Failed Forceps Delivery

Failed forceps delivery is failure to deliver the baby with forceps after 3 pulls with no descent, when the blades will not lock or when the head does not advance or rotate. It results from a mistaken head position or station, disproportion, poor blade application, rotation attempts on a wedged head and inadequate analgesia. It matters because persistent traction causes skull, facial nerve and brain injury to the baby, and severe vaginal, cervical, perineal and bladder trauma to the mother.

• Risk factors: head above station +2, occiput posterior or transverse position, large baby, obesity, maternal exhaustion, inexperienced operator.
• Forceps are applied only with full dilatation, ruptured membranes, an empty bladder and a known position.
• Failure at 3 pulls needs caesarean section.

The blades slip or will not lock, or traction does not bring the head down. The mother is exhausted in lithotomy, and bleeding or fetal heart abnormalities may appear during attempts.

• No descent after 3 pulls, or blades slipping off the head.
• Fetal bradycardia during traction.
• Differential diagnosis: wrong head position, cephalopelvic disproportion, wrongly applied blades, deflexed head, asynclitism, shoulder dystocia, bony pelvic obstruction.
• Complications: facial bruising, facial nerve palsy, skull fracture, intracranial haemorrhage, scalp laceration, neonatal asphyxia, third and fourth degree tears, vaginal and cervical lacerations, bladder and urethral injury, uterine rupture, postpartum haemorrhage, caesarean section.

The diagnosis is made when the head fails to descend after the limit, by checking application and position.

• Confirm dilatation, station, position and flexion; check parallel blade placement and locking; confirm the bladder is empty.
• Count pulls (limit 3) and time; check fetal heart between pulls.
• Maternal pulse, blood pressure and blood loss; inspect the vagina for tears after blades are removed.
• Examine the baby for facial marks, scalp injury and fractures after birth.

The principle is to stop at the limit, avoid sequential vacuum use, and deliver by caesarean section.

• Supportive: remove the forceps without traction; inform the paediatric team; empty the bladder; two cannulae and group and cross-match 2 units; senior help; consent for caesarean section; explain to the mother.
• Pharmacological: cefazolin 2 g IV as a single dose before incision (3 g above 120 kg); amoxicillin-clavulanate 1.2 g IV as a single dose if the vaginal tissues were torn; oxytocin 10 IU IM after birth, then 20 IU in 1 litre Ringer's lactate at 125 mL per hour for 4 hours; tranexamic acid 1 g IV over 10 minutes if bleeding exceeds 500 mL; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); newborn vitamin K 1 mg IM.
• Procedures: caesarean section; with a deeply impacted head, an assistant pushes the head up from the vagina or the surgeon uses reverse breech extraction; repair of vaginal and perineal tears under good light; inspection of bladder and cervix.
• Special groups: preterm babies delivered by forceps need extra care for skull injury and cranial ultrasound.
• Red flags: facial swelling or asymmetry, bleeding above 500 mL, fetal bradycardia, expanding vaginal mass, urine with blood, floppy baby.
• Follow-up: newborn examination for facial nerve palsy, fractures and head swelling with cranial ultrasound if neurological signs appear; bladder catheter for 24 hours; wound and perineal checks; review at 1 week and 6 weeks.