What are the consequences if a child is dragged with tongs? Childbirth using obstetric forceps. General surgical technique

The obstetrician who cannot
wait for the gentle tactics of nature,
wants to conduct a surgical birth
principles and always grabs onto
forceps or other operations. How
The more active obstetric care is, the more
it's more dangerous! Doing a lot and
impatience only harms

E. Bumm, 1913

What is best for mother and newborn; vacuum extraction or obstetric forceps?

When assessing the role of a particular delivery operation, one should proceed primarily from the consequences of the use of these benefits for the woman in labor and the newborn. In the memory of many obstetricians, there are so-called “forceps” children - children extracted with the help of obstetric forceps with clear manifestations of birth traumatic brain injury. We decided to monitor how “vacuum” children (extracted using vacuum extraction) develop.

To date, there is no common point of view regarding the use of vacuum extraction of the fetus and the operation of applying obstetric forceps. The published relatively insignificant and contradictory information about the consequences of these operations for the mother and fetus disorients the obstetrician in the tactics of managing complicated labor.

The first literary mentions of the use of vacuum extraction of the fetus date back to 1706. V. James, R. Jonge reported a case of prolonged labor when

“a glass cup fixed on the baby’s head, with an air pump attached to it, helped in the delivery.”

The classics of the obstetric renaissance era, almost at the same time, proposed a lot of various techniques for surgical delivery, including the operations discussed in this chapter.

Since the inception of vacuum extraction, the method has found both fans and categorical opponents. Along with rave reviews, there were also opposite ones. One of them:

“We are very afraid that this proposed replacement of forceps may lead to disappointment. We are afraid that the child's skull will be ruptured or the parental bone will pop out.”

As we have seen in our research, the terrible prophecy of the classics of obstetrics comes true in almost every case of surgical delivery.

In previous years, there was a peculiar attitude towards vacuum devices. Thus, R. Arnott points out that

"The pneumatic tractor is extremely suitable for the purposes of obstetric surgery as a substitute for steel forceps in the hands of persons who are deprived of manual dexterity, either from lack of experience or from nature."

This phrase largely determined the development of this technique and attitude towards it and can explain the excessive fascination with vacuum by young doctors in previous years. Such proposals as the use of vacuum tractors in connection with the fatigue of a woman in labor during childbirth (J. Brej, 1961), with increased fearfulness and excitability of women in labor (V. Brinvill, 1958) or as an aid to first-time mothers during the normal course of pregnancy (B Docuer, 1957) or “simply out of compassion for women.”

"Epoch excessive hobby vacuum extraction gave way to a period of abrupt negative attitude to him. However, in recent years, in some obstetric institutions, vacuum devices are again finding their place and replacing the operation of applying obstetric forceps.”

Given the conflicting data presented, we tried to compare the long-term health outcomes of mothers and children extracted using vacuum extraction and obstetric forceps. 75 histories of births that ended with vacuum extraction of the fetus and the follow-up of these children were analyzed, making up the first group. The data obtained were compared with the results of 565 operations using obstetric forceps (group 2). Indications for vacuum extraction in 55% of births were fetal hypoxia, in 32% the operation was performed due to weakness of the pushing period, in 13% a combination of these complications was observed. The operation was carried out with cups No. 5-6 at a negative pressure of 0.8 atm and lasted up to 5 minutes in 35 births, up to 10 minutes in 43, 20 minutes in 18 births, and more than 20 minutes in 4 births. In 30% of births, the operation was started with the head located in the wide part of the cavity of the small pelvis, in 62% - in the narrow part, in 8% the head was on the pelvic floor at the time of applying the vacuum. The bulk of newborns, from 2500 g to 3500 g (63%), large children - 10%, immature - 1 child. Of the 75 children, 38 were extracted in a state of asphyxia, requiring resuscitation therapy.

IN maternity hospital damage nervous system fetuses were found in 60% of children extracted using vacuum extraction, of which we found brain injury in 20%, neurological symptoms of damage to the cervical enlargement spinal cord in the form of obstetric paralysis, myatonic syndrome, spastic tetraparesis was found in 23.4%, signs of damage to the lumbar enlargement of the spinal cord in the form of inferior flaccid paraparesis were found in 16.6%, signs of combined lesions of the spinal cord and brain were found in 14.5% children.

