Obstetric forceps. Conditions necessary for the imposition of obstetric forceps. Conditions for the operation

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

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

Purpose and action of obstetric forceps

The following questions are most frequently discussed in the literature:

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

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

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

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

Indications for the imposition of obstetric forceps

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

These are: decompensated heart defects, serious illnesses lungs and kidneys, eclampsia, acute infection, accompanied by a rise in body temperature, fetal asphyxia. In addition to these general and for other obstetric operations, there are special indications for forceps.

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

Conditions necessary for the imposition of obstetric forceps

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

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

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

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

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

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

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

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

Forceps Models

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

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

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

General rules for applying obstetric forceps

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

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

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

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

Obstetric forceps technique

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

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

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

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

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

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

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

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

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

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

Technique for applying abdominal (atypical) obstetric forceps

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

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

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

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

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

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

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

Exit forceps showed no increase in perinatal morbidity and mortality. In a relationship abdominal forceps and up to now the question remains not entirely clear. Some authors believe that the reduction in perinatal morbidity and mortality is associated with more wide application caesarean sections, and obstetrical forceps are offered only for difficult births.

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

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

Over the past three centuries, medical and public 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, Simpson forceps are used, as well as Neville-Barnes, Ferguson, Tucker-McLain forceps similar to them with spoons in the form of a plate. The tongs consist of two branches, right and left, each of which includes a spoon, a lock and a handle. The head curvature of the spoon, concave on the inside and convex on the outside, corresponds to the shape of the fetal head, and the pelvic curvature is expressed in the curvature of the spoons in the form of an arc, which corresponds to the curvature of the birth canal of the mother. The branches of the tongs are closed in the area of ​​the lock and handles. Forceps designed for rotation (most often these are Killand's forceps) are distinguished by a pronounced head curvature and a slightly pronounced pelvic curvature of the spoons. Such a device allows rotation in the pelvic cavity and reduces the risk of injury to the mother's tissues, because. reduces the arc of rotation due to the narrowing of the tips of the spoons. When applying rotational forceps, asynchronous insertion is often encountered, therefore, such forceps have a sliding lock. Each obstetrician prefers a different style of forceps based on skill and awareness. In clinical practice, the obstetrician needs to be familiar with two of their types - the classic Simpson forceps and the Keelland rotary forceps. More 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 precisely established, for example, anterior occipital presentation, first or second position, both arms of the forceps are picked up and folded in front of the patient's perineum in such a way as to lay on the fetal head. The left branch of the obstetric forceps is taken with the left hand, inserted from the left side and placed in front of the left ear of the fetus. During this action, the fingers of the right hand are inserted into the vagina, and thumb 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 the first or second position in the anterior occiput presentation, the method of applying the forceps is the same, but the location of the head must be taken into account. The imposition of spoons of tongs on the head and the locking of the lock should be done without effort. If, however, when inserting 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 fontanelle is located further from the indicated surface, then traction will lead to extension of the head, and it will pass through the birth canal with its large size;
• the sagittal suture should be perpendicular to the locking surface of the forceps throughout its entire length. The location of the locking surface of the forceps obliquely with respect to the sagittal suture means that the spoons of the forceps are applied asymmetrically, closer to the areas of the eyebrow and mastoid process;
• palpable parts of the openings of the forceps spoons should be equal on both sides. With the correct application of the forceps, the holes in the spoons should almost not be palpated, more than one finger should not pass between them and the head.

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

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

Tractions should be carried out during the fight, combining them with attempts, and with their help to advance the head according to the wired axis of the pelvis - the curvature of Carus. During traction, the obstetrician can stand or sit, his arms should be bent at the elbows. It's hard to describe how strong the traction 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.

As the head descends toward the perineum and the occiput passes under the pubic symphysis, the direction of traction should gradually change anteriorly and upwards at approximately a 45° angle. When the fetal head is incised, the forceps are raised at an angle of 75°, one hand begins to hold the perineum or, if necessary, an episiotomy is performed. When the fetal head is almost born, the spoons of the forceps can be removed by 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 sagittal suture is in the right or left oblique size, then after the correct application of the forceps spoons, it is necessary to gradually and accurately, without traction, turn the head 45 degrees towards the midline. This can be done by slightly lifting the handles of the forceps and slowly turning them in an arc, allowing the maternal soft tissues to adapt to the changing position of the fetal head. After turning the head, it is necessary to check again the correct application of the forceps spoons, because. they could slip.

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

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

The following types of obstetric forceps are distinguished: a) Simpson's forceps - used for traction in anterior occipital presentation; b) Tooker-McLean forceps - used to rotate from the rear view of the occipital presentation to the anterior view of the occipital presentation and extraction of the fetus; c) Keelland and Barton forceps - with a transverse arrangement of the sagittal suture for turning into an anterior view of the occipital presentation; d) Piper forceps - designed to extract the head in breech presentation.

