The operation of applying obstetric forceps. Cavity obstetric forceps, indications, conditions, technique, complications Conditions for applying obstetric forceps

The name itself will surely evoke associations with the distant Middle Ages for most readers. In a sense, they will be right: obstetrical forceps were invented at the end of the sixteenth century. At that time it was a real advance in obstetrics. Caesarean section was practically not used then, and if some healer undertook such a dangerous operation, it was only for the sake of saving the life of the child - the woman in labor did not have a single chance. Forceps helped the baby to be born, facilitated too difficult childbirth and saved the life of the mother.

The sight of this instrument will certainly not cause much confidence among the uninitiated: the third millennium and - some kind of tongs! In fact, this “outdated” and “backward” instrument, albeit in rare cases, is still indispensable. Of course, medical science and practice have risen to cosmic heights compared to the 17th century. Many methods quickly become obsolete, something is improved, something is abandoned altogether. But the imposition of forceps is used in the generic practice of experienced obstetricians in all countries of the world to this day. Over the past three centuries, their design and indications for use have changed significantly, and the benefits disproportionately outweigh the risk of complications.

Application conditions

Receiving the application of obstetric forceps is possible only in the second stage of labor with the full opening of the cervix, when the fetal head is in the pelvic cavity or at the exit from it.

The operation of applying obstetrical forceps is quite painful: the born head of the fetus will be large due to the spoons of forceps applied to it, therefore, it requires mandatory anesthesia. Most often, short-term intravenous anesthesia is given, but if a woman is giving birth under epidural anesthesia, the anesthesiologist simply injects an additional amount of the pain medication used.

The use of forceps is often accompanied by an episiotomy - an operation to cut the perineum to expand the birth canal. This will prevent the formation of deep tears in the woman in labor.

The capture of the baby's head is carried out only when it is already almost at the exit from the female pelvis, which further increases the safety of the procedure. The shape of the tool is maximally adapted to gently and safely for the fetus, but securely grab the head of the newborn. With the help of practiced professional movements (the so-called traction) an experienced obstetrician helps a newborn baby to pass through the birth canal. In addition, a sterile towel is usually placed between the handles of the forceps, which reduces the risk of excessive squeezing of the fetal head to almost zero. We repeat that this procedure is used only in case of serious difficulties in the natural passage of the child or the need to complete the birth process as soon as possible and it is impossible to use other methods of childbirth. However, the baby's head should correspond to the average size of the head of a full-term fetus. Obstetricians formulate this condition a little differently: it should not be too large or too small. This is due to the size of the forceps, which are designed for the average size of the head of a full-term fetus. The use of obstetric forceps without taking this condition into account can lead to too much injury for the baby and mother.

Forceps become a very dangerous tool even with a narrow pelvis, so their use is contraindicated. The operation of applying obstetric forceps is carried out only if all of the above conditions are present.

Mechanism of action

The purpose of the forceps is to tightly grasp the head of the fetus and replace the expelling force of the uterus and abdominals with the pulling force of the doctor. The process of "pulling out" the baby can not be called violent: traction are applied almost effortlessly, no artificial turns or any displacement of the fetal head are made. The movements of the obstetrician diligently copy the movements of the head and shoulders of the child, which he would produce in the process of natural childbirth.

In the process traction the doctor can also perform rotational movements, but only following the natural movement of the fetal head. In this case, the doctor does not prevent the head from turning, but, on the contrary, contributes to them.

Indications for use

There are several indications for this procedure. Firstly, the state of health of the woman in labor, which requires the maximum shortening of the period of expulsion of the fetus, the exclusion of attempts and stress of the woman in labor: diseases of the cardiovascular and broncho-pulmonary systems, kidneys, heart failure, very severe late toxicosis. Secondly, obstetric forceps are superimposed with weak attempts or weakness of labor activity. In this case, the fetal head stays in the same plane of the pelvis for more than 2 hours, which can lead to excessive fatigue of the woman in labor and very serious obstetric complications. In the second stage of labor, the fetal head passes through a rather narrow bone ring - the pelvic cavity. Difficulty in moving the fetal head is fraught with unpleasant consequences for both the child and the mother: the pelvic bones squeeze the fetal head, the bones of the skull, in turn, put pressure on the soft tissues of the woman's birth canal, which leads to various injuries. Therefore, if medications, such as intravenous administration of oxytocin, which causes the uterus to contract, do not help the birth of a child, forceps must be resorted to. Thirdly, bleeding in the second stage of labor, due to premature detachment of a normally located placenta, rupture of the umbilical cord vessels during their shell attachment. Fourth, with acute intrauterine hypoxia (oxygen starvation) of the fetus, when the delay in childbirth will inevitably lead to the death of the child and the count goes literally for minutes (with a short umbilical cord, its entanglement around the child's neck).

