Childbirth with forceps and a vacuum extractor. Obstetric forceps. Indications, conditions, contraindications

1. Small medical encyclopedia. - M.: Medical encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. encyclopedic Dictionary medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

OPERATION OF APPLYING OBSTETRIC FORCEPS

Obstetric forceps called an instrument designed to extract a live, full-term fetus by the head.

Application of obstetric forcepsis a delivery operation in which a live, full-term fetus is removed through the natural birth canal using obstetric forceps.

Obstetric forceps were invented by the Scottish physician Peter Chamberlain (died 1631) at the end of the 16th century. For many years, obstetric forceps remained a family secret, passed down from generation to generation, as they were the object of profit for the inventor and his descendants. The secret was later sold for a very high price. 125 years later (1723), obstetric forceps were “reinvented” by the Geneva anatomist and surgeon I. Palfin (France) and immediately made public, so priority in the invention of obstetric forceps rightfully belongs to him. The tool and its application quickly became widespread. In Russia, obstetric forceps were first used in 1765 in Moscow by Moscow University professor I.F. Erasmus. However, the credit for introducing this operation into everyday practice inherently belongs to the founder of Russian scientific obstetrics, Nestor Maksimovich Maksimovich (Ambodik, 1744-1812). He outlined his personal experience in the book “The Art of Weaving, or the Science of Women’s Business” (1784-1786). According to his drawings, instrumental maker Vasily Kozhenkov (1782) made the first models of obstetric forceps in Russia. Subsequently, domestic obstetricians Anton Yakovlevich Krassovsky, Ivan Petrovich Lazarevich, Nikolai Nikolaevich Fenomenov made a great contribution to the development of the theory and practice of the operation of applying obstetric forceps.

DEVICE OF OBSTETRIC FORCEPS

Obstetric forceps consist of two symmetrical parts - branches, which may have differences in the structure of the left and right parts of the castle. One of the branches, which is grabbed with the left hand and inserted into the left half of the pelvis is called left branch. Another branch - right.

Each branch has three parts: spoon, lock element, handle .

Spoon is a curved plate with a wide cutout - window. The rounded edges of spoons are calledribs(top and bottom). The spoon has special shape, which is dictated by the shape and size of both the fetal head and the pelvis. The spoons of obstetric forceps do not have a pelvic curvature (straight Lazarevitz forceps). Some models of forceps also have a perineal curvature in the area where the spoons and handles connect (Kieland, Piper).Head curvature - this is the curvature of the spoons in the frontal plane of the forceps, reproducing the shape of the fetal head. Pelvic curvature - this is the curvature of the spoons in the sagittal plane of the forceps, corresponding in shape to the sacral cavity and to a certain extent to the wire axis of the pelvis.

Lock serves to connect the branches of the forceps. The design of the locks is not the same in different models of tongs. Distinctive characteristic is the degree of mobility of the branches connected by it:

Russian tongs (Lazarevich) - the lock is freely movable;

English tongs (Smellie) - the lock is moderately movable;

German tongs (Naegele) - the lock is almost motionless;

-French tongs (Levret) - the lock is motionless.

Lever serves for gripping the forceps and producingtractions. It has smooth internal surfaces, and therefore, when the branches are closed, they fit tightly to each other. The outer surfaces of the parts of the forceps handle have a corrugated surface, which prevents the surgeon’s hands from slipping when performing traction. The handle is made hollow to reduce the weight of the tool. At the top of the outer surface of the handle there are side projections calledbush hooks. When performing traction, they provide reliable support for the surgeon’s hand. In addition, Bush hooks allow us to judge whether correct application obstetric forceps, if, when closing the branches of the hook, they are not located opposite each other. However, their symmetrical arrangement cannot be a criterion for the correct application of obstetric forceps. The plane in which the Bush hooks are located after inserting the spoons and closing the lock corresponds to the size in which the spoons themselves are located (transverse or one from the oblique dimensions of the pelvis).

In Russia, forceps are most often used Simpson-Fenomenov. N.N. Fenomenov made an important change to the Simpson design, making the lock more movable. The mass of this model of forceps is about 500 g. The distance between the most distant points of the head curvature of the spoons when closing the forceps is 8 cm, the distance between the tops of the spoons is 2.5 cm.

MECHANISM OF ACTION

The mechanism of action of obstetric forceps includes two moments of mechanical effect (compression and attraction). The purpose of the forceps is to tightly grasp the fetal head and replace the expelling force of the uterus and abdominal press with the attracting force of the doctor. Hence, obstetric forceps are only attractive instrument, but not a rotary or compression one. However, the known compression of the head during its extraction is nevertheless difficult to avoid, but this is a disadvantage of the forceps, and not their purpose. There is no doubt that during the process of traction, obstetric forceps perform rotational movements, but exclusively following the movement of the fetal head, without disturbing the natural mechanism of childbirth. Therefore, in the process of removing the head, the doctor should not interfere with the rotations that the fetal head will make, but, on the contrary, facilitate them. Forced rotational movements with forceps are unacceptable, since incorrect positions of the head in the pelvis are not created without reason. They arise either due to anomalies in the structure of the pelvis, or due to the special structure of the head. These causes are persistent, anatomical and cannot be eliminated by the use of obstetric forceps. The point is not at all that the head does not turn, but that there are conditions that exclude both the possibility and the necessity of turning at a given time. Forcible correction of the position of the head in this situation inevitably leads to to birth trauma of mother and fetus.

INDICATIONS

Indications for the operation of applying obstetric forceps arise in situations where conservative continuation of labor is impossible due to the danger of serious complications for both the mother and the fetus, up to fatal outcome. During the period of exile, under appropriate conditions, these situations can be completely or partially eliminated operative delivery by applying obstetric forceps. Indications for surgery can be divided into two groups: indications from the mother and indications from the fetus. And indications from the mother can be divided into indications related to pregnancy and childbirth (obstetric indications) and indications related to extragenital diseases of the woman, requiring “switching off” attempts (somatic indications). A combination of the two is often observed.

Indications for the operation of applying obstetric forceps are as follows:

-Indications from the mother:

- obstetric indications:

severe forms of gestosis (preeclampsia, eclampsia, severe hypertension, refractory to conservative therapy) require the exclusion of pushing and straining of the woman in labor;
persistent weakness of labor and/or weakness of pushing, manifested by standing of the fetal head in one plane of the pelvis for more than 2 hours, in the absence of effect from the use of medications. Prolonged standing of the head in one plane of the small pelvis leads to an increased risk of birth trauma for both the fetus (a combination of mechanical and hypoxic factors) and the mother (genitourinary and intestinal-genital fistulas);
bleeding in the second stage of labor, caused by premature detachment of a normally located placenta, rupture of the umbilical cord vessels during their membrane attachment;
endometritis during childbirth.

Somatic indications:

diseases of the cardiovascular system in the stage of decompensation;
breathing disorders due to lung disease;
high myopia;
acute infectious diseases;
severe forms of neuropsychiatric disorders;
intoxication or poisoning.
-Indications from the fetus:

fetal hypoxia, developing as a result various reasons in the second stage of labor (premature abruption of a normally located placenta, weakness of labor, late gestosis, short umbilical cord, entanglement of the umbilical cord around the neck, etc.).
The application of obstetric forceps may be required for women in labor who have had childbirth the day before surgical intervention on the abdominal organs (the inability of the abdominal muscles to provide full pushing).

Once again, I would like to emphasize that in most cases there is a combination of the listed indications that require emergency termination of labor. Indications for the operation of applying obstetric forceps are not specific to this operation; they may also be an indication for other delivery operations (caesarean section, vacuum extraction of the fetus). The choice of delivery operation fully depends on the presence of certain conditions that allow a specific operation to be performed, therefore, in each case, their careful assessment is necessary to the right choice method of delivery.