The device of obstetric forceps. The forceps have 2 spoons (branches), each of which consists of three parts - the spoon itself (which captures the head of the fetus, it is fenestrated, the length of the window is 11 cm, the width is 5 cm); castle part; handle (hollow, the outer side of the handle is wavy). On the outside forceps near the lock there are protrusions, bush hooks, which, when folding the forceps, should be turned in different directions, i.e. laterally, and lie in the same plane. Most models of forceps have two curvatures - head (calculated for the circumference of the head) and pelvic (goes along the edge of the spoon, curvature along the plane of the pelvis). The ends of the spoons when folded do not touch each other, the distance between them is 2-2.5 cm. The head curvature in the folded forceps is 8 cm, the pelvic curvature is 7.5 cm; the largest width of the spoons is not more than 4-4.5 cm; length - up to 40 cm; weight - up to 750 g.

Indications for the imposition of obstetric forceps:

1. Indications on the part of the woman in labor: weakness of labor activity not amenable to drug therapy, fatigue; weakness of attempts; bleeding from the uterus at the end of I and II periods of labor; contraindications for exertive activity (severe gestosis; extragenital pathology - cardiovascular, renal, high myopia, etc.; feverish conditions and intoxication); severe forms neuropsychiatric disorders; chorioamnionitis in childbirth, if the end of labor is not expected within the next 1-2 hours.

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

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

Conditions for applying obstetric forceps:

1. Full disclosure of the uterine pharynx.

2. Opened fetal bladder.

3. Empty bladder.

4. Head presentation and finding the head in the cavity or at the exit from the small pelvis.

5. Correspondence of the size of the fetal head with the size of the pelvis of the woman in labor.

6. Average head sizes.

7. Living fetus.

Complications after applying obstetric forceps:

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

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

3. Postpartum infectious complications.

Three triple rules for applying obstetric forceps:

1. About the sequence of insertion of forceps spoons:

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

the right spoon is inserted with the right hand into the right half of the pelvis under the control of the left hand ("three on the right").

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

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

forceps should capture the parietal tubercles of the fetus;

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

in the plane of the entrance - obliquely down, to the socks of the seated obstetrician;

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

in the exit plane - from the bottom up, on the face of the seated obstetrician.

Moments of the operation of applying obstetric forceps:

1. Introduction of tongs spoons. Produced after a vaginal examination. The left spoon of tongs is introduced first. Standing, the doctor inserts four fingers of the right hand (half-hand) into the vagina into the left half of the pelvis, separating the fetal head from the soft tissues of the birth canal. The thumb remains outside. Taking the left branch of the forceps with the left hand, the handle is taken to the right side, setting it almost parallel to the right inguinal fold. The top of the spoon is pressed against the palmar surface inserted into the vagina of the hand, so that the lower edge of the spoon is located on the fourth finger and rests on the retracted thumb. Then, carefully, without any effort, the spoon is advanced between the palm and the head of the fetus deep into the birth canal, placing the lower edge between the III and IV fingers of the right hand and leaning on the bent thumb. In this case, the trajectory of movement of the end of the handle should be an arc. The promotion of the spoon into the depths of the birth canal should be carried out due to the gravity of the instrument and by pushing the lower edge of the spoon 1 with the finger of the right hand. The half-hand, located in the birth canal, is a guide hand and controls the correct direction and location of the spoon. With its help, the obstetrician makes sure that the top of the spoon does not go into the vault, onto the side wall of the vagina and does not capture the edge of the cervix. After the introduction of the left spoon, in order to avoid displacement, it is passed to the assistant. Further, under the control of the left hand, the obstetrician inserts the right branch into the right half of the pelvis with the right hand in the same way as the left branch.

2. Closing the lock of the tongs. To close the tongs, each handle is grasped with the same hand so that the first fingers of the hands are located on Bush's hooks. After that, the handles are brought together, and the tongs close easily. Properly applied forceps lie across the swept seam, which occupies a median position between the spoons. The elements of the lock and Bush hooks should be located on the same level.

3. Trial traction. This necessary moment allows you to make sure that the forceps are correctly applied and that there is no danger of them slipping. It requires a special position of the hands of the obstetrician. For this, the doctor's right hand covers the handles of the forceps from above so that the index and middle fingers lie on the hooks. He puts his left hand on the back surface of the right, and the extended middle finger should touch the head of the fetus in the region of the leading point. If the forceps are correctly positioned on the fetal head, the tip of the finger is in constant contact with the head during trial traction. Otherwise, it moves away from the head, which indicates that the forceps are not applied correctly and, in the end, they will slip off. In this case, the forceps must be applied again.

4. Actually traction for the extraction of the fetus. After a trial traction, after making sure that the forceps are correctly applied, they begin their own traction. Traction of the fetal head with forceps should mimic natural contractions. For this you should:

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

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

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

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

Rocking, rotational, pendulum movements are not allowed

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

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

2. The head is slightly pressed against the entrance to the small pelvis - this means that during external examination it is motionless, and during vaginal examination it is repelled.