Preparation and conduct of the operation

Based on the well-known truth “forewarned is forearmed”, and, I would add, “calm down”, I will try to describe in detail what awaits you during the preparation for the operation and its implementation.

Preparation for the operation of applying obstetric forceps includes several points: choosing the method of anesthesia, preparing the woman in labor, examining the vagina and determining the position of the fetus, checking the forceps.

During the operation of applying obstetric forceps, the woman in labor lies on her back, with her legs bent at the hips and knees. The bladder must be emptied before the operation. The external genitalia and inner thighs are treated with a disinfectant solution.

We repeat once again that due to the fact that when removing the fetal head with forceps, the risk of perineal rupture increases, the application of obstetric forceps is combined with an episiotomy. When introducing spoons, the obstetrician grabs the forceps handle in a special way: a special type of grip avoids the application of force when it is introduced.

The left spoon of tongs is introduced first. Standing, the doctor inserts four fingers of the right hand into the vagina into the left half of the pelvis, separating the fetal head from the soft tissues of the birth canal. The thumb remains outside. Taking the left spoon with the left hand, the handle is taken to the right side, setting it almost parallel to the right inguinal fold. Then, carefully, without any effort, the spoon is advanced between the palm and the head of the fetus deep into the birth canal. In this case, the trajectory of movement of the end of the handle, as it were, describes an arc. The advancement of the entire branch into the depths of the birth canal is carried out practically due to the instrument's own gravity. The hand located in the birth canal is a guide hand and controls the correct direction and location of the branch. With its help, the obstetrician makes sure that the top of the spoon does not go into the vault, onto the side wall of the vagina and does not capture the edge of the cervix. Further, under the control of the left hand, the obstetrician introduces the right branch with the right hand into the right half of the pelvis in the same way as the left one.

Spoons capture the baby's head in the widest place in such a way that the parietal tubercles are in the windows of the forceps spoons, and the line of forceps handles faces the leading point of the fetal head. traction they try to carry out simultaneously with contractions, thus strengthening the natural expelling forces.

Possible Complications

We emphasize once again that timely and correctly applied forceps do not have a negative impact on the health of a woman and a child.

Complications in the baby. Most often, the consequences of using obstetric forceps are expressed in reddish loop-shaped traces that remain on the head and face of the baby. Usually these marks disappear within the first month without any medical intervention. Due to too much pressure of the forceps spoons on the presenting part of the fetus, hematomas may occur, damage to the skin or facial nerve may occur. In exceptional cases, infants have eye injuries, damage to the brachial plexus (manifested by a “dangling” handle in a child). The use of forceps can also cause damage to the uterus, bladder, or sciatic nerve roots.

Mom's complications. These include possible ruptures of the vagina and perineum, less often - the cervix. Severe complications can be ruptures of the lower segment of the uterus and damage to the pelvic organs: the bladder and rectum. But such things can happen only if the conditions for the operation and the rules of its technique are violated, which is basically impossible in modern maternity hospitals.

But still!...

Of course, the application of obstetric forceps is an unpleasant procedure, it, like, in fact, any operation, has dangerous moments. I assure women that just like that, with a "preventive" purpose, no one will resort to this procedure. It is produced only when absolutely necessary, when there is no other way out and it is really about saving the baby's life. But if you happen to experience on your own experience the methods of ancient obstetrics in modern conditions - do not panic, but perceive it simply as a conscious necessity that helps your long-awaited baby see the light.

Obstetric forceps were invented by the Scottish physician William Chamberlain in 1569.For many years, this instrument remained a family secret, passed down only by inheritance: the doctor's family and his descendants made considerable wealth from this invention. As happened with many scientific discoveries, after 125 years, in 1723, obstetric forceps were again "invented" by the Dutch surgeon I. Palfin. These were already more enlightened times, so the surgeon immediately published his invention and submitted it for testing to the Paris Academy of Sciences, for which he was rewarded: the priority in the invention of obstetric forceps belongs to him. Although it is believed that these forceps are less perfect than Chamberlain's instrument. In Russia, obstetric forceps were first used in 1765 in Moscow by Professor of Moscow University I.F. Erasmus. However, the merit of introducing this operation into everyday practice belongs to another outstanding doctor, the founder of Russian scientific obstetrics, Nestor Maksimovich Maksimovich-Ambodik. He described his personal experience in the book The Art of Weaving, or the Science of Womanhood, published in 1786. According to his drawings, the Russian "instrumental" master Vasily Kozhenkov in 1782 made the first models of obstetric forceps in Russia. Later, domestic obstetricians Anton Yakovlevich Krassovsky, Ivan Petrovich Lazarevich and Nikolai Nikolaevich Fenomenov made a great contribution to the development of the theory and practice of the operation of applying obstetric forceps.

