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President Barack Obama swallowed hard Monday morning and admitted the health insurance exchanges simply are not working. But aside from promising that the exchange’s problems would be fixed soon, there was no indication that the White House has any sense of how long it might take to get the websites into working order. For that matter, there has been little indication that the administration even has a handle on the depth of problems plaguing the much-heralded exchanges that formed a cornerstone of the Affordable Care Act. After three weeks, the White House also refuses to release information on how many people have successfully navigated the exchanges and signed up for health insurance.  If the experience of many state-run exchanges is any indication, there are not too many. GOING UP: Premiums are going to rise in 45 out of 50 states, according to an analysis by the Heritage Foundation. Regardless of how long it takes to get the exchanges up and running — if they ever do — opponents of the president’s health care initiative say there are other problems that won’t be addressed by fixing the exchange websites. For a law that was literally and figurative sold to the American people as promising “affordable” health insurance, the Affordable Care Act doesn’t seem to be keeping up its end of the promise. Though the department has avoided providing cost comparisons, the Heritage Foundation, a conservative think tank, did their best to crunch the numbers based on the current costs of insurance through nongroup plans (the closest equivalent to the Obamacare exchanges that existed before Oct. So if you live in Colorado, New Jersey, New York, Ohio or Rhode Island, congratulations!  If not, hopefully you don’t live in Virginia, where rates are expected to climb by more than 200 percent, the highest increase in the nation. Like the old saying about leading a horse to water, you can build a working health insurance exchange, but you can’t force young people to use it.
But there already is some pretty good evidence that young people wouldn’t be flocking to the exchanges even if they were in good working order.  And that’s a big deal, because the arithmetic behind Obamacare requires that lots of young, relatively healthy people buy insurance and effectively subsidize the cost of the older, less healthy, more expensive people in the system. As Cathy Reisenwitz wrote last week, this is why the whole scheme shouldn’t be called insurance at all – because it’s really cost-pooling.
If lots of young people decide they would rather go without health coverage, even if it means paying higher taxes as a penalty, it could seriously undercut the entire system. Because of how the subsidies in the Affordable Care Act are structured, people may have a pretty good incentive to avoid things like marriage and job promotions that pay them a higher salary.
That same phenomena could affect people who get offered promotions and higher pay at their jobs.  Taking a pay increase actually could hurt their individual bottom line by reducing the amount of subsidies available.
In a sense all insurance is cost pooling, where to limit risk and protect assets participants willingly accept a small loss (the premium) to provide a pool from which to protect against a much larger unexpected loss that would be unaffordable otherwise.
America fell into the third party trap over the years and became a huge problem and the number one driver of healthcare costs outstripping inflation. Don’t miss our newsGet the latest on government waste, fraud, and abuse - directly in your inbox. Karl Holt has chosen a life of service -- as a Green Beret medic, or 18-Delta, serving all over the world, and today as a UNC medical student. Despite still recovering from his injuries, Karl ran the 2010 Marine Corps Marathon to honor the families of fallen soldiers, including his friends and brothers SFC David E. For Karl Holt, completing the 2010 Marine Corps Marathon had special meaning beyond the usual triumph of preparation, sacrifice, and endurance.
The crash had claimed the lives of 10 people, including Karla€™s friends and brothers from his Green Beret unit. He credits pain medication, anti-inflammatory drugs, and sheer will for helping him successfully complete the marathon a€“ held each October in Washington, D.C.
Karl considers his mission as a Green Beret and eventually as a physician to be related -- they are both part of a larger service, a commitment to something bigger than himself. As Karla€™s interest in medicine developed and the conflicts in Iraq and Afghanistan raged on, he increasingly thought about his grandfather and felt compelled to try to serve as a Green Beret medic, known as an 18-Delta. In 2009, Karla€™s unit, which previously had focused missions in Central and South America, deployed to Afghanistan. In the five months he was in Afghanistan, the team operated all over the country, conducting missions that pitted them against Taliban and Al-Qaeda fighters. One night in October 2009, the team went to a storage depot nestled between two mountains in a valley in Daree-ye Bu, in the western province of Badghis, to destroy drugs, IEDs, and other weapons. Karl began crawling from one patient to the next, stopping hemorrhages, applying tourniquets, splinting fractures, and trying to keep everyone conscious.
