Obstetric Forceps are Outdated Medieval Instruments & How Design Needs To Change

Obstetric Forceps

Have you had obstetric forceps delivery?

Can you believe that obstetric forceps design has barely changed in over 400 years?

Did you know that the size of obstetrics forceps during manufacturing remains unregulated?

Forceps is major cause of prolapse after childbirth and their use is on the increase in many western countries!

 

If you’ve had a forceps delivery and now have pelvic floor problems, this information is for you.

  1. What are obstetric forceps?
  2. What did Medieval forceps look like?
  3. How are forceps used?
  4. What is the current size of obstetric forceps?
  5. Lack of forceps manufacturing standards
  6. How can technology improve forceps design?
  7. How can Obstetricians help?

1. What are Obstetric Forceps?

Obstetric forceps are medical instruments used to assist vaginal delivery.

As you can see in this modern forceps image (above right), obstetric forceps consist of 2 metal pieces that slot together, each consisting of a blade and a handle.

Forceps are rigid stainless steel instruments. Their metal construction makes them very durable and they are rarely discarded from hospital birthing units.

2. What did Medieval Forceps Look Like? Chamberlen Obstetrics Forceps 1580

Obstetric forceps were first used in the 16th Century. They were invented by the Chamberlen family of obstetricians to avoid infant and maternal mortality during childbirth.1

Here is an image (right) of the Chamberlen forceps from 1580. (Courtesy of Wikimedia)

The basic forceps design remained largely unchanged throughout the 20th Century.

You can clearly see the strong resemblance to modern day forceps!

3. How are Forceps Used?

Forceps Delivery

Forceps are used to guide the foetus (unborn baby) through the vagina (birth canal).

When the woman’s cervix is fully dilated (opened) the forceps blades are inserted through the vagina one at a time and locked in position around the foetal head. The forceps handles are then grasped to traction and guide the foetus out of the vagina.

An episiotomy (incision/cutting of tissues between anus and vagina) may accompany forceps delivery.

Let’s be clear on this issue; forceps are definitely indicated in some circumstances e.g. when vacuum extraction can’t be used in some medical conditions or stillborn deliveries. In some low resource, low income countries e.g. Africa, vacuum is not available and forceps save the lives of many.

However, both the rigidity and size of current obstetric forceps design may contribute to tearing of the pelvic floor muscles, nerves and supporting tissues during delivery.

According to Professor Peter Dietz pelvic floor damage occurs in approximately 44% of forceps deliveries and the use of forceps is currently on the rise in some Australian hospitals.3

4. What is the Current Size of Obstetric Forceps?

Ismail et.al.2 investigated the dimensions of 100 pairs of the most commonly used forceps in the UK (Neville Barnes’ and Wrigley’s forceps).

To show you the size of forceps, I’ve mocked this image from the manufacturer specifications for dimensions in results of this study.2

Forceps Dimensions

 

Just in case the numbers seem meaningless (which they were initially to me), here is the same image below with the real obstetric forceps size represented using standard size tennis balls where the foetal head is grasped. For the sake of accuracy, 3.7 tennis balls fit between the blades of these forceps.

This is the part of the rigid instrument that is withdrawn through the vagina once locked in place. There’s little wonder there is so much potential for prolapse after childbirth and beyond!Forceps with Tennis Balls

5. Lack of Forceps Manufacturing Standards

Of major concern is that manufacturers can currently vary the dimensions of the forceps they produce owing to the lack of official government prescriptive guidelines.

This means that while manufacturers must comply with general government industry guidelines for designing obstetric forceps, in many countries including USA, Australia and the UKthe manufacturers can use their own specifications for the dimensions of the forceps they produce.

Manufacturers currently determine the dimensions/size of the forceps they produce.

There are currently no set government regulated prescriptive dimensions for forceps manufacture.

This means that obstetric forceps made by different manufacturers vary in size.2

Here is a sample obstetric forceps approval by the FDA (US  regulatory body) for one manufacturer in 2010.

I found this online with a simple web search.

I would like to draw your attention to the “Description of the Device” which lacks any reference to size of instrument and the FDA approval safety “Summary”.

Sample FDA Obstetric Forceps Approval

Click to enlarge

6. How can Technology Improve Forceps Design?

We now have new medical technologies that were never dreamed of in the middle ages!

To improve forceps design and reduce birth trauma here are a few suggestions …

  • Instant 3D printing of single use forceps2

– Why not have a set of appropriately sized single use forceps at the ready for a woman at high risk?

  • Medical imaging to measure the size of the female pelvis before delivery
  • Medical imaging of neonatal head size before delivery
  • Modern materials (e.g. plastics) that allow single use disposable forceps
  • Implement government specifications for consistency in forceps dimensions by manufacturers before approval is given by the relevant therapeutic body i.e. TGA (Australia), FDA (USA) and European Union

How Obstetricians Can Help Improve Forceps Design?