Obstetric forceps - 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 A. shch. 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 A. shch. Simpson 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 removal. The compression of the head, which is inevitable during the application of forceps, should be minimal, in any case not exceed that observed in childbirth with the natural configuration of the head. Otherwise, the bones, vessels and nerves of the fetal head will inevitably suffer. A. sh. are only an exciting and enticing tool, but by no means correcting incorrect presentations and insertions 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 fetal asphyxia, 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 the following scheme for determining the location of the head. 1. The head stands above the entrance to the small pelvis (Fig. 1), easily moves with a push, returning back (balloting). Forceps are contraindicated. 2. The head entered the pelvis as a small segment (Fig. 2). Its largest circumference (biparietal diameter) is located above the entrance to the pelvis. The cervical-occipital sulcus stands three transverse fingers above the symphysis; the head is limitedly mobile, slightly fixed. During vaginal examination, the cape is accessible to the examining finger; swept seam - in the transverse or slightly oblique size of the pelvis. Forceps cannot be applied either. 3. Head at the entrance to the pelvis with a large segment (Fig. 3); with a biparietal diameter, it passed the entrance to the pelvis, motionless; the cervical-occipital sulcus stands two fingers above the symphysis. With a vaginal examination, the cape cannot be reached; the head is occupied in front - the 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. The wire point almost reaches the line of the 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. With vaginal examination, the ischial spines are achievable, the sacral cavity is almost completed, the promontory cannot be reached. The wire point almost reaches the spinal line, the sagittal suture is in an oblique size. III and IV sacral vertebrae and coccyx are freely palpable. 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. The head comes close to the 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. The 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).

Indications for forceps can be both from the side of the mother and from the side of the fetus (although this division is conditional).

Mother's testimony:

Severe diseases of the cardiovascular 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 umbilical cord loops 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 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:

a live fetus

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. The attraction for membranes can cause premature detachment of the 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;

emptied bladder.

Contraindications to the imposition of obstetric forceps:

- dead fetus

- incomplete opening of the uterine os;

- 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 woman in labor is placed in a position for vaginal operations (the legs are 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, octenisept, 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 capture the head along the large oblique dimension and biparietal, so that the wire point of the head is in the middle of the spoons of the forceps.

Third rule. The direction of traction corresponds to the wire line of the pelvis. In this case, the direction is determined in relation to the standing woman: down - means to the kidneys, to the front - to the stomach, backwards - towards the back.

36. Exit obstetric forceps in the posterior view of the occipital presentation. Indications, conditions for applying forceps. Anesthesia.

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.

Obstetric forceps are one of the oldest instruments for obstetrics, designed to extract a live full-term fetus by the head.

Obstetric forceps were invented in Scotland at the end of the 16th century, and began to be used in Russia starting in 1765.

The design of obstetrical forceps has not changed since their invention, they are two metal spoon-shaped branches connected in a lock in a special way.

Forceps are used for weak labor, when the woman in labor is not able to push the fetus out on her own, while the condition of the child or mother requires the fastest possible completion. Also, with the help of obstetric forceps, the obstetrician can turn the fetus head down, which is located in the gluteal, to facilitate the process of childbirth.

The benefits and dangers of tongs

There are a number of indications for the use of forceps when the fetus or mother is in serious danger, so most often the application of forceps exceeds the risk of possible complications.

However, the imposition of forceps - which can be accompanied by serious complications. For the mother, they consist in damage to the birth canal: ruptures of the vagina and perineum. In severe cases, these can be ruptures of the cervix and lower segment of the uterus, damage to the bladder and rectum.

There may also be a number of complications for the fetus, primarily swelling and cyanosis on the soft tissues of the head, hematomas with strong compression of the forceps, paresis of the facial nerve. The most severe complications are damage to the bones of the child's skull.

The use of obstetric forceps is not the only possible cause of complications, but it significantly increases their risk.

Correct and timely application of forceps usually does not lead to serious complications. They are used when the cervix is ​​fully dilated and the widest part of the baby's head is under the pubic bone in the woman's pelvis. In addition, when using them, anesthesia is necessary, most often it is a short-term intravenous anesthesia, which also facilitates the course of childbirth.

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

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

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

CLASSIFICATION

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

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

INDICATIONS

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

CONTRAINDICATIONS

Relative contraindications - prematurity and large fetus.

