Midforceps delivery

MIDFORCEPS ROY E. MOON, M.D., (Born

AND

DELIVERY”

D. D.

M.D., SAN AKGELO,

WALL,

the Clinic-Hospitccl

of

Son

TEXAS

Angelo)

T

HE high forceps operation has been relegated to the obsolete obstetrical procedures within the past twenty-five years. Everyone in this audience has probably at least at one delivery wished the midforceps had gone with it. The problem of delivering every patient wit,h a minimum of trauma to mother and child is one to which every obstetrician has applied himself. Operative obstetrics has benefited in all branches as a result of this effort. Dieckmannl states, “Forceps delivery requires teaching and practice, a very definite knowledge of fetal and pelvic anatomy, of physics and of engineering. The man must also be adept with his fingers. ” In general, a higher incidence of low forceps has reduced the fetal and maternal trauma in midforceps because the operator becomes more adept. Version and extraction is in disrepute because it is done so infrequently that we are all inexperienced, and bad results are inevitable. Dieckmann also says, “I do not subscribe to trial forceps or to gentle trial forceps. I do not, know what either procedure is. I believe that the properly trained man can determine on vaginal examination, which is done if necessary under anesthesia, whether or not he can safely deliver the baby with forceps. If he is in doubt, he should have consultation with someone who can determine this fact. ” While we admit the truth of these statement,% it can do no harm to point out that we are less certain of our ability to decide whether to perform a cesarean section or a vaginal delivery-and, once decided, to justify that decision. We can measure the bony pelvis with a fair degree of accuracy, but as yet no one claims to be able to measure the fetal head accurately in all cases. About twenty years ago the concept of “t,rial labor” was started and seemed on the surface to render unnecessary any detailed information about the size of the fetus or the size and shape of the pelvis. Actually, the opposite has been shown to be true. Douglas and KaltreideP have advocated “tria.1 forceps” in midpelvic arrest. since bony disproportion represents only one cause. Midpelvic arrest may occur from cephalopelvic disproportion, from malposition of the fetal head, or from uterine inertia. Not infrequently in the latter two vaginal delivery is easy and safe. After a prolonged labor all of us have been faced with delivery we thought would be difficult or even impossible, only to have it terminate without the slightest difficulty. It is not uncommon for a patient who has had a cesarean section for cephalopelvic disproportion subsequently to delivery spontaneously a larger baby. Trial forceps may show that we are unable to determine on vaginal examination whether we can safely deliver a baby with forceps, but trial forceps are routine at the Clinic-Hospital of San Angelo. *Presented cologists. Dallas,

at

the Texas,

Annual Feb.

Meeting 18, 3956.

of

the 954

Texas

Association

of

Obstetricians

and

Gyne-

Volrme

i?

Number i

MIDFORCEPR

DELI\-ERT

955

Greene and SmithlO state that an occiput transverse or posterior presentxtion should always be corrected before any traction is exerted to deliver the baby. As a routine, this is certainly true except when the head is excessivrl> molded. This excessive molding may be, as he says, due to a prolonged second stage. WC do not as a rule rotate the head if it descends without, difficult) with traction. If it, does not descend, it is pnshcd up and rotated. with the use of Bill’s maneuver. The term “undue force” recurs in each article concerning forceps delivery, but it defies definition. A definition referred to ‘rr RrothcrZ states t,hat “it is the amount of force which can be applied to the forceps with the rollers of the table unlocked without. moving the table.” In our patients with midpelvic arrest, a normally flcscd hcacl in an occiput anterior position gives more of a problem than a head in malposit.ion at the same 11~vcI. This was true of Taylor’s’ cases also. In 68 per cent of our cases of midforccps. t,hc occiput was rotated from posterior or transverse before delivery, and itI fi ptr cent of the cases the occiput was clcli~crcd in the posterior position witholr t rota1 ion. [nterest in the baby has increased in recent, years. There are at lea.4 t,hrcci recent articles”, 5l c concerning birth injury with follow-up for as long as 3tl years. These are practically in agreement that the midforceps delivery results in a slightly higher stillbirth rate, but those who survive are no worse off than babies born spontaneously. Corstonj followed 430 cases, some for as long as 33 to determine the limits of safety of the “squeeze effect,” in mild disproportic~tl with or without a forceps delivery. Apnea in t.he newborn defies an unequivocal solution. Anoxia in the newborn can eausc damage, but who can assess tllcx damage or the cause in a baby who survives? Anesthesia, analgesia, trauma. ant1 placental circulation are always set against developmental and hereditary influences as the cause of retarded development. At the present timr thcrc is 1~1 clear-cut case against midforceps delivery, but considerably more data a P, necessary. Taylor has offered some reasonable data against the midforceps operation. Out of 10,055 deliveries, there were only 31 midforceps operations. Of these. 8 infants were stillborn (26 per cent) and 7 more suffered a demonstrable birth injury (total 48 per cent). In addition, 1.6 of the mot,hcrs had evidence of in-. jury ( lacerations, shock, hemorrhage, etc.) sufficient to require treatment. &I?~

