the spoons of the forceps are located. The handles of the forceps are straight, their outer surface is ribbed, which prevents the surgeon's hands from slipping. The inner surface of the handles is smooth, and therefore, with closed branches, they fit snugly against each other. The branches of the tongs differ in the following ways: 1) on the left branch, the lock and the plate of the lock are on top, on the right - on the bottom; 2) Bush's hook and the ribbed surface of the handle (if the tongs are on the table) on the left branch are turned to the left, on the right - to the right; 3) the handle of the left branch (if the forceps are on the table and the handles are directed towards the surgeon) is turned to the left hand, and the handle of the right branch is turned to the right hand of the surgeon. The left branch is always inserted with the left hand into the left half of the pelvis, the right branch with the right hand into the right half of the pelvis.

Other well-known forceps models include: 1) Lazarevich forceps (Russian model), having one head curvature and non-crossing spoons; 2) Levre tongs (French model) - long tongs with two curvatures, crossed handles and a screw lock that is tightly screwed; 3) German Negele tongs, combining the main qualities of the Simpson-Fenomenov tongs (English tongs) and Levre models.

Indications for the imposition of obstetric forceps. The imposition of forceps is used in cases where an urgent end of labor is required in the period of exile and there are conditions for performing this operation. There are 2 groups of indications: those related to the condition of the fetus and the condition of the mother. Often there are combinations of them.

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

AT interests of the woman in labor forceps are applied according to the following indications: 1) secondary weakness of labor activity, accompanied by a stop in the forward movement of the fetus at the end of the exile period; 2) severe manifestations of late preeclampsia (preeclampsia, eclampsia, severe hypertension, not amenable to conservative therapy); 3) bleeding in the second stage of labor, due to premature detachment of a normally located placenta, rupture of blood vessels during sheath attachment of the umbilical cord; 4) diseases of the cardiovascular system in the stage of decompensation; 5) respiratory disorders due to lung diseases, requiring the exclusion of attempts; 6) diseases of a general nature, acute and chronic infections, high temperature in a woman in labor. 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 due to the inability of the abdominal muscles to provide full-fledged attempts. The use of obstetric forceps in some cases can be indicated for tuberculosis, diseases of the nervous system, kidneys, organs of vision (the most common indication for applying forceps is high myopia).

Thus, the indications for the imposition of obstetric forceps in the interests of the woman in labor may be due to the need for an urgent end of labor or the need to exclude attempts. The listed indications in many cases are combined, requiring an emergency end of childbirth in the interests of not only the mother, but also the fetus. Indications for the imposition of obstetric forceps are not specific to this operation, they may be indications for other operations (caesarean section, vacuum extraction of the fetus, fruit-destroying operations). The choice of a delivery operation largely depends on the presence of certain conditions that allow a particular operation to be performed. These conditions have significant differences, therefore, in each case, their careful assessment is necessary for the correct choice of the method of delivery.

When applying forceps, the following conditions are necessary:

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

Full disclosure of the uterine pharynx. Deviation from this condition will inevitably lead to rupture of the cervix and the lower segment of the uterus.

2. Absence of the amniotic sac. This condition follows from the previous one, since with the correct management of childbirth, when the uterine os is fully opened, the fetal bladder must be opened.

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

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

Sufficient size of the pelvis, allowing the head to be removed by forceps. With a narrow pelvis, forceps are a very dangerous tool, so their use is contraindicated.

The operation of applying obstetric forceps requires the presence of all of the above conditions. When embarking on forceps delivery, the obstetrician must have a clear understanding of the biomechanism of childbirth, which will have to be artificially imitated. It is necessary to be guided in what moments of the biomechanism of childbirth the head has already managed to do and what it will have to do with the help of forceps. Forceps are a pulling tool that replaces the missing force of attempts. The use of forceps for other purposes (correction of incorrect head insertions, rear view of the occipital insertion) as a corrective and rotational instrument has long been ruled out.

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

The use of anesthesia when applying obstetric forceps is desirable, and in many cases mandatory. In multiparous (as an exception), exit obstetric forceps can be applied without anesthesia. The operation of abdominal obstetric forceps requires the use of anesthesia, since the introduction of spoons, one of which "wanders" in the small pelvis, is a difficult moment of the operation, especially with the resistance of the pelvic floor muscles, which is eliminated by anesthesia. In addition, in many cases, the use of obstetric forceps is due to the need to exclude straining activity in the parturient woman, which can only be achieved with adequate anesthesia. Anesthesia is also required for anesthesia of this operation, which in itself is very important. When applying forceps, inhalation, intravenous anesthesia or pudendal anesthesia is used.

Due to the fact that when removing the fetal head in forceps, the risk of perineal rupture increases, the imposition of obstetric forceps is usually combined with perineotomy.

Output obstetric forceps. Output obstetric forceps is an operation in which the forceps are applied to the head of the fetus, located in the outlet of the small pelvis .; At the same time, the head has completed the internal rotation, and the last moment of the biomechanism of childbirth before its birth is carried out with the help of forceps. In the anterior view of the occipital insertion of the head, this moment is the extension of the head, and in the posterior view, it is flexion followed by extension of the head. Output obstetric forceps are also called typical, in contrast to abdominal, atypical, forceps.