To perform the operation of applying obstetric forceps, certain conditions are necessary to ensure the most favorable outcome for both the woman in labor and the fetus. If one of these conditions is not present, then surgery is contraindicated.



-Live fruit. Obstetric forceps are contraindicated in the presence of a dead fetus. In case of fetal death and there are indications for emergency delivery, fetal destruction operations are performed.

-Full opening of the uterine os. Failure to comply with this condition will inevitably lead to rupture of the cervix and lower segment of the uterus.

-Absence of amniotic sac. If the amniotic sac is intact, it should be opened.

-The fetal head should correspond to the average size of the head of a full-term fetus. Obstetricians formulate this condition somewhat differently: the fetal head should not be too large or too small. An increase in this parameter occurs with hydrocephalus, a large or giant fetus. Decreased in a premature fetus. This is due to the size of the forceps, which are calculated for the average size of the head of a full-term fetus. The use of obstetric forceps without taking this condition into account becomes traumatic for the fetus and the mother.

-Correspondence between the sizes of the mother's pelvis and the fetal head. With a narrow pelvis, forceps are a very dangerous instrument, so their use is contraindicated.

-The fetal head should be located at the outlet of the small pelvis with a sagittal suture in a straight dimension or in the pelvic cavity with a sagittal suture in one of the oblique dimensions. Precise definition position of the fetal head in the pelvis is possible only with a vaginal examination, which must be performed before applying obstetric forceps.

Depending on the position of the head, there are:

Exit forceps (Forceps minor) - typical . Outlets are called forceps applied to the head, which stands as a large segment in the plane of the outlet of the small pelvis (on the pelvic floor), while the sagittal suture is located in a straight dimension.

Abdominal obstetric forceps (Forceps major) - atypical. Cavity forceps are called forceps applied to the head located in the pelvic cavity (in its wide or narrow part), while the arrow-shaped suture is located in one of the oblique dimensions.

High obstetric forceps ((Forceps alta)placed on the fetal head, which stood as a large segment at the entrance to the pelvis. Application of high forceps was technically difficult and dangerous operation, often leading to severe birth trauma mother and fetus. Currently not used.

The operation of applying obstetric forceps can be performed only if all of the above conditions are present. An obstetrician, when starting to apply obstetric forceps, must have a clear understanding of the biomechanism of childbirth, which will have to be artificially imitated. It is necessary to clearly understand which moments of the biomechanism of labor the fetal head has already completed, and which it will have to accomplish during traction.

PREPARATION FOR OPERATION

Preparation for the operation of applying obstetric forceps includes several points (choosing a method of anesthesia, preparing the woman in labor, preparing the obstetrician, vaginal examination, checking the forceps).

Choosing a pain relief method determined by the woman’s condition and indications for surgery. In cases where the woman's active participation in childbirth seems appropriate (weakness of labor and/or intrauterine fetal hypoxia in a somatically healthy woman), the operation can be performed using long-term epidural anesthesia (DPA), pudendal anesthesia or inhalation of nitrous oxide with oxygen. However, when applying abdominal obstetric forceps in somatically healthy women, it is advisable to use anesthesia, since applying spoons to the head located in the pelvic cavity is a difficult moment of the operation, requiring the elimination of resistance of the pelvic floor muscles.

In women in labor for whom pushing is contraindicated, the operation is performed under anesthesia. At initial arterial hypertension The use of anesthesia with nitrous oxide and oxygen with the addition of fluorothane vapor in a concentration not exceeding 1.5 vol.% is indicated. Ftorotan inhalation is stopped when the fetal head is removed to the parietal tubercles. In a woman in labor with initial arterial hypo- and normotension, anesthesia with seduxen in combination with ketalar at a dose of 1 mg/kg is indicated.

Anesthesia should not be terminated after removing the child, since even with exit forceps, the operation of applying obstetric forceps is always accompanied by a control manual examination of the walls of the uterine cavity.

The operation of applying obstetric forceps is carried out in the position of the woman in labor on her back, with her legs bent at the knee and hip joints. Before surgery, the bladder must be emptied. The external genitalia and inner thighs are treated with a disinfectant solution. Obstetricians treat their hands as for surgical operations.

Immediately before applying forceps, it is necessary to carry out a thorough vaginal examination (half-handed) in order to confirm the presence of conditions for the operation and determine the location of the head in relation to the planes of the pelvis. Depending on the position of the head, it is determined which type of operation will be used (abdominal or exit obstetric forceps). Due to the fact that when removing the fetal head using forceps, the risk of perineal rupture increases, the application of obstetric forceps should be combined with episiotomy.

OPERATIONAL TECHNIQUE

The technique of applying obstetric forceps includes the following points.

Insertion of spoons

When inserting spoons of obstetric forceps, the doctor should follow the first "triple" rule (rule of three “lefts” and three “rights”): left spoon left inserted by hand into left side of the pelvis, similarly, right spoon right hand in right side of the pelvis. The handle of the tongs is grabbed in a special way: by type writing pen(at the end of the handle opposite thumb place the index finger and middle fingers) or by type bow(opposite the thumb along the handle there are four others widely spaced). Special view gripping the spoons with forceps allows you to avoid the application of force during its insertion.

The left spoon of the forceps is inserted 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 it with your left hand left branch forceps, the handle is retracted into right side, placing it almost parallel to the right groin 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 abducted thumb. Then, carefully, without any effort, the spoon is moved between the palm and the fetal head deep into the birth canal, placing the lower edge between the third and fourth fingers of the right hand and resting on the bent thumb. In this case, the trajectory of movement of the end of the handle should be an arc. Advancement of the spoon into the depths of the birth canal should be accomplished due to the instrument’s own gravity and by pushing the lower edge of the spoon with 1 right finger hands. The half-arm, located in the birth canal, is a guide hand and controls the correct direction and position of the spoon. With its help, the obstetrician makes sure that the top of the spoon is not directed into the fornix, onto the side wall of the vagina and does not capture the edge of the cervix. After inserting the left spoon, it is handed over to the assistant to avoid displacement. Next, 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.

Correctly applied spoons are located on the fetal head according to "second" triple rule . The length of the spoons is on the fetal head along a large oblique size (diameter mento-occipitalis) from the back of the head to the chin; the spoons grasp the head in the greatest transverse dimension in such a way that the parietal tubercles are located in the windows of the spoons of the forceps; the line of the forceps handles faces the leading point of the fetal head.

Closing the forceps

To close the pliers, each handle is grabbed with the same hand so that the first fingers of the hands are located on the Bush hooks. After this, the handles are brought together and the tongs are easily closed. Correctly applied forceps lie across the sagittal suture, which occupies a mid-position between the spoons. The lock elements and bush hooks should be located at the same level. When closing correctly applied forceps, it is not always possible to bring the handles together; this depends on the size of the fetal head, which is often more than 8 cm (the greatest distance between the spoons in the area of ​​the cephalic curvature). In such cases, a sterile diaper folded 2-4 times is placed between the handles. This prevents excessive compression of the head and a good fit of the spoons to it. If the spoons are not symmetrically positioned and a certain force is required to close them, it means that the spoons are not applied correctly, they need to be removed and reapplied.

Test traction

This necessary moment allows you to ensure that the forceps are applied correctly and that there is no risk of them slipping. It requires a special positioning of the obstetrician's hands. To do this, the doctor covers the handles of the forceps from above with his right hand so that the index and middle fingers lie on the hooks. He places his left hand on the back surface of his right, and the extended middle finger should touch the fetal head in the area of ​​the leading point. If the forceps are positioned correctly on the fetal head, then during test traction the fingertip will always be in contact with the fetal head. 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.