58 of the 75 children removed by vacuum extraction were re-examined. The age of the examined children was as follows: 6 months - 8 children, 12 months - 2-2, 1.- 5 years - 24, 6 years - 18 children.

Symptoms indicating damage to the nervous system remained in 45% of children. Another 18% of supposedly formerly healthy children were found to have an interest in brain structures even during the first examination in the maternity hospital, and the same was given. symptoms upon re-examination, some of them - 48%, with mental disorders. 10 of these children are being registered with a psychiatrist, four are studying in a special school.

Upon repeated examination, signs of neurological pathology of the spinal cord were found in 29% of children in the form of myatonic syndrome (16.8%), obstetric paralysis (5.4%), and lower flaccid paraparesis with clear symptoms (6.8%).

Every fourth child extracted using a vacuum extractor develops frequent pneumonia; 25% of children with signs of nervous system trauma have poor vision and are forced to wear glasses. Screams at night are observed in 25.4% of children; they are restless, inadequate to comments, have an unstable psyche, and are not in contact with peers.

In one child, a re-examination revealed a depression parietal bone in the area where the vacuum cup is applied. The boy was born weighing 3500 g; a vacuum extractor was applied to the head, located in the wide part of the pelvic cavity. The indication for delivery was fetal hypoxia of 1-2 severity, the duration of the operation was 15 minutes. At the time of examination, the boy was 6 years 9 months old, registered with a psychiatrist, and easily excitable. Upon examination, attention is drawn to sharp muscle hypotonia, recurvation of large joints, increased proprioceptive reflexes from the arms, and decrease from the legs, which suggests a combined lesion of the spinal cord. On the right parietal bone there is a depression measuring 8*4*1 cm, painless on palpation. This child has one of the rather rare complications associated with the use of vacuum extraction - a fracture of the parietal bone at the site where the vacuum cup was applied.

Most severe consequences were observed in children survivors of intrauterine hypoxia. The use of brute mechanical force applied to the skull of an already suffering fetus against the background of hypoxic and hemodynamic disorders led to the development of severe neurological pathology in 72% of such children. Such a high frequency of neurological abnormalities is explained by the presence of “biochemical trauma” that develops when the fetus suffers and the duration of the extraction itself.

Predisposing factors for injury to the child’s nervous system are complications of pregnancy such as late toxicosis, threatened miscarriage, and anemia of pregnant women. Of the complications of childbirth, the most unfavorable were premature rupture. amniotic fluid, weakness labor activity, which was the reason for the surgical completion.

Every obstetrician is interested in the possibility of predicting the development of a child removed during vacuum extraction. We analyzed the condition of children depending on the height of the head at the time of applying a vacuum cup, the duration of extraction and weight at birth. An important factor determining the health status of the newborn is the height of the head at the time of applying the vacuum cup,

If a vacuum cup was applied to the head, located in the wide part of the pelvic cavity, then almost every child was injured. When the head was located in a narrow part of the pelvis, signs of damage to the nervous system were found in 50% of children, and finally, if the head was on the pelvic floor at the time the vacuum was applied, 27.2% of children were damaged. When vacuum extraction lasts 20 minutes or more, all children, without exception, unfortunately, develop severe neurological pathology, due to both the duration of the operation itself and the presence of pathological process, which served as an indication for urgent delivery. If the operation lasted up to 15 minutes, lesions of the nervous system were found in 80% of the extracted children; if the operation lasted up to 10 minutes, neurological symptoms were found in 66.7% of children, and the least damage was found when the extraction lasted 3-5 minutes - 22.2%.

Of great prognostic significance is fetal weight at birth. If the weight of a child extracted using vacuum extraction is 4 kg or more, 80% of those born have neurological pathology; with a weight of 3.5-4 kg, neurological pathology is found in 67% of children, in every second child with a weight of 2.5-3. 5 kg you can find one or another neurological symptoms.

Thus, of the three parameters (the duration of the operation, the height of the head, body weight at birth), which significantly affect the further development of the child, we see two - the height of the head at the time of applying the vacuum cup and the duration of extraction. The minimum damaging and optimal for the further development of the child is the extraction time of 3-5 minutes and the height of the head, located on the pelvic floor or in the narrow part of the pelvic cavity.

In response to one of the postcards inviting us to an examination, we received a letter that is of undoubted interest to doctors of many specialties.