The technique of applying both typical and atypical forceps includes the following points: 1) the introduction of spoons, which is always carried out in accordance with the following rules: first, the left spoon is inserted with the left hand to the left side ("three left"), the second - the right spoon with the right hand in right side ("three right"); 2) forceps closing; 3) trial traction, which allows you to make sure that the forceps are correctly applied and that there is no threat of their slipping; 4) actual traction - extraction of the head with forceps in accordance with the natural biomechanism of childbirth; 5) removing the forceps in the reverse order of their application: the right spoon is removed first with the right hand, the second - the left spoon with the left hand.

Technique of imposing output obstetric forceps in the anterior view of the occipital insertion. The first point is the introduction of spoons. The folded tongs are placed on the table to pinpoint the left and right spoons. The left spoon is inserted first, since when the forceps are closed, it must lie under the right one, otherwise the closure will be difficult. The obstetrician takes the left spoon in his left hand, grabbing it like a writing pen or a bow. Before inserting the left hand into the vagina, four fingers of the right hand are inserted into the left side to control the position of the spoon and protect the soft tissues of the birth canal. The hand should be facing the palmar surface of the head and inserted between the head and the side wall of the pelvis. The thumb remains outside and is retracted to the side. The handle of the left spoon before its introduction is set almost parallel to the right inguinal fold, while the top of the spoon is located at the genital slit in the longitudinal (anteroposterior) direction. The lower edge of the spoon rests on the first finger of the right hand. The spoon is introduced into the genital slit carefully, without violence, by pushing the lower rib I with the finger of the right hand, and only partially the introduction of the spoon is facilitated by the easy advancement of the handle. As the spoon penetrates deep into the handle, it gradually descends down to the crotch. With the fingers of the right hand, the obstetrician helps to guide the spoon so that it lies on the head on the side in the plane of the transverse dimension of the pelvic outlet. The correct position of the spoon in the pelvis can be judged by the fact that the Bush hook is strictly in the transverse dimension of the exit from the pelvis (in the horizontal plane). When the left spoon is correctly placed on the head, the obstetrician removes the inner hand from the vagina and passes the handle of the left forceps spoon to the assistant, who must hold it without moving it. After that, the obstetrician spreads the genital gap with his right hand and inserts 4 fingers of his left hand into the vagina along its right wall. The second is inserted the right spoon of forceps with the right hand into the right half of the pelvis (Fig. 109, b). The right spoon of tongs should always lie on the left. Properly applied forceps capture the head through the zygomaticotemporal plane, the spoons lie slightly in front of the ears in the direction from the back of the head through the ears to the chin. With this placement, the spoons capture the head in its largest diameter, the line of the handles of the tongs is facing the wire point of the head. The second point is the closing of the tongs. Separately introduced spoons must be closed so that the forceps can act as a tool for capturing and extracting the head. Each of the handles is taken with the same hand, while the thumbs are located on Bush's hooks, and the remaining 4 clasp the handles themselves. After that, you need to bring the handles together and close the tongs. For proper closure, a strictly symmetrical arrangement of both spoons is required.

The third point is trial traction (Fig. 111). This is a necessary test to ensure that the forceps are correctly applied and that there is no danger of them slipping. The technique of trial traction is as follows: the right hand clasps the forceps handles from above so that the index and middle fingers lie on the side hooks; the left hand rests on top of the right, and its index finger is extended and in contact with the head in the region of the wire point. The right hand carefully makes the first traction. Traction should be followed by the forceps, the left hand on top with the index finger extended, and the head. If the distance between the index finger and the head increases during traction, this indicates that the forceps are applied incorrectly and eventually they will slip off.

Fourth moment- extraction of the head with forceps (actual traction). During traction (Fig. 112), the forceps are usually grasped as follows: with the right hand they cover the lock from above, putting (with Simpson-Fenomenov forceps) the III finger in the gap between the spoons above the lock, and the II and IV fingers on the side hooks. The left hand grasps the handles of the tongs from below. The main force of traction is developed by the right hand. There are other ways to grab the forceps. N. A. Tsovyanov proposed a method of capturing forceps, which allows simultaneous traction and abduction of the head into the sacral cavity (Fig. 113). With this method, II and III fingers of both hands of the obstetrician, bent with a hook, capture the outer and upper surface of the instrument at the level of the side hooks, and the main phalanges of these fingers with Bush hooks passing between them are located on the outer surface of the handles, the middle phalanges of the same fingers are on the upper surface, and the nail phalanxes - on the upper surface of the handle of the opposite spoon of forceps. IV and V fingers, also slightly bent, grab the parallel branches of the forceps extending from the lock from above and move as high as possible, closer to the head. The thumbs, being under the handles, rest against the middle third of the lower surface of the handles. The main work with this grip of forceps falls on the IV and V fingers of both hands, especially on the nail phalanges. With the pressure of these fingers on the upper surface of the branches of the forceps, the head is retracted from the pubic joint. This is also facilitated by the thumbs, which produce pressure on the lower surface of the handles, directing them upward.

In the anterior view of the occipital insertion, the extraction of the head with the exit obstetric forceps occurs due to its extension around the fixation point - the suboccipital fossa. The first tractions are performed horizontally until the suboccipital fossa appears from under the pubic arch. After that, the tractions are given an upward direction (the obstetrician directs the ends of the handles to his face) in order for the head to be extended. Tractions should be made in one direction.

Rocking, rotational, pendulum movements are unacceptable. Traction must be completed in the direction in which it was started. The duration of a separate traction_corresponds to the duration of the effort, the tractions are repeated at intervals of 30-60 s. After 4-5_tractions, the forceps are opened to reduce the compression of the head. According to the strength of tractions, they imitate a fight: each traction begins slowly, with increasing strength and, having reached a maximum, gradually fading away, goes into a pause.