Traction proper (extraction of the head)

After trial traction, making sure that the forceps are applied correctly, 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 diverging branches of the forceps, the thumb and little finger cover the handle on the sides. With your left hand, grab the end of the handle from below. There are other ways to grab the forceps: by Tsovyanov, attraction to Osiander(Osiander).

When removing 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 imitate natural contractions. To do this you should:

Imitate a contraction by force: start tractions not sharply, but with a weak pull, gradually strengthening them and weakening them again towards the end of the contraction;

When performing traction, do not develop excessive force by tilting your torso back or resting your foot on the edge of the table. The obstetrician's elbows 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 minutes. After 4-5 tractions, the forceps are opened for 1-2 minutes to reduce the pressure on the head;

Try to perform traction simultaneously with contractions, thus strengthening the natural expulsion forces. If the operation is performed without anesthesia, the woman in labor must be forced to push during traction.

Rocking, rotating, pendulum-like movements are unacceptable. It should be remembered that forceps are a drag tool; traction should be performed smoothly in one direction.

The direction of traction depends on in which part of the pelvis the head is located and what aspects of the biomechanism of labor need to be reproduced when removing the head with forceps. The direction of traction is determined third "triple" rule - it is fully applicable when applying forceps to the head located in the wide part of the pelvic cavity (cavitary forceps);

The first direction of traction (from the wide part of the pelvic cavity to the narrow) - down and back , according to the wire axis of the pelvis*;

The second direction of traction (from the narrow part of the pelvic cavity to the outlet) - downwards and anteriorly ;

- third direction of traction (extraction of the head in forceps) - anteriorly .

*Attention! The direction of traction is indicated relative to an upright woman.

Removing the forceps

The fetal head can be removed using forceps or manually after removing the forceps, which is carried out after cutting through the largest circumference of the head. To remove the tongs, take each handle with the same hand, open the spoons and remove them in the reverse order: first - 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 and grabs the forceps with his right hand in the lock area; The left hand is placed on the perineum to protect it. Traction is directed more and more anteriorly as the head extends and cuts through the vulvar ring. When the head is completely removed from the birth canal, open the lock and remove the forceps.

DIFFICULTIES ARISING WHEN APPLYING OBSTETRIC FORCEPS

Difficulties in inserting spoons may be associated with the narrowness of the vagina and rigidity of the pelvic floor, which requires dissection of the perineum. If it is not possible to insert the guide hand deeply enough, then in such cases the hand must be inserted somewhat posteriorly, closer to the sacral cavity. In the same direction, insert the spoon of forceps in order to position the spoon in the transverse dimension of the pelvis, it must be moved using a guide hand, acting on posterior rib spoon inserted. Sometimes the spoon of the forceps encounters an obstacle and does not move deeper, which may be due to the top of the spoon getting into the fold of the vagina or (which is more dangerous) into its fornix. The spoon must be removed and then reinserted with careful control of the fingers of the guide hand.

Difficulties may also occur when closing the forceps. The lock will not close if the spoons of the tongs are not placed on the head in the same plane or one spoon is inserted higher than the other. In this situation, it is necessary to insert your hand into the vagina and correct the position of the spoons. Sometimes, when the lock is closed, the handles of the forceps diverge greatly; this may be due to insufficient depth of insertion of the spoons, poor coverage of the head in an unfavorable direction, or excessive size of the head. In case of insufficient insertion depth spoons, their tops put pressure on the head and when you try to squeeze the spoons, severe damage to the fetus can occur, including a fracture of the skull bones. Difficulties in closing the spoons also arise in cases where the forceps are applied not transversely, but in an oblique and even fronto-occipital direction. Incorrect position of the spoons is associated with errors in diagnosing the location of the head in the small pelvis and the location of the sutures and fontanelles on the head, so repeated vaginal examination and insertion of spoons is necessary.

Lack of head advancement during traction may depend on their incorrect direction. Traction should always correspond to the direction of the wire axis of the pelvis and the biomechanism of childbirth.

With traction it can happen slipping of the forceps - vertical(through the head outwards) or horizontal(forward or backward). The reasons for the forceps slipping are improper grip of the head, improper closure of the forceps, and inappropriate sizes of the fetal head. Slipping of the forceps is dangerous due to the occurrence of serious damage to the birth canal: ruptures of the perineum, vagina, clitoris, rectum, bladder. Therefore, at the first signs of the forceps slipping (increasing the distance between the lock and the fetal head, divergence of the forceps handles), it is necessary to stop traction and remove the forceps and apply them again if there are no contraindications for this.

OUTPUT OBSTETRIC FORCEPS

Anterior view of occipital presentation. The internal rotation of the head is completed. The fetal head is located on the pelvic floor. The sagittal suture is located in the direct dimension of the pelvic outlet, the small fontanel is located in front of the womb, the sacral cavity is completely filled with the fetal head, the ischial spines do not reach. The forceps are applied in the transverse dimension of the pelvis. The handles of the tongs are located horizontally. Traction is applied in a downward-posterior direction until the occipital protuberance emerges from under the pubis, then the head is extended and removed.

Posterior view of occipital presentation. The internal rotation of the head is completed. The fetal head is located on the pelvic floor. The sagittal suture is in the direct size of the exit, the small fontanel is located at the coccyx, the posterior corner of the large fontanel is under the pubis; The small fontanel is located below the large one. The forceps are applied in the transverse dimension of the pelvis. Traction is performed in the horizontal direction (downwards) until the anterior edge of the greater fontanelle comes into contact with the lower edge of the symphysis pubis (the first point of fixation). Then traction is performed anteriorly until the area of ​​the suboccipital fossa is fixed at the apex of the coccyx (second point of fixation). After this, the handles of the forceps are lowered posteriorly, the head is extended and the fetus is born from under the pubic symphysis of the forehead, face and chin.

CAVITY OBSTETRIC FORCEPS

The fetal head is located in the pelvic cavity (in its wide or narrow part). The head will have to complete the internal rotation in the forceps and perform extension (in the anterior view of the occipital presentation) or additional flexion and extension (in the posterior view of the occipital presentation). Due to the incompleteness of the internal rotation, the swept seam is in one of the oblique dimensions. Obstetric forceps are applied in the opposite oblique size so that the spoons grasp the head in the area of ​​the parietal tuberosities. Applying forceps obliquely presents certain difficulties. More complex than exit obstetric forceps are traction, which completes the internal rotation of the head by 45° and more, and only then does extension of the head follow.

First position, anterior view of the occipital presentation. The fetal head is in the pelvic cavity, the sagittal suture is in the right oblique size, the small fontanel is located on the left and in front, the large one is on the right and behind, the ischial spines are reached (the fetal head in the wide part of the pelvic cavity) or are reached with difficulty (the fetal head in the narrow parts of the pelvic cavity). In order to the fetal head was grasped biparietally, forceps must be applied in the left oblique direction.

When applying abdominal obstetric forceps, the order of insertion of the spoons is maintained. The left spoon is inserted under the control of the right hand into posterolateral section of the pelvis and is immediately located in the region of the left parietal tubercle of the head. The right spoon should lie on the head on the opposite side, in the anterolateral part of the pelvis, where it cannot be inserted immediately, since this is prevented by the pubic arch. This obstacle is overcome by moving (“wandering”) the spoon. The right spoon is inserted in the usual way into the right half of the pelvis, then, under the control of the left hand inserted into the vagina, the spoon is moved anteriorly until it is positioned in the area of ​​the right parietal tubercle. The spoon is moved by carefully pressing the second finger of the left hand on its lower edge. In this situation, the right spoon is called - "wandering", and the left one - "fixed". Traction is performed downwards and backwards, the head makes an internal rotation, the sagittal suture gradually turns into the straight size of the pelvic outlet. Next, traction is directed first downwards until the occipital protuberance emerges from under the pubis, then forwards until the head is extended.