The birth history is as follows: mother K., 37 years old, engineer, unmarried, primigravida, multigravida (the previous pregnancy a year ago ended in spontaneous miscarriage at 8 weeks of gestation), was admitted to the maternity ward on October 2 at 24 hours from the onset of labor activities. On external examination, the dimensions of the pelvis are normal and not reduced. She went through pregnancy without any deviations from the norm; among the diseases she suffered were childhood infections.

The first stage and the beginning of the second stage of labor proceeded without complications. At the end of the second period, auscultation reveals a decrease in the fetal heart rate to 96 beats per minute. Conventional therapy for fetal hypoxia was carried out, which did not improve the child’s condition. The doctor decided to end the birth with vacuum extraction.

A vacuum cup No. 5 was placed on the head located in the narrow part of the pelvic cavity, the extraction lasted 15 minutes. The boy was recovered alive. The obstetrician who performed the delivery assessed the child at 8 points on the Apgar scale, the micropediatrician, who was at that time in the maternity unit, assessed the newborn at 5 points. Such a discrepancy, a contradiction observed in the assessment of newborns produced by obstetricians and neonatologists, is observed all over the world and dictates the need for a neonatologist to evaluate a newborn child. After 5 minutes the child was rated 7 points. On the 5th day of life, the newborn was examined by a neurologist and diagnosed with myatonic syndrome.

On the 10th day of life, the baby, together with the happy mother, is discharged from maternity hospital, the woman signs for a living, full-fledged child. Everyone is happy - a 37-year-old single woman who received a long-awaited child, and an obstetrician who saved the life of another child. The connection between the obstetrician and the happy family is severed. And now, 6 years later, a letter arrives with the following content.

“Dear comrades! I, full name, who gave birth in the Red Cross maternity hospital, inform you that my son O. is sick. The boy has a severe form of encephalopathy, epilepsy with propulsive type seizures (the boy winces up to 200 times a day). Diagnosis: consequences of severe intrapartum hypoxia. At present (he is 5 years and 4 months old) he hardly sits by himself, walks with support, does not speak at all. Recognizes loved ones."

It seems to us controversial that the diagnosis made by the local neuropathologist in outpatient card the child that the mother rewrites: "the consequences of severe intranatal hypoxia." How to evaluate the data, auscultatory examination - 96 beats per minute - at the end of the second period and the head, located in the narrow part of the pelvic cavity? Hypoxia?

Before answering this question, it is not superfluous to recall that the stethoscope with which obstetricians listen to the fetal heartbeat is about 200 years old (the stethoscope was invented by R. Laennec in 1818, for the first time it was used for auscultation in obstetrics by R. Karcaradec in 1822) . The auscultation method is simple, accessible to a practical obstetrician, absolutely safe, but at the same time it does not make it possible to listen to the true heart rate - the fetal heart rate exceeds that during auscultation by 10-15 beats per minute, which, unfortunately, is not always taken into account by doctors and midwives.

Thus, the true heart rate of the fetus in our case was 106-111 beats per minute. It should be recalled that this heart rate was noted at the moment of the highest configuration of the head - the presenting part was in the narrow part of the pelvic cavity. Thus, bradycardia was most likely vagal rather than hypoxemic. However, of course, it is impossible to completely exclude the presence of fetal suffering in this case, just as, however, it is impossible to agree with the categorical statement of the district pediatrician that the neurological status of the child is the result of intrauterine hypoxia alone. The sad outcome is most likely a consequence of the use of vacuum extraction against the background of the onset of hypoxia.

“...Under the supervision of a neurologist from three months (in the nursery republican hospital and local psychiatrist). Consulted at the children's clinic for nervous diseases with Professor Ratner and in Moscow. He was treated for epilepsy (insignificant improvement), and received massage (by a professional masseuse) for up to two years.

During this time, he suffered from pneumonia, dysentery, and recently the flu. There is no point in showing you the boy, the diagnosis is correct, his illness is “obvious”. You probably need this for statistics. If you need details, I can drive up, but without the boy, because we currently live in the Leninsky district, the child is being raised at home and almost cannot stand the road (he is afraid).

With respect to you - signature.”