After several surgeries, Karl recalls waking up in Germany and piecing together what had happened.
Since then, he has remained close to the families of some of those who died, and occasionally hears from his friends who made it home. As he returned home, despite feeling fortunate to have survived, he faced his own challenges, not only from the physical injuries he suffered but also from the psychological scars of his experiences and the difficulty of adjusting to life away from the battlefield.
Like so many members of Special Forces, long periods away from home had put a tremendous strain on his marriage, and he and his wife divorced upon his return. During that time, as a Special Operations medic instructor at the Joint Special Forces Medics Training Center (JSOMTC) at Fort Bragg, Karl met Eric Strand and Bruce Cairns, MD, the Fort Bragg and UNC Medical Center representatives, respectively, of the Advanced Medic Instructor Training (AMIT) program.
Strand, a former Green Beret medic, was vacating his position as the Fort Bragg point of contact for AMIT as he prepared to go to medical school at UNC.
Karl has been a wonderful advocate for veterans, a truly thoughtful, supportive voice for those in need and a great friend to many, including myself. During that time, Karl also had begun to consider the possibility of going to medical school.
Throughout that period, however, he noticed that something wasna€™t right a€“ beyond the physical injuries he had sustained, he wasna€™t feeling himself. Karl went to a neurologist, who discovered that during the helicopter accident, he had suffered a traumatic brain injury that had gone undiagnosed. Karl took his medical school requirements in four-hour classes, four nights a week, after work. He doesna€™t often speak about his combat experiences unless ita€™s done in the context of helping others, whether talking to other veterans who have suffered from PTSD or to providers who care for veterans.
A few years ago, he spoke with the psychiatry residency program at UNC about his experiences.
He never forgets how he felt when he returned home and had to face not only the long recovery from his physical injuries and psychological and emotional problems, but also the dilemma of applying his skills in a civilian setting. Two years ago, Karl traveled to Arlington National Cemetery with his fiancee to visit the grave of his friends SFC David E. As he continues his medical school education and advances into his career, these experiences will help him develop relationships with his own patients, allowing him to relate to them, whether or not theya€™re aware of his personal experiences. Throughout his treatments, he learned that words matter: what providers say to patients and how they say it can make a difference in how a patient handles his or her outcome. For now, though, Karl is focused on the educational opportunities that lie immediately before him and is grateful to UNC for its investment in him.
ANATOMY OF THE FORCEPSThe forceps consists of a blade connected to a handle by a shank (Fig. 7Ramin S, Little B, Gilstrap L: Survey of operative vaginal delivery in North America in 1990. 13Hagadorn-Freathy AS, Yeomans ER, Hankins GDV: Validation of the 1988 ACOG Forceps Classification System. 15Ahuja GL, Willoughby MLN, Kerr MM et al: Massive subaponeurotic hemorrhage in infants born by vacuum extraction. 17Plauche WC: Fetal cranial injuries related to delivery with the Malstrom vacuum extractor (review). 19Baerthlein WC, Moodley S, Stinson SK: Comparison of maternal and neonatal morbidity in mid-forceps delivery and mid-pelvis vacuum extraction. 21Greis JB, Bieniarz J, Scommegna A: Comparison of maternal and fetal effects of vacuum extraction with forceps or cesarean deliveries. 25Uchil D, Arulkumaran S: Neonatal subgaleal hemorrhage and its relationship to delivery by vacuum extraction.
We use cookies to ensure you get the best experience from our website.By using the website or clicking OK we will assume you are happy to receive all cookies from us. Refer back to the first point.  While all adults will see higher premiums in most states, the increases are generally sharper for young people. It counts on young people enrolling, but young people don’t want any part of it,” Patrick Richardson, a senior at the University of Toledo in Ohio, told Watchdog.org’s Kathryn Watson earlier this month. As a Green Beret medic, he saved the lives of others during a helicopter crash in Afghanistan in 2009.
