Forceps or cupping assisted delivery

Forceps and suction cups: how and when to use them

Forceps or cupping assisted delivery

Dr. Miguel Ángel Herráiz Martínez , Head of Obstetrics at the San Carlos Clinical Hospital in Madrid

Dra. D. Rosario del Moral García , associate physician of the Gynecology Service of the Fuenlabrada Hospital

The scarce twelve centimeters that separate the mother’s pelvis from the baby’s departure into the world is the most important journey in human life. But that first great path is not without complications. Therefore, specialists have to use instruments in certain circumstances to bring the birth to a successful conclusion. 

Forceps and suction cups have been used in delivery rooms for centuries and are fully accepted by modern obstetrics.

Forceps and cupping are two different obstetric tools that gynecologists use to extract the baby by reproducing the mechanism of delivery. 

The forceps consists of two normally articulated metal branches that end in tweezers in the shape of the baby’s head . Its use is simple, although it requires a lot of skill. The specialist introduces the branches into the vagina, presses them on the baby’s cheekbone – very close to the ears – and pops the head out with a gentle rotational movement. 

The suction cup , meanwhile, has a different procedure. This utensil normally comprises a small cup , a rubber tube and a draw bar. Once the ideal conditions have arisen, the doctor makes a negative vacuum by applying said cup on the fetal head, grasping the skin and subcutaneous tissues well, to later extract the baby. The vacuum can take between 5 and 10 minutes, although there are already suction cups that do it in a couple of minutes. 

Forceps and suction cup have been used in delivery rooms for centuries . The first was created in the 17th century by the Chamberlen family and, since then, modifications have been made over the years to expand its usefulness. The suction cup appeared a century later, in 1706 specifically, when James Yonge described the first attempt at vacuum-assisted delivery with a glass suction cup. Later, in 1954, Malmstrom introduced a metal vacuum cup with inward curved sides and a chain drive system. Today, both instruments are fully accepted by modern obstetrics .


When are forceps or suction cups used?

The obstetricians usually assist one of these two instruments in certain circumstances . It is common, for example, that the baby experiences excessive suffering, that his head does not rotate well when taking it out or any other inappropriate dynamics during delivery. It may also be, for example, that labor is prolonged due to the epidural, the mother’s exhaustion or her little cooperation. In all these cases, a suction cup and forceps are essential tools to quickly extract the baby when it is too late for a cesarean section.


Forceps or suction cup application conditions 

Although the above cases exist, these instruments cannot or should not always be used . Its conditions of application necessarily require that the mother has completely dilated, that the soft tissues of childbirth and analgesia are appropriate, in addition to the absence of cephalopelvic disproportion and that the urinary bladder is empty.

In the case of the baby, the use of forceps and a suction cup also requires the absence of serious head malformations , that the gestational age is adequate and that the head is below the third plane. In the latter case, the head has already reached the ischial spines, it is quite low, and therefore it is impossible for the specialist to resort to a cesarean section.


Types of forceps and suction cups

Muchos son los tipos de fórceps clasificados y resultaría realmente complicado enumerarlos todos. En general, estos instrumentos se catalogan en fórceps clásicos, con tracción axial y especiales. Los clásicos -Simpson, Naegale o Elliot- pueden comprender ramas paralelas o cruzadas, los de tracción axial -Tarnier o Demelin- poseen un elemento tractor y los especiales presentan modificaciones para situaciones concretas. En este último tipo, por ejemplo, el fórceps de Kjelland y el de Barton serían los más adecuados para hacer rotar la cabeza del bebé, mientras que el de Pipper se usaría concretamente para facilitar la extracción en el caso de un parto de nalgas.

As for the suction cups , there are currently two main types: the metallic ones -Malmstrom, Bird and O’Neil- and the elastic ones , such as the Kiwi type, for example. Although there are no significant differences between the two, the metallic ones tend to slip less and produce more grip than the elastic ones.


Possible complications

Specialists agree that forceps and suction cups are very safe and save many lives as long as they are used properly . For this, they must be used in the right circumstances and given the conditions of application, in addition to having a skilled doctor who knows the technique perfectly.

However, like any self-respecting surgical intervention, assisted delivery with these tools is not without complications , although these are generally mild. In the case of forceps, the mother can suffer tears of the soft tissues of the birth canal or bruises with some frequency and, in very rare cases, serious complications such as uterine, bladder or rectal ruptures.

The baby, on the other hand, may present small difficulties such as marks, bruises, small facial paralysis or skin nerve injuries that usually disappear in 48 or 72 hours. Serious complications, such as osteocartilaginous injuries or neurological trauma, occur very occasionally and are usually associated with misuse of this instrument.

The suction cups can also cause small complications such as injuries to the vagina, the anal sphincter or cause urinary incontinence , while the fetus can present bruises and even hemorrhage if the cup is incorrectly placed.


The spatula, the latest instrument

The spatula is used to dilate the canal and thus free the fetus from possible obstacles on its way out. If the cesarean section is performed 20%, the forceps 10% and the suction cup 7%, the use of the spatula is usually around 3%, depending on the hospital and the specific circumstance of delivery. Unlike the other two, this obstetric instrument is of recent creation and consists of two independent branches, and therefore not articulated or crossed, which end in the shape of a spoon.

Like forceps and suction cups, spatulas also attempt to artificially reproduce labor, but in this case dilating the canal and freeing the fetus from obstacles that may be in its path. The Thierry model is the most widely used and its use is recommended especially to protect skulls with poor ossification -premature babies- , cases in which it would be very dangerous to use both forceps and suction cups.

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