It is impossible to imagine a more tragic content of the letter. But what is most striking is that the unfortunate mother ends her message “with respect” to the staff of the maternity hospital and makes a direct appeal to the obstetricians:

“I gave birth using a vacuum and I’m sure it also affected the boy. The pregnancy went through without any deviations from the norm, the birth lasted 14 hours, who knows, if not for the vacuum, perhaps the boy would not have been so hopelessly ill. There is no strength to look at his suffering when he is shaking, especially in the morning.

I implore the doctors to cancel the vacuum, how much suffering and in the name of what..."

Behind this letter lies the twisted fate of two people. How many mothers who gave birth using a vacuum extractor could write something like this? Thousands...

However, what is better for the mother, fetus and newborn: vacuum extraction or forceps?

First of all, we compared the health status of mothers (see table).

The bulk of women in both groups are primigravidas aged 20 to 30 years, the most frequent complications there were gestosis and the threat of miscarriage; in 92% of women the pregnancy was full-term. This contingent of pregnant women is characterized by a high frequency of complications during labor, which was the reason for their surgical completion. Untimely rupture of amniotic fluid, weakness contractile activity uterus, fetal hypoxia.

If in the group of women delivered using a vacuum there is no maternal mortality, then in the second group it increases sharply, reaching 1.2%. The causes of death of these women are as follows: postpartum hemorrhage with unrecognized incomplete uterine rupture in the lower segment, thromboembolism as a complication of thrombophlebitis of the deep veins of the pelvis, sepsis.

The frequency of rupture of soft tissues and the birth canal is almost the same, but not uniform in structure. If, in group 1, surgical expansion of the vulvar ring, grade I perineal ruptures predominate, and there are no grade III perineal tears, then in group 2 the percentage of grade III perineal ruptures reaches 9.4, which is explained by an increase in the volume of the presenting part due to the applied forceps.

The long-term consequences for mothers who give birth are sad using obstetric forceps. Menstrual dysfunction (9.5%) and secondary infertility (3.8%) may develop due to complications of the postpartum period. But this is not the worst thing. Almost every second (44%) of these women was found to have functional incontinence urine when walking fast, coughing, sneezing. 10% of them have gas incontinence and loose stool. There is hardly any need to explain that these violations extremely depress a woman, deprive her of normal human communication, and lead to neurotic disorders. This is the “price” of tongs. Nothing similar is observed in mothers who gave birth using vacuum extraction.

In newborns extracted using obstetric forceps, perinatal mortality, the incidence of brain and spinal cord injuries (see table above), hemorrhages in the fundus of the eye increase sharply (compared to children of group 1), blood is found in the spinal puncture much more often, which is direct evidence of the presence of severe birth trauma.

Watch a video about the use of obstetric forceps in obstetrics:

Obstetric forceps were proposed in the 17th century by the Chamberlan family of doctors. It’s amazing: since then, the shape and dimensions of the curvature of the spoons have remained unchanged. And this despite the fact that acceleration processes affected newborns - children became larger. It is enough to visualize from memory the volume of the spoons of the forceps, and you can immediately draw attention to the discrepancy between the dimensions of the curvature and the dimensions of the head of a full-term child of the 20th century. Obstetricians, when applying forceps and closing the handles, very often resort to the strength of both hands! (force alone is not enough), forgetting that with exactly the same force, rough metal spoons squeeze the child’s skull.

According to A. S. Blindykh, even correctly applied obstetric forceps increase intracranial pressure 20 times. If obstetricians continue to question whether vacuum extraction or forceps is better, we are unlikely to achieve significant reductions in perinatal morbidity and mortality. The answer is clear - both are extremely evil for the fetus. Both operations have a negative impact on the health of mother and child. They cannot be considered as competing; each of them has its own indications and contraindications. One should strive to eliminate these traumatic methods of delivery from modern obstetrics, giving preference to cesarean section.

The use of VE or AS in the practice of a maternity hospital should be considered as a result of incorrect assessment or insufficient diagnosis and treatment of pregnant women and women in labor at high risk, as a result of a planned cesarean section not carried out in a timely manner when there were indications. However, if there are missed opportunities for a cesarean section and the need to choose a method of delivery, in our opinion, preference should be given (based on the results obtained) to vacuum extraction of the fetus.

Natural childbirth is a risky situation. When passing through the birth canal, there may be a need for obstetric care, which can be provided using obstetric instruments or manually.

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

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

The design of obstetric forceps has not changed since their invention; they consist of two metal spoon-shaped branches connected into a lock in a special way.