3. The head is pressed into the small pelvis - this is the norm in the absence of childbirth in primiparas.

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

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

6. Head in the pelvic cavity:

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

7. Head in the exit cavity.

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

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

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

Etiological factors:

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

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

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

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

e) Anomalies in the development of the fetus: hydrocephalus, anencephaly.

Diagnostics.

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

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

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

3. Vaginal examination. At the beginning of labor with a whole fetal bladder, it is not very informative, it only confirms the absence of the presenting part. After the outflow of amniotic fluid with sufficient opening of the pharynx (4-5 cm), it is possible to determine the shoulder, shoulder blade, spinous processes of the vertebrae, axillary cavity. By the location of the spinous processes and the scapula, the type of fetus is determined, by the armpit - the position: if the cavity is facing to the right, then the position is the first, with the second position armpit open to the left.

The course of pregnancy and childbirth.

Most often, pregnancy in transverse positions proceeds without complications. Sometimes when increased mobility the fetus is observed unstable position - frequent change of position (longitudinal - transverse - longitudinal).

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

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

When limbs fall out, it is necessary to clarify what fell into the vagina: a pen or a leg. The handle lying inside the birth canal can be distinguished from the leg by greater length fingers and the absence of the calcaneal tuberosity. The hand is connected to the forearm in a straight line. The fingers are spread apart, the thumb is especially taken away. It is also important to determine which handle fell out - right or left. To do this, as it were, "hello" right hand with a dropped handle; if this succeeds, the right handle falls out; if it fails, the left handle falls out. By the dropped handle, the recognition of the position, position and type of the fetus is facilitated. The handle does not interfere with the internal rotation of the fetus on the stem, its reduction is an error that makes it difficult to rotate the fetus or embryotomy. A dropped handle increases the risk of ascending infection during childbirth and is an indication for faster delivery.

Prolapse of the umbilical cord. If, during a vaginal examination, loops of the umbilical cord are felt through the fetal bladder, they speak of its presentation. Determination of loops of the umbilical cord in the vagina with a ruptured fetal bladder is called prolapse of the umbilical cord. The umbilical cord usually falls out during the passage of water. Therefore, for timely detection such a complication should be immediately made vaginal examination. Prolapse of the umbilical cord in the transverse (oblique) position of the fetus can lead to infection and, to a lesser extent, to fetal hypoxia. However, in all cases of umbilical cord prolapse with a live fetus, it is necessary to urgent help. With a transverse position, full opening of the cervix of the uterus and a moving fetus, such help is the rotation of the fetus on the leg and its subsequent extraction. When not full disclosure pharynx produce a caesarean section.

Obstetric forceps I Obstetric forceps

Overlay A. shch. produced for the purpose quick end childbirth in the interests of the woman in labor and (or) the fetus with the onset of fetal hypoxia, pregnancy complications (severe, preeclampsia,), weakness of labor during the period of fetal expulsion, extragenital diseases of the woman requiring the exclusion of attempts (, high myopia, etc.).

The operation can be performed only with a live and full-term fetus, the size of the pelvis of the woman in labor and the fetal head, full disclosure of the uterine os, the presence of the fetal head in the pelvic cavity or in the exit from it, and the absence of a fetal bladder. Imposes A. shch. obstetrician-gynecologist. Women in labor are preliminarily carried out with four fingers (the large one remains outside the genital gap) in order to determine the degree of opening of the uterine os, the condition of the fetal bladder, the position of the swept suture and the fontanels of the fetal head. The operation is performed in the position of a woman on her back in a gynecological chair, on an operating table or on a Rakhmanov bed; the legs of the woman in labor should be bent in hip joints and divorced (held with a foot holder). Before the operation, it is emptied with a catheter, the external genital organs are toileted. When applying A. shch. apply inhalation or intravenous, conduction ischiorectal is possible. Depending on which part of the small pelvis (at the outlet or in the cavity) the fetal head is located, there are output (typical) and cavity (atypical) A. shch.