Traction is performed by the doctor while standing (rarely sitting), the elbows of the obstetrician should be pressed to the body, which prevents the development of excessive force when removing the head.

The fifth moment is the opening and removal of the tongs. The fetal head is removed with forceps or by manual means after removing the forceps, which in the latter case is carried out after the eruption of the largest circumference of the head. To remove the forceps, each handle is taken with the same hand, the spoons are opened, then they are moved apart and after that the spoons are removed in the same way as they were applied, but in the reverse order: the right spoon is removed first 1, while the handle is retracted to the left inguinal fold, the second is removed spoon, its handle is retracted to the right inguinal fold.

Cavity obstetric forceps. Abdominal forceps are used in cases where the head is located in a narrow part of the pelvic cavity. The head will have to complete the internal rotation in forceps and perform extension (with anterior view of the occipital insertion). Due to the incompleteness of the internal rotation, the sagittal (sagittal) suture 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 the oblique size of the pelvis presents certain difficulties. More complex than the output obstetric forceps are tractions, in which the internal rotation of the head is completed by 45 ° or more, and only then the head is extended.

The technique of applying abdominal obstetric forceps in the anterior view of the occipital insertion, the first position of the fetus. In the first position, the sagittal suture is in the right oblique dimension. In order for the head to be captured biparietally with spoons, forceps must be applied in the left oblique, size,

The first point is the introduction of spoons. When applied abdominal forceps the order of introduction of spoons is preserved: the first is the left spoon with the left hand into the left half of the pelvis, the second is the right spoon with the right hand into the right half of the pelvis. The left spoon is inserted under the control of the right guide hand into the posterolateral pelvis and immediately placed in the region of the left parietal tubercle of the head; the handle of the forceps is passed to the assistant. 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 the movement ("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 forward) until it is established in the region of the right parietal tubercle. The movement of the spoon is carried out by carefully pressing the II yalz of the left hand on its lower edge, the handle of the tongs is shifted somewhat backwards and in a clockwise direction.

The second moment - the closure of the tongs - is performed when the forceps lie on the head bipari-etally and are in the left oblique size of the pelvis.

The third moment - trial traction -

The fourth moment is the extraction of the head(actual traction). Completing the internal turn, the head simultaneously makes two movements: it moves more and more downward and at the same time turns the back of the head forward. The head reaches the pelvic floor after a counterclockwise rotation of approximately 45° and is positioned with a sagittal suture in the direct dimension of the exit from the pelvis. To imitate the natural biomechanism, traction is performed first down and somewhat backwards. As it advances, the head, together with the forceps, will rotate counterclockwise until it reaches the pelvic floor, where the spoons are located in a transverse dimension. In this case, only extraction should be active, while the rotation of the forceps is due to the independent rotation of the head as it moves along the birth canal. After the head has reached the pelvic floor, further tractions are performed in the same way as with the exit obstetric forceps: first horizontally until the suboccipital fossa appears from under the pubic arch, then anteriorly upwards so that the head is extended.

Fifth moment - opening and removing the tongs - performed in the same way as with exit obstetric forceps.

Operation technique in the second position of the fetus. In the second position, the sagittal suture is in the left oblique dimension, the forceps should be applied in the opposite pelvic dimension, i.e., in the right oblique.

First moment - the introduction of spoons is carried out in the usual sequence, i.e. the left spoon is introduced first, the second - the right one. In order for the spoons to lie in the right oblique size, the left spoon must be located in the anterolateral part of the pelvis, therefore, in this case, this spoon will be “wandering”. After the usual introduction into the posterolateral pelvis, the left spoon is moved anteriorly; The right spoon is inserted immediately into the required position - into the posterolateral section of the right half of the pelvis. As a result, the spoons are located biparietally in the plane of the right oblique size.

Second and third moments operations are performed normally.

Fourth moment - actually traction - are produced in the same way as in the first position. The differences lie in the fact that as you advance, the head, together with the forceps, will turn not, against, but clockwise by 45 °.

Fifth moment performed typically.

Difficulties encountered when applying obstetric forceps. Difficulties in inserting spoons may be due to the narrowness of the vagina and the resistance of the pelvic floor, which requires incision of the perineum. 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 withdrawn and then re-introduced under careful finger control of the guide hand. Sometimes difficulties in the introduction of spoons are caused by a sharp configuration of the head when the head curvature of the spoon does not correspond to the changed shape of the head. Carefully overcoming this difficulty, it is possible to correctly insert and apply the spoon.

In some cases, difficulties may also be encountered when closing the spoons, usually arising if the spoons do not lie in the same plane. In such cases, the handles of the forceps should be lowered backwards towards the perineum and an attempt should be made to close the forceps. If this fails, then under the control of the fingers inserted into the vagina, the spoons move until they are in the same plane. If this technique does not lead to the goal, it is necessary to remove the forceps and apply again. If the forceps handles diverge when attempting to close them, this may be due to insufficient depth of insertion of the spoons, poor grip on the head in an unfavorable direction, or excessive size of the head. With insufficient depth of insertion of the spoons, their tops press on the head, and when trying to compress the spoons, severe damage to the fetus can occur, up to a fracture of the skull bones. 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. 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, therefore, to eliminate it, a second vaginal examination and appropriate movement or re-insertion of the spoons is necessary.

Obstetric forceps ( forceps obstetrician) are designed to extract a live full-term or almost full-term fetus by the head, if necessary, urgently complete the second stage of labor.

