History

Fact Explanation
Breech presentation [1] Forceps are used for delivery of the head at assisted breech delivery (singleton or twin) [1]
Face presentation [1] Indication for forcep delivery (Assisted delivery with a face presentation) [1]
Delay or maternal exhaustion in the second stage of labour / prolong second stage of labour [2] Indication for instrumental delivery [2] The advantages of metal-cup vacuum extraction over soft-cup extraction include a higher success rate and easier cup placement in the occipitoposterior (OP) position, especially when an OP cup is used. Compared with metal-cup devices, soft-cup vacuum extractors cause fewer neonatal scalp injuries. However, these instruments have a higher failure rate [2]
Severe hypertension, heart failure [1] Instrumental deliveries are indicated when maternal effort is contraindicated [2]
Caesarean section [1] Forceps are used for Controlled delivery of head at caesarean section [1]
References
  1. PATEL RR, MURPHY DJ. Forceps delivery in modern obstetric practice BMJ [online] 2004 May 29, 328(7451):1302-1305 [viewed 28 August 2014] Available from: doi:10.1136/bmj.328.7451.1302
  2. PUTTA LV, SPENCER JP. Assisted vaginal delivery using the vacuum extractor. Am Fam Physician [online] 2000 Sep 15, 62(6):1316-20 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11011860

Examination

Fact Explanation
Breech presentation, face presentation (mento-anterior) [1] Forcep deliveries are indicated [1]
Full dilatation of the Cervix and membranes ruptured. Engagement of the Fetal Head [2] pre-requisites for Instrumental Vaginal Delivery [2] Mid forceps (Neville-Barnes are used when the baby's head is engaged, but is sitting higher than station +2 (or 2 centimetres below the ischial spines of the pelvis). Low forceps are the ones most commonly used today. The baby's head is below station +2, which is fairly low in the vaginal canal. Simpson's forceps are the most common type of low forceps used. Outlet forceps are used when the baby's head can be easily seen at the opening of the woman's vagina, but the baby's head is not emerging any further. Wrigley's forceps are commonly used for this. Rotational forceps (such as Kielland's) have straighter handles that are capable of having some 'slip' instead of locking together. They are used to turn the baby into a more favourable anterior position, and then traction is used with the same forceps to deliver the baby. [1]
Fetal heart rate [1] Instrumental deliveries are indicated in fetal distress (fetal tachycardia or bradycardia) [1]
References
  1. PATEL RR, MURPHY DJ. Forceps delivery in modern obstetric practice BMJ [online] 2004 May 29, 328(7451):1302-1305 [viewed 28 August 2014] Available from: doi:10.1136/bmj.328.7451.1302
  2. PUTTA LV, SPENCER JP. Assisted vaginal delivery using the vacuum extractor. Am Fam Physician [online] 2000 Sep 15, 62(6):1316-20 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11011860

Differential Diagnoses

Fact Explanation
Cephalopelvic Disproportion [1] can give rise to prolong labour.(large baby / small pelvis) Contra indicated for instrumental delivery. diagnosed by pelvimetric measurements [1]
References
  1. DRENNAN KATHRYN J., BLACKWELL SEAN, SOKOL ROBERT J.. Abnormal Labor: Diagnosis and Management. GLOWM [online] 2009 December [viewed 28 August 2014] Available from: doi:10.3843/GLOWM.10132

Investigations - for Diagnosis

Fact Explanation
Vaginal examination [1] Obstetric pre-requisites for Instrumental Vaginal Delivery are: Full dilatation of the Cervix and membranes ruptured. Engagement of the Fetal Head [1]
References
  1. PATEL RR, MURPHY DJ. Forceps delivery in modern obstetric practice BMJ [online] 2004 May 29, 328(7451):1302-1305 [viewed 28 August 2014] Available from: doi:10.1136/bmj.328.7451.1302

