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Forceps should not used in a homebirth setting and by individuals that are not fully trained in the proper use of and dangers of these obstetric tools.
DESCRIPTION
The obstetric forceps is designed to grasp the fetal head when it is in the vagina and bring about delivery by traction and guidance without causing injury to the mother or baby. The forceps consists of two arms which are movable.
The blades have two curves.
The cephalic curve is adapted to provide a good application to the fetal head. The pelvic curve allows the blades to fit in with the curve of the birth canal.
There are several kinds of locks:
The pelvic axis necessitates traction "round a corner", so some forceps have detachable handles, rods or tapes which allow traction in the pelvic axis. This technique of "axis traction" should be unnecessary in present day practice. Difficult forceps delivery is avoided by cesarean section.
The traction rods can make the forceps a very powerful and therefore dangerous instrument.
Forceps operations are of two kinds:
Low Forceps
The fetal head has reached the perineal floor and is visible at the vulva.Mid Forceps
Engagement has taken place and the leading part of the head is below the level of the ischial spines.
Application of the forceps when the head is not "engaged" is known as "high forceps". Some suggest that only low forceps should be used and that mid forceps should be replaced by cesarean section.
TYPES OF FORCEPS
There are very many different patterns. The forceps shown here are all well known and are identified with the three main operations - the low forceps, the mid forceps, and the rotation-extraction forceps delivery.
Wrigley's Forceps: Wrigley's Forceps is designed for use when the head is on the perineum and local anesthesia is being used. It is a short light instrument with pelvic and cephalic curves and an English lock.
Milne Murray's Axis Traction Forceps: In theory the axis traction rods which were designed to apply traction to a head high in the pelvis are now obsolete; but in practice they are often of considerable help and the action of the rods allows the forceps blades to move more naturally along the pelvic curve without hindrance from the operator's hands. The forceps has an English lock and an additional screw lock to maintain a firm application, and the traction rods are connected in such a way as to give the best mechanical advantage. This instrument is a little awkward for the beginner, and the traction rods if used may damage the perineum unless a large episiotomy is made. This instrument can be very powerful and therefore very dangerous if not used with caution.
Kielland's Forceps: This forceps was originally designed to deliver the fetal head at or above the pelvic brim, lying in the transverse axis of the pelvis and rotating it when it had reached the pelvic cavity. The forceps is used today for rotation and extraction of the head which is arrested in the deep transverse or occipito-posterior position.
The blades have very little pelvic curve and are virtually an axis traction forceps. A large episiotomy is needed. The shallowness of the curve allows safe rotation in the vagina. Downward traction encourages rotation of the head.
The Claw Lock allows the blades to slide on each other and correct or encourage synclitism of the fetal head as required.
The range of movement allowed by the lock makes it possible to apply lethal compression to the fetal head if the instrument is used improperly.
INDICATIONS FOR THE USE OF FORCEPS
1. Second stage delay. When progress is absent or slow and the laboring woman is tiring, whatever the position of the baby's occiput. This covers a wide variety of attitudes to the second stage; but in general, in the current medical practice it may be said that the second stage should not last over an hour in a primigravida and half-an-hour in a multigravida.
2. Fetal Distress.
3. Maternal Distress. When the mother is exhausted by a long labor or is emotionally unequal to the demands of a second stage labor; or when some condition such as cardiac failure or hypertension makes the effort of the second stage undesirable.
CONDITIONS & PREPARATIONS FOR FORCEPS DELIVERY
1. The cervix must be fully dilated. If the forceps is applied before this stage is reached the operator may produce severe lacerations and hemorrhage.
2. Except when the head is on the perineum, the bladder should be emptied by catheter.
3. The laboring woman should be in the lithotomy position, although some practitioners find delivery easier with the laboring woman in the left lateral position. She must be cleaned and draped and aseptic precautions must be observed. Negligence in this respect will almost certainly lead to genital infection.
4. For low forceps operations local anesthesia may be used provided it is acceptable to the mother. It avoids the risks of general anesthesia and allows the mother to assist in the delivery by bearing down when asked.
5. Epidural anesthesia may be used for pain relief, and this is adequate for low forceps or when little manipulation is required.
