Procedures Flashcards
. Which of the following describes proper forceps placement in relationship to the stated landmark?
A. The anterior fontanelle should be one fingerbreadth above the blade
B. The posterior fontanelle should align with the plane of the shanks
C. The posterior fenestration of the blade should admit two or more finger widths
D. The sagittal suture should be parallel to the plane of the shanks
E. For occiput anterior position, the posterior fontanelle should be one fingerbreadth above the plane of the shanks
E
A. The anterior fontanelle should be one fingerbreadth above the blade- should be POSTERIOR
B. The posterior fontanelle should align with the plane of the shanks - SHOULD BE ABOVE
C. The posterior fenestration of the blade should admit two or more finger widths - should be no more than one fingertip
D. The sagittal suture should be parallel to the plane of the shanks- should be PERPENDICULAR
E. For occiput anterior position, the posterior fontanelle should be one fingerbreadth above the plane of the shanks
The three landmarks used to assess proper placement are the posterior fontanelle, the sagittal suture, and the fenestration of the blade (which must be estimated in solid blade instruments). For occiput anterior positions, the posterior fontanelle should be one fingerbreadth above the plan of the shanks. If this relationship is not achieved, the pivot point of the had will not be the center of the cephalic curve of the blades and traction may cause overextension or overflexion of the head. Thus, answer E is correct. Regarding the other positional checks, the sagittal suture should be perpendicular to the plan of the shanks (NOT parallel). If not perpendicular, a brow-mastoid application can occur resulting in an increased risk of fetal trauma. Regarding the posterior fenestration of the blade, no more than a fingertip should be able to be inserted between the fenestration and the scalp. Larger distances may indicate that the forceps may not be anchored at or below the malar eminences and traction may cause slippage.
- ACOG Practice Bulletin 154: Operative Vaginal Delivery 2. 1. ACOG Practice Bulletin 154: Operative Vaginal Delivery
- Gynecology and Obstetrics. Lippencott Williams and Wilkins; 2004; Chapter 72
. Which of the following correctly pairs the instrument to the indication?
A. Tucker-McLean forceps: Delivery of the aftercoming head in breech fetus
B. Simpson forceps, delivery of fetus with molded head
C. Piper forceps: Rotation of fetal head to allow for vaginal delivery
D. Kielland forceps: Delivery of the non-molded fetal head
E. Vacuum extractor: Delivery of the fetal head when station is too high for safe forceps placement
B.
Forceps consist of a blade connected to the handle by a shank. The two classical types of forceps are the Elliot type (and its modifications including Tucker-McLean) and the Simpson type (and its modifications). Other forceps have been developed for specific purposes. Elliot and Tucker-McLean forceps have overlapping shanks with move space toward the heel of the blade. Thus, these instruments are optimal for delivery of the fetus with a non-molded head. The overlapping shanks also cause less stretching of the perineum. Simpson type forceps have parallel shanks and a longer blade and are thus more appropriate for the molded fetal head. Piper forceps are designed to keep the fetal head flexed during a vaginal breech delivery. This instrument is characterized by long shanks with a backward curve, dropping the handles well below the level of the blades. The dropped handles are important to allow for application without elevating the delivering body above the level of horizontal. The Piper forceps do not have a pelvic curve. Kielland forceps were introduced in 1915, specifically for rotation of the fetal head. Modifications include only a slight pelvic curve, overlapping shanks with a sliding lock, and knobs to identify the anterior surface of the instrument. Although classic forceps may be used for rotation (Scanzoni maneuver), they are not specifically designed for this purpose. The indications and contraindications of vacuum extractor and forceps are the same. Thus, it is not appropriate to use vacuum if forceps are contraindicated.
Elliot or Tucker McLean forceps
have overlapping shanks with move space toward the heel of the blade. Thus, these instruments are optimal for delivery of the fetus with a non-molded head. The overlapping shanks also cause less stretching of the perineum
Simpsons forceps
Simpson type forceps have parallel shanks and a longer blade and are thus more appropriate for the molded fetal head
Piper forceps
Piper forceps are designed to keep the fetal head flexed during a vaginal breech delivery. . This instrument is characterized by long shanks with a backward curve, dropping the handles well below the level of the blades. The dropped handles are important to allow for application without elevating the delivering body above the level of horizontal. The Piper forceps do not have a pelvic curve
Piper forceps
Piper forceps are designed to keep the fetal head flexed during a vaginal breech delivery. . This instrument is characterized by long shanks with a backward curve, dropping the handles well below the level of the blades. The dropped handles are important to allow for application without elevating the delivering body above the level of horizontal. The Piper forceps do not have a pelvic curve
Kielland forceps
ROTATIONAL Kielland forceps were introduced in 1915, specifically for rotation of the fetal head. Modifications include only a slight pelvic curve, overlapping shanks with a sliding lock, and knobs to identify the anterior surface of the instrument. Although classic forceps may be used for rotation (Scanzoni maneuver), they are not specifically designed for this purpose.
. Which of the following is considered a contraindication to operative vaginal delivery?
A. Leading point of fetal skull not yet on the pelvic floor
B. Osteogenesis Imperfecta, type I
C. Previous Cesarean delivery
D. Indeterminate fetal heart rate pattern
E. HELLP syndrome
B.
Any type of bone demineralization disorder is considered a contraindication to operative vaginal delivery (OVD). Although type I osteogeneis imperfect may be less severe than other types, these individuals still experience multiple fractures. Other contraindications include known or suspected fetal bleeding disorder, unknown head position, and unengaged fetal head. Answer A is part of the definition of “low forceps”—leading point of fetal skull at +2 or lower but not yet on the pelvic floor. Low forceps are an acceptable intervention when OVD is indicated. In a patient who is otherwise a candidate for TOLAC, Cesarean delivery is not a contraindication to OVD. Indeterminate fetal heart rate pattern is also not considered a contraindication and OVD may allow expeditious delivery in the setting of a non-reassuring fetal heart tracing. Although maternal thrombocytopenia is a feature of HELLP syndrome, fetal platelet counts should not be affected. Therefore, the mode of delivery should be determined by obstetric considerations.
ACOG Practice Bulletin 154, Operative Vaginal Delivery
OMIM Osteogenesis Imperfect, accessed November 2017
ACOG Practice Bulletin 166, Thrombocytopenia in Pregnancy
- Which of the following is correct regarding forceps as compared to vacuum in the setting of operative vaginal delivery?
A. Risk for third/fourth degree lacerations is about equal
B. Vacuum is associated with a decreased risk of intracranial hemorrhage
C. Vaginal birth is more likely to be achieved with forceps
D. It is not as important to know fetal head position if vacuum is chosen
E. If one instrument is unsuccessful, a trial of the other instrument is generally appropriate
C.
Both devices can be used to expedite vaginal delivery and have a low risk of complications. However, when compared to one another, forceps are more likely to achieve a vaginal delivery but are associated with an increased risk of perineal trauma. Some studies have suggested an increased risk of intracranial hemorrhage with vacuum delivery and thus it is not recommended for use at less than 34 weeks. Other studies have suggested that the two instruments are relatively equal in risk for ICH. There are no data to suggest that forceps are associated with a higher risk of this complication than vacuum. Unknown fetal head position is a contraindication to OVD regardless of the choice of device. In general, sequential use of both devices is discouraged secondary to reported higher rates of neonatal complications.
ACOG Practice Bulletin 154, Operative Vaginal Delivery.
