A method for eliminating difficult midforceps rotations

OBSTETRICS

A method for eliminating

difficult midforceps

rotations A reappraisal

CHARLES MICHAEL Brooklyn,

New

of the Leff forceps

A.

WEXLER,

S.

BURNHILL,

M.D. M.D.

York

The method of applying the short-bladed, Lefi forceps for occiput posterior and occiput transverse presentations is described. This instrument was used for 9 per cent of all midforceps deliveries at The ]ewish Hospital of Brooklyn from 1961 to 1965, with minimal fetal and maternal trauma. It is suggested that trial with a Leg rotation should be the first step in the management of midpelvic malpresentations so as to eliminate the trauma produced by a classical forceps rotation.

Description of the forceps and method of application As can be seen from Figs. 1 and 2 where the Leff forceps is compared to both a Kjelland and Elliot forceps, the most striking characteristic of the instrument is the shortness and straightness of the tips of the blades. They are in fact 35 to 40 mm. shorter than the usual forceps and the abbreviated cephalic curve makes them incapable of applying traction to the fetal head. It is obvious that these blades are useful only for rotation because their thin, narrow tips allow them to be applied where the hand cannot fit and where the application of longer blades requires greater skill. Fig. 2 shows the presence of a slight pelvic curve that enables the fetal head to be rotated without the blade traumatizing the upper vagina. The lock is of the pivot and notch type. The bar on the end of the handles is to lock the forceps after they have been applied. The screw locks the bar

T H E w E L L - T R A I N E D obstetrician of the twentieth century relies less on the use of forceps than was customary with his predecessors. Indeed, the liberalization of the indications for cesarean section has resulted in many younger men finishing residencies who are largely unfamiliar with the subtleties of midforceps deliveries and of the hazards posed by varying pelvic architecture.5 The purpose of this paper is to describe the Leff forceps* and its method of application so as to revive interest in this particularly safe and efficacious instrument and to outline an approach to midforceps rotations that eliminates the more difficult and traumatic rotations. From

The

Jewish

Hospital

of Brooklyn.

Read at a meeting of the Brooklyn Gynecologic Society on May 17, 1967. *Manufactured bv Grimm d Norton Company, 240 East 26th Street, New York, New York.

3

4

Wexler

and

Burnhill

Fig. 1. Comparison and the rotating

Amer.

of Kjelland, Elliot, “wings” on the handle

and Leff forceps showing of the Leff forceps.

in place and also indicates the convex side of the pelvic curve. The “wings” are grasped for rotation. The method of application is similar to that for other forceps. It has been described b Y Leff I3 Friedman lo and by Posner, Friedman, a)nd Posner.2d The latter included a series of clear line drawings showing the method of application and recommended its use only for rotations when the head is on the pelvic floor. In direct posterior presentations either blade can be introduced first. In transverse presentations it is preferable to introduce the anterior blade first. This is done in the posterior oblique position and wandered with the index finger over either the occiput or face. The posterior blade is then introduced, also in the posterior oblique position, and wandered to its proper position in relationship to the anterior blade, Follow-

the absence

of cephalic

January I, 1970 J. Obstet. Gynec.

curve

ing this, the bar and screw locks are then set. With the forceps in proper position their relationship to the fontanels and the “touch picture” obtained should be the same as with any other forceps. The thumb and forefinger are then placed over opposite surfaces of the protruding wings and rotation is accomplished by twisting in the desired direction. This can generally be accomplished at station or with only a slight upward displacement. The fetal head should be slightly over-rotated as there is a tendency for the head to slip back when the blades are removed. If the head should restitute after an easy Leff rotation and prior to the application of the second forceps, the operator may resort to a Kjelland forceps secure in the knowledge that there was no pmnounced cephaIopeIvic disproportion present. After rotation one Leff blade is remo\,rd and

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106 1

Fig. 2. Comparison present

of Elliot, Leff, in the tips of the Leff forceps.

and

Kjelland

a standard blade (i.e., Elliott) is applied. The other blade is then removed and the second standard blade applied. Extraction is then performed in the usual fashion. Material

