[Effects of assisted labor on the fetal vascular system. IV. Comparative observation between the use of obstetrical forceps and obstetrical vacuum extraction].
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A multiple lineage is proposed for the invention of the obstetric forceps. Having been conceived by a member of the Chamberlen family in fifteenth- or seventeenth-century England, the instrument seems to have been reinvented in Flanders by Jan Palfyn and in Holland by Rogier Roonhuyse. Later, Roonhuyse invented a more effective instrument for coping with the impacted head: the obstetric lever. Palfyn's "Iron Hands" inspired Dussé to produce the "French" forceps which bears his name.
A prospective evaluation of 140 forceps deliveries with the Hay's flexion rotation obstetric forceps was undertaken over a 5-year period. The Hay's forceps was used for a variety of indications and included outlet forceps application in 35.7%, low or midforceps application in 29.3% with forceps rotation in 16.4%, 19.3% of applications for an aftercoming head and 19.3% applications at caesarean section. Outlet forceps deliveries had maternal and neonatal outcomes comparable with the Wrigley's short obstetric forceps. Midforceps applications were compared to the Simpson's long forceps, with maternal morbidity at 21% being significantly less, blade marks being the only neonatal morbidity and the Apgar scores being significantly higher with the Hay's forceps. Every forceps application at caesarean section resulted in an easy delivery. Thus the Hay's forceps with innovations such as parallelism and flexion potential could revalidate the role of the forceps in contemporary obstetrics.
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Obstetric forceps pressure strong enough to leave a periorbital depression and corneal injury would probably be severe enough to leave an occipital depression from the opposite forceps blade. The presence of a depression at the correct occipital position would support the diagnosis of forceps injury when the birth history is unknown and the cornea has decompensated enough to make observation of the Descemet's membrane scrolls difficult. We studied six patients with known or suspected obstetric forceps injury to the cornea. Complete ocular examinations included examination for periorbital forceps depressions and posterior skull depressions 180 degrees from the affected cornea (which correlates with the opposite blade of the forceps). All of the patients with Descemet's scrolls had posterior skull depressions. This method of palpation for a contralateral skull depression may assist in the diagnosis of forceps-induced corneal decompensation.
A new obstetric forceps is presented which has been used since April 1975 in 52 cases for outlet forceps deliveries. The model is a divergent forceps with the rotational axis in the posterior 1/3. The forceps is applied as usual. The shanks do not cross. The distance between the blades is variable by a mechanism in the handle with an automatic stopping mechanism. Pressure on the fetal head is largely avoided. Our experience has shown that this forceps has advantages over the types of forceps in common usage.
Details of the design of obstetric forceps are important to ensure that they can be used safely for mother and baby. One of the most important measurements is the radius of the cephalic curve of the blades since if this is inappropriate there will be a poor grip on the baby's head and risk of slippage, superficial injury or even intracranial haemorrhage and brain damage because of undue compression. Because of the complex design of the forceps blades, which have a pelvic curve as well as a cephalic curve and a fenestra, the radius of the cephalic curve is difficult to measure. A device was designed to facilitate this measurement and was found to be accurate and reliable in use. This was the first stage in the study to assess the suitability for modern practice of instruments designed many years ago.
OBJECTIVE: Our purpose was to determine the efficacy of the obstetric forceps versus the M-cup, a new vacuum extractor cup, and maternal-neonatal complication rates. STUDY DESIGN: Over a 10-month period operative vaginal deliveries were randomized between the obstetric forceps and the M-cup vacuum extractor cup. Maternal demographics, indication for intervention, analgesia, position, station, degree of asynclitism, fetal caput-molding, and time from application to delivery were prospectively recorded. Episiotomy and extensions, lacerations, and the reason for abandonment of the randomized instrument were noted in both groups. Fetal weight, Apgar scores, cord arterial gases, hyperbilirubinemia, phototherapy, and any evidence of fetal trauma were documented at delivery or in the nursery. RESULTS: Six hundred thirty-seven women were randomized, 315 in the forceps group and 322 in the M-cup group. There were no differences in maternal demographic variables. The station, position, degree of asynclitism, or requirement for rotation was not different between the groups. The corrected efficacy rates were forceps 92% and M-cup 94% (p = 0.217). The M-cup deliveries were accomplished more rapidly than forceps deliveries (p < 0.001) and were associated with a lower rate of episiotomy (p < 0.001), third-degree (p < 0.001) and fourth-degree (p = 0.002) lacerations, but blood loss as clinically estimated (p = 0.232) or as measured by hemoglobin levels (p = 0.166) was not significantly different. Forceps deliveries were associated with fewer clinically diagnosed cephalhematomas (p = 0.015) than M-cup deliveries were, but there were no differences in the number of neonates diagnosed with hyperbilirubinemia (p = 0.377) or in the number of infants treated with phototherapy (p = 0.660). CONCLUSIONS: The M-cup vacuum extractor cup appears to be as efficient (and faster) than the obstetric forceps but is associated with significantly more fetal cephalhematomas, whereas maternal injuries are more common with the forceps.