Obstetrician discussion

Obstetricians and medical caregivers are frequently placed in a very difficult position in relation to the use of forceps due to:

  • Pressure from hospitals to reduce c/section rates and opt for vaginal delivery
  • Pressure from expectant mothers who want a ‘natural’ delivery
  • Rising maternal age and obesity driving the rate of forceps deliveries3

Obstetricians can help by:

  • Demanding that manufacturers improve the current outdated forceps design
  • Lobbying for the introduction of single use 3D printed forceps
  • Identifying their patients at risk of protracted labour
  • Discussing the risks of protracted labour before labour begins
  • Taking a proactive approach by providing medical imaging of ‘at risk’ women and neonates prior to delivery

Yes we need to ensure that our obstetricians are proficient and highly trained in the use of forceps and perhaps some women need to be more flexible in their birth planning when it comes c/section versus vaginal delivery too.

Isn’t it time to move forceps design out of the middle ages?

Obstetric forceps 16th Century – 21st Century RIP

Have you had a forceps delivery? Have you experienced problems as a result of forceps?

I’d love to hear your comments below

Further reading:

» What Causes Prolapse After Childbirth

» How to Treat and Manage Your Prolapse after Childbirth

» What Dr Google Never Told Me About Prolapse After Childbirth

 

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References

Sheikh, S., Ganesaratnam, I., & Jan, H. (2013). The birth of forceps. JRSM Short Reports, 4(7), 1–4. http://doi.org/10.1177/2042533313478412

Ismail, A., Qader, T. & Ismail K (2016) Exploring variation in dimensions of obstetric forceps European Journal of Obstetrics and Gynecology and Reproductive Biology , Volume 198 , 170 – 171

http://www.abc.net.au/news/2016-03-15/concern-over-maternal-injuries-caused-by-forceps/7248986 Accessed 23/05/2018.

Comments

  1. Thank you so much for this article & in fact your whole website. Sadly ended up with a nasty forceps delivery for my son despite stating in my birth plan “no forceps” & requesting a c-section hours earlier. Recovery has been difficult & finally after 8 months I was diagnosed with a rectocele but your information has been invaluable in helping me! Personally I think forceps need to be investigated & like you say surely modern technology can offer something a bit more gentle?! Thank you again

    • Author: Michelle Kenway Pelvic Floor Physiotherapist says

      My pleasure Emma, take care and see a pelvic floor physio if you need some extra support. This can be challenging to deal with having a baby to care for as well and the demands of motherhood – reach out if you need to, it can make a big difference long term. All the best to you

  2. Hi Michelle,

    Thanks again for taking time to reply and so quickly – it really is very much appreciated! I am in the UK and this whole prolapse thing has stressed to pieces! I have looked at your information and it is brilliant, was looking at the weight exercises and also reading about low pressure/safe exercises. You have given me hope that I can get back to normal! I have been told the prolapse will never go, but hopefully by exercising my pelvic floor and adapting some exercises I can improve it and me!
    Thank you so much again – going to look at your book now!
    Best wishes Alex x

    • Author: Michelle Kenway Pelvic Floor Physiotherapist says

      Hi Alex
      I’m really happy to help. Too many women with prolapse issues become too frightened of exercising when they need not be. Obviously this can have a very negative impact on overall physical and emotional health. Please stay in touch with any questions. I send out a newsletter approximately monthly that may help you too, please feel welcome to add your name to the newsletter list (it’s on the home page RHS facing). All the best to you Alex

  3. Hi Michelle,

    Thank you so much for the quick reply and advice, it is very much appreciated! Physio has never mentioned pessaries but she did say I could do more than most with my pelvic floor because I could feel when I wasn’t doing them right. I know I don’t drink enough water so have bought a bottle that hold 1L, if I drink at least two of those it surely must be enough. Am trying again with my diet today. When you say bike is spin okay? Also, in terms of weights, is anything okay as long as I am not standing up? I don’t know what is a safe exercise and what isn’t and don’t understand the whole thing about exercises that don’t increase pressure? Again, I really appreciate your help and advice thank you!

    • Author: Michelle Kenway Pelvic Floor Physiotherapist says

      Hi Alex
      My pleasure Alex. Yes spin is great, just try not to strain with really heavy resistance through your legs, better to spin/cycle fast. Some women notice increase in pelvic floor loading when they stand out of the saddle but this is an individual thing. As for weights there are some important principles – they are all listed on site (for free) you may like to start here in the weights for women section. Alternatively (and this is not a plug) my book Prolapse Exercises summarizes all the cardio, weights and weight loss exercises to choose and those to avoid and is inexpensive to download if you haven’t already. Hope this info helps you get started and good luck!