Obstetric forceps were invented by P. Chamberlen (P. Chamberlen, England) at the end of the 16th century. The invention lasted for a long time big secret. After 125 years (1723), the forceps were created a second time by J. Palfyn (France) and immediately published by the Paris Medical Academy, so Palfin is rightly considered the inventor of the forceps.

In Russia, forceps were first used in Moscow by I.V. Erasmus in 1765. The founder of the Russian scientific obstetrics Nestor Maksimovich Maksimovich-Ambodik.

Russian obstetrician N.N. Phenomenov made fundamental changes to the English Simpson forceps, due to which their branches became more mobile (Simpson-Fenomenov forceps). These forceps are still in use today.

For almost two centuries, the imposition of obstetrical forceps in all developed countries of the world has been widespread.

In Russia, at the end of the 20th century, the frequency of applying obstetric forceps has sharply decreased and currently it is 0.56-0.40%. This operation is more traumatic for the fetus than a timely caesarean section.

The frequency of applying obstetric forceps is constantly decreasing abroad, but there it is used in 2% of women in labor. The reason for the decrease in the frequency of this operation is primarily associated with the expansion of indications for caesarean section. In addition, the imposition of obstetric forceps can be very traumatic for the fetus if the head has not descended into the narrow part of the pelvic cavity. But if the head is in the indicated plane of the pelvis and there are indications for extreme delivery, then obstetric forceps remain the most important tool, especially in the hands of an experienced obstetrician (Fig. 30.12).

Rice. 30.12. A - Simpson-Fenomenov forceps. B - Branch of Simpson-Fenomenov forceps. 1 - spoon; 2 - part of the castle; 3 - Bush hook; 4 - handle

Obstetric forceps consist of two halves, called branches. One branch, which is grasped with the left hand, is intended for insertion into the left half of the pelvis - it is called the left branch; the second branch is called the right one. In each branch, a spoon, a lock and a handle are distinguished. The tongs are 35 cm long and weigh about 500 g.

A spoon is a plate with a wide cutout in the middle and rounded ribs. Spoons are curved according to the curvature of the head. The inner surfaces of the spoons in closed forceps fit snugly against the head of the fetus due to the existing curvature. The curvature of the spoons that is concave on the inside (and curved on the outside) is called the head curvature. The greatest distance between the inner surfaces of the folded spoons is 8 cm, and between the tops of the folded spoons is 2.5 cm. This second curvature of the spoons is called the pelvic curvature, as it corresponds to the shape of the sacrum.

Lock serves to connect branches. The lock in the Simpson-Fenomenov tongs is very simple: on the left branch there is a notch into which the right branch is inserted, and the branches cross.

The movable lock allows you to place spoons on the head in any plane of the pelvis and prevent excessive compression of the head.

handles forceps are rectilinear, their inner surface is even, flat, and the outer -

ribbed, wavy, which prevents the surgeon's hands from slipping. On the outer surface of the handles near the lock, there are Bush side hooks designed to support the fingers when removing the fetus.

It is very important to distinguish the left branch (spoon) from the right one, since the left one must be inserted first and when the forceps are closed, it must lie under the right one, otherwise the forceps cannot be closed. To determine the spoons, forceps are placed on a horizontal surface, with the pelvic curvature facing downward. Then the spoons open, and the left one remains in the left hand.

The purpose of the forceps is to replace the expelling force of the uterus and abdominals with the force of the doctor. The forceps are only a pulling tool, not a rotary or compression tool.. During extraction it is difficult to avoid some compression of the head, but this is a disadvantage of forceps, not their purpose.

After the spoons of the forceps are placed on the head, their branches are closed and the doctor, with the help of forceps, helps to remove the head. It is important that the forceps do not compress the head excessively. For this purpose, a diaper is laid between the branches.

Currently, it is recommended to apply obstetrical forceps only when the head is in a large segment narrow part of the pelvic cavity, i.e. the sagittal suture approaches the direct size or is in the direct size of the pelvis. With a higher standing head -

in the wide part of the pelvic cavity and above - it is preferable to perform a caesarean section.

Depending on the height of the head in relation to the planes of the pelvis, there are output and cavity forceps.

Weekend called forceps, superimposed on the head, standing as a large segment at the exit of the pelvis, an arrow-shaped suture in the direct size of the exit from the pelvis; while the head is visible in the genital gap.

Such forceps are called elective, prophylactic; they are applied quite often. In our country, they are used extremely rarely: if the head is at the bottom of the pelvis, and the suboccipital fossa has come under the bosom, then an episiotomy is enough for its birth.

cavity(typical) forceps are called, applied to the head, which is a large segment in the narrow part of the pelvic cavity, when the sagittal suture is in a straight or almost straight, less often in the transverse (low transverse standing of the head) size of the pelvis.

cavity(atypical) forceps with the head, which is a large segment in the wide part of the pelvic cavity, are currently used extremely rarely, since they are very traumatic for the fetus and mother. Under these conditions, it is better to perform a caesarean section.

Indications to the imposition of forceps can be both on the part of the mother and on the part of the fetus (although this division is conditional).

Mother's testimony:

Severe cardiovascular disease and respiratory systems; kidneys, organs of vision, etc.;

Severe preeclampsia, eclampsia;

Myopia of a high degree;

Weakness of labor activity, not amenable to drug therapy.

Fetal indications:

Acute hypoxia;

Prolapse of the umbilical cord at the end of the second stage of labor;

Premature placental abruption that occurred at the end of the exile period.