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In April, 1983, a questionnaire was sent to all 144 United States and Canadian members of the Association of Professors of Gynecology and Obstetrics to survey residency training and current use of obstetric forceps in 1981. One hundred five programs (73%), responsible for at least 283,000 births in 1981, were subsequently analyzed. All training programs used outlet forceps and all programs but one used midforceps for delivery. Hospitals with high cesarean birth rates did not perform significantly fewer midforceps operations. Hospitals with high midforceps rates did not also have high outlet forceps rates nor did these high rates closely reflect the personal attitude to obstetric forceps of the director of the obstetric training program. Simpson's forceps were most commonly used for outlet forceps and occipitoanterior midforceps operations, whereas Kielland's forceps were selected by 76% of programs for rotational midcavity deliveries. Staff obstetricians were the primary instructors of forceps technique in the delivery room in only 50% of United States programs; all Canadian respondents reported the staff obstetrician as the principal educator in obstetric residency forceps training.
The design and use of a divergent obstetrical forceps, which was developed at the Staatliche Frauenklinik und Hebammenschule in Bamberg by Sipli and Krone are presented. The major advantage associated with the use of this instrument is that it permits the exertion of a limited constant application force (max 300 g) on the fetal head. Thus, compression injuries are effectively prevented and slippage of the forceps with resultant trauma is precluded. The Bamberg forceps was evaluated at the Frauenklinik und Poliklinik der Technischen Universität München and at the Staatliche Frauenklinik und Hebammenschule Bamberg, Federal Republic of Germany. An evaluation of 483 cases where this forceps was used is presented. No serious complications directly attributable to the use of this instrument could be documented.
The assisted vaginal delivery methods of rigid obstetric forceps and polyethylene vacuum cup extraction were compared in a prospective, randomized study. The 99 women studied had all completed 35 full weeks' gestation, required attempted assisted vaginal delivery, and were randomly assigned to either attempted forceps or vacuum-assisted delivery. All presentations were cephalic, with stations ranging from +1 to +4. Neonates were evaluated at 24 hours by neonatal staff. The infants underwent intracranial ultrasound screening during the first 24 hours of life and ophthalmologic examination within 48 hours. Vaginal delivery was successful with the intended method in 83% of vacuum-assisted deliveries and in 78% of forceps deliveries (not statistically significant). Neonatal retinal hemorrhage was found in 17 and 38% (P less than .043) of the randomized forceps and vacuum deliveries, respectively. No intraventricular hemorrhage was found. Apart from associations between vacuum-assisted delivery and mild hyperbilirubinemia and neonatal retinal hemorrhage (of uncertain clinical significance), and between assisted forceps delivery and an increased potential for facial injury, neonatal outcomes did not differ significantly. Maternal outcomes also did not differ significantly. No significant differences in safety or efficacy were found between polyethylene cup vacuum extraction and rigid obstetric forceps-assisted vaginal delivery in this population of predominantly low-pelvic assisted deliveries. Patients delivered by sequential use of forceps after vacuum or by vacuum after failed forceps application did not suffer significantly increased morbidity relative to those delivered by forceps or vacuum alone. Use of alternate or sequential methods allowed an overall cesarean rate of 3% in this population.
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Johan Gottfried Erichsen (1713-68), born in Germany and chief medical officer in Bergen from 1747, was probably the first to perform a forceps delivery in Norway, on 14 February 1748. The mother, who had been in labour for five days, survived; the child, however, did not. The obstetric forceps had been a secret in the Chamberlen family and had become more widely known only a few decades earlier. Erichsen, who was the first man-midwife in Norway, had learned obstetrics in Paris by the younger Grégoire. He mastered both the techniques of internal version and forceps delivery. This article describes Erichsen's medical and obstetric background and his qualifications for operative obstetrics. He worked in the period when the obstetric forceps changed obstetrics, birth delivery became an arena also for men, and a part of medicine. Obstetrics was established as a science and physicians had a tool whereby also children could be saved during complicated delivery.
A total of 166 pairs of obstetric forceps of three different types in regular use in two major obstetric units was measured and compared with manufacturers' master instruments and drawings. As well as linear measurements of blade, shank and handle the distances between the tips and maximum distance between the blades, and the mean radius of the cephalic curve were determined. The purpose of the study was to assess the suitability of instruments in common use for present day practice. It was found that the measurements differed significantly from the original descriptions and there were wide variations between instruments of the same type, even when supplied by the same manufacturer. In some cases the blades had not been packed in matching pairs in the Central Sterile Supplies Department. It is suggested that critical reappraisal of the forceps in current use in many obstetric units is overdue. As well as a need for reconsidering the type of forceps used the dimensions of individual pairs should be checked.
The use of the standard obstetric forceps has been associated with varying degrees of maternal and fetal trauma. To reduce the degree of skin markings, a pliable polyurethane pad with selfadherent backing has been designed, which can be applied to each blade of the forceps. One hundred five neonates who required forceps-assisted deliveries were observed for evidence of skin trauma immediately after delivery and again at 24 hours. Padded forceps significantly reduced craniofacial visible skin markings when compared with the skin markings produced by the unpadded forceps. The addition of the pad to the forceps blade had no adverse effect on the mother, and obstetricians encountered no problems in the application and use of the pads.
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