Twelve months earlier, he had been in a tragic helicopter accident during Operation Enduring Freedom in Afghanistan. His back, leg, and ankle were broken, both of his shoulders were dislocated, and he suffered facial fractures that would require dozens of reconstructive surgeries.
He and his friends in Alaska had been getting into trouble, and the move helped him get on track.
By participating in the care, he developed confidence in his ability to treat trauma cases and became comfortable with the prospect of being the lone medic on a unit. They were based at Forward Operating Base Shindand in the western part of the country, in the Herat province, only 75 miles from Iran. Karl and nine or ten others, sometimes fewer, worked alone in highly isolated and austere conditions. The mission had been a success, but as the group was ready to depart via two Chinook helicopters, it came under fire. He had broken his back, and his left leg was a€?pretty much destroyed.a€? His face had been crushed and hea€™d lost several teeth.
He quickly became a single father, with joint custody of his two children, Kendon and Kerrigan.
AMIT needed a replacement, and Karl had done rotations at UNC Medical Center through the program. I am very proud to know Karl; I am extremely grateful for his service and so appreciative of his accomplishments at UNC and am excited to see what he will accomplish in the future. In addition to teaching at the JSOMTC, working to recover from his injuries, and being a father, he decided to take his undergraduate prerequisites for medical school at Campbell Universitya€™s Fort Bragg campus. He became depressed easily, and sometimes was incapable of doing even the slightest amount of reading and studying. He did almost two years of cognitive and occupational rehabilitation, using his eyes to track objects in his peripheral vision. Among the complications of adjusting to life back home was figuring out whether certain psychological challenges were from his undiagnosed traumatic brain injury or from PTSD, which hea€™d also been battling.
This community is an inclusive environment for veterans and sees veterans as untapped resources in North Carolina who have a lot to contribute. During that time, he averaged a surgery every other month, including more than 30 on his face, where he had lost so much bone that doctors had to take bone from his hips and graft it in. He recalls that physicians sometimes a€?thought out louda€? in front of him during clinical visits, explaining what they believed they could do for him, without any reliable information to back it up. Drake believes that students like Karl make the UNC School of Medicine a stronger institution. He nearly lost his life that night, and spent years recovering from his injuries, both physical and psychological.
Prior to the crash, he could run 10 miles in less than an hour, routinely bench-press hundreds of pounds, and had run multiple marathons. After living in Mexico City for a time to become fluent in Spanish, he learned that his good friend, a police officer in Houston, had been shot in the stomach with an AK-47. During visits, Karl spoke with the doctor about medicine and became fascinated by the possibility of caring for others as a medical professional. Karl recalls an RPG zooming above him, its velocity knocking him to the ground as it passed. Cairns, the director of the North Carolina Jaycee Burn Center, and others from UNC Medical Center had developed AMIT to further the medical training and education of JSOMTC medic instructors by inviting them to UNC Hospitals for rotations. During sessions, he rehabbed until he became nauseated, at which point he sat down for 30 minutes, letting the feeling subside, and then returned to the therapy.


Bruce Cairns, and spoken frequently on behalf of the new UNC School of Medicine Physician Assistant Program.
Subsequently, over the years the ability to use forceps separated the obstetricians from the midwives.
9 companies exit Nebraska’s health insurance marketObamacare: Children of undocumented parents face an uncertain futureWhich way do we go? His work has appeared in Reason Magazine, National Review Online, The Freeman Magazine, The Philadelphia Inquirer, The Washington Examiner and Fox News.
Today, he is on his way to becoming a physician, and hopes that his experiences will help other veterans as they transition into civilian life. But he was determined to regain his strength and return to an active lifestyle, despite his injuries.
In 1998, he completed a BA in Theology and began speaking with inner-city kids from Los Angeles to Chicago to New York, trying to motivate them to make good decisions with their lives. Karla€™s helicopter, meanwhile, in the confusion of war and while maneuvering away from incoming fire, nearly ran into the cliff. The program, which launches in January, is designed to provide educational and career-development opportunities for nontraditional students, including veterans with medical experience, and to reduce North Carolina's healthcare workforce shortage in underserved areas.
A few years earlier, at their funeral in Arlington, Virginia, he was on his way home, driving back to North Carolina, when he realized that he could not overcome the psychological scars of his experiences by himself.