Second position, anterior view of occipital presentation. The fetal head is in the pelvic cavity, the sagittal suture is in the left oblique size, the small fontanel is located on the right and in front, the large one is on the left and behind, the ischial spines are reached (the fetal head in the wide part of the pelvic cavity) or are reached with difficulty (the fetal head in the narrow parts of the pelvic cavity).In order for the fetal head to be grasped biparietally, the forceps must be applied in the right oblique direction. In this situation, the “wandering” spoon will be the left spoon, which is applied first. Traction is performed, as in the first position, in the anterior view of the occipital presentation.

COMPLICATIONS

The use of obstetric forceps, subject to the conditions and technique, usually does not cause any complications for the mother and fetus. In some cases, this operation may cause complications.

Damage to the birth canal. These include ruptures of the vagina and perineum, less often - the cervix. Severe complications are ruptures of the lower segment of the uterus and damage to the pelvic organs: the bladder and rectum, which usually occur when the conditions for the operation and the rules of technique are violated. Rare complications include damage to the bone birth canal - rupture of the pubic symphysis, damage to the sacrococcygeal joint.

Complications for the fetus. After surgery on the soft tissues of the fetal head, there is usually swelling and cyanosis. With strong compression of the head, hematomas can occur. Strong pressure from a spoon on the facial nerve can cause paresis. Severe complications are damage to the bones of the fetal skull, which can be of varying degrees - from bone depression to fractures. Brain hemorrhages pose a great danger to the life of the fetus.

Postpartum infectious complications. Delivery using obstetric forceps is not the cause of postpartum infectious diseases however, increases the risk of their development, and therefore requires adequate prevention infectious complications V postpartum period.

VACUUM EXTRACTION OF FRUIT

Vacuum extraction of the fruit - a delivery operation in which the fetus is artificially removed through the natural birth canal using a vacuum extractor.

The first attempts to use the power of vacuum to extract a fetus through the vaginal birth canal were made in the middle of the last century. Simpson's invention of the aerotractor dates back to 1849. The first modern model of a vacuum extractor was designed by the Yugoslav obstetrician Finderle in 1954. However, the design of the vacuum extractor proposed in 1956 Maelstrom(Malstrom), is most widely used. In the same year, a model invented by domestic obstetricians was proposed K. V. Chachava And P. D. Vashakidze .

The principle of operation of the device is to create negative pressure between the inner surface of the cups and the fetal head. The main elements of the apparatus for vacuum extraction are: a sealed buffer container and an associated pressure gauge, manual suction to create negative pressure, a set of applicators (in the Maelstrom model - a set of metal cups from 4 to 7 numbers with a diameter of 15 to 80 mm, in the Maelström model - a set of metal cups from 4 to 7 numbers with a diameter of 15 to 80 mm, in E.V. Chachava and P.D. Vashakidze - rubber cap). In modern obstetrics, vacuum extraction of the fetus has extremely limited use due to adverse consequences for the fetus. Vacuum extraction is used only in cases where there are no conditions for performing other delivery operations.

Unlike the operation of applying obstetric forceps, vacuum extraction of the fetus requires the active participation of the woman in labor during traction of the fetus by the head, so the list of indications is very limited.

INDICATIONS

weakness of labor, with ineffective conservative therapy;
the onset of fetal hypoxia.
CONTRAINDICATIONS

diseases that require “switching off” pushing (severe forms of gestosis, decompensated heart defects, high myopia, hypertonic disease), since during vacuum extraction of the fetus active pushing activity of the woman in labor is required;
discrepancy between the sizes of the fetal head and the mother’s pelvis;
extension presentation of the fetal head;
fetal prematurity (less than 36 weeks).
The last two contraindications are associated with the peculiarity of the physical action of the vacuum extractor, so placing the cups on the head of a premature fetus or in the area of ​​the large fontanel is fraught with serious complications.

CONDITIONS FOR THE OPERATION

- Live fruit.

Complete opening of the uterine os.

Absence of amniotic sac.

Correspondence between the sizes of the mother's pelvis and the fetal head.

The fetal head should be in the pelvic cavity with a large segment at the entrance to the small pelvis.

-Occipital insert .

OPERATIONAL TECHNIQUE

The technique of vacuum extraction of the fetus consists of the following points:

Inserting the cup and placing it on the head

The vacuum extractor cup can be inserted in two ways: under hand control or under vision control (using mirrors). Most often in practice, the cup is inserted under hand control. To do this, under the control of the left guide hand, the cup is inserted into the vagina with the lateral surface in the direct size of the pelvis with the right hand. Then it is turned and the working surface is pressed against the fetal head, as close as possible to the small fontanelle.

Creating negative pressure

The cup is attached to the apparatus and a negative pressure of up to 0.7-0.8 amt is created within 3-4 minutes. (500 mmHg).

Attraction of the fetus by the head

Tractions are performed synchronously with pushing in the direction corresponding to the biomechanism of childbirth. During the pauses between attempts, attraction is not produced. A mandatory step is to perform a test traction.

Removing the cup

When cutting through the vulvar ring of the parietal tubercles, the calyx is removed by breaking the seal in the apparatus, after which the head is removed manually.

COMPLICATIONS

Most a common complication is the slipping of the cup from the fetal head, which occurs when the tightness in the apparatus is broken. Cephalohematomas often occur on the fetal head, and brain symptoms are observed.

OBSTETRIC FORCEPS (forceps obstetricia) - 1) an operation of artificial extraction of a live full-term or almost full-term fetus by the head (rarely by the buttocks) in case of urgent need to complete the second stage of labor using a special instrument - obstetric forceps; 2) obstetric instrument. The design of obstetric forceps and their various models - see Obstetric and gynecological instruments.

The first description of obstetric forceps was made in the second edition of Heister's manual of surgery (L. Heister, 1683-1758), published in Holmstedt in 1724. (see Obstetrics). The purpose of obstetric forceps is to replace the expelling force of the uterus and abdominal press of a woman in labor with the attracting force of the doctor. Obstetric forceps are only a retraction instrument, not a rotational or compression instrument. The known compression of the head, inevitable when applying obstetric forceps, should be minimal.

More or less compression of the head depends on whether the obstetric forceps are applied correctly and whether the direction of the drive corresponds to the mechanism of fetal birth. Excessive compression of the head with obstetric forceps is dangerous for the life of the fetus (fractures of the skull bones, hemorrhage in the brain).

Indications, conditions and contraindications for the operation of applying obstetric forceps. The application of obstetric forceps is indicated in all cases where the mother, the fetus, or both are in danger during the expulsion period, which can be eliminated by immediate removal of the fetus. Indications may include: insufficiency of labor (in case of secondary weakness of labor forces, obstetric forceps should be applied if the expulsion period for primiparous women lasts more than 2 hours, and for multiparous women - more than one hour); severe nephropathy and eclampsia, not eliminated by appropriate conservative treatment; premature placental abruption; diseases of the mother without stable compensation or remission (endocarditis, heart defects, hypertension, nephritis, pneumonia, tuberculosis and others); febrile state of a woman in labor with high temperature, fetal hypoxia. Certain conditions are required to apply obstetric forceps. The dimensions of the pelvis must be sufficient for the passage of the head removed with forceps. Forceps can only be applied when the external pharynx of the cervix is ​​fully dilated (the insertion of spoons and especially the removal of the head when the pharynx is not fully dilated inevitably leads to rupture of the cervix and lower segment of the uterus).