From 1961 to 1965 there were 20,500 vaginal deliveries at The Jewish Hospital of Brooklyn. During this time there were 1,234 midforceps deliveries. Of these, 106 or 9 per cent of the midforceps deliveries were Leff forceps rotations. There were no failed rotations or fetal or maternal deaths ascribed to the Leff forceps. The case material is analyzed in Tables I through IV. Table I shows the age of each patient, parity, and the station of the fetal head prior to application of the Leff forceps in 106 women. Table II shows the type of anesthesia used

forceps

Table

showing

Midforceps

rotation

the

pelvic

slight

forceps

5

curve

I Parity

Age 15-19

=

13

20-24 = 52 25-29 = 24 30-34 = 11 35-39 = 4 40= 2

0 =

69

1 = 21 2= 8 3= 3 4= 1 5= 4

Station +1 =

17

+2 = 50 +3 = 35 +4= 4

for the delivery, the position of the head prior to the application of the forceps, and the utilization of oxytocin. Table III shows the total length of labor, the length of the second stage of labor, and the number of maternal genital lacerations. Table IV gives the distribution of babies by birth weight and Apgar index. A composite profile for this series of midforceps rotations indicates that 84 per cent of the mothers were less than 29 years in

6

Wexler

Table

and

January 1, 1970 Amer. J. Obstet. Gynec.

Burnhill

II Position

Anesthesia Cyclopropane Epidural Pudendal

Table

= = =

45 44 17

ROT, ROP, OP

LOT LOP

= = =

47 45 14

Table

III

Length labor

Pitocin

of

0- 4hr.=14 4- 8 hr. = 36 8-12 hr. = 30 12-16 hr. = 15 16-20 hr. = 11

Duration of second stage 30 min. 30-l hr. 1-1% hr. l%-2 hr. 2 hr.

= 33 = 42 = 23 = 5 = 3

Fetal Lacerations Cervix Vaginal

= =

9 4

age; 85 per cent were primigravidas or secundagravidas; 75 per cent had a total labor less than 12 hours; oxytocin stimulation or induction was employed in 76 per cent; the second stage was less than one hour in 71 per cent, and less than 1M hours in an additional 22 per cent; the oblique posterior or transverse position in 87 per cent; cyclopropane or epidural anesthesia was used equally in 84 per cent of the deliveries; 12 per cent of the women had cervical or vaginal lacerations; 76 per cent of the babies weighed between 6 and 8 pounds, the remainder were approximately equally distributed between the lower and higher birth weights; and finally 92 per cent of the babies had Apgar scores greater than 7. Nine infants had Apgar scores under 7. Of these, one had premature separation of the placenta; one had a loop of cord tightly around the neck; one had heavy sedation 2 hours prior to delivery consisting of Sparine 50 mg. and Seconal gr. 3, Demerol 100 mg., and Scopolamine gr. ysoo; 2 cases had prolonged second stages of 3 hours; one case was a difficult delivery utilizing Luikert forceps with a Bill handle; 3 patients had prolonged cyclopropane anesthesia, one for 16 minutes, one for 10 minutes (which had a prior attempt with Barton forceps), another for 10 minutes (which had a prior attempt with Kjelland ,forceps) . This case is presented be-

None Stimulation Induction

= = =

25 76 5

IV sire (pounds) 5= 5-6 6-7 7-8 8-9 9=

= = = =

2 12 38 43 10 1

A$gar 9-10 8 7 6 5 5

score = = = = = =

64 25 8 ; 1

low. The cervical and vaginal laceration were all described as abrasions or small the exception of the case presented. Case report B. R., a 30-year-old para O-O-O-O, with an estimated date of confinement of Aug. 29, 1962, began labor at 1l:OO A.M. on Sept. 19, 1962. At 4:40 P.M. the cervix was fully dilated, +l, ROP. At 5: 35 P.M. it was +3, ROP. The patient was brought to the delivery room, general anesthe%ia was administered, and a Kjelland rotatitjn attempted. It was found, however, that the pas terior blade could not be applied despite extensive manipulation. At this time the Leff forceps were easily applied, the vertex rotated to occipitoanterior position, and a living male infant weighing 6 pounds, 10 ounces, Apgar 2, was extracted with Elliott forceps over a right mediolateral episiotomy. There were extensive cervical and vaginal lacerations requiring blood transfusions. The postoperative course was complicated by cystitis and a transfusion reaction. Comment There is an almost universal consensus of opinion that very difficult midforceps deliveries should be eliminated. Indeed the obstetrician of the present decade is considerably more likely to perform a cesarean section than attempt a difficult midforceps rotation. This trend is apparently carried over to the obstetric literature. NeumannI could only find 25 articles on midforceps deliveries