The use of forceps reached its acme in the United States as a result of the influence of DeLee, who in 1920 taught the importance of prophylactic forceps and episiotomy to protect against maternal and fetal injury.Fig. The blade may be fenestrated or solid and has two curves: the cephalic curve to encompass and protect the fetal head, and a pelvic curve to accommodate to the maternal pelvic curve. Within six months of the accident, he was doing cardio work in a pool at a rehab facility near Fort Bragg, where he was stationed. Jeremy Valdez, the only other surviving Green Beret, who pulled Karl from the area amid the 'cooking off' of ammunition. It lost control and fell 800 feet to the village below, crashing through a two-story compound. There are several lock configurations, but the most common are the English and sliding locks. It should be noted that each feature of a forceps was designed for a purpose, and knowledge of the reasons for these features is important for the proper use of the forceps. There are two types of solid blades: (1) smooth, as seen in the Tucker-McLane modifications of the Elliot forceps (Fig.
A properly chosen and well-executed forceps delivery does not increase the risk of a bad result. Overlapping shanks, as seen in the Elliot or Tucker-McLane forceps, are accompanied by more space toward the heel of the blades. However, due to the provocative studies by Friedman and colleagues2, 3, 4 and the increasing tendency for an adverse obstetric outcome to result in a malpractice suit, obstetric forceps delivery rates have fallen in the United States. The overlapping shanks also cause less stretching of the perineum and are therefore a better choice for rotation maneuvers. The parallel shank and longer blade make the Simpson-type forceps more appropriate for delivery when molding and caput are present.
Significantly, staff obstetricians were present and instructing in the delivery room only 50% of the time in the United States, but in Canada a staff obstetrician was the principal instructor.
Further, the mode of selection of the forceps most commonly used for midforceps and outlet forceps was habit and past experience, rather than design and function. Ironically, the authors of the study pointed out, two major postgraduate obstetrics texts devoted fewer than 2% of their pages to forceps delivery. A study by Powell et al.8 in 2007 found that current training results in a substantial portion of residents graduating who do not feel competent to perform forceps deliveries and this affected their future operative delivery plans. Dennen1 emphasized detailed lectures about forceps, practice with mannequins, and supervision first in easy cases and later in more complicated ones to ensure proper training in the use of forceps.A vicious cycle of decreased opportunity, poorly supervised procedures, and even lack of detailed instruction in textbooks may lead to a generation of obstetricians who are lacking skills in forceps deliveries and therefore are unable to pass these skills on to the next generation.Is the abandonment of forceps (especially midforceps) deliveries desirable?
The issue is clearly debated in two articles, one by Friedman, who is against it,9 and the other by Hayashi, who is for it.10 Interestingly, both authorities quote many of the same articles to support their opposing points of view. Friedman makes a compelling argument for abandoning midforceps by proposing that failure to prove statistical significance for poor outcomes is not the same as proving that a significant difference does not exist.
The problem with studies of midforceps operation has always been and will continue to be one of determining whether the operation really is a midforceps one. Locks of obstetric forceps: French lock (top left ), English lock (top right ), German lock (middle left ), Sliding rock (middle right ), and Pivot lock (bottom ). In an effort to simplify the terminology for forceps procedures and redefine midforceps, the American College of Obstetricians and Gynecologists (ACOG) reclassified forceps deliveries according to station and rotation (Table 1).11Table 1. Sagittal suture is in anteroposterior diameter or right or left occiput anterior or posterior position 4.
In a complicated case where there is a question of whether the head is well into the pelvis, it is helpful to do a rectal examination and verify whether the head fills the sacral hollow. Occasionally ultrasound may help if the degree of molding creates confusion.The type of pelvis should be known. 196, ACOG, Washington, DC 1994) The reasons for forceps applications may be fetal or maternal.
Forceps can be used to correct rotational defects or abnormalities of fetal attitude (deflexions). Often, the two conditions go together and are corrected with appropriate forceps maneuvers. Forceps can also be used to aid maternal expulsive efforts, which may be impeded by exhaustion, sedation, or regional anesthetics. They should lie evenly against the sides of the head, reaching from the parietal bones to and beyond the malar eminences covering symmetrically the spaces between the orbits and the ears (Fig.