Forceps are used during weak labor, when the woman in labor is unable to push out the fetus on her own, and the condition of the child or mother requires completion as quickly as possible. Also, with the help of obstetric forceps, the obstetrician can turn the fetus, which is located in the gluteal region, head down to facilitate the birth process.

The benefits and dangers of forceps

At one time, this tool helped significantly reduce maternal and infant mortality. But today the attitude towards obstetric forceps is often negative.

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

However, applying forceps can be accompanied by serious complications. For the mother, they consist of damage to the birth canal: ruptures of the vagina and perineum. In severe cases, these may be ruptures of the cervix and lower segment of the uterus, injuries Bladder and rectum.

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

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

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

Vacuum extraction of the fetus is surgery during childbirth. It consists of removing the child using a special device. Vacuum extraction is used in cases where the moment for caesarean section is missed.

Vacuum extraction: indications and contraindications

Vacuum extraction is used in cases of acute lack of oxygen or weak labor that cannot be corrected with medications (prostaglandins or). To exclude unfavorable conditions, the following conditions for vacuum extraction of the fetus are observed: the uterine os must be completely open, the child must be alive, its head must be in the birth canal.

Vacuum extraction of the fetus is carried out as follows. A catheter is inserted into the bladder for the woman in labor, anesthesia is applied, and the birth canal is examined. Then he opens the entrance to the vagina with one hand, and with the other hand he inserts the cup of the device inside, places it on the child’s head, and creates negative pressure in the cup. Then the woman in labor, at the doctor’s command, begins to push, and the doctor at this time must pull out the fetus.

Vacuum birth is not used if the uterine pharynx is not open, if the uterus is too high, or if baby dead or the fetus is premature. Contraindications for vacuum extraction are also: severe condition of the woman in labor, which excludes the possibility of pushing, premature delivery, discrepancy between the size of the baby’s head and the woman’s pelvis, extensor types of fetal presentation.

Vacuum extraction is not used if the woman in labor is prohibited from pushing for certain reasons.

What are the possible consequences of vacuum extraction?

Vacuum extraction is not a very effective and traumatic procedure, so in most cases a caesarean section is used instead. May be damaged during vacuum delivery soft skin baby's head. If the procedure takes longer, to save the baby’s life he will have to be pulled out with forceps. Other consequences of vacuum extraction include the cup of the device slipping off the baby’s head, the baby’s lack of movement along the birth canal, and birth injuries to the baby.

During vacuum extraction, the mother's uterus and vagina may be injured.

The consequences of birth trauma can be varied: hemorrhages in the brain, paresis, paralysis, convulsions, retarded growth and development of limbs, impaired muscle tone, hydrocephalus, intracranial hypertension, hypertension syndrome, damage to cranial nerves, perinatal encephalopathy(PEP), children's cerebral paralysis(cerebral palsy), delay speech development, psychomotor development delay, pneumonia, minimal brain dysfunction, urosepsis.

We have already talked a lot about the comparison of childbirth in the past and those that are practiced now. To make our story as complete as possible, we cannot ignore such obstetric aids as the application of forceps during childbirth or the use of vacuum extraction. These methods of delivery are used in emergency situations when the birth of a child is in great doubt due to problems encountered during childbirth serious problems, and a caesarean section is no longer possible due to circumstances. Then these benefits are used, although they are classified as serious and quite traumatic benefits.

Application of obstetric forceps.
When the cervix is ​​fully dilated in the first phase of labor, the baby gradually begins to move inside the birth canal. Often he and his mother have enough opportunity and strength to independently complete the entire journey in the birth canal. But if insurmountable obstacles arise, then obstetricians can again come to help during the birth process. In these cases, it is too late to perform a caesarean section, since the baby has already left the woman’s uterine cavity. An operation in this position of the child will no longer be technically possible. In the past, when childbirth was carried out, and also today, in modern conditions, the only way out in such a situation is to use obstetric forceps or use a special device - a vacuum extractor. To carry out both manipulations today, the mother’s consent is required, although in past decades it was not asked.