If the mother is shown to turn off the attempts (high myopia with changes in the fundus, the threat of retinal detachment, cardiopulmonary insufficiency, etc.), it is advisable to deliver by caesarean section in order to avoid possible injury to the fetus when forceps are applied.

Elective exit forceps are very popular in the United States, which are applied when using epidural analgesia, since the latter can weaken the attempts.

Conditions for applying forceps:

live fruit;

Full disclosure of the uterine os. In case of incomplete opening of the pharynx, it is possible to capture the cervix with forceps, and often there is a rupture of the cervix, which can go to the lower segment of the uterus;

Absence of a fetal bladder. Shell attraction can cause premature detachment placenta;

There should be no pronounced prematurity, the head should have a normal density (otherwise, the forceps may slip off the head during attraction);

The head should be in the narrow part of the pelvic cavity with an arrow-shaped suture in a straight or almost straight size of the pelvis;

Empty bladder.

Contraindications to the imposition of obstetric forceps:

Stillbirth;

Not full disclosure uterine pharynx;

Hydrocephalus, anencephaly;

Deeply premature fetus;

High location of the fetal head (the head is pressed, with a large segment at the entrance to the pelvis, in a wide part of the pelvic cavity);

Threatening or incipient uterine rupture.

Preparation for the operation. The mother is placed in position for vaginal operations(legs bent at the knee and hip joints and divorced). Before the operation, the bladder is catheterized and the external genital organs are treated with a 1% solution of iodonate, octinisept, octeniderm, etc. Sterile shoe covers are put on the mother's legs, the external genital organs are covered with sterile underwear, leaving the entrance to the vagina free.

When applying forceps, intravenous, less often inhalation general anesthesia is used. If epidural anesthesia is used in childbirth, then it can be continued.

Operation technique. When applying forceps, the following rules should be followed (triple rule).

First rule. First, the left spoon is inserted with the left hand into the left half of the pelvis (mother) under the control of the right hand; the right spoon is inserted with the right hand into the right side of the pelvis under the control of the left hand.

Second rule. The tops of the spoons should be facing the wire axis of the pelvis; forceps should grab the head along a large oblique dimension and biparietal so that the wire point of the head is in the middle of the spoons of the tongs.

Third rule. The direction of traction corresponds to the wire line of the pelvis. In this case, the direction is determined in relation to standing woman: way down -

means to the kidneys, to the front - to the stomach, backwards - towards the back.

The imposition of obstetric forceps consists of four points:

Introduction and placement of spoons;

Forceps closure and trial traction;

Traction or attraction (extraction) of the head;

Removing forceps.

Cavity (typical) forceps in anterior view occiput presentation. The first point is the introduction and placement of the spoons. Standing, the obstetrician spreads the genital slit with his left hand and inserts four fingers of the right hand into the vagina along its left wall so that the palm of the hand fits snugly against the head and separates it from the soft tissues of the birth canal (vaginal wall). The doctor takes the left branch by the handle, like a writing pen or like a bow. The handle is taken aside and set almost parallel to the right inguinal fold, and the top of the spoon is turned to the genitals of the woman in labor, pressing it to the palmar surfaces of the fingers located in the vagina. The lower edge of the spoon rests on the third finger of the right hand. The spoon is inserted into the genital slit, pushing its lower rib with the thumb of the right hand under the control of the fingers inserted deep into the vagina. The spoon should slide between fingers II and III (Fig. 30.13).

Rice. 30.13. Insertion of the left spoon of obstetric forceps

While the spoon is moving along the birth canal, the hand inserted into the vagina controls the correct movement of the top of the spoon so that it does not deviate from the head and does not put pressure on the vaginal fornix (danger of damaging it), on the side wall of the vagina and does not capture the edges of the cervix.

As the spoon moves into the birth canal, the handle of the forceps should be brought closer to the midline and lowered backwards. Both of these movements should be performed smoothly under the control of the four fingers of the right hand inserted into the vagina. When the left spoon lies well on the head, the handle is passed to the assistant in order to avoid displacement of the forceps branch.

Under the control of the left hand, the doctor performing the operation introduces the right branch into the right half of the pelvis with the right hand (Fig. 30.14).

Rice. 30.14. Insertion of the right spoon of obstetrical forceps

Then you need to make sure that the spoons lie correctly on the head and that the cervix is not captured. At correct location heads are easily closed.

The second point is the closing of the forceps and trial traction. Each handle is grasped with the same hand so that the thumbs are located on the side hooks of Bush. After that, the handles are combined, and the tongs close easily (Fig. 30.15)

Rice. 30.15. Closing forceps

Properly applied forceps are located in the transverse size of the pelvis, their branches are located at the level of the ears of the fetus (Fig. 30.16). You should not squeeze the head when closing the spoons; it is better to put a sterile diaper folded several times between the handles.

Rice. 30.16. Correct application of pincers in anterior occiput presentation

Before removing the fetal head, a trial traction is performed with the right hand, and with the index finger of the left hand, it is determined whether the head moves with forceps or the instrument slips. With correctly applied forceps, the head follows the traction, and this is felt by the finger of the left hand (Fig. 30.17).

Rice. 30.17. Trial traction (diagram)

The third point is the extraction of the head (traction). After making sure that the forceps are correctly applied, the doctor tightly clasps the handles of the forceps with both hands and proceeds to remove the head. To do this, fingers II and IV of the right hand are placed on the side hooks of Bush, III is located between the divergent branches of the forceps, I and V cover the handles on the sides. Left hand located on the right (Fig. 30.18).