8 of the patients had any degree of contracted pelvis and in none of these was the pelvic contraction sufficient to warrant, abdominal delivery without a trial of labor. AS given, this represents a st,rong argument against the midforceps operation. We would give up the operation in our practice if our figures even approached those. There are those who say, and I agree fully, that traumatic vaginal delivery should be replaced by cesarean section. Some3 even state the solution by saying that a cesarean section rate of 6 per cent should eliminate these undesirable vaginal deliveries. But the fact, remains that an increase of even 10 per cent or more has not eliminated them in any institution which has published its statistics to date. It is true that many institutions such as the Chicago Lying-in Hospital have reduced the incidence of midforceps delivery from 3.9 per cent in 1931 to 1.5 per cent in 1954, and increased the cesarean section rate correspondingly, but they have not eliminated the occasional difficult midforceps delivery. At the Clinic-Hospital of San Angelo there are two obstetricians who have delivered all the patients studied. In general the patients are all handled in the same way. We have performed 3,308 deliveries between January, 1951, and December, 1955. There were 131 midforceps operations (3.9 per cent), 873 low forceps operations (26.4 per cent), 116 breech deliveries (3.5 per cent) ; 106 cesarean sections (3.2 per cent), and 2,082 spontaneous deliveries (63 per cent). There were 30 stillborn babies (0.9 per cent), only 2 of whom were delivered by midforceps. In both cases no fetal heartbeat could be heard when delivery was started. There were 40 neonatal deaths (1.3 per cent) and only one of these infants was delivered by midforceps. In this case there was no question-the baby was damaged by the delivery. The others were either spontaneous or low forceps. Two were delivered by cesarean section. With one exception (listed above) we have no regret for having done 131 midforceps operations.

Indications

for Midforceps

Delivery

The indication for every particular midforceps operation is not specific. In many, several factors operate simultaneously. Uterine inertia is certainly a factor contributing to a higher midforceps rate, but we have never given this as the direct indication. We do not consider labor to be an endurance test between mother, baby, and the doctor. We feel that active intervention is sometimes more conservative than a “wait-and-see” attitude. Dieckmann is correct in saying that it is all right to watch a patient if you are watching for something and Failure to progress after are prepared to recognize when this is accomplished. the cervix is fully dilated should be explained. By far the most common indication was occiput posterior position (84 per cent), with occiput transverse position (2 per cent) an occasional occurrence. Cephalopelvic disproportion with the occiput in the anterior position represented most of the remaining cases. Fetal distress was an occasional indication. This was associated with dehydration in the mother in a prolonged labor, as a rule (with some distress in the doctor). Partial separation of the placenta with bleeding occurred in 3 cases. Sedation as a cause of midpelvic arrest is not considered an important factor when taken alone in any case. By most standards we use heavy sedation in all of our patients. Our opinion is that lack of analgesia reduces voluntary effort more than oversedation. Midforceps delivery of the second twin (8 cases) has caused no trouble in the group studied.