More often, output obstetric forceps are used in the anterior view of the occipital presentation of the fetus. They are applied in the transverse size of the pelvis and on the transverse (biparietal) size of the head. In order not to make a mistake in choosing a spoon of tongs, before introducing them, they are folded so that the left spoon (there is a lock on its handle) lies under the right one; the handle of the left spoon should be in the left hand, the right - in the right hand ( rice. one ). The left spoon is always introduced first. It is taken with the left hand, held like a bow or bow and inserted into the genital gap on the left side; before inserting the left spoon, to control and protect soft tissues, four fingers of the right (control) hand are inserted so that they go beyond the parietal tubercles of the fetal head ( rice. 2, a ). The forward spoon of the tongs should be carried out mainly due to the force of its gravity, the thumb of the right hand, located outside, slightly pushes the lower spoon. With the remaining fingers of the right hand, inserted inside, direct the spoon of forceps forward so that it lies on the fetal head from the side, in the plane of the transverse size of the pelvic outlet. The correct position of the inserted spoon in the pelvis can be judged by the Bush hooks on the handle of the forceps: they must be strictly in the transverse size of the exit from the pelvis. The spoon must certainly go beyond the ends of the fingers of the control hand, i.e. for the heads of the fetus. The handle of the inserted left spoon is passed to the assistant, who must hold it in this position. Any kind of displacement of a correctly applied spoon can lead to complications in the future. Right spoon A. sh. is inserted into the genital gap on the right with the right hand under the protection of the fingers of the left hand inserted into the vagina ( rice. 2b ). The right spoon of tongs should always lie on the left. After the introduction of the right spoon close ( rice. 2, in ). In this case, it is necessary to check whether the perineum or vagina has got into the lock. For proper closure, the handles of the spoons must lie in the same plane and parallel. Correctness of forceps is checked by means of trial traction. To do this, the left hand should be placed on the right, which grabs the handles of the tongs from above; the extended index finger of the left hand should be in contact with the head of the fetus in the region of the small fontanel ( rice. 2, g ). During traction, the fetal head should follow the forceps and the index finger of the left hand.

To extract the head with the right hand, located on the handle and in the area of ​​Bush's hooks, energetic drives (actual traction) are carried out; while the left one should be at the bottom, and her index finger is in the recess near the lock ( rice. 2, d ). In this position, the left hand provides energetic assistance to the right during traction. together with the head of the fetus during traction, they must move along the wire line of the pelvis. You can not do any rocking, or rotational, or pendulum-like movements. When removing the head with obstetric forceps, it is necessary to alternate traction with pauses, as is the case with contractions. Each traction starts slowly, gradually increasing its strength and, having reached a maximum, reduce the traction strength, passing into a pause. Pauses should be long enough. Traction along the arc is done until the suboccipital fossa appears and reaches the lower edge of the pubic symphysis. Then an episiotomy is performed (see Perineotomy) and the head is removed. More often, before removing the fetal head, the forceps are removed - at first they are carefully opened, the spoons are moved apart, then each spoon is taken in the same hand and removed in the same way as they were applied, but in the reverse order (the spoons should slide smoothly, without jerking). After removing the forceps, the head and fetus are removed along general rules(see Childbirth). Sometimes the fetal head is removed with forceps. To do this, the obstetrician stands to the right of the woman in labor, grabs the forceps with his left hand, and protects with his right. Carefully, very slowly, slightly pulling the head with forceps, he raises the handle of the forceps anteriorly and unbends the head of the fetus. After removing the head, the forceps are removed, the fetal body is removed according to the general rules.

Cavitary A. shch. impose on the fetal head, which is located in a narrow, less often in a wide, part of the pelvic cavity. In forceps, the head must complete internal turning (rotation), cutting and cutting. When the swept seam of the head is located in one of the oblique dimensions of the pelvis, forceps are applied in the opposite oblique dimension. In this case, one spoon is inserted behind the head and left here (back, or fixed, spoon); another spoon is inserted from behind or from the side, and then it is turned obliquely in an arc by 90 ° or 45 °, respectively, so that it falls on the parietal tubercle lying in front (the so-called wandering spoon). If the arrow-shaped is located in the right oblique size of the pelvis, the left spoon will be fixed, if it is located in the left oblique size, the right one. Tractions are performed along the wire line of the pelvis - obliquely backwards, downwards and anteriorly (in relation to the woman in labor).

When A. sh is applied, ruptures of the cervix, vagina, vulva, and perineum often occur, therefore, after the operation, it is necessary to carefully examine the soft and sutured tears (see Childbirth, generic). As a result of the imposition of A. shch. fetuses may occur (see Birth of newborns (Birth trauma of newborns)): skin, depression of the bones of the skull, facial nerve, intracranial, etc. After discharge from the hospital, the woman should be observed by an obstetrician-gynecologist antenatal clinic or a midwife at a feldsher-obstetric station (see Postoperative period, features of outpatient management of patients after gynecological and obstetric operations), the child is a pediatrician and a neuropathologist.

Bibliography: Bodyazhina V.I., Zhmakin K.N. and Kiryushchenkov A.P. , With. 447, M., 1986; Golota V.Ya., Radzyansky V.E. and Sotnik G.T. Obstetric forceps and vacuum extraction of the fetus, Kyiv, 1985; Malinovsky M.S. Operative, M., 1967.

1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First health care. - M.: Bolshaya Russian Encyclopedia. 1994 3. Encyclopedic Dictionary medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

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.

Cavitary (typical) forceps in the anterior view of the occipital 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 palmar surfaces of the hands fit snugly against the head and separate it from the soft tissues of the birth canal (vaginal walls, uterine os). The doctor takes the left branch of the forceps 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 drawn to the genitals of the woman in labor and pressed against the palmar surfaces of the fingers in the vagina. The lower edge of the spoon rests on the first finger of the right hand. The spoon is inserted into the genital slit, pushing its lower rib I with the finger 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. 25.13).