CONDITIONS FOR THE OPERATION

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

PREPARATION FOR OPERATION

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

PAIN RELIEF METHODS

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

OPERATIONAL TECHNIQUE

General surgical technique

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

Rules for the introduction of spoons

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

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

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

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

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

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

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

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

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

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

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

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

Typical obstetrical forceps

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

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

In the posterior view of the occipital presentation, traction is carried out first horizontally until the first fixation point is formed (the front edge of the large fontanel is the lower edge of the pubic joint), and then anteriorly until the suboccipital fossa is fixed at the top of the coccyx (the second fixation point) and the handles of the forceps are lowered backwards, resulting in extension heads and the birth of the forehead, face and chin of the fetus.

Cavity Obstetric Forceps

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

COMPLICATIONS

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

FEATURES OF THE POSTOPERATIVE PERIOD

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

Obstetric forceps- 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 outer side of the forceps, near the lock, there are protrusions, Bush hooks, which, when the forceps are folded, 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 of 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: stillbirth; hydrocephalus or microcephaly; anatomically (II - III degree of 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; pelvic presentation of the 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.

Difficulties and complications when applying forceps and extracting the fetus:

1. Difficulty inserting spoons due to the narrowness of the entrance to the vagina. It is necessary to perform an episiotomy before applying spoons.

2. Difficulty in introducing spoons due to obstruction in the pelvic cavity. It is necessary to stop the introduction of spoons, remove them, conduct a study to clarify the correct place for introducing the instrument.

3. Inability to close the forceps, as they are applied in the wrong plane. To correct it, you can change the position of the wandering spoon under the control of the hand; if the reception fails, then the forceps must be removed and reapplied.

4. Sliding of forceps, which is associated with the imposition of spoons without capturing the parietal tubercles. The forceps must be removed and reapplied.

5. Inability to remove the head due to a significant narrowing of the exit from the pelvic cavity. If this circumstance, being a contraindication, was underestimated before the operation, then it is necessary to remove the forceps and proceed to the fruit-destroying operation.

Complications after applying obstetric forceps:

1. For the mother: damage to the soft birth canal; rupture of the pubic joint; damage to the roots of the 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 of the facial nerve, damage to the eyes; 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.

Depending on the location of the fetal head in the small pelvis, there are:

1. high tongs- superimposed on the head, standing above the entrance to the small pelvis, a small or large segment at the entrance to the small pelvis.

2. cavity forceps(medium, atypical) - superimposed on the head, located in the cavity of the small pelvis and not completed the internal rotation.

3. exit forceps(low, typical) - superimposed on the head, located on the pelvic floor and rotated, the sagittal suture is in direct size.

Three triple rules for applying obstetric forceps:

1. About the sequence of insertion of forceps spoons:

ü 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;

ü 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:

ü the tops of the spoons of tongs should be turned towards the wire point;

ü forceps should capture the parietal tubercles of the fetus;

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

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

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

ü 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 spoon tongs. 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. When closing properly applied forceps, it is not always possible to bring the handles closer together, this depends on the size of the fetal head, which is often more than 8 cm (the largest distance between the spoons in the area of ​​​​the head curvature). In such cases, a sterile diaper folded 2-4 times is inserted between the handles. This prevents excessive compression of the head and a good fit of spoons to it. If the spoons are not arranged symmetrically and a certain force is required to close them, it means that the spoons are placed incorrectly, they must be removed and applied again.

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

4. Actually traction for extraction of the fetus. After a trial traction, after making sure that the forceps are correctly applied, they begin their own traction. To do this, the index and ring fingers of the right hand are placed on top of the Bush hooks, the middle one is between the divergent branches of the tongs, the thumb and little finger cover the handle on the sides. The left hand grabs the end of the handle from below. When extracting the head with forceps, it is necessary to take into account the nature, strength and direction of traction. Traction of the fetal head with forceps should mimic natural contractions. For this you should:

ü 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;

ü while producing traction, do not develop excessive force, 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;

ü 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;

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

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

The direction of traction depends on which part of the pelvis the head is located in and what moments of the biomechanism of labor must be reproduced when removing the head with forceps (see triple rules).

5. Removing forceps. The fetal head can be brought out with forceps or by manual means after removal of the forceps, which is carried out after the eruption of the largest circumference of the head. To remove the 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. You can remove the head without removing the forceps as follows. The obstetrician stands to the left of the woman in labor, grabs the forceps with her right hand in the area of ​​​​the castle; the left hand is placed on the crotch to protect it. Traction directs more and more anteriorly as the head is extended and erupted through the vulvar ring. When the head is completely removed from the birth canal, open the lock and remove the forceps.