Investigations - Fitness for Management

Fact Explanation
Blood pressure [1] Instrumental deliveries are indicated in severe high blood pressure where maternal effort is contraindicated. [1]
Echocardiogram [1] To detect the ejection fraction. Instrumental deliveries are indicated in heart failure where maternal effort is contraindicated. [1]
References
  1. PATEL RR, MURPHY DJ. Forceps delivery in modern obstetric practice BMJ [online] 2004 May 29, 328(7451):1302-1305 [viewed 28 August 2014] Available from: doi:10.1136/bmj.328.7451.1302

Investigations - Followup

Fact Explanation
Neonatal examination [1] Subgaleal hemorrhage is a serious neonatal complication of vacuum extraction. This complication occurred in 1.0 to 3.8 percent of vacuum extractions in one series but has been much less common in more recent studies. Infants with subgaleal hemorrhage present with a boggy scalp, swelling crossing the suture lines and an expanding head circumference. They may also have signs of hypovolemia, pallor, tachycardia and a falling hematocrit. Cephalohematoma is another fetal complication of vacuum extraction. This complication has a mean incidence of 6 percent (range: 1 to 26 percent) in vacuum-assisted deliveries. [1]
References
  1. PUTTA LV, SPENCER JP. Assisted vaginal delivery using the vacuum extractor. Am Fam Physician [online] 2000 Sep 15, 62(6):1316-20 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11011860

Investigations - Screening/Staging

Fact Explanation
Partogram [1] To screen for prolong second stage of labour. Prolonged second stage - Nullipara - >2 h (>3 h) Multipara - >1 h (>2 h) [1]
cardiotocography [2] To screen for fetal distress. Non-reassuring patterns seen on cardiotocography: increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and after a contraction decreased variability in the fetal heart rate late decelerations [2]
References
  1. DRENNAN KATHRYN J., BLACKWELL SEAN, SOKOL ROBERT J.. Abnormal Labor: Diagnosis and Management. GLOWM [online] 2009 December [viewed 28 August 2014] Available from: doi:10.3843/GLOWM.10132
  2. Fetal Distress Can Med Assoc J [online] 1960 May 28, 82(22):1128-1129 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1938151

Management - General Measures

Fact Explanation
Analgesics [1] In the immediate post partum period forceps have been associated with increased perineal and vaginal trauma and a greater requirement for analgesia.[1]
References
  1. PATEL RR, MURPHY DJ. Forceps delivery in modern obstetric practice BMJ [online] 2004 May 29, 328(7451):1302-1305 [viewed 28 August 2014] Available from: doi:10.1136/bmj.328.7451.1302

Management - Specific Treatments

Fact Explanation
looking for neonatal and maternal complications [1] - Fetal complications a. Shoulder dystocia and consequences The need to perform an instrumental delivery for lack of progress in the presence of anticipated macrosomia should alert the clinician to the increased likelihood of shoulder dystocia. b. Subaponeurotic/subgaleal haemorrhage A potentially life threatening complication, occurring in approximately 1 in 300 cases of vacuum delivery. c. Facial nerve palsy, corneal abrasion, retinal haemorrhage Facial nerve palsy and corneal abrasion are more common with forceps and retinal haemorrhage with vacuum delivery. d. Skull fracture and/or intracranial haemorrhage e. Cervical spine injury A consequence of rotational forceps delivery may be minimised by ensuring uterine relaxation prior to performing the rotation. rigidity of metal cups can make application difficult and uncomfortable, and their use is associated with an increased risk of fetal scalp injuries than soft cups. -Maternal complications Pelvic trauma (more in forcep deliveries than vacuum deliveries). Suturing of tears. [1]
References
  1. PATEL RR, MURPHY DJ. Forceps delivery in modern obstetric practice BMJ [online] 2004 May 29, 328(7451):1302-1305 [viewed 28 August 2014] Available from: doi:10.1136/bmj.328.7451.1302