Rice. 25.13.

Rice. 25.14.

During the whole time, 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 to the side and does not put pressure on the vaginal fornix (danger of its perforation into the abdominal cavity), on the side wall of the vagina and did not capture the edges of the uterine os.

As the spoon moves into the birth canal, the forceps handle should approach the midline and descend backwards. Both of these movements should be performed smoothly under the control of the IV 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 to avoid displacement of the 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 in the same way as the left branch (Fig. 25.14).

Then you need to make sure that the spoons lie correctly on the head and that the cervix is ​​​​not captured.

The second moment is the closure of the forceps and the trial tracing. 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 placed and the tongs close easily (Fig. 25.15).

Properly applied forceps lie in the pelvis in a transverse dimension. They tightly wrap around the head in its large size, biparietal (Fig.! 5.16). The sagittal suture is in direct size, and the leading point of the head (small fontanel) faces the lock. Internal surfaces handles of the tongs should fit snugly (or almost snugly). If the handles do not fit tightly to each other, put a sterile napkin folded in 2-4 layers between them. This achieves a good habituation of the tongs spoons to the head and avoids the possibility of excessive compression in the tongs.

Rice. 25.16.

Rice. 25.15.

Rice. 25.17.

After that, a trial traction is performed (Fig. 25.17). Its purpose is to make sure that the forceps are in the correct position and that there is no threat of slipping (does the head follow the forceps). To do this, the doctor sits on a chair i with his right hand grabs the handles of the forceps from above so that the index-1st and middle fingers lie on the side hooks. At the same time, he puts the left system on the back surface of the right one, and the end of the elongated index or middle finger touches the head. moves away from the head, the distance between the lock of the forceps and the head increases, and their handles diverge: slipping begins.

Rice. 25.18..

Rice. 25.19. Capturing forceps according to Tsovyanov.

The third point is the extraction of the head (tractions). After making sure that the forceps are correctly applied, the doctor tightly wraps both hands around the handles of the forceps and proceeds to the actual attraction. For this, index and ring fingers the right hand is placed on the side hooks, the middle one is between the diverging branches of the forceps, and the big and little fingers cover the handles on the sides. The left hand grabs the end of the handle (Fig. 25.18).

Due to the fact that in forceps with pelvic curvature the direction of movement of the handles does not coincide with the direction of movement of the spoons, N.A. Tsovyanov suggested next move capture and traction with forceps (Fig. 25.19): II and III bent fingers of both hands of the obstetrician capture from under the handles of the forceps at the level of the Bush hooks their outer and upper surface, and the main phalanges index fingers with 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, nail phalanges are also located on the upper surface of the handles, but opposite tongs spoons. Bent IV and V fingers grab the parallel branches of the forceps extending from the castle from above and move as high as possible, closer to the head. thumbs, being under the handles, should rest against the middle third bottom surface handles. Such capture allows both attraction and abduction of the head into the sacral cavity at the same time. All moments of the operation of applying forceps according to Tsovyanov are performed while standing.

When using the generally accepted method of applying obstetric forceps during traction, the doctor sits on a chair (rarely standing), feet are pressed to the floor (you can not rest against any object), and elbows are against 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 the head is pulled with forceps, the doctor seeks to imitate natural attempts. These drives should coincide in time with the attempts of the woman in labor, if she is not under anesthesia. The force of attraction, insignificant in the first seconds, gradually increases, is brought to a maximum and does not decrease for about 20-30 seconds, then it gradually decreases and by the end of the attempt completely weakens. The duration of each drive is 2-3 minutes. Between each two adjacent drives there is a break of 1 - 1.5 minutes. At this time, the doctor relaxes the hands squeezing the handle in order to open the forceps somewhat and thereby reduce the almost unavoidable compression of the fetal head with forceps spoons and restore intracerebral circulation of the fetus Rest is also necessary for a woman in labor in order to relax the tension of the perineum and restore the correct blood circulation in it, which is disturbed during traction. Finally, the doctor also needs rest, since attraction is tiring. physical activity. After rest, the attraction is repeated again, alternating it with a short respite.

During drives, neither rotational, nor rocking, nor pendulum-like movements, nor jerky drives are allowed. It should be remembered that tongs are a drawing tool; traction should be performed smoothly and only in one direction.

The direction of the drives depends on the height of the head. This is best determined by the direction of the forceps handle: the higher the head is in the pelvis, the steeper the handles are turned backwards.

At the weekend, the forceps handles are placed horizontally and traction is done anteriorly (upward) in order for extension and birth of the head to occur.