Before applying obstetric forceps, the obstetrician must clearly understand in which part of the pelvis (cavity or outlet) the fetal head is located and what its position is. The forceps can be applied to the fetal head, standing as a large segment in the cavity (the wide and narrow part of it) or at the pelvic outlet. If the fetal head has descended into the cavity or to the pelvic floor, this is convincing evidence that there is no discrepancy between the sizes of the pelvis and the fetus, except in very rare cases of a funnel pelvis (it is important to measure the planes of pelvic outlet!). Forceps should, as a rule, only be used for cephalic presentations. The head should not be too large (hydrocephalus) or too small (forceps should not be applied to the head of a fetus less than 7 months old), it should have normal density (otherwise the forceps will slip off the head during attraction). The amniotic sac must be ruptured and the membranes tucked behind the largest circumference of the head: the forceps do not hold well on the membranes, and if they do, then the attraction for the membrane will cause premature detachment placenta. The fetus must be alive. If the fetus is dead, then the operation of craniotomy rather than forceps is less traumatic for the mother. Obstetric forceps should not be used if there is a threatening or existing uterine rupture, as well as with a posterior view of the facial presentation (chin posterior).

Preparation for the operation of applying obstetric forceps and pain relief

Before applying obstetric forceps, it is necessary to carry out an internal examination and accurately determine the location of the head, the wire point of the head, navigate the position of the sagittal suture, the degree of opening of the external pharynx of the cervix, etc. When applying obstetric forceps, it is desirable to use inhalation anesthesia (see). When exiting obstetric forceps, you can limit yourself to bilateral anesthesia of the pudendal nerves or intravenous administration epontola. Obstetric forceps are applied with the woman in labor on her back; she should be laid on the operating table or Rakhmanov bed with her legs brought to her stomach, held by assistants; in the absence of the latter, leg holders are used. The bladder is emptied using an elastic catheter. For this purpose, when the presenting part is low, insert 2-3 fingers of the right hand into the vagina between the symphysis and the head, with the back surface to the pubis, spread the fingers slightly and try to carefully insert a catheter into the urethra. A metal catheter should not be inserted, as this may damage the urethra. Thoroughly disinfect the external genitalia, top part inner thighs and tissue in the perineal area.

General principles of applying obstetric forceps with pelvic curvature (the most commonly used is the Fenomenov-Simpson model). When applying forceps, first of all, it is necessary to clearly and accurately know the mechanism of fetal birth and remember three basic rules: 1) the forceps must capture the largest surface of the head, the tops of the spoons of the forceps must extend beyond the parietal tubercles; Failure to comply with this rule may result in the spoons of the tongs slipping; 2) the forceps should be applied so that the tops of their spoons are directed towards the wire point, and the concavity of the pelvic curvature of the instrument is facing the pubis; 3) the tongs must be locked in such a way that the wire point is always in the plane of the head curvature of the instrument, that is, by placing the locking parts of the tongs in the same plane, their handles should be connected so that the spoons grip the proper surface of the head.

Depending on the height of the head, the forceps can be closed: a) directly on the obstetrician (horizontally); b) with the handles raised anteriorly (upwards); c) with the handles lowered backwards. Obstetric forceps can be applied typically and atypically. Typical A. shch. applied to the fetal head, which has completely completed the internal rotation (rotation), to its transverse (biparietal) size and in the transverse size of the pelvis. Such obstetric forceps are also called output forceps, since the head is located at the outlet of the pelvis. With typical obstetric forceps, the head is grasped in the temporoparietal region. With this grip, the above three rules for applying forceps are observed. Obstetric forceps, which have to be applied to the head, which has not yet completed rotation, located in the pelvic cavity (in its narrow or wide part), are called atypical, or cavitary. Atypical obstetric forceps have to be applied: 1) to the head, which has not completely completed the internal rotation (the sagittal suture is located in one of the oblique dimensions of the pelvis); 2) with a low transverse position of the head. When applying atypical obstetric forceps, one general rule should be followed: they must be applied in the oblique size of the pelvis, opposite the sagittal suture or facial line. If the sagittal suture is located in the left oblique dimension, then the spoons of the forceps are located in the right oblique dimension and vice versa. In both cases, the forceps grasp the head in the ear area (perfect capture). When the transverse position of the head is low, obstetric forceps with pelvic curvature are applied according to the general rule: in one of the oblique dimensions where the wire point is deviated - the small (posterior) fontanel. The forceps grasp the parietal tubercle and temporal region. This capture of the head is not perfect, but it manages to meet the requirement that the pelvic curvature of the forceps and the birth canal almost coincide. High forceps are atypical when they grasp and try to remove the fetal head located above or at the entrance to the pelvic cavity. Currently, high obstetric forceps are not used, since this operation is very difficult and traumatic for the mother and fetus. In cases where it is necessary to quickly complete childbirth with this position of the head, they resort to cesarean section (see) or vacuum extraction (see) of the fetus.

Technique for applying obstetric forceps with pelvic curvature (general rules). The technique of applying both typical and atypical obstetric forceps includes the following five points: 1) insertion of spoons; 2) closing the forceps; 3) test traction; 4) traction itself (pulling the head with forceps); 5) removing the forceps. Positive result The operation can only be guaranteed if a thorough study of the purpose, purpose and technique of each of these points is made.

The first moment of the operation. The left spoon is introduced first. When closing the tongs, it must lie under the right one, otherwise closing the tongs will be difficult, since a significant part of the lock (pin, pin, plate) is always on the left spoon. In order not to make a mistake when choosing a spoon, you should make it a rule to fold the forceps before insertion (Fig. 1) in order to clearly see which of the spoons is the left and which is the right. Then the obstetrician spreads the genital slit with his left hand and inserts four fingers of his right hand into the vagina along its left wall.

If the edges of the external os of the cervix are still preserved, then it is necessary to determine the gap between its edges and the head. Next, with the left hand, take (like a writing pen or like a bow) the left branch of the forceps by the handle and lift the handle anteriorly and to the right inguinal fold of the woman in labor so that the top of the spoon of the forceps enters the genital slit according to its longitudinal (antero-posterior) diameter. The lower edge of the spoon rests on the thumb of the right hand. The spoon is inserted into the genital slit, pushing its lower rib with the thumb of the right hand and under the control of the fingers inserted into the vagina (Fig. 2). The spoon should slide between your index and middle fingers. When inserted correctly, the spoon should lie so that the head curvature of the forceps does not capture the edge of the pharynx and fits well to the head; the insertion of the obstetrician's right hand is intended to control the advancement of the spoon. As the spoon moves into the birth canal, the handle of the forceps should approach the midline and descend posteriorly. The spoon must be inserted with great care, easily, smoothly, without any violence. The correct position of the spoon in the pelvis can be judged by the fact that the Bush hook is positioned strictly in the transverse dimension of the pelvic outlet (in the horizontal plane). The inserted left spoon must certainly go beyond the ends of the fingers, therefore, beyond the parietal tubercle, located in the temporo-parietal region of the head. If the spoon is inserted deep enough, the lock is close to the external genitalia. When the left spoon fits well on the head, its handle is handed over to the assistant. The right (second) spoon of the forceps is inserted in the same way as the left one (Fig. 3), with the right hand to the right side under the protection of the fingers of the left hand inserted into the vagina.

The second moment of the operation. To close the pliers, each handle is grabbed with the same hand so that thumbs were located on Bush's hooks. After this, the handles are brought together and the forceps are easily closed (Fig. 4). Correctly applied obstetric forceps tightly grasp the head along its large oblique size (in the direction from the back of the head through the ears to the chin) - biparietally. The sagittal suture occupies a mid-position between the spoons, the curved tops of which are directed anteriorly, the leading point of the head (posterior fontanel) is in the plane of the forceps (Fig. 5). The inner surfaces of the handles of the pliers should be close to each other (or almost close). A sterile napkin folded 2-4 times is placed between the handles; This ensures good alignment of the spoons of the forceps to the head and avoids the possibility of excessive compression in the forceps. Having closed the forceps, you should make a thorough examination to see if they have caught soft fabrics birth canal.

