Obstetric Forceps are Outdated Medieval Instruments & How Design Needs To Change

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?

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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? 

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 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

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!

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 UK² the 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”.

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?

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

References

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

² 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

³ http://www.abc.net.au/news/2016-03-15/concern-over-maternal-injuries-caused-by-forceps/7248986 Accessed 23/05/2018.