A prolonged second stage of labor with prolonged compression of the pelvic floor may cause damage to the pelvic muscular supports and nerves to the pelvic muscles. The proper use of forceps to shorten the prolonged second stage of labor may prevent these long-term disabilities. Forceps should not be used to overcome cephalopelvic disproportions.Schifrin12 criticized ACOG for making new definitions and changes in forceps delivery classification without support from conclusive data. Hagadorn-Freathy and co-workers,13 however, prospectively studied 357 forceps deliveries, comparing the older classification with the newly recommended classification.
Allowing a 45° rotation or less at S + 2 or more did not increase morbidity measured by any criterion. The posterior fontanelle in anterior positions should be one finger breadth above the plane of the shanks.
If the relationship of the plane of the shanks to the posterior fontanelle is not proper, the pivot point of the head will not be in the center of the widest diameter of the cephalic curve of the blades, and traction may cause either overextension or overflexion of the head, resulting in larger diameters passing through the birth canal and increasing the risk of trauma to the maternal soft tissues.The sagittal suture should be perpendicular to the plane of the shanks. He also indicated that the new classification provides no new data for evaluating the specific impact of midforceps procedures on the prosecution and defense of malpractice litigation. Schifrin correctly pointed out numerous confounding variables that make evaluation of forceps data virtually impossible (Table 2).Table 2. J Perinatol 8(3):242, 1988) I believe Schifrin has correctly identified the problem with classifying any forceps operation. The operator stands before the perineum with the forceps articulated and oriented to the position of the fetus' head. It is quite clear that estimating fetal weight is fraught with error, leading to miscalculations in the difficulty of delivery. Neither clinical experience nor the use of ultrasound seem to have improved estimations of fetal weight.
For the left occipitoanterior (LOA) or direct OA positions, the left blade (posterior) is applied first. The accurate estimation of the station of the fetal head is probably the most common problem in evaluating a forceps operation. Applying the left blade first has the advantage of not needing to cross the shanks in order to lock the forceps (see Fig. Difficulties with determining position and attitude become complicated by molding and asynclitism. Determining the midstation of the pelvis and defining the station are difficult for less experienced operators. The operator places his or her back to the maternal right thigh and holds the handle between the fingers, as in holding a pencil.
Although the type of pelvis and its dimensions are important in determining the type of forceps and the delivery technique, rarely is this calculated by inexperienced operators.
The shank is held perpendicular to the floor, the middle and index fingers are inserted into the vagina, and the thumb is applied to the heel of the blade (Fig. There are numerous types of forceps, each offering distinct advantages, while others are designed for specific functions. This blade is inserted more anteriorly in the vagina to avoid rotating the head further to the left (Fig. How can we compare the outcomes of fetal distress in the second stage of labor delivered by midforceps compared to cesarean section? Any adjustments to ensure a cephalic application should generally be made with the right blade.
Under these conditions, presumably, midforceps operations may be as safe or safer for both mother and offspring than cesarean sections.
A successful forceps operation does not depend on the technical skill of the operator, but on the operator's judgment and experience. Schifrin12 espoused the concept that defense against litigation requires a reasonable note, which should contain the indication for the forceps, a statement of informed consent, the station of the vertex, the attitude, degree of flexion, the instrument chosen, and the effort needed to complete the operation.
Apgar scores, cord blood gases, and a description of any trauma observed should be recorded. These notations, clearly stated at the time of delivery, are the obstetrician's best defense in the event of litigation. Introduction of right (anterior) blade for the left occipitoanterior (LOA) position and locking of handles. Philadelphia, FA Davis, 1955)For the LOA position, the handles are now swept in a wide arc counterclockwise to bring the head into the OA position (Fig.
It is important that the handles be rotated in a wide arc; unless this is done, the toes of the blades, because of the pelvic curve, will be rotated through a wide angle in the vagina, increasing the risk of maternal trauma (Fig. Once the forceps has been applied and rotation to an OA position accomplished, traction is to be applied. The operator should be seated in front of the patient, with elbows kept pressed against the sides of the body. To avoid excessive force during traction, the only force exerted should be that which can be exerted only through the wrist and forearms.