Obstetric forceps were first used by their inventor, English doctor Chamberlain Guillaume, it was the second half of the sixteenth century. His secret of creating obstetric forceps was kept in the strictest confidence, passed down from one doctor to another by inheritance. This monopoly would have continued if, at the beginning of the eighteenth century, the Dutch surgeon Palfin Jan had not rediscovered this method of obstetrics, also making a special design of forceps to help a woman during childbirth. At that time, there was already an era of enlightenment, and this discovery quickly became the property of many obstetricians, thanks to which many thousands of children were born.

Today, obstetric forceps are used very rarely, in no more than 0.3-0.4% of births, and there are strong trends towards this method gradually falling into oblivion. Doctors have now learned to predict events during labor that has begun, and at the slightest hint of the possibility of complications, they try to play it safe and take action. emergency surgery caesarean section. At the same time, the very scheme of applying forceps has not changed in any way since ancient times, however, the equipment itself has become safer and more convenient both for doctors and for the baby and woman.

The use of vacuum extraction in childbirth.
Another device in childbirth is a vacuum extractor, a special device for extracting a child from the mother’s birth canal, which first appeared in 1849, then it was called differently, an air tractor. At that time, the device did not become popular and was simply forgotten for a hundred years. The doctors found it inconvenient and difficult to use. Only many years later, in 1954, a new improved model was created in Switzerland, which began to be used everywhere instead of using forceps during childbirth. Today, the device, brought to perfection, is especially popular all over the world, especially in the USA and Europe, and childbirth with its use is practiced much more often there than in our country.

Today, improved variations of this device, as well as obstetric forceps, are used in cases where the cervix is ​​fully dilated and the baby’s head is in the area of ​​the pelvic outlet. Thus, obstetric forceps are two specially designed metal spoons that are placed in the area of ​​the baby’s ears. After installing this device, the baby is carefully pulled out by the arms, bringing the fetal head to the outlet of the pelvis, and as soon as the head is born, the device is immediately removed from the head. The modern device of a vacuum extractor is also simple - it is a special soft suction cup made of a lightweight type of plastic, unlike what devices were previously (metal), and the device is connected to a manual vacuum pump. The suction cup is attached to the area of ​​the baby's head, clasps it tightly and gradually pulls it out. The doctor will adjust the speed and strength of suction manually depending on the situation.
Indications for the use of obstetric forceps.
It is important to know that these devices are used only according to strict indications, if conservative delivery will be impossible due to the prevailing circumstances and the formation of serious complications due to which the mother cannot continue to give birth to the baby on her own. Naturally, if there is a threat to the life of the fetus, it is better to use this kind of benefits rather than lead to the death of both. During the period of fetal expulsion, if there are appropriate conditions and indications, problems can be partially or completely eliminated through surgery with the application of forceps or an extractor. Indications for such an operation can be relatively roughly divided into two large groups:
- Indications from the maternal body
- Indications from the fetus itself.
In addition, maternal indications can also be divided into those that are directly related to pregnancy and childbirth itself (they are also obstetric indications), as well as those associated with extragenital pathology (these are indications for health reasons), when it is necessary to exclude the period of pushing. Combinations of indications can often be observed.

What indications will be relevant?
If we talk about the mother’s condition, the main indications for applying forceps may be severe manifestations of gestosis and the development of preeclampsia or eclampsia, a severe form of hypertension that is not amenable to conservative treatment. These conditions require the expectant mother to turn off the efforts and tension. Forceps will also be indicated for severe and prolonged weakness of labor or weakness of pushing, which is manifested by the standing of the fetal head in the pelvic cavity in the same plane for more than two hours, as well as in the absence of effects from taking medications. Prolonged standing of the head in one of the planes of the pelvis leads to an increased risk of trauma during childbirth for the fetus (these are mechanical and hypoxic factors), as well as for the mother herself - the development of fistulas in the intestines and bladder. Forceps are also indicated if bleeding develops in the second stage of labor, if this occurs due to placental abruption, rupture of umbilical cord vessels due to their abnormal attachment, or endometritis during childbirth.

From the side of the fetus, the indications will be the development of its hypoxia due to various reasons in the second stage of labor. This is a condition of premature placental abruption, weakness of labor, gestosis, entanglement of the umbilical cord or its shortening. Also, the application of forceps may be required for those women who have recently had surgical operations in the abdominal area, and it is not possible to push using the abdominal muscles.