With cavity (typical) forceps, the handles are located horizontally. The doctor must produce attraction to himself - horizontally. At the same time, the head moves with a small fontanelle along the wire axis of the pelvis, making the same movements in the forceps as when independently following the birth canal. The attraction is produced horizontally until the suboccipital fossa appears from under the pubic arch. After that, the drives are given an upward direction so that the extension of the head occurs. To do this, the doctor gets up from the chair and stands on the side of the woman in labor. Grabbing the handles of the forceps with one hand, he draws them anteriorly, protecting the perineum from tearing with the entire palmar surface of the second hand. In this state, the parietal puffs, crown and forehead are carefully removed from the genital slit (Fig. 25.20). When a large segment of the head is installed in the genital gap, the doctor can remove the head from it either in forceps without removing them, or with his hands, having previously removed the forceps. When the fetal head erupts, a mid-lateral episiotomy is indicated to ensure the removal of the head and avoid rupture of the rectal sphincter. The direction of traction, as a rule, is determined in relation to a standing woman: towards the sacrum - backwards, towards the legs - down, towards the stomach anteriorly. , to the stomach - up.

What force must be expended when extracting the fetal head with forceps? The strength of traction should be commensurate with the forces of the obstetrician and the available resistance. In this regard, the strength of the average person is usually sufficient. The force of the forceps on the fetal head is composed of traction, compression by the forceps and the resistance of maternal tissues. The force of traction when applying forceps is approximately 30 kg, and it is transmitted to the base of the skull.

Rice. 25.20.

Rice. 25.21. Opening of forceps.

The fourth moment is the removal of forceps. Forceps are usually removed after removing the head. If the forceps are removed when the head begins to erupt, it must be held to avoid rapid eruption and rupture of the perineum. First, they take the handles in their hands and open the lock; the right spoon is taken out first, and the handle must go the opposite way compared to its introduction, the second one takes the left spoon (Fig. 25.21).

The birth of the shoulders and trunk of the fetus usually does not cause difficulties. Cavity (typical) forceps with posterior occipital presentation. Posterior occipital presentation is a variant of the normal mechanism of labor, so it is necessary to remove the fetal head in the posterior view (Fig. 25.22; 25.23).

The operation consists of four steps.

The first point is the introduction and placement of the spoons. Forceps are applied in the transverse size of the pelvis so that the spoons lie on the head of the fetus biparietally.

The second point is the closure and trial traction. When the forceps are closed, their handles should be lowered somewhat, trying to capture the head in accordance with its large size. However, this is not always possible, since there is an obstacle from the perineum. Due to its insufficient flexion, the head can be captured in the suboccipital-chin, and more often in the vertical size. Many obstetricians recommend using straight forceps (Lazarevich-Kielland) for posterior occiput presentation. You should make sure that the cervix is ​​not trapped. Then a trial run is carried out.

The third point is traction. When extracting, one should strive to imitate the natural mechanism of childbirth; do traction on yourself almost horizontally until the area of ​​​​the large fontanelle fits under the bosom. If by the beginning of the operation the head is already fixed in the region of the large fontanel under the pubis (exit forceps), it is necessary to carefully traction anteriorly in order to bring the occiput above the perineum - maximum flexion of the head. In this case, it is necessary to ensure that the head is well captured and the forceps do not slip, as this threatens with significant injury to the perineum and vagina. A mid-lateral episiotomy should be performed.

Rice. 25.22.

Rice. 25.23. Removal of the head in forceps with posterior occipital presentation

After removing the nape of the fetus, the obstetrician lowers the handles of the forceps and removes the forehead, face and chin of the fetus from under the pubis.

If the head is located in the narrow part of the pelvic cavity (typical forceps) with an arrow-shaped suture in a straight size and an occipital one facing backwards, traction is done downwards until the large fontanel is fixed under the pubis (maximum flexion of the head), and then the handles of the forceps are lowered backwards and at the same time removed from under the pubis the forehead, face and chin of the fetus (extension of the head). The extension of the head is most often carried out by manual techniques after removing the spoons of the tongs. A mid-lateral episiotomy must first be performed.

The fourth moment is the removal of forceps. Forceps remove pos / 16 opening the lock.

Exit forceps for posterior face presentation. The operation of applying forceps in posterior facial presentation presents great difficulties and poses a risk of damage to the vagina and perineum, as well as trauma to the fetus. The operation can be performed if the head is on the pelvic floor, the front line is in a straight size, the chin is forward.

Rice. 25.24..

An ideal grip of the head, according to its large oblique size, is impossible, since there is no place under the pubis for closing the handles. The head is captured vertical dimension(Fig. 25.24). When introducing and noting the spoons, it is important to remember that the forceps are not applied to the face, but to the skull through the face, and therefore it is necessary to raise the handles forward, since the main part of the head lies in the recess of the sacrum. After closing the forceps, traction is done downward to bring the chin out from under the pubis, then the handles of the forceps are raised anteriorly and the forehead, parietal tubercles and occiput are brought above the perineum.

Cavity forceps (atypical).