Rotation with Simpson-type forceps from the left occipitoanterior (LOA) position to the OA position preliminary to traction. Showing line of axis traction (perpendicular to the plane of the pelvis at which the head is stationed) at different planes of the pelvis: (1) high, (2) mid, (3) low-mid, (4) low. Philadelphia, FA Davis, 1955)An alternative method of traction is to use a Bill axis traction handle and pull in the direction of the pointer (Fig.
In exerting traction, it is well to keep in mind the bell-shaped curve of a uterine contraction as seen on a fetal monitor.
The traction force should gradually increase, reaching its acme at about 30–40 seconds and then gradually relaxing. For the resident being taught, it is instructive to actually count off the seconds out loud so that they can appreciate the time involved. The amount of force applied and the vector of pull to advance the head will vary, and adjustments will be made as the operator gains experience. When the occiput comes under the symphysis, the head can be gently extended with one hand on the forceps handles.


When the extension is almost complete, the forceps can be removed, right blade first and left blade second, and the delivery completed by the Ritgen maneuver (Fig.
Philadelphia, FA Davis, 1955)The question of when to perform an episiotomy in conjunction with forceps delivery is debatable. The advantages and disadvantages of an episiotomy are beyond the scope of this chapter and are discussed elsewhere. Although this may entail a slightly increased blood loss, it does allow more room for inserting the fingers and forceps. An alternative method is to apply the forceps and, before the perineum is stretched too greatly, to perform the episiotomy.For low forceps or midforceps from the occipitotransverse (OT) positions using the classic instruments, the above-mentioned techniques apply.
The wide sweep of the handles for the rotation is vital for the prevention of injury to the mother (see Fig.
10).Occipitoposterior positions Since a persistent OP position is usually accompanied by a degree of deflexion, a bigger diameter is presented to the maternal pelvis. Therefore, it is preferable to perform a forceps maneuver that will flex and rotate the head for delivery. If a classic instrument is chosen, the Scanzoni or modified Scanzoni maneuver may be chosen. The modified Scanzoni maneuver is more likely to succeed in converting a posterior to an anterior position, but the operator should be aware that delivery in the posterior position may be more desirable in a patient with an anthropoid or android pelvis. In this maneuver, the forceps most appropriate is a Tucker-McLane or Elliot-type forceps with a solid blade. The forceps are applied as though to an anterior position, and after flexing the head, a wide sweep of the handles rotates the head to an OA position. The anterior blade is now removed, leaving the posterior blade splinting the head and preventing its rotating back to its original position.
The anterior blade is now inserted against the head inside of the posterior blade, the posterior blade is removed and reinserted as the anterior blade, and delivery can be accomplished (Fig. One caveat: often arrest of the fetal head occurs at the tightest part of the pelvis, so that rotation may be facilitated at a higher plane by dislodging the head upward with the forceps before rotation.
A solid blade is preferred because with a fenestrated blade, one blade may pass through the other during this maneuver and become entangled, causing technical problems with the delivery. Insertion of posterior or right blade (Tucker-McLane), solid Elliot-type, in the first stage of the modified Scanzoni maneuver for instrumental rotation from left occipitoposterior (LOP) to occipitoanterior (OA) position. Insertion of anterior or left blade and crossing the handle, left over right, for locking in the first stage of the modified Scanzoni maneuver for left occipitoposterior (LOP) position.