The third moment of the operation. Test traction allows you to once again verify the correct application of the forceps (whether the head follows the forceps). To do this, the obstetrician grabs the handles of the forceps with his right hand from above so that the index and middle fingers lie on the Bush hooks. At the same time, he places his left hand on the back surface of his right, with the end of the extended index or middle finger touching the head (Fig. 6). If the forceps are applied correctly, then during the attraction process the fingertip will always be in contact with the head. Otherwise, it slowly moves away from the head, the distance between the lock of the tongs and the head increases, and their handles diverge: the tongs begin to slip and they must be immediately repositioned.

The fourth moment of the operation. After making sure that the forceps are applied correctly, they begin to extract the fetus with forceps (traction itself). To do this, the index and ring fingers of the right hand are placed on the Bush hooks, the middle finger is placed between the diverging branches of the forceps, and the thumb and little finger cover the handles on the sides. The left hand clasps the handles from below (Fig. 7). The main traction force is developed by the right hand. When extracting a fetus using obstetric forceps, it is necessary to carry out all manipulations in accordance with the mechanism of its birth in each individual case and take into account three points: the direction of traction, the strength, and the nature of the traction. According to the direction, traction is divided posteriorly (with a horizontal position of the woman in labor - from top to bottom), towards itself (parallel to the horizon) and anteriorly (from bottom to top). These directions are determined by the desire to imitate the natural mechanism of birth and advancement of the fetal head along the wire axis of the birth canal when applying obstetric forceps. The direction of traction must strictly correspond to the position of the head in the birth canal: the higher the head is in the pelvic cavity, the more posterior the direction of traction should be. When the head is positioned at the outlet of the pelvis, traction during its eruption is performed in the third position, from bottom to top. Due to the fact that in obstetric 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 proposed the following method of grasping (Fig. 8) and traction with forceps: the bent II and III fingers of both hands of the obstetrician grasp from under the handles obstetric forceps at the level of the Bush hooks, their outer and upper surface, and the main phalanges of the indicated fingers with the Bush hooks passing between them are located on the outer surface of the handles, the middle phalanges of the same fingers - on the upper surface; the nail phalanges are also located on the upper surface of the handle, but only on the other (opposite) spoon of the obstetric forceps; The fourth and fifth fingers, also slightly bent, grasp the parallel branches of the forceps extending from the lock from above and move as high as possible, closer to the head. The thumbs, being under the handles, rest against the middle third of the lower surface of the handles with the flesh of the nail phalanges. The main work when extracting the head falls on the nail phalanges of the IV and V fingers of both hands. By pressing your fingers on the upper surface of the parallel branches of the forceps extending from the lock, the head is moved away from the symphysis pubis. This prevents its inevitable friction against the posterior surface of the pubis and ensures correct movement along the pelvic axis towards the sacral cavity. The same movement is facilitated by the thumbs, which exert pressure on the lower surface of the handles, directing them upward (anteriorly). The action of the main phalanges of the II and III fingers of both hands, squeezing at the level of the Bush hooks outer surface handles, comes down to grasping and holding the head under a certain and constant pressure throughout the entire operation. Thus, the obstetrician’s fingers, located above and below the forceps, acting simultaneously in different directions, ensure the production of traction and advancement of the head along the axis of the birth canal. The force of traction should be commensurate with the strength of the obstetrician and the available resistance. The pulling force should not be excessive.

It is not allowed to perform traction with four hands (two obstetricians at once or one after the other). If 8-10 tractions are unsuccessful, further use of obstetric forceps should be abandoned. During traction, the obstetrician strives to complete the unfinished stages of the birth mechanism. The extraction of the fetus with obstetric forceps should not occur continuously, but with intervals of 30-60 seconds. The duration of an individual traction corresponds to the duration of pushing; it should begin, like an effort, slowly, gradually increase in strength and, having reached a maximum, go into a pause, gradually fading away. After 4-5 tractions, open the forceps and take a break for 1-2 minutes. No rocking, rotating, pendulum-like or other movements should be made during traction. Rotating the head with forceps is unacceptable; the tongs should turn along with the head due to its rotation; during traction, imitating the natural mechanism of fetal birth, the head is rotated in forceps.

Fifth moment of the operation. Obstetric forceps are removed either after the head is removed, or when it is still erupting. IN the latter case The forceps are carefully opened, both spoons are moved apart, each spoon is taken in the corresponding hand of the same name and removed in the same way as they were applied, but in the reverse order, that is, the right spoon, describing an arc, is taken to the left inguinal fold, the left - to the right (Fig. 9). The spoons should slide smoothly, without jerking. It is necessary to consistently focus on both the pelvic and cephalic curvature. After the birth of the head, the fetal body is removed according to general rules.

Technique for applying direct obstetric forceps

The first moment of the operation. When applying straight parallel Lazarevich forceps, it does not matter which spoon is inserted first, since this is not prevented by the locking device. When applying straight but crossing forceps, the left (with the lock) branch is inserted first. When inserting a spoon with straight forceps, each branch is held horizontally and the spoon is inserted under the control of the inner hand, describing an arc according to the circumference of the fetal head. The design of straight obstetric forceps allows them to be applied to the presenting part of the fetus not only in the transverse and oblique, but also in the direct dimension of the small pelvis. However, the latter option is unsafe (possibility of injury to the urethra, bladder, rectum).

Second and third moments of the operation- closing the forceps and testing traction - have no features compared to the operation of applying obstetric forceps with pelvic curvature.

The fourth moment of the operation- traction itself. When using straight forceps, you can more accurately control and direct the movements of the head, since the direction of movement of the handles of straight forceps coincides with the direction of movement of the fetal head. When removing the head using straight obstetric forceps, you should never lift the handles of the forceps high (as when using forceps with pelvic curvature), as this will lead to significant trauma to the perineum and vagina.

Fifth moment of the operation- opening the lock and removing straight forceps is also done after the birth of the head or during its eruption. If the forceps are removed during the process of eruption of the head, then (unlike obstetric forceps with pelvic curvature) it does not matter which branch is removed first - the forceps are removed when the handle is moved to the side, and each branch of the forceps describes an arc corresponding to the circumference of the head. In the crust, straight forceps (more convenient when applied to a high head) due to the refusal to use high obstetric forceps are used much less frequently than forceps with pelvic curvature.

Typical (exit) obstetric forceps with the anterior view of the occipital presentation, it is used most often. On palpation through the anterior abdominal wall the head is not defined above the entrance to the pelvis. During vaginal examination, the sagittal suture of the head is located in the direct size of the pelvic outlet, the leading point is the small (posterior) fontanel, in relation to the large (anterior) fontanel it is located downward and anteriorly, under the pubis; the sacral cavity is completed, the ischial spines are not reached. The forceps should be applied in the transverse dimension of the pelvic outlet, that is, biparietally on the head. If the head has approached the lower edge of the pubic fusion with the occipital protuberance, then traction is performed along a horizontal line until the occipital protuberance comes out from under the pubis. Then the head is brought out, slowly and carefully lifting the handles of the forceps anteriorly, and the movement characteristic of this moment of childbirth should occur - extension of the head around the point of fixation, that is, the area occipital bone. The perineum is supported by hand, preventing rapid eruption of the frontal tubercles.