Volume 72 Number 5

MIDFORCEPS

DELIVERY

!I517

Management At the Clinic-Hospital, we ordinarily try to deliver vaginally any patient in whom the cervix is completely dilated with the head engaged, even if we think it to be impossible. No figures are available on which cases we thought would be impossible because our records do not show all of our thoughts, but it is not an uncommon occurrence. We have almost adopted “trial forceps” as a routine. This applies to the midforceps and low forceps; no high forceps application or deliveries have been attempted. Our records show no attempts to rotate a malposition of the head if the head is not fully engaged. We do sometimes allow an hour or two more of labor in the second stage in such a patient, but as a rule elect abdominal delivery after two hours in second stage. In this group of trial forceps, we have had 11 cases of failed forceps in which c(‘sarean section was done for delivery. None of these resulted in stillbirth or neonatal injury or death (one infant had a one-side facial paralysis t,hat elearcd in one week). Of the 11 cases, 3 were occiput anterior, 4 were occiput posterior which were corrected by forceps rotation but still could not be delivered, 3 were molded and we considered the force necessary to rotate to be excessive; and in one a brow presentation was ronverted to occiput posterior, but could not be rotated with ease. No serious attempt to deliver this was made. These were all large babies except one (7 exceeded 81/2 pounds). The largest weighed 11 pounds, 14 ounces, and the one normal-sized baby weighed 7 pountls, 8 ounces. X-ray pelvimetry had been done on all except 2 patients. S-ray evidence of disproportion (of a mild degree) was present in only 4 of these patients. In adopting a test or trial of labor and in attempting trial forceps, we try to approach any questionable delivery without forming a final opinion. WV have less trouble with cases we have considered questionable than with an occasional case that, comes as a complete surprise. The 2 cases above in which x-ra) pelvimetry was not done were complete surprises and in one of these the effort at forceps delivery resulted in the baby with a temporary facial paralysis. Wc would like to think that (1) every vaginal delivery is approached with a firm resolve not to injure mother or child; (2) no vaginal delivery is done simply t,o avoid a cesarean section; (3) once a delivery is started, it is only st,arted and the end is not necessarily committed.

Comment Our uncorrected stillbirth rate was 0.9 per cent and the uncorrectetl neonatal mortality rate was 1.3 per cent. These include any fetus exceeding 20 weeks’ gest,ation and does not exclude congenital deformities incompatible with life. We arc in no way comparing our figures with those of Taylor-there are too many intangible factors. Even so simple a thing as establishing the station 01 the head is not so simple; a molded head with a caput has confused us even with vaginal examination. Ordinarily if the apparent position of the skull bones of the baby is at the ischial spines or below, we consider it in the midpelvis. The size of the baby, the degree of molding of t,hc baby’s head, and the force of the uterine contractions we can only estimate. We have practically adopted “test of labor” and “trial forceps” in cases of vertex prcscnt.ation with mild pelvic contraction or mild cephalopelvic disproportion. These would be more intelligent if we had an accurate method fox measuring t,he fetal head.

958

MOON

AND

WALL

The study of postpartum tissue injuries in the mother is apropos in a st,udy of midforceps deliveries. However, we have been unable to correlate these injuries wit,h the midforceps operations we have done. It is obvious that injuries to the vagina are more common in midforceps deliveries than in low forceps deliveries but if properly repaired the final results may be identical. There were no maternal deaths in this group of 3,308 deliveries. Morbidity studies show no significant increase in morbidity in the women delivered by midforceps when compared with those who have spontaneous deliveries.

Conclusion We have studied 3,308 deliveries done in private practice of which 131 (3.9 per cent) were midforceps operations. The results obtained leave something to be desired, but compare favorably with all types of deliveries. We doubt that midforceps should be discarded in favor of cesarean section in all cases (our rates are 3.9 and 3.2, respectively, at present). We desire very much to eliminate traumatic midforceps deliveries and plan to do so, but up to the present we have occasionally failed. We also desire to avoid unnecessary abdominal deliveries, but, by the same token, we occasionally fail. References 1. 2. 3. 4. 5. 6.

Dieckmann, Douglas, Morgan, Taylor, Corston, Eastman, 7. Gainey, 8. Gibberd, 9. Thorns, 10. Greene,

W. J.: AM. J. OBST.& GYNEC. 69: 1005,1955. L. H., and Kaltreider, D. F.: AM. J. OBST. & GYNEC. 66: 889, J. E., and Reyes, C. T.: AM. J. OBST. & GYNEC. 59: 1193, 195.5. E. S.: Obst. & Gynec. 2: 302, 1953. J. M.: AM.J.OBST.& GYNEC.~~: 263,1954. N.J., and de Leon,M.: AM.J.OBST.& GYNEC.~~: 950,1955. H. L.: AM.J.OBST.& GYNEC.~~: 800,1955. Aa6.J. OBST.& GYNEC.~~: 1284,1953. G. F.: AM. J. OBST. & GYNEC.~~: 424,195O. H., and Wyatt? R. H.: G. G., and Smith, A. E. M.: AM. J. OBST. & GYNEC. 66: 611, 1953.

1953.