Rice. 30.18. Start of traction

When using the generally accepted method of applying obstetric forceps during traction, the doctor sits on a chair (less often, he stands), the feet are pressed to the floor, and the elbows are to the body. This position prevents the development of excessive force, which can lead to rapid removal of the head, and sometimes the entire fetus, and cause severe injury to the fetus and the woman in labor.

When removing the head with obstetric forceps, you should try to combine attraction with natural attempts. If the woman in labor is under anesthesia and there are no attempts, the doctor needs to mentally imitate the attempts: after attraction for 1-2 minutes, for 1 minute, loosen the compression of the head with the instrument in order to restore blood flow in it.

The head should be removed in accordance with the direction of the birth canal and in no case should rotational and rocking movements be made.

To reduce the pulling force, the obstetrician can stand on the side of the woman in labor and with his right hand carefully remove the head so that it fits under the bosom with the suboccipital fossa, and at this time protect the perineum with his left hand. If there is a risk of perineal rupture, an episiotomy is necessary.

The fourth moment is the removal of forceps. Forceps are usually removed after eruption of the head. First open the lock. Next, the right spoon is withdrawn first, and the handle must go the opposite way compared to the introduction, the second one is the left spoon. Then from the side of the perineum, unbending the head, contribute to its birth.

The birth of the shoulders and trunk of the fetus usually does not cause difficulties.

Cavity (typical) forceps for posterior occipital presentation. The technique of introducing and placing spoons on the head (Fig. 30.19), located in the narrow part of the pelvic cavity in the posterior view, their closure and trial traction do not differ from those in the anterior view. The direction of traction during extraction is carried out down; meaning (on oneself) before placing the area of a large fontanel under the bosom (Fig. 30.20). Further, traction is carried out anteriorly in order to contribute to some flexion of the head and removal of the occiput from the side of the perineum. Then, according to the mechanism of childbirth, the head should be helped to straighten, which can be done after removing the forceps. From under the womb, the forehead and the front part are born. To avoid trauma to the perineum, it is better to perform an episiotomy before starting extension.

Rice. 30.19. Grasping the head with forceps in the posterior view of the occipital presentation

Rice. 30.20. Removal of the head in forceps with posterior occipital presentation

Cavity (typical) forceps in posterior face presentation. Childbirth in facial presentation can only occur in the rear view, i.e. the chin is turned forward. The front line should be in direct size.

The introduction of spoons and their placement on the head does not differ from those in the occiput presentation (Fig. 30.21). Traction is carried out down until the chin is removed from under the womb, then the handles of the forceps are raised anteriorly and the parietal tubercles and the back of the head are brought out above the perineum.

Rice. 30.21. Grasping the head with forceps in the posterior face presentation

The imposition of forceps for surgery with facial presentation is very traumatic for the fetus. If difficulties are expected during the birth act (weakness of the birth force, the weight of the fetus is more than 3500 g), it is better to perform a caesarean section in a timely manner.

Cavity (atypical) forceps on the head, located in the wide part of the small pelvis, is now extremely rare, as they are very traumatic for the fetus and mother. On the head, located in a wide part of the pelvic cavity in an oblique size, it is necessary to put spoons in a biparietal size (through the ears), in the opposite oblique size of the pelvis in relation to the position of the sagittal suture. This is only possible when, in the first position - front view - one of the spoons is inserted to the right and behind (left) (Fig. 30.22), and the second (right) from the side, but it must then move to the left and anteriorly with the help of the hand inserted into vagina.

Rice. 30.22. The imposition of cavity forceps in the anterior view of the occipital presentation. A - I position; B - II position

In the second position of the occipital presentation, the left spoon first to the left, and then it moves to the left-anterior pelvis, the right spoon is inserted into the right-posterior pelvis. Only with their biparietal position on the head is it possible for the branches to close. After trial traction, the attraction of the head is carried out in the direction backwards (towards the sacrum), downwards (toward the legs), and after the suboccipital fossa is passed under the bosom, the head unbends and is born. Before this, it is better to remove the forceps after the eruption of the head.

Complications when applying obstetric forceps. Failed forceps application most often observed with the head located in a wide part of the pelvic cavity (atypical, or high abdominal forceps). In such a situation, it is necessary to perform a caesarean section. If the fetus dies, then a fruit-destroying operation is performed.

slipping forceps occurs when the head is not properly grasped (atypical abdominal forceps), with a very small or large size of the head, when, in essence, the application of forceps is contraindicated. If during traction the head does not follow the forceps, then the operation should be stopped and either a caesarean section should be performed if the head is in a wide part of the pelvic cavity, or a vacuum extraction should be performed. Sliding forceps can lead to serious injuries fetal head and maternal birth canal.

Traumatic injuries of the birth canal of the mother and the head of the fetus. Even with the correct application of forceps to the head, injuries to the soft birth canal of the mother and the skin of the fetal head are possible. Injuries to the tissues of the mother are more often observed with a narrow vagina (in primiparas) or with its inflammatory changes. When the head is in the narrow part of the pelvic cavity, the trauma to the fetus is small, although abrasions are possible. When forceps are applied to the head, located in a wide part of the pelvic cavity, paresis of the facial nerve, cephalohematoma is sometimes observed.