Instrumental rotation, counterclockwise, from left occipitoposterior (LOP) to anterior position. Reinversion and reinsertion of the left blade between the splinting right blade and the posterior or left ear, as for left occipitoanterior (LOA) position. Reapplication of the right splinting blade to the anterior right ear, as for left occipitoanterior (LOA) position, after removal in a downward direction and reinversion. Philadelphia, FA Davis, 1955)SPECIAL INSTRUMENTSOver the years, special forceps have been created to overcome specific problems. The blades have only a slight pelvic curve, the shanks are overlapping and joined by a sliding lock, and knobs on the fingergrips identify the anterior surface of the instrument. The Kielland forceps are excellent for correcting most rotational defects because of the minimal pelvic curve of the blades, enabling the operator to rotate the forceps like turning a key in a lock (Fig. The technique of application of the forceps depends on the position of the fetus' head. It is important before applying the forceps, to hold them articulated with the knobs facing the occiput. Once again, it is important to emphasize that since the head may be arrested at a tight portion of the pelvis, it may be necessary to either elevate or bring the head down a little before exerting a rotational effort. Since there is little pelvic curve, the handles can be turned in the appropriate direction like turning a key in a lock. In addition, due to the lack of a pelvic curve, the direction of pull is in the plane of the pelvic curve. Once the head reaches the pelvic floor and extension is to occur, it is important to remember that the handles should not be elevated above the horizontal. This is because, due to the lack of a pelvic curve, elevating the handles above the horizontal will dig the toes of the blades into the vagina increasing the risk of sulcus tears. This can be overcome by opening the forceps, lowering the handles, reapproximating, and continuing the extension until the head is delivered or deliverable via the Ritgen maneuver.
As the blade enters the uterus, there is usually a little gush of amniotic fluid as the uterine wall is elevated from the fetus' head. 23B), causing the forceps blade to rotate to bring the cephalic curve over the fetus' face (Fig. It is important that this blade be inserted to the right side of the anterior blade, since crossing of the shanks would be dangerous.
The operator's left hand should be deep in the vagina, guiding the toe of the blade alongside the head and passing by the sacral promontory (Fig. Since most OT positions involve some degree of asynclitism, pulling down on the fingerguard of the forceps blade closest to the perineum will correct the asynclitism.
For the ROT position, the same maneuvers are performed, except that the left blade is the anterior blade inserted with the right hand and the right blade is the posterior blade. Inversion technique of insertion, application, articulation, rotation, and traction using Kielland forceps, LOT position. This is because the fetus must be delivered in the OT position and the cephalic curve of the anterior blade of the Kielland forceps would be forced against the symphysis, potentially damaging the symphysis or the bladder. 24) are an anterior hinged blade, flexible over an arc of 90°, and a posterior blade with a deep cephalic curve. The blades are attached to the shanks at an angle of 50°, forming a perfect pelvic curve when held with the shanks perpendicular to the horizontal.
Properly positioned, the hinge should be close to the sagittal suture and one fingerbreadth medial to the occiput. The posterior blade is then inserted, with care being taken to ensure that the blade will fit into the sliding lock. The guiding fingers should be high in the pelvis to ensure that the tip of the blade passes the sacral promontory.
A Bill axis traction handle can then be applied, and with gentle but firm traction, the head is brought down in the OT position until it crowns under the pubic arch. At this time, rotation to the OA position can be performed by rotating the forceps handles. In the absence of a Bill handle, a towel can be wrapped around the forceps shanks and used as a traction handle, or Pajot-Saxtorph's maneuver can be used.
Although the Barton forceps can be used for other types of rotations, its most important use is for delivery of OT positions in a platypelloid pelvis. Piper in 1924, the Piper forceps was designed to facilitate delivery of the aftercoming fetal head in breech deliveries. Piper forceps should be on the table, unwrapped, and ready for use in any attempted vaginal breech delivery. 25) are characterized by long shanks with a backward curve dropping the handles well below the level of the blades.
The dropped handles allow direct application to the baby's head without the necessity of elevating the body above the horizontal. Excessive traction on the body may lead to a high and severe spinal cord injury due to subluxation of the atlas on the axis.
The infant should be supported by an assistant, and the operator should kneel for the forceps insertion. This blade is always applied first to avoid having to cross the shanks in order to lock the forceps. Once the face appears at the introitus, the forceps handles are elevated to flex and deliver the rest of the head. Since the blades have no pelvic curve, a deep episiotomy should be performed to prevent damage to the vagina and perineum.
Piper forceps on aftercoming head during traction, with body resting on shanks, leg clamped to handle by thumb, handles resting in upturned palm of right hand with middle finger in the space between the shanks at the lock, neck splinted by fingers of the left hand. Philadelphia, FA Davis, 1955)Vacuum extractions The original vacuum extractor was designed by Sir John Young in Edinburgh in 1849.