Abdominal forceps are applied to the head, standing in a wide part of the pelvic cavity (station + 1). Due to the fact that the internal rotation of the head has not been completed, with occiput presentation, the sagittal suture may be in one of the oblique dimensions or in the transverse dimension of the pelvis.

With atypical forceps, in the process of removing the head, the internal rotation of the head by 45 ° and even by 90 ° is also completed. As a result, the operation of applying cavity forceps is much more difficult than typical ones. Some foreign authors recommend preliminary correction of the position of the fetal head with forceps or manual techniques, which is very traumatic for both the mother and the fetus and is not always possible. The forceps should be applied without first correcting the position of the fetal head and, after applying the forceps, remove the head. During attraction (traction), one should not consciously promote those turns that the head must make according to the mechanism of childbirth.

Cavity, atypical forceps in occipital presentation, first position, anterior view. Forceps must be applied in the biparietal size of the head, i.e. perpendicular to the right oblique dimension of the pelvic cavity in its left oblique dimension.

The first point is the introduction and placement of the spoons. With the left hand, the genital gap is bred and four fingers of the right hand are inserted into the vagina. With three fingers of the left hand, they take the left branch of the forceps by the handle and raise the handle slightly to the right and anteriorly parallel to the right inguinal fold, and the top of the forceps spoon is inserted into the vagina between the hand and the head in the posterolateral part of the pelvis so that the spoon lies on the head in the region of the left parietal buff. The handle of the forceps is passed to the assistant, reminding him of the importance of maintaining the position of the branch. The right spoon should lie on the head in the area of ​​\u200b\u200bthe right parietal tubercle, but it is not possible to enter it immediately, as this is prevented by the pubic arch; this obstacle is circumvented by the so-called movement ("wandering") of the spoon. With the right hand, the genital slit is bred and along right wall vagina enter four fingers of the left hand. The handle of the forceps is taken into the right hand and placed in the direction of the left inguinal fold, a spoon is inserted between the left hand and the head along the right wall of the vagina. In order for the forceps to close, the spoons must lie on diametrically opposite points of the head; the right spoon is moved anteriorly, gently pressing the second finger of the left hand on its lower rib until the spoon lies on the head in the region of the right parietal tubercle; the handle is slightly shifted backwards and clockwise. This movement of spoons is called spiral.

The second point is the closing of the forceps and trial traction. When the forceps lie on the head biparietally and, therefore, are in the left oblique size of the pelvic cavity, the forceps are closed and a trial traction is performed.

The third point is traction. Traction is first done obliquely posteriorly, then down and anteriorly. At the same time, making traction backwards down, feeling the rotation of the head, it is necessary to promote this movement. In the first position, the front view is a small fontanel, i.e. the back of the head, will rotate counterclockwise - to the right and anteriorly by 45 °. When the turn is completed, the small fontanel will be palpable under the pubis, and the sagittal suture will be in the direct size of the exit from the small pelvis. Then they make traction downwards until the occipital protuberance comes out from under the pubis, and then anteriorly - extension of the head; the point of fixation is the region of the suboccipital fossa. The obstetrician removes the head in forceps, standing to the right of the woman in labor, and protects the perineum with his right hand.

The fourth moment is the removal of forceps. It is made only after removing the head and opening the spoons. The removal of the forceps is carried out in the reverse order: the right spoon is removed first, while the handle is retracted to the left inguinal fold, then the left one - its handle is retracted to the right inguinal fold. After the birth of the child, attention is paid to the traces of spoons: if they are correctly located, the traces wrap around the child's ears.

Abdominal (atypical) forceps in occipital presentation, second position, anterior view. Forceps must be applied biparietally, i.e. perpendicular to the left oblique dimension of the pelvic cavity in the right oblique dimension of the head.

The first point is the introduction and placement of the spoons. First enter the left spoon into the left half of the pelvis. Due to the fact that the sagittal suture is in the left oblique dimension, it is necessary to move the left spoon anteriorly, towards the pubis. Holding the handle of the forceps with the left hand, with the right hand, gently pressing on the lower rib, move the left spoon ("wandering") anteriorly and to the right (to the left anterolateral pelvis) until it lies on the left parietal tubercle of the fetal head; at the same time, with the left hand, the handle is turned backwards and in a spiral - counterclockwise. The right spoon is inserted (under the control of the left hand) into the right posterolateral part of the pelvis so that it lies on the right parietal tubercle of the fetal head.

The second point is the closing of the forceps and trial traction. The right handle of the forceps should be in front of the left, otherwise the forceps will not close. When applying the forceps in the right oblique size of the pelvis, they close well, after which a test traction is made.

