KIELLAND OBSTETRICS FORCEPS

 KIELLAND OBSTETRICS FORCEPS:

Kielland’s Obstetric forceps:

• Long, straight (very slight) pelvic curve.
• It has a backward or a perineal curve on the posterior aspect.
• Overlapping shanks (upper and lower)
• A sliding lock allowing application to asynclitic heads.
• Light weight
• Main indication: rotation of the head and for application to asynclitic heads.
• Disadvantages: an unstable lock predisposes to cervical and vaginal lacerations

     Action of the forceps:

1. Traction on the head (the main action).
2. Rotation of the head.
3. Compression of the head (this should be minimal to avoid intracranial hemorrhage).
4. Stimulation of uterine action.
5. Dilatation of the vulva.
6. One blade can be utilized to dislodge the head out of a lower segment cesarean section incision.

Indications of forceps delivery:

1. Maternal
   1. Threatened dangers to the mother (prophylactic forceps):
      • Toxemia of pregnancy (pre-eclampsia and eclampsia).
      • Previous cesarean section
      • Weakness in the abdominal wall (hernias and a history of a recent abdominal operation).
      • Associated disease, e.g. Diabetes, heart disease, lung disease, chronic nephritis, hypertension, etc.
   2. Rigid pelvic floor and perineum
   3. Uterine inertia
   4. Maternal distress

2.Fetal

1. Threatened dangers to the fetus (prophylactic forceps), as in the case of prolapse of a pulsating umbilical cord
2. Abnormal presentations and positions: occipitoposterior, deep transverse arrest, face presentation, after-coming head.
3. Large sized fetal head
4. Fetal distress

3.Prolonged second stage of labor

1. Over 1-2 hours in multiparae or 2-3 hours in primigravidae, depending on the uterine activity.
2. When the head is on the perineum for one hour or more

Conditions to be fulfilled before forceps application (pre-requiites):

1. A deliverable cephalic presentation.
2. Engaged head
3. Empty bladder and rectum. (Dangers of a full bladder: genito-urinary fistula, rupture of the bladder, failed forceps, atonic post-partum hemorrhage, and stress incontinence).
4. Fully dilated cervix. Otherwise it might cause trauma to the cervix causing cervical tears or uterine prolapse (remote complication).
5. Use of anesthesia.

        Allows proper application and extraction and avoids the development of obstetric shock.

        It can be either: pudendal nerve block, low spinal or saddle block, epidural or general anesthesia.

6. Some uterine contractions must be present. Delivery with the obstetric forceps in the complete absence of contractions is followed by severe post-partum hemorrhage.
7. Ruptured membranes.
8. Episiotomy. Not always done, it is mostly indicated for primigravidae with rigid perineum

Complications:

1. Fetal
   1. Asphyxia (intracranial injury, aspiration, cord compression and anesthesia)
   2. Fracture of the skull bones
   3. Intracranial hemorrhage
   4. Nerve lesions: Bell’s pulsy, Brachial plexus injury.
   5. Lacerations and contusions of the scalp and cephalhematoma which might get infected and forms an abscess.

(B)Maternal

1. Risks of anesthesia.
2. Traumatic lesions of the lower uterine segment, cervix, vagina and perineum.
3. Sepsis
4. Obstetric shock

5. Bone injuries:

         Separation of the symphysis.

         Dislocation of the sacro-iliac joint; this may be followed by a waddling gate, and severe low backache 

Fracture of the coccyx or its dislocation from the lower end of the sacrum.

6. Post-partum hemorrhage (traumatic, or atonic if delivery is  completed in the absence of labor pains).
7. Vesico-vaginal fistula and stress incontinence. The former results either from direct trauma to a full bladder during application or extraction, or from ischemic effects of prolonged compression in protracted labor.