More articles on the topic “Childbirth, pathologies during childbirth”:

The name itself will probably evoke associations with the distant Middle Ages for most readers. In a sense, they will be right: obstetric forceps were invented at the end of the sixteenth century. At that time, this was real progress in obstetric care. C-section then it was practically not used, and if some healer took on such dangerous operation, then only for the sake of saving the life of the child, the mother in labor did not have a single chance. The forceps helped the baby to be born, eased too difficult labor and saved the mother’s life.

The appearance of this instrument will probably not inspire much confidence among the uninitiated: the third millennium and - some kind of tongs! In fact, this “out-of-date” and “backward” tool, albeit in rare cases, is still indispensable. Certainly, medical science and practice, compared to the 17th century, rose to cosmic heights. Many methods quickly become outdated, some are improved, and some are abandoned altogether. But the application of forceps is used in labor practice by experienced obstetricians in all countries of the world to this day. Over three centuries, their design and indications for use have changed significantly, and the benefits disproportionately outweigh the risk of complications.

Conditions of use

The application of obstetric forceps is possible only in the second stage of labor when the cervix is ​​fully open, when the fetal head is in the pelvic cavity or at the exit from it.

The operation of applying obstetric forceps is quite painful: the nascent fetal head will be large due to the forceps placed on it, and therefore requires mandatory anesthesia. Most often, a short-term intravenous anesthesia is given, but if a woman gives birth under epidural anesthesia, the anesthesiologist will simply administer an additional amount of the painkiller used.

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

The baby's head is captured only when it is almost at the exit from the female pelvis, which further increases the safety of the procedure. The shape of the instrument is maximally adapted to gently and safely for the fetus, but securely grasp the head of a newborn. With the help of proven professional movements (the so-called tractions) an experienced obstetrician helps a newborn child pass through the birth canal. In addition, a sterile towel is usually placed between the handles of the forceps, which reduces the risk of excessive compression of the fetal head to almost zero. Let us repeat that this procedure is used exclusively in cases of serious difficulties in the natural passage of the child or the need to quickly complete the birth process and the impossibility of using other methods of childbirth. However, the baby's head should correspond to the average size of the head of a full-term fetus. Obstetricians formulate this condition somewhat differently: it should not be too large or too small. This is due to the size of the forceps, which are designed for the average size of the head of a full-term fetus. The use of obstetric forceps without taking this condition into account may result in too much trauma for the baby and mother.

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

Mechanism of action

The purpose of the forceps is to tightly grasp the fetal head and replace the expelling force of the uterus and abdominal press with the attracting force of the doctor. The process of “pulling out” a baby cannot be called violent: traction are applied almost effortlessly, no artificial rotations or any displacement of the fetal head are made. The obstetrician's movements carefully copy the movements of the baby's head and shoulders that he would make during natural childbirth.

In progress tractions the doctor can also make rotational movements, but only following the natural movement of the fetal head. In this case, the doctor does not prevent the head from turning, but, on the contrary, promotes it.

Indications for use

There are several indications for this procedure. Firstly, the state of health of the woman in labor, which requires the maximum shortening of the period of expulsion of the fetus, the exclusion of pushing and straining of the woman in labor: diseases of the cardiovascular and bronchopulmonary systems, kidneys, heart failure, very severe late toxicosis. Secondly, obstetric forceps are applied when efforts are weak or labor is weak. In this case, the fetal head stands in one plane of the pelvis for over 2 hours, which can lead to excessive fatigue of the woman in labor and very serious obstetric complications. In the second stage of labor, the fetal head passes through a fairly narrow bone ring - the pelvic cavity. Difficulty in advancing the fetal head can lead to unpleasant consequences both for the child and for the mother: the pelvic bones compress the fetal head, the skull bones, in turn, press on soft fabrics woman's birth canal, which leads to various injuries. Therefore, if medications, e.g. intravenous administration Oxytocin, which causes the uterus to contract, does not help the birth of a child, you have to resort to using forceps. Third, bleeding in the second stage of labor caused by premature detachment a normally located placenta, rupture of the umbilical cord vessels during their membrane attachment. Fourth, with acute intrauterine hypoxia ( oxygen starvation) of the fetus, when delaying labor will inevitably lead to the death of the child and literally minutes count (with a short umbilical cord, it is entwined around the child’s neck).