6. If general anesthesia is used, it should be given by an experienced anesthesiologist. The stomach must be emptied by gastric suction, the laboring woman should receive pre-medication, and endotracheal intubation is probably the safest technique.
7. Mechanical suction should be available for mother and child, and the head end of the bed or table used for the operation should be capable of being lowered rapidly if vomiting should occur when the mother is under anesthetic.
USE OF ANESTHESIA FOR FORCEPS DELIVERY
LOCAL ANESTHESIA
Local anesthesia for forceps delivery is usually a combination of local infiltration and pudendal nerve block. Lidocaine or xylocaine in 1% without adrenaline solution is satisfactory and up to 50 mls may be used with safety.
Local infiltration is usually all that is needed for low forceps operation.
PUDENDAL NERVE BLOCK
The forefinger is placed on the ischial spine (behind which runs the pudendal nerve) and a long needle is passed via the ishiorectal fossa. When needle point, spine and finger are in conjunction, 5 ml of anesthetic is injected. It is advisable to withdraw the plunger before injecting to make sure that the needle is not in a blood vessel. The needle, preferably a guarded one can be passed per vagina if the practitioner finds it easier.
LOW FORCEPS DELIVERY
MID FORCEPS DELIVERY
DELIVERY WITH KEILLAND'S FORCEPS
THE CLASSICAL TECHNIQUE
The "Classical Technique" is to guide the anterior blade round under the pubis into the space between head and shoulder and then rotate the blade gently in this space in the direction of the "dip" of the blade so that it lies with the fetal curve facing the head and shoulder. The blade is then withdrawn slightly to lie on the head in the usual fashion.
OTHER APPLICATIONS OF FORCEPS
Delivery of the Head in the Occiput-Posterior Position
This is the easiest and often the best method of delivering an infant with the head in the direct OP position. If the head is low in the pelvis it is likely to be deliverable with vary little traction and the fetus is spared the risks of manipulation. A large episiotomy is necessary.
The correct cephalic application is with the head in the OA position as shown. 
Sometimes an oblique grip is obtained by mistake. This is undesirable unless very little traction is needed for delivery. 
If the head is transverse it is permissible to apply the forceps laterally, obtaining an anterio-posterior application. Manual rotation or by Kielland's forceps is better. 
In a breech presentation the safest method of delivering head is by applying the forceps once it has entered the pelvis. 
In a face presentation (mento-anterior) the forceps may be applied direct. (Mento-posterior positions must be rotated.) 
COMPLICATIONS OF FORCEPS DELIVERY
LACERATIONS
1. Perineal tears are inevitable unless episiotomy is done at the right time.
2. Vaginal wall may be split especially if compressed between ischial spine and fetal head or forceps inserted carelessly.
3. Cervical and vaginal tears may be caused during a Kielland's rotation. After delivery the vagina and cervix should be carefully palpated and all damage repaired.
HEMORRHAGE
Except from lacerations, hemorrhage is no more likely than after spontaneous delivery. If the uterus is "atonic" (i.e., if contractions have ceased for some time before delivery) intravenous oxytocin should be given.
INJURIES TO BABY
If the blades have been properly applied, the fetal head should be protected by the rigid case of the forceps blades. Where excessive traction force has been applied, there may be bruising, facial nerve palsy, or depression fracture of the skull.
FAILED FORCEPS
This is an old term which means that an attempt to deliver with forceps has been unsuccessful. The causes are:1. Unsuspected disproportion.
2. Misdiagnosis of the position of the head.
3. Incomplete dilation of the cervix.
4. Outlet contraction (very rare in an otherwise normal pelvis).
TREATMENT
1. If the mother is in good condition and the cause is undiagnosed malposition, an attempt at correction may be made by an experienced practitioner. Antibiotic cover should be started and general anesthesia should be used.
2. If the cause is incomplete dilation of the cervix and mother and child are in good condition, the woman should be given sedatives and given intravenous fluids and antibiotic cover. Contractions should be stimulated with oxytocin to see if labor advances.
3. If disproportion is present, or if the woman is exhausted and lacerated, cesarean section should be carried out. In such circumstances there is a good argument for the classical operation which avoids the edematous and easily torn lower segment.
Information obtained from Obstetrics Illustrated by Garrey, Govan, Hodge, & Callander, 3rd edition.
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