Forceps seem to be controversial in some quarters. To be clear, I don’t find them at all controversial nor do my patients by and large. But I realize that for some, forceps are the standard bearers for all that is intrusive and perhaps malevolent in obstetrics. Everybody seems to have an aunt or second cousin somewhere that has had a bad experience with them, so I have had several requests from readers to comment on the use and abuse of forceps. I speak only from my own experience, naturally, and am not suggesting that everybody would agree with me. Speak to your own doctor if you are confused.
First of all, a little background. When labour has been hard and perhaps slow, and the baby’s head has not descended along the vagina despite a completely dilated cervix, prolonged pushing, and the passage of time, decisions have to be made. There are several options -there are always options… First, one could continue to observe and see whether progress occurs. There might be problems with this approach of course: maternal fatigue, increased swelling of the tissues around the opening of the vagina that would be more likely to tear as the head and body of the baby pass through, and the fact that the mother has likely been pushing for a considerable time already with no progress. But, as long as there are no other contraindications to waiting -like an abnormal fetal heart rate pattern, or maternal fever, to name but two- it is still an option the couple may wish to choose.
A second option is to do a Caesarian section. There is nothing wrong with this option of course, but for many people surgery is something they would rather avoid unless absolutely necessary. If the baby is in trouble, few would argue -including me. But often things are not so clear-cut: the baby ‘s heart pattern on the monitor is normal, the woman is exhausted, but not ill, and she is frustrated at the lack of progress. She wants her baby -ideally with minimal fuss, and soon.
A third option presents itself: helping the baby to come out, but vaginally. This assumes that the baby’s head is low enough and likely to fit through the vagina of course -in other words, deliverable but not so far. And there are two choices for this: vacuum and forceps. Vacuum first. There are several types of vacuum currently available and all work on the principle of a suction cup on the baby’s scalp. Common sense suggests the method is only applicable to situations where the head is so low that pulling on the skin of the head would be likely to make a difference. To be honest, I do not like the method, but I concede that in untrained hands, it is probably the safer of the two choices because the vacuum usually is not strong enough to do much damage -i.e. the suction cup comes off if you pull too hard.
But if the head is a little further up inside the vaginal canal, and the mother has been unable to push it further using both the contractions and her own expulsive efforts, vacuum isn’t likely going to work either. Here’s where forceps might be useful.
A word about forceps. No, they are not like salad tongs that work by squeezing to gain their traction, and certainly not like vice-grips. Properly applied and skillfully employed, they work more like a helmet that forms a dilating wedge in front of the head to help it to travel along the vaginal canal. Yes, they make contact with the head -so does a helmet- and yes, traction is applied by the obstetrician, but only in conjunction with a uterine contraction and active pushing by the mother. A dilating wedge requires traction to open the way for the head and the head has to follow in close proximity to the wedge…
But there are many different types, shapes and sizes of forceps. Without getting into the names and the multiple conditions for each type, let me say that there are several basic requirements that need to be considered before, during and after the use of forceps. First of all, the head has to be low enough in the vagina to apply the forceps; secondly the blades of the forceps should be thin -after all they have to fit between the head and the skin of the vagina without injury; and thirdly, the shank of the forceps should be narrow so that undo pressure is not exerted on the vaginal opening until the head actually reaches it.
At that point -when the head is ‘crowning’- the forceps can be removed and the woman deliver the baby on her own. The dilating wedge has succeeded; the head is where the woman was trying to get it in the first place with all her pushing. There are many techniques, of course, but I do not do an episiotomy with forceps -or any time, for that matter (unless there is a dire emergency). By taking off the forceps in a timely fashion, damage to the area is minimized and likely equivalent to what the head would cause had the mother been able to deliver it on her own and without help. Even without the episiotomy, patience and allowing the tissues to stretch as the head begins to emerge from the vagina allows for deliveries that are well tolerated by both mom and baby -often without stitches, often without tears.
I’ve only scratched the surface of the topic of forceps I realize; I just wanted to introduce the idea and perhaps clarify it a little for further and hopefully less passionate discussion. The use of forceps, like much of medicine, requires practice and skill, not to mention judgement and knowledgeable consent from patient and partner. They are only one tool in a box of many tools, but one that is extremely useful and also safe -in the right hands.