The birth of children with asphyxia after the application of obstetric forceps can be determined not by the operation, but by the initial state of the fetus (hypoxia). But often this circumstance is the reason for refusing to apply 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, inevitable when forceps are applied, 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. Obstetric forceps are only a gripping and pulling 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, the fetus, or both together: with eclampsia, premature detachment of the placenta, prolapse of the umbilical cord, incipient asphyxia of the fetus, maternal diseases that complicate the course of the exile period (heart defects, nephritis), febrile condition, etc. With secondary weakness of labor, obstetric forceps are used in cases where the period of exile in primiparas lasts more than 2 hours. (3-4 hours), and for multiparous - more than an hour.

It is necessary to strictly consider contraindications to the use of obstetric forceps. They arise from the following conditions under 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. At vaginal examination the cape is accessible to the exploring 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 articulation, behind - the cape and the inner surface of the 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. The head has completed the internal rotation (rotation), the sagittal suture is in the direct size of the pelvic outlet. favorable conditions for applying forceps (typical forceps).

Obstetric forceps (forceps obstetricia) is a tool designed to remove a live full-term or almost full-term fetus by the head, if necessary, urgently complete the second stage of labor.

Obstetric forceps were invented by P. Chamberlain (England) at the end of the 16th century (Fig. 1). The invention was kept a closely guarded secret for a long time.

After 125 years (1723), the tongs were invented again by J. Palfyn (France) and immediately published in the Paris medical academy, therefore, Palfin is rightly considered the inventor of tongs. The tool and its application quickly became ubiquitous (Fig. 2).

Rice. one.

Rice. 2.

In Russia, forceps were first applied in Moscow by I.V. Erasmus in 1765. Nestor Maksimovich-Ambo-dik, the founder of Russian scientific obstetrics, introduced the operation of applying obstetric forceps into everyday obstetric practice. I.P. Lazarevich created an original type of Russian forceps, the main features of which are the simplicity of the device, the absence of pelvic curvature, the mobility of the castle branches, yes).

N.N. Phenomenov made fundamental changes to one of the most common models of tongs - to the English Simpson tongs: thanks to changes in the lock, greater mobility was given to the branches (Simpson tongs - Fenomenov).

Among delivery operations in the USA, England, France and Russia, the second place after caesarean section is the operation of applying obstetric forceps.

The main model of forceps used in our country is the Simpson-Fenomenov forceps.

The forceps are made up of two halves called branches. One of the branches, which is grasped with the left hand, is intended to be introduced into the left half of the pelvis - it is called the left branch; the second branch is called the right one. Three parts are distinguished in each branch: a spoon (cochlear), a lock (pars juncture) and a handle (manubrium). The forceps are 35 cm long and weigh about 500 g. medicine full-term fetus forceps

The spoon is a plate with a wide cutout in the middle - a window - and rounded ribs - top and bottom. Spoons are curved according to the curvature of the head. The inner surfaces of the spoons in closed forceps fit snugly against the head of the fetus due to the coincidence of the curvature of the head and spoons. The curvature of the spoons that is concave on the inside (and curved on the outside) is called the head curvature. The greatest distance between the inner surfaces of the folded spoons is 8 cm, and between the tops of the folded spoons is 2.5 cm. The edges of the spoons are also curved in the form of an arc, with the top edge concave and the bottom curved. This second curvature of the spoons is called the pelvic curvature, as it corresponds to the curvature of the pelvic axis.

The lock serves to connect the branches. The device of the lock is not the same in various models forceps. The lock in the Simpson-Fenomenov tongs is very simple: on the left branch there is a notch into which the right branch is inserted, and the branches cross. An essential feature is the degree of mobility of the branches connected by it: the castle can be freely movable (Russian tongs), moderately movable (English tongs), almost immovable (German tongs) and completely immovable (French tongs).

The movable lock allows you to place spoons on the head in any plane of the pelvis and prevent excessive compression of the head.

The forceps handles are rectilinear, their inner surface is even, flat, and the outer surface is ribbed, wavy, which prevents the surgeon's hands from slipping. On the outer surface of the handles near the lock there are Bush side hooks designed to support the fingers during attraction. It is very important to distinguish the left branch (spoon) from the right one, since it must be inserted first and when the forceps are closed, it must lie under the right one, otherwise the forceps cannot be closed.

The purpose of the forceps is to tightly grasp the head and replace the expelling force of the uterus and abdominals with the pulling force of the doctor. Therefore, the forceps are only a pulling tool, not a rotational or compression tool. During extraction, it is difficult to avoid the known compression of the head, but this is a disadvantage of the forceps, not their purpose.

Indications for the application of forceps can be both on the part of the mother and on the part of the fetus (although this division is conditional).

Mother's testimony:

W serious illnesses cardiovascular and respiratory systems, kidneys, organs of vision, etc.;
Ø severe nephropathy, eclampsia;
Ø weakness of labor activity, not amenable to drug therapy, fatigue;
III chorioamnionitis in childbirth, if the end of labor is not expected within the next 1-2 hours.

Fetal indications:

Ø acute fetal hypoxia;
Ш prolapse of umbilical cord loops;
Ø premature detachment of the placenta.

Conditions for applying forceps. There are the following conditions for applying forceps:

Ø the presence of a live fetus;
Ø full disclosure of the uterine pharynx. In case of incomplete opening of the pharynx, it is possible to capture the cervix with forceps, while the cervix often breaks and its transition to the lower segment of the uterus is possible;
Ш absence of a fetal bladder. The attraction for membranes can cause premature detachment of the placenta;
The head should not be too small (pronounced prematurity) or too large, it should have a normal density (otherwise the forceps may slip off the head during attraction);
Ш head should be in a narrow (sometimes in a wide) part of the pelvic cavity with an arrow-shaped seam in a straight and one of the oblique dimensions of the pelvis;
Ø lack of disproportion of the pelvis and head;
Empty bladder.