In the posterior view of the occipital presentation, the position of the head in the pelvic outlet is characterized by the fact that the occiput has completed a posterior rotation, the sagittal suture is located in the direct size of the outlet, the leading point is the posterior (small) fontanelle, in relation to the anterior (large) fontanel it is located downward and posteriorly. The posterior view of the occipital presentation is a variant of the normal mechanism of fetal birth, therefore the head must be removed in the posterior view. When applying forceps in the posterior view, you should remember all the details of the mechanism for cutting the head, trying to imitate it when removing it with obstetric forceps. Apply forceps and perform traction in the same way as with the anterior view of the occipital presentation. When cutting through the head, you must remember about two points of fixation of the head: one to enhance flexion and the other to extend. As soon as, with horizontal traction, the area of ​​​​the border of the scalp of the forehead appears under the symphysis (the anterior point of fixation), you should proceed to extracting the head in the direction along the anterior arc (Fig. 10). At the same time, the head is bent even more to allow the back of the head and both parietal tubercles to emerge (special attention to protecting the perineum!). After the birth of the occiput, they begin to straighten the head around another fixation point (occipital bone), which is fixed in front of the coccyx. To do this, the handles of the forceps are lowered posteriorly towards the perineum.

In case of anterior cephalic presentation, typical obstetric forceps are applied to the head when its sagittal suture is in the direct size of the pelvic outlet, the anterior (large) fontanel is located anteriorly, the posterior (small) fontanel is posterior and is difficult to reach. The anterior (large) fontanel lies below, the small one - above. The insertion of spoons is carried out, as usual, in the transverse dimension of the pelvis. Closing is done with the handles relatively raised. To avoid further extension, the first spoon is held by an assistant with the handle raised anteriorly. Ideal grip through the parietal region is impossible; spoons are applied according to the vertical size of the head. The first tractions are done with relatively raised handles, and later - in a horizontal direction until the area of ​​the bridge of the nose (anterior fixation point) appears under the symphysis. Then the head is flexed by traction anteriorly (Fig. 11) until the birth is born above the perineum. occipital region(be aware of the possibility of perineal rupture!). After this, the handles of the forceps are lowered posteriorly, the head is extended around the occipital protuberance (posterior fixation point), and the face is released from under the pubis. The lock is opened and the spoons are removed only after the head has been removed. Correction of anterior cephalic presentation with obstetric forceps (translation into a more physiological one - occipital or facial) is currently not used.

In case of facial presentation, typical obstetric forceps are rarely used. The technique of applying forceps for facial presentations is much more complicated than for occipital presentations. Only an experienced obstetrician can perform the operation, with a strict assessment of the indications. The application of forceps is permissible only in cases where the head is on the pelvic floor and the chin is facing anteriorly. If the chin is turned posteriorly, childbirth is impossible (if there are no conditions for cesarean section, a craniotomy is performed). Forceps are applied in the transverse dimension of the pelvis with the handles raised anteriorly, since in these presentations the wire point (chin) is always located at the pubic symphysis, and the bulk of the head lies in the recess of the sacral bone. The spoons are placed perpendicular to the vertical dimension (Fig. 12). After closing the spoons and testing traction, traction is done somewhat posteriorly in order to bring the chin out from under the pubis; then the handles of the forceps are raised anteriorly, the head is bent around the hyoid bone (fixation point) and the forehead, parietal tubercles and occiput are brought above the perineum.

Atypical (cavitary) obstetric forceps

If with typical exit forceps, when removing the head, the process of cutting, cutting and birth of the head is reproduced, then with cavity forceps, an internal rotation of the head in the forceps is also performed during traction. This is due to the fact; that the fetal head standing in the pelvic cavity has not completed the internal rotation, and its sagittal suture may be in one of the oblique or transverse dimensions of the pelvic cavity. The peculiarities of the technique concern only the first moment (insertion of spoons) and the fourth (traction).

In the first position of the fetus, occipital presentation, anterior view, atypical obstetric forceps are applied in the biparietal size of the head, that is, in the left oblique size of the pelvic cavity (Fig. 13). The left spoon is inserted first (as with typical forceps), but somewhat posteriorly - so that the spoon rests on the head in the area of ​​the left parietal tubercle. The right spoon of the forceps is also first inserted from behind, then, together with the fingers of the control hand, it is carefully raised (the handle of the forceps is lowered at this time) to the right parietal tubercle (the spoon “wanders”), after which the forceps are closed and a test traction is performed. The direction of traction is first done downwards and somewhat posteriorly. At the same time, feeling the rotation of the head (with the posterior fontanelle counterclockwise - to the right and anteriorly), they contribute to this movement. When the rotation of the head is completed (posterior fontanel at the pubis, sagittal suture in the direct size of the pelvic outlet), traction is performed horizontally until the birth of the occipital protuberance from under the pubis, and then anteriorly - extension and birth of the head.

Atypical obstetric forceps for the second position of the fetus, occipital presentation, anterior view are also applied in the biparietal size of the head, but in the right oblique size of the pelvic cavity (Fig. 14). To do this, the left spoon is inserted into the left half of the pelvis, and then it is moved anteriorly and to the right until it rests on the left parietal tubercle. The right spoon is inserted so that it rests on the right parietal tubercle. Traction is done slightly backwards and downwards; when the head begins to descend, it is rotated in the forceps by the posterior (small) fontanel anteriorly and to the left, that is, clockwise by 45°. Next, traction is performed as with typical obstetric forceps: horizontally and anteriorly.

Atypical obstetric forceps for the first position of the fetus, occipital presentation, posterior view are applied in the right oblique dimension of the pelvic cavity so that they cover the head biparietally. The insertion of spoons is carried out in the same way as in the second position, anterior view. With traction downward (towards oneself) and somewhat posteriorly, the head is rotated by the posterior (small) fontanelle posteriorly (very rarely anteriorly, in these cases the spoons of the forceps are shifted accordingly). Then the direction, strength and nature of traction are determined by the same rules as with typical obstetric forceps.

Atypical obstetric forceps for the second position of the fetus, occipital presentation, posterior view are applied in the left oblique dimension of the pelvic cavity to the biparietal dimension of the head. The technique for inserting forceps is the same as for the anterior view of the occipital presentation of the first position. Only when the head is lowered during traction does its posterior fontanelle rotate posteriorly in the forceps. This is followed by additional flexion and extension of the head.

Rice. 15. Application of atypical forceps with a low transverse position of the head (bottom view). The arrows show the movement (wandering) of the right and left spoons (the initial position of the right and left spoons of the forceps is shaded): 1 - in the first position (the spoons of the forceps in the left oblique size); 2 - in the second position (spoon tongs in the right oblique size)

Atypical obstetric forceps with a low transverse position of the head is a very difficult operation. Obstetric forceps of the usual type (with pelvic curvature) are applied, like atypical ones, in the oblique dimension of the pelvic cavity, in accordance with the wire point (posterior fontanelle): in the first position of the fetus - in the left oblique dimension of the pelvic cavity (Fig. 15, 1), and in the second position - in the right oblique size of the pelvic cavity (Fig. 15, 2). Among the features of the technique, we should mention the transfer of spoons of tongs. When the sagittal suture, after several tractions, becomes an oblique size, the forceps are removed and then applied again to the transverse dimensions of the head in the oblique size of the pelvis. In this position of the head, straight obstetric forceps are also used, which do not need to be repositioned, since they are placed on the biparietal size of the head and in the direct size of the pelvic cavity. First, a spoon is inserted, the edges should lie on the front side of the head. Take any spoon and insert it into the vagina towards the sacroiliac cavity closest to the face, then the spoon by transfer (“wandering”) is passed through the forehead and face to the front side of the head to the front end of the true conjugate. The posterior spoon is inserted through the same cavity as the first and advanced towards the posterior end of the conjugate.

In case of breech presentation, obstetric forceps are used very rarely and only if the buttocks are fixed in the cavity or are located at the bottom of the pelvis. Forceps are applied to the pelvic end of the fetus, if possible, only in a transverse dimension. When the buttocks are standing in the direct size of the pelvis, apply one spoon of forceps to the sacrum and the other to the back of the thighs. In this position of the buttocks, straight obstetric forceps are also used, applying them in the direct size of the pelvis.