The third point is traction. Traction is done obliquely backwards and down. When the head begins to descend, the head turns in the forceps with a small fontanel anteriorly and to the left, i.e. clockwise by 45°. When the turn is made, the small fontanel is palpated under the pubis, and the sagittal suture is located in the direct size of the pelvis. Next, downward traction is performed (i.e., on the face of a doctor sitting in front of a woman in labor) until the occipital protuberance comes out from under the pubis, and then anteriorly - extension of the head with a fixation point in the suboccipital fossa. Standing to the right of the woman in labor, the obstetrician carefully removes the head in forceps with his right hand, protecting the perineum.

The fourth moment is the removal of forceps. Conducted as usual.

Abdominal (atypical) forceps in occipital presentation, first position, posterior view. Since the sagittal suture is in the left oblique dimension, the forceps must be applied in the right oblique dimension of the pelvis so that they are located along the large oblique dimension and grasp the head biparietally.

The left spoon is introduced first and is "wandering". The right spoon is inserted into the right posterolateral pelvis ("stationary"). Produce forceps closure and trial traction and make sure that the forceps are applied correctly.

Traction is carried out obliquely posteriorly and somewhat downward. In this case, the small fontanelle turns the head posteriorly by 45 ° clockwise; very rarely, the small fontanel rotates anteriorly (by 135 ° counterclockwise; in these cases, it is necessary to shift the forceps spoons accordingly). When the sagittal suture turns to the direct size of the exit from the pelvis and is located posteriorly, and the large fontanelle (or the front edge of the scalp) is fixed under the pubis, the forceps handles are raised anteriorly and the back of the head is brought out above the perineum, producing additional flexion of the head. Then, the handles of the forceps are lowered somewhat backwards in order to extend the head around the fixation point (in the region of the suboccipital fossa) and bring out the forehead and chin.

Remove the forceps in the usual way.

Abdominal (atypical) forceps in occipital presentation, second position, posterior view. In order to capture the head biparietally, it is necessary to apply forceps in the left oblique size of the pelvis. The technique for inserting the forceps is similar to that in the anterior view of the occipital presentation of the first position. The left spoon is stationary and is located in the left posterolateral part of the pelvis, the right one is "wandering" and is located in the right anterolateral part of the pelvis. Tractions are performed, as with abdominal forceps in the posterior view of the occipital presentation, the first position. The small fontanelle rotates posteriorly by 45° counterclockwise. If the small fontanel rotates anteriorly 135 ° clockwise, then in these cases it is necessary to shift the forceps spoons.

Traction and removal of obstetric forceps is carried out in the same way as when using atypical forceps.

Sometimes obstetric forceps have to be applied at a low transverse position of the swept suture. In this case, the following features must be taken into account. Since, due to the presence of pelvic curvature, the Simpson-Fenomenov forceps cannot be applied in the direct size of the pelvis, the only possible in such cases is the atypical imposition of forceps - in one of the oblique sizes of the pelvis.

At the first position, forceps are applied in the left oblique size of the pelvis. The left spoon is introduced first - into the left posterolateral pelvis, and the right one - into the right anterolateral pelvis ("wandering"). Both spoons are located in the left oblique size of the pelvis, opposite each other, and clasp the rear parietal tubercle behind and to the left; the tops of the spoons are facing the chin, and the leading point (small fontanel) is facing the castle.

During the attraction, the heads, together with the forceps, make a 90 ° counterclockwise turn, which ends with the transition of the sagittal suture to the direct size of the exit plane of the small pelvis and the establishment of a small fontanel anteriorly. After that, the forceps are removed and reapplied, but already typically - in the transverse size of the pelvis.

In the future, the operation is performed in the same way as in the anterior view of the occipital presentation.

In the second position, the left spoon is inserted into the left anterolateral pelvis ("wandering"), and the right one into the right posterolateral pelvis (stationary). At the same time, spoons are placed in the right oblique size of the pelvis, with the right spoon wrapping around the parietal, and the left - frontal tubercle. In the future, the operation is performed in the same way as in the first position of the low transverse standing of the swept seam.

Anterior presentation often serves as a kind of manifestation of clinical inconsistency in a transversely narrowed pelvis, and therefore delivery by caesarean section is correct. If, due to various circumstances, they decide to apply obstetric forceps, then the spoons are usually placed according to the vertical size of the head, and not according to the large oblique size.

Tractions are performed carefully on yourself until the bridge of the nose is fixed under the pubis. Then the head is flexed by traction anteriorly until the occipital region is born above the perineum; after that, the handles of the forceps are lowered backwards and the face and chin are removed from under the pubis.

The lock is opened and the spoons are removed only after the head is removed.

After the operation of applying abdominal obstetric forceps, especially if the operation was difficult, are shown manual separation and the allocation of the placenta and the control examination of the walls of the postpartum uterus to determine its integrity.

In all cases, after the application of obstetric forceps, an examination of the cervix and vagina with the help of mirrors is shown, and if their integrity is violated, suturing is necessary. To prevent bleeding in the afterbirth and early postpartum periods, it is necessary intravenous administration uterotonic agents (1 ml of a 0.02% solution of methylergometrine, 5 IU of oxytocin).