  4. Hi Michelle, thank you so much for replying to my comment. I was doing 1 hr on a cross trainer and 30 mins strength training from a YouTube video this one youtu.be/PYkJRUz5x1E. I don’t know how severe my prolapse is as no one has told me. My pelvic floor physio said do Kegel and am managing 10×10 fast but only 5 holds for 3 seconds otherwise I start using my stomach. I am just so afraid of making things worse. I was told by the dr no weights no high impact no hit no cardio and I just feel like I’ve aged overnight and it’s affecting me badly. Healthy diet out of the window, put on a stone and look and feel awful. I had no idea this could happen

    • Author: Michelle Kenway Pelvic Floor Physiotherapist says

      Hi Alex, I understand what you’re saying and how you’re feeling. It’s most important that you take charge of your diet ASAP. The extra load this additional body weight weight will place on your pelvic floor will likely cause more problems that exercise will. Take a really good look at what you’re eating and drinking as this is what matters most. Exercise is far less important for weight management. Have you tried stationary bike HIT? Why can’t you perform pelvic floor safe weight training exercises in the interim until your pelvic floor strengthens? Has your specialist suggested using a support pessary while your pelvic floor strengthens to allow you to exercise the way you’d like to? Pessary devices can be a great way of supporting a pelvic prolapse especially when the pelvic floor muscles aren’t working well. Some Physios fit pessaries or perhaps you can seek a second opinion from another Gynae on your suitability for getting a pessary to help get you out of your current position (if your current Gynae doesn’t use support pessaries). I can only imagine a “no exercise” recommendation if the prolapse is moderate to severe and your physio will be able to tell you your prolapse severity. It’s important that you know this for your own self management. I hope this gives you some direction Alex

  5. Hi, just been diagnosed with recrocele prolapse, never felt right since 1st child 20 years ago and had forceps and episiotomy. Feel like my life’s over, no exercise with weights, no aerobics, and told because I’m old, 52, and it is very common. Absolutely devastated. I lost 3 stone by changing my lifestyle and eating healthily etc and have more weight to lose and now this happens. Told there is an operation but in my mind they should be lifesaving only due to risks, also read the ops aren’t that successful. Any suggestions for ways to help would be very much appreciated. Thank you

    • Author: Michelle Kenway Pelvic Floor Physiotherapist says

      Hi Alex
      I’m sorry to read how you’re feeling. Why do you feel you can’t exercise now? Many women can exercise with rectocele and there are also options that are non surgical including pelvic floor exercises and pessary. Alex how severe is your prolapse? There is definitely a lot many women can do in terms of cardio and strengthening despite having a mild-moderate rectocele. When the rectocele is severe, symptomatic and protruding from the vagina this can make exercise very difficult however some forms of pessary may be able to support the pessary and help women exercise.

  6. I had a forceps delivery 38yrs ago to deliver my daughter. Three pelvic surgeries later I still live with daily discomfort and may require further surgeries in the future. The use of forceps with their present barbaric design should be banned. Obstetricians like mine who do not monitor their patients in a satisfactory manner also contribute to these unfortunate outcomes. Mine arrived 24 hours after I was admitted leaving me in the care of an inexperienced resident for all that time who did not even realise that there was a need for intervention.

    • Author: Michelle Kenway Pelvic Floor Physiotherapist says

      Yes Sara lack of monitoring is a problem plus lack of informed consent regarding the procedure – this should be discussed as a possible alternative where possible before delivery and the possible outcomes explained

  7. I had severe problems after a forceps delivery, not only did my baby have two black eyes, I was so badly damaged all my organs were prolapsed and I had to have to have 9 surgeries to fix it taking 18 years. It’s good that you are campaigning for change :)

    • Michelle Kenway Physiotherapist says

      I’m so sorry to read your story M, yes it is time for change that’s for sure and your history is testament to this.

  8. Wow! Holy Moly.. Interesting read, I didn’t realize forceps were still in use.

    • Michelle Kenway Physiotherapist says

      Hi Alison
      Still in use and currently on the increase in some hospitals! They’ve undoubtedly saved the lives of hundreds of thousands of mothers and their babies, however it’s the damage they potentially cause and the fact that there’s plenty of room to improve their design to reduce the rate of suffering afterwards that is one big issue.

      Thanks so much for commenting!

  9. Thanks so much – interesting article!

  10. Pauline Brien says

    They just look evil and an instrument of torture. I think I will have nightmares for a week.
    As always, great article and thank you for trying to make a difference.

    • Michelle Kenway Physiotherapist says

      Hi Pauline
      Sorry to give you nightmares! Not intended, just to raise awareness of the need for change
      Cheers

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