Outcomes of the operation of applying obstetric forceps

Applied in a timely manner, technically correct, according to established indications, in compliance with the appropriate conditions, rules of asepsis and antisepsis and in the absence of contraindications, the operation of applying abdominal and exit obstetric forceps usually makes it possible to deliver a live fetus without compromising the health of the woman in labor. In some cases, this operation can cause a number of complications: damage to the birth canal (ruptures of the cervix, vaginal walls and perineum), fetal injuries (damage to the skin, depression of the skull bones, paresis of the facial nerve, intracranial hemorrhages), postpartum diseases infectious origin. These complications may be due to non-compliance with the conditions and technical errors during the operation, but they are often the result of pathological condition mother or fetus, which served as an indication for the application of obstetric forceps. Rare cases of genitourinary fistula (see) after the operation of applying obstetric forceps should be explained by the excessive duration of the birth act and their delayed application.

Postoperative period

Compliance with the strictest sanitary and hygienic regime. If there are sutures (staples) on the perineum, in addition to the usual thorough washing of the external genitalia, wiping the tissues in the area of ​​the sutures with alcohol after each urination and defecation is recommended. Whenever infectious process appropriate treatment is carried out. The duration of bed rest is determined individually. Before discharge, the woman should be carefully examined in a gynecological chair. After the application of obstetric forceps, postpartum leave for a woman in labor is extended to 70 days.

Bibliography: Lankowitz A. V. Operation of applying obstetric forceps, M., 1956, bibliogr.; Malinovsky M. S. Operative obstetrics, M., 1967; Practical obstetrics, ed. A. P. Nikolaeva, p. 321, Kyiv, 1968; Tsovyanov N. A. On the technique of applying obstetric forceps, M., 1944, bibliogr.

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

Obstetric 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 labor expulsion forces with the attractive force of the obstetrician.

Obstetric forceps have two branches connected to each other using a lock; each branch consists of a spoon, a lock and a handle. The spoons of the forceps have a pelvic and cephalic curvature and are designed specifically for grasping the head; the handle is used for traction. Depending on the design of the lock, there are several modifications of obstetric forceps; in Russia, Simpson-Fenomenov obstetric forceps are used, the lock of which is characterized by a simple design and significant mobility.

CLASSIFICATION

Depending on the position of the fetal head in the small pelvis, the surgical technique 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 straight), are called low abdominal (typical).

The most favorable option for the operation, associated with the least number of complications for both the mother and the fetus, is the application of typical obstetric forceps. Due to 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

· Preeclampsia severe course, not amenable to conservative therapy and requiring the exclusion of pushing.
· Tenacious secondary weakness labor or weakness of pushing, not amenable to drug correction, accompanied by prolonged standing of the head in one plane.
· PONRP in the second stage of labor.
· The presence of extragenital diseases in the woman in labor that require stopping pushing (diseases of the cardiovascular system, high myopia, etc.).
· Acute fetal hypoxia.

CONTRAINDICATIONS

Relative contraindications are prematurity and large fetuses.

CONDITIONS FOR THE OPERATION

· Live fruit.
· Complete opening of the uterine os.
· Absence of amniotic sac.
· The location of the fetal head in the narrow part of the pelvic cavity.
· Correspondence between the sizes of the fetal head and the mother's pelvis.

PREPARATION FOR OPERATION

It is necessary to consult an anesthesiologist and choose a method of pain relief. The woman in labor is lying on her back with her legs bent at the knees and hip joints. The bladder is emptied and treated disinfectant solutions external genitalia and inner thighs of a woman in labor. A vaginal examination is performed to clarify the position of the fetal head in the pelvis. The forceps are checked, and the obstetrician's hands are treated as for performing a surgical operation.

METHODS OF PAIN RELIEF

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

OPERATIONAL TECHNIQUE

General surgical technique

The general technique for 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: inserting spoons and placing them on the fetal head, closing the branches of the forceps, test traction, removing the head, removing the forceps.

Rules for introducing spoons

· The left spoon is held with the left hand and inserted into left side 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 on top of the left spoon.
To control the position of the spoon, all fingers of the obstetrician’s hand are inserted into the vagina, except for the thumb, which remains outside and is moved to the side. Then, like a writing pen or bow, take the handle of the forceps, with the top of the spoon facing forward and the handle of the forceps parallel to the opposite inguinal fold. The spoon is inserted slowly and carefully using 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 his hand from the vagina and passes the handle of the inserted spoon to the assistant, who prevents the spoon from moving. Then the second spoon is introduced. The spoons of the forceps rest on the fetal head in its transverse dimension. After inserting the spoons, the handles of the tongs are brought together and an attempt is made to close the lock. This may cause difficulties:

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

· one spoon is located higher than the other and the lock does not close - under the control of fingers inserted into the vagina, the overlying spoon is shifted downwards;

· the branches are closed, but the handles of the forceps diverge greatly, which indicates that the spoons of the forceps are placed not on the transverse size of the head, but on the oblique one, about the large size of the head or the position of the spoons on the head of the fetus is too high, when the tops of the spoons rest against the head and the head curvature of the forceps is not fits it tightly - it is advisable to remove the spoons, conduct a repeated vaginal examination and repeat the attempt to apply forceps;

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

After closing the branches of the forceps, you should check whether the soft tissues of the birth canal are captured by the forceps. Then a test traction is carried out: the handles of the forceps are grasped with the right hand, they are fixed with the left hand, and the index finger of the left hand is in contact with the head of the fetus (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 extract 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 pelvic cavity, traction is directed downwards and backwards; when traction is from the narrow part of the pelvic cavity, the traction is directed downwards, and when the head is located at the outlet of the small pelvis, it is directed downwards, towards oneself and anteriorly.

Tractions 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 the vulvar ring, the perineum is usually cut (obliquely or longitudinally).

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

If the forceps are removed before the head erupts, then first the handles of the forceps are spread apart and the lock is unlocked, then the spoons of the forceps are withdrawn in the reverse order of insertion - first the right, then the left, deflecting 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 the anterior direction, and the perineum is supported with the left. After the head is born, the lock of the forceps is opened and the forceps are removed.

Typical obstetric forceps

The most favorable option for surgery. The head is located in a narrow part of the pelvis: two-thirds of the sacral cavity and the entire inner surface of the pubic symphysis are occupied. During vaginal examination, the ischial spines are difficult to reach. The sagittal suture is located in the straight or almost straight dimension 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 dimension 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 downwards and anteriorly until the suboccipital fossa is fixed at the lower edge of the symphysis, then anteriorly until the head erupts.

In the posterior view of the occipital presentation, traction is carried out first horizontally until the first point of fixation is formed (the anterior edge of the greater fontanelle - the lower edge of the symphysis pubis), and then anteriorly until the suboccipital fossa is fixed at the apex of the coccyx (the second point of fixation) and the handles of the forceps are lowered posteriorly, resulting in extension head and birth of the forehead, face and chin of the fetus.

Abdominal forceps

The fetal head is located in the wide part of the pelvic cavity, filling the sacral cavity in the upper part, the anterior rotation of the occiput has not yet occurred, the sagittal suture is located in one of the oblique dimensions. At the first position of the fetus, the forceps are applied in a left oblique size - the left spoon is behind, and the right spoon “wanders”; in the second position, it’s the other way around - the left spoon “wanders”, and the right spoon remains behind. Traction is carried out downwards and backwards until the head passes into the plane of the pelvic outlet, then the head is released using manual techniques.

COMPLICATIONS

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

FEATURES OF MANAGEMENT IN THE POSTOPERATIVE PERIOD

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