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106 1

in the American literature and 7 in the French literature from 1952 to 1962. This he felt indicated declining interest in midforceps techniques. Neumann expressed the philosophical viewpoint that instrumental vaginal delivery should not provide added trauma to the fetus. His attitude is that a trial of forceps is an attempt at delivery under conditions determined and recognized in advance which provides minimal risk to mother and fetus if the procedure proves to be easy. If the trial proves to be difficult a cesarean section is done immediately. Danforth and Ellis5 reviewed 461 indicated midforceps deliveries. They found 50 (14.7 per cent) followed by cervical lacerations, 19 (3.9 per cent) by postpartum hemorrhage, and only 6 by other relatively minor maternal complications. Four babies had cephalic trauma attributable to the forceps application. They felt that adequate training in midforceps deliveries made the procedure a safer one than cesarean section. Parry- Jones, I8 the British authority on the Kjelland forceps, found the incidence of complications following the use of the forceps to be relatively low. I’n his series of 1,052 occiput posterior or transverse positions (from 37,000 vaginal deliveries), 233 were delivered using Kjelland forceps. Sixteen Kjelland applications failed, 5 of these due to an inexperienced operator. Four vesicovaginal and one urethrovaginal fistula were noted post partum. Eleven of the author’s personally delivered 60 patients had hematuria following the delivery. Twelve fetal deaths were felt to be related to the midforceps procedure. Nyirjesy and ‘PierceI note no increase in the fetal survival when cesarean section is employed more liberally. There was a slight but not statistically significant increase in vaginal lacerations and postpartum hemorrhage in their midforceps group. However, they admitted they had no long-term followUP* Despite the safety of most midforceps procedures, a review of some of the literature on fetal damage shows clearly that there are still babies being injured by traumatic vaginal

Midforceps

rotation

forceps

7

procedures. MorrisonlS found in two series of stillbirths (Belfast and Chicago) that 11 per cent were related to a traumatic birth. In a second series that he reviewed the range was from 3 to 23 per cent of the stillbirths following traumatic delivery. Potte? noted a range from 20-40 per cent of deaths during or following delivery caused by intracranial hemorrhage. Perlsteinlg noted a history of difficult delivery in one third of infants with brain injury. This was based on a retrospective study of 4,500 children. Malamud,14 in studying 162 brain-injured children, noted that 86 per cent of 101 children with subcortical damage had had a traumatic birth. Courville,4 on the other hand, could only find a history of trauma in 20 of 441 injured children (0.045 per cent). Steer and the background of cereBonney,“2 studying bral palsy in 3 17 children, could only find direct injury as a factor in 5 cases. On the other hand, Browne,’ in reviewing a series of 462 midforceps deliveries, focused attention on the roughly 25 per cent incidence of forceps deliveries found in the history of children with cerebral palsy. Eastman and his co-author? studied a series of 753 cases of cerebral palsy where the infants were matched with a control series of infants born to mothers of a similar background. The incidence of midforceps deliveries was twice as high in the palsied group. It was also noted that “poor condition” at birth was also observed much more frequently in the midforceps (and breech) deliveries. In their series 10.5 per cent of the mature babies who had cerebral palsy were found to have had midforceps deliveries. In their own words, g “It is well known that in some cases midforceps deliveries may be easy and relatively innocuous, while in others it may be exceedingly difficult and traumatic. The main circumstances governing the ease or difficulty of the operation are the station of the head, the presence or absence of midpelvic contraction, and the skill of the operator. . . . The pronounced difference between the condition of the baby in the two series of midforceps and breech deliveries (the cerebral palsy series and the controls) would

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Wexler

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indicate that these operative procedures in the cerebral palsy series were difficult and traumatic.” Dill’ devoted a chapter to the mechanism of fetal injury during midforceps procedures. Cooke,3 in a study of midforceps deliveries, noted that this operation accounted for 6 per cent of the total number of deliveries. Approximately 2 per cent of the total number of deliveries were classified as difficult midforceps and this small group accounted for 65 per cent of the birth canal trauma, 52 per cent of the postpartum hemorrhages, 66 per cent of the postpartum urinary tract complications, 90 per cent of the fetal trauma, and all of the severely depressed babies found in the total midforceps group. The author makes a plea for elimination of the difficult midforceps delivery. LeP in 1955 described his forceps which he felt represented an extremely safe and simple instrument for midforceps rotation, Apparently this instrument was largely overlooked, as it does not appear in the standard obstetric textssl l1 or books on forceps deliverieP> I2 or discussions in managing transverse or posterior position17 5 The authors feel that this instrument has been unjustly neglected. In this era of modern obstetrics where greater attention is being focused on the long-range results to mother and baby, on mental retardation, cerebral palsy, and minimal brain damage syndromes, a method must be sought which separates easy from difficult midforceps rotations. In the search for neither doing an unnecessary cesarean section nor leaving the