Preparation and performance of the operation

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

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

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

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

The left spoon of the forceps is inserted first. Standing, the doctor inserts four fingers of his right hand into the vagina into the left half of the pelvis, separating the fetal head from the soft tissues of the birth canal. The thumb remains outside. Taking the left spoon with your left hand, the handle is moved to right side, placing it almost parallel to the right groin fold. Then carefully, without any effort, the spoon is moved between the palm and the fetal head deep into the birth canal. In this case, the trajectory of the end of the handle seems to describe an arc. The advancement of the entire branch into the depths of the birth canal occurs almost due to the instrument’s own gravity. The hand located in the birth canal is a guiding hand and controls the correct direction and location of the branch. 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. Then, under the control of his left hand, the obstetrician inserts with his right hand right branch into the right half of the pelvis in the same way as the left.

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

Possible complications

Let us emphasize once again that timely and correctly applied forceps do not cause negative influence on the health status of women and children.

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

Complications for mom. These include possible ruptures of the vagina and perineum, less often - the cervix. Severe complications can include ruptures of the lower segment of the uterus and injuries pelvic organs: bladder and rectum. But such things can only happen if the conditions for the operation and the rules of the technique for carrying it out are violated, which is basically impossible in modern maternity hospitals.

But still!...

Of course, applying obstetric forceps is an unpleasant procedure; like, in fact, any operation, it also has dangerous moments. I assure women that no one will resort to this procedure just like that, for a “preventative” purpose. It is carried out only when absolutely necessary, when there is no other way out and we're talking about It's really about saving the baby's life. But if you happen to own experience experience the techniques of ancient obstetrics in modern conditions - do not panic, but take it simply as perceived need, helping your long-awaited baby see the light.

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

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

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

Obstetric forceps have two branches 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 in wide plane small pelvis impose cavity or atypical forceps. 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

Severe preeclampsia, not amenable to conservative therapy and requiring the exclusion of attempts.
· Persistent secondary weakness of 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, myopia high degree and etc.).
· Acute fetal hypoxia.

CONTRAINDICATIONS

Relative contraindications - prematurity and large fetus.

CONDITIONS FOR THE OPERATION

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

PREPARATION FOR OPERATION

It is necessary to consult an anesthesiologist and choose the method of anesthesia. The woman in labor is in the supine position with her knees bent and hip joints feet. Empty the bladder, treat disinfectant solutions external genitalia and the inner surface of the thighs of the 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 the attempts, the operation is performed under anesthesia.

OPERATIONAL TECHNIQUE

General technology operations

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

· The right spoon is held with the right hand and inserted into the right side of the mother's pelvis 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 large sizes head or too high position of the spoons on the fetal head, when the tops of the spoons rest against the head and the head curvature of the forceps does not fit it - it is advisable to remove the spoons, conduct a second vaginal examination and try again to apply the 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, serious complications may occur, such as lack of advancement of the head and slipping of the spoons from the fetal head, the prevention of which consists in clarifying the position of the head in the small pelvis and correcting the position of the spoons.

If the forceps are removed before the head erupts, then first the handles of the forceps are spread apart and the lock is unlocked, then the spoons of the forceps are removed 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 variant of the operation. The head is located in the narrow part of the small pelvis: two-thirds of the sacral cavity and the entire inner surface of the pubic joint are occupied. With vaginal examination, the ischial spines are difficult to reach. The sagittal suture is located in a straight or almost straight size of the pelvis. The small fontanel is located below the large one and anterior or posterior to it, depending on the type (anterior or posterior).

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

In the posterior view of the occipital presentation, traction is first carried out horizontally until the first fixation point is formed (the front edge of the large fontanelle is the lower edge of the pubic symphysis), and then anteriorly until the suboccipital fossa is fixed at the top of the coccyx (the second fixation point) and the handles of the forceps are lowered posteriorly, as a result of which extension occurs 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, fulfilling the sacral cavity in the upper part, the occiput has not yet turned anteriorly, the sagittal suture is located in one of the oblique dimensions. At the first position of the fetus, forceps are applied in the left oblique size - the left spoon is behind, and the right spoon "wanders"; in the second position, on the contrary - the left spoon “wanders”, and the right spoon remains behind. Traction is carried out in the direction downwards and backwards until the head passes into the plane of the exit of the pelvis, then the head is released by manual techniques.

COMPLICATIONS

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

FEATURES OF 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 control the function of the pelvic organs.
· IN postpartum period it is necessary to carry out the prevention of inflammatory complications.