Interest in the vacuum extractor increased in Europe after Malmström developed the prototype of the modern vacuum extractor in Sweden. The Malmström extractor consisted of a metal cup with a flat plate inside it and a chain attached to the plate. The chain is placed inside a rubber tube, which is necessary to develop the vacuum, and attached to a traction bar. Traction is applied to the cup by the chain and plate, not the rubber tubing, which is a significant improvement over previous designs. The metal cup comes in four sizes, and it is recommended that the largest cup possible be used for delivery.There had been little enthusiasm for the vacuum extractor in the United States until 1973, when Kobayashi developed the soft Silastic cup. The Silastic cup has many advantages over the metal cup, the most important being that the vacuum can be developed quickly and therefore can be released between contractions, which decreases injury to the fetal scalp due to abrasions. The interest in this instrument in the United States has also been stimulated by the adverse publicity that midforceps delivery has received, so much so that some obstetricians no longer perform this procedure. As an alternative, they are using the Silastic vacuum extractor rather than proceeding directly to cesarean section when the fetal head is arrested in midpelvis. The final reason for the increasing interest in this type of delivery is that some patients believe that a vacuum extractor is safer for the infant than a forceps delivery.Theoretically, the vacuum extractor has several advantages over obstetric forceps. Only traction is applied to the instrument; therefore, if the occiput is not directly anterior, it is presumed the head will rotate at the most appropriate level in the pelvis, just as it would with a spontaneous delivery. It is surprising how often with a vacuum extraction delivery the head rotates when it reaches the perineum.
When there is loss of pelvic muscle tone due to epidural anesthesia, however, this may not occur.
However, an increased incidence of cephalohematomas and retinal hemorrhages have been noted after vacuum deliveries.For reasons listed earlier, the Silastic vacuum extractor is gaining in popularity in the United States, and several studies18, 19, 20, 21 have posed that this type of delivery is less traumatic for the mother and is as safe as a forceps delivery for the infant. In 1984, however, Nilsen22 reported on an 18-year follow-up of 62 males delivered by low forceps and midforceps and 38 delivered by vacuum extraction in Norway. He found an actual increase in mean intelligence score in the forceps-delivered group, whereas the group delivered by vacuum extraction did not differ from the national average of those men presenting themselves for the military draft.23 Since vacuum assisted delivery is considered easier than forceps delivery, the focus of training afforded to forceps deliveries in the past has not been given to vacuum deliveries and has led to increasing numbers of complications. Among these complications are increased risk of shoulder dystocia, postpartum hemorrhage and intracranial hemorrhage,24 and subgaleal hemorrhage.25TECHNIQUE As soon as the vacuum has been built up and the operator has checked that all vaginal tissue has been excluded from the Silastic cup, traction should be applied with each uterine contraction. The patient is encouraged to push at the same time so that a minimum amount of traction is required to complete the delivery.
The direction of traction should be at right angles to the plane of the cup, and this requires that two fingers be inserted into the vagina to pull back the posterior vaginal wall.With the new Silastic cups, the vacuum can be released between contractions and rapidly achieved again, thus avoiding many of the serious complications reported with the metal cup. Within six to eight pulls, it will be obvious whether the delivery will be successful; if so, approximately 20 minutes will be required to complete the delivery. Because only traction is applied, irrespective of the position of the occiput, the fetus should rotate at the most suitable level in the pelvis, and this often happens on the perineum.
The vacuum extractor mimics the normal mechanism of labor, which failed owing to the lack of expulsive efforts on the part of the uterus and patient.Two successive detachments of the vacuum cup from the fetal head are usually considered a failure for this instrument, and a forceps delivery should then be considered.
However, even if the vacuum extractor is not capable of completing the delivery, a low forceps delivery may be all that is required, and if the obstetrician does not perform midforceps deliveries, a cesarean section will have been avoided. With the vacuum extractor a midline episiotomy is adequate, and a pudendal nerve block is the optimal form of anesthesia.SUMMARYThe complete obstetrician must be well trained and capable of using all of the modalities available to ensure a safe outcome for both the mother and child.




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