REFERENCES

Anderson, D. G.: Clin. Obst. & Gynec. 8: 867, 1965. 2. Browne, A.:J. Obst. & Gynaec. Brit. Emp. 72: 866, 1965. 3. Cooke, W. A. R.: AM. J. OBST. & GYNEC. 99: 327, 1967. 4. Courville, C. B.: Bull. Los Angeles Neural. Sot. 28: 209, 1963. 5. Danforth, D., and Ellis, A.: AM. J. OBST. & GYNEC. 86: 29, 1963. 6. Dennen, E.: Forceps Deliveries, ed. 2, Philadelphia, 1964, F. A. Davis Company. 1.

Amer.

January J. Obstet.

1, 1970 Gynec.

mother with a damaged body or baby because her physician persisted with a difficult midforceps rotation, the Leff forceps finds its place, especially with the increasing use of conduction anesthesia. With long-bladed forceps, it is relatively simple to rotate the blades, producing severe maternal and fetal damage if the operator is not aware of his own strength. The short tips of the Leff blades will slip off before the damage is done. It can be easily applied where a Kjelland or Barton blade may be difficult. Its short blades do not traumatize the upper vault, cervix, or lower uterine segment. Rotation can be accomplished with relative ease in dl but the most difficult of cases. The safety of the rotation far outweighs the awkwardness of the double application of blades. The Leff forceps eliminates many of the difficulties of midforceps rotations. Its use can be easily taught, requiring a considerably shorter training span and less experience to be well used. The forceps accomplishes rotation easily except where a midforceps contraction makes a rotation dangerous and dI& cult. Assuming all criteria for midforceps, SI& as station of the vertex and no gross c&proportion are met, the authors feel that 8 trial Leff forceps rotation should be &tempted as the method of choice for all o ciput transverse or posterior presentatic Failing this, a cesarean section should performed to safeguard both mother zg baby.

7

Dill, L.: The Obstetrical Forceps, field, Illinois, 1953, Charles C Thorn lisher. 8. Eastman, N., and Hellman, L.: Wil stetrics, ed. 13, New York, 1966, Century-Crofts, Inc. 9. Eastman, N., Kohl, S., Maisel, J., Kavaler, F.: Obst. & Gynec. Surv. 17: #$#t$ 1962. 10. Friedman, S.: Harlem Hosp. Bull. 10: 86, 1957. 11. Greenhill, J.: Obstetrics, ed. 13, Philadelphh, 1965, W. B. Saunders Company. ”

Volume Number

12.

13. 14. 15.

16. 17. 18.

106 1

King, E.: Occiput Posterior Positions, Springfield, Illinois, 1957, Charles C Thomas, Publisher. Leff, M.: AM. J. OBST. & GYNEC. 70: 208, 1955. Malamud, N.: J. Neuropath. & Exper. Neurol. 18: 141, 1959. Morrison, J. E.: Foetal and Neonatal Pathology, Washington, 1963, Butterworth & Company, Ltd. Neumann, E.: Bull. Fed. Sot. GynCc. et Obst. 15: 399, 1963. Nyirjesy, I., and Pierce, W.: AM. J. OBST. & GYNEC. 89: 568, 1964. Parry-Jones, E.: Kiellands Forceps, London, 1952, Butterworth & Company, Ltd.

Midforceps

19.

20. 21.

22.

rotation

forceps

9

Perlstein, M.: Perinatal Brain Injury with Special Reference to Cerebral Palsy, in Greenhill, J., editor: Obstetrics, ed. 13, Philadelphia, 1965, W. B. Saunders Company, chap. 72. Posner, L. B., Friedman, S., and Posner, A. C.: Obst. & Gynec. 11: 65, 1958. Potter, E. L.: Pathology of the Fetus and Infant, ed. 2, Chicago, 1962, Year Book Medical Publishers. Steer, C. M., and Bonney, W.: AM. J. OBST. & GYNEC. 83: 526, 1962. 450 Clarkson Avenue Brooklyn, New York

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