Contraindications to the imposition of obstetric forceps:

1) dead fetus;
2) incomplete disclosure of the uterine os;
3) hydrocephalus, anencephaly;
4) anatomically ( II-III degree narrowing) and clinically narrow pelvis;
5) a very premature fetus;
6) high location of the fetal head (the head is pressed by a small or large segment at the entrance to the pelvis);
7) threatening or beginning uterine rupture.

Preparation for the operation. A woman in labor is placed on a Rakhmanov bed or an operating table in a position for vaginal operations. At the same time, the legs are bent at the knee and hip joints and spread apart to provide free access to the crotch area. Before the operation, catheterization of the bladder and treatment of the external genitalia are performed. The sequence of processing should be strictly observed: first, the pubic area is treated, then inner surface thighs, vulva and anus. To do this, use a 1% solution of iodonate or 5% alcohol solution iodine, octenisept, octeniderm, etc. Sterile shoe covers are put on the woman's legs, the external genitalia are covered with sterile linen, leaving an opening for entering the vagina.

When applying forceps, intravenous is used, less often inhalation anesthesia. Nice results obtained from the use of bilateral pudendal anesthesia.

Depending on the height of the head in the pelvis, there are output forceps, cavity forceps.

The output forceps are called, superimposed on the head, standing as a large segment at the exit of the pelvis (station +3), with an arrow-shaped suture in the direct size of the exit from the pelvis; while the head is visible from the genital gap.

Such forceps are called elective, prophylactic; they are applied quite often. In our country, they are used extremely rarely, because if the head is at the bottom of the pelvis, it is enough to perform an episiotomy for the birth of the fetal head.

Cavitary (typical) forceps are called, applied to the head, which is a large segment in the narrow part of the pelvic cavity (station +2), when the sagittal suture is in a straight or almost straight, less often in the transverse (low transverse standing of the head) size of the pelvis.

Principles of applying forceps. Before proceeding to the technique of applying forceps, let us dwell on some general principles, which apply to both typical and atypical forceps.

When applying forceps, the following triple rules should be followed.

The first triple rule. The left spoon is introduced first, which is inserted with the left hand into the left half of the pelvis (mother) ("three from the left") under the control of the right hand; the right spoon is inserted with the right hand into the right side of the pelvis ("three from the right") under the control of the left hand.

The second triple rule. The tops of the spoons should be facing the wire axis of the pelvis; forceps should capture the head along the large oblique dimension (mentooccipitalis) and biparietally, so that the wire point of the head is in the plane of the forceps.

The third triple rule. With the head located in the wide part of the pelvic cavity, the tractions (in relation to the standing woman) are directed obliquely backward, then down and forward, if the head is in the narrow part, down and forward, and if in the exit of the pelvis, forward.

The operation of applying obstetric forceps consists of 4 points:

1. Introduction and placement of spoons.
2. Forceps closure and trial traction.
3. Traction or attraction (extraction) of the head.
4. Removing the forceps.

Complications during the operation of applying obstetric forceps

slipping forceps.

Among the complications of applying obstetric forceps, there are two types of slippage - horizontal and vertical. Causes of forceps slipping are incorrect head grip, head size mismatch (excessively small or large head). Careful vaginal examination usually reveals the cause of the mishandling (insufficient advancement of the forceps or inappropriate size of the fetal head).

The diagnosis of impending forceps slippage is based on the protrusion of the spoons out of the genital slit (although the fetal head does not advance) and the increase in the distance between the forceps lock and the head. In this case, one should abandon the attempt to prevent slipping by tightening the handles; such an approach threatens fatal injury fetus without preventing the risk of slipping. If slippage of the forceps is suspected or threatened, traction should be stopped and a thorough investigation should be carried out to determine the cause of the slippage. Then you should remove the forceps and re-apply them correctly.

Failed forceps application. One of negative points when applying obstetric forceps, there is a failed attempt to apply them, which is observed in 1.2--6.7% of cases. The negative result is due to insufficient consideration of the obstetric situation, non-compliance with the conditions and incorrect technique for performing the operation.

With a failed attempt to apply forceps, the question arises of further delivery. If the head is located high enough, then a caesarean section is performed; if the fetus dies during the operation of applying obstetric forceps, then a fruit-destroying operation is performed.

Traumatic injuries of the birth canal and fetus. During the operation, ruptures of the perineum, vagina, large and small labia, clitoris, cervix, lower uterine segment, bladder and urethra, rupture of the symphysis and injury of the sacroiliac joint. A common complication is continued perineal rupture or episiotomy to the rectal sphincter.

Other complications. After the application of forceps, there is an increased blood loss during childbirth, and the frequency of intrauterine interventions reaches 70%. Frequency postpartum diseases very high (13.5--96%) and is associated with prolonged labor, extensive trauma to the birth canal. The fetus is also subjected to significant trauma. These damages range from small damage soft tissues of the head deep wounds. Among the injuries of the fetal head, cephalohematomas, paresis of the facial nerve, fracture of the bones of the skull, cerebrovascular accidents, cerebral hemorrhages, etc. can be noted.

A significant number of complications during the operation of applying obstetric forceps and not always favorable long-term results somewhat reduced the frequency of this operation in modern obstetrics.

The operations of applying obstetrical forceps and vacuum extraction of the fetus are not competing. Each of these operations has its own indications and conditions. Many obstetricians believe that obstetric forceps have a wider range of indications than a vacuum extractor.