Kjelland forceps

 I want to talk but I don't have time this week. The clinics are overbooked - I haven't had a meal in daylight yet, and the other obstetrician has taken sick leave so I have been on call continuously. My wife has been in hospital for her usual pre-Christmas stay so I haven't been able to finish shopping for presents and for the meal for nearly twenty people. I have not had enough sleep.

On a positive note I have done two Kjelland  forceps deliveries which were perfect for a posterior position under epidural and unable to push. The baby is stuck then once it is rotated into the anterior position it flexes, narrows the effective diameter of the head and slides out easily.
However, there are definitely traps when using rotational forceps. Disasters have occurred. Some women have an android or funnel-shaped pelvis which is wide enough at the inlet but narrows progressively as it descends. Initially labour progresses very well and everyone is optimistic but it becomes slower and slower as the head squeezes tighter and tighter until the cervix is nearly or actually fully dilated. Abdominal examination seems to indicate that the head is no longer palpable and therefore it is safe to do an instrumental delivery but the head is almost always in a posterior position with the head facing forwards, thus only the little face is easily felt and the bulk of the head is missed because it is not at the front. Thus it is not appreciated that the head is too high for safe delivery. On vaginal examination the marked moulding into the pelvis and the oedematous scalp extends the length of the head and gives the misleading impression that it is further down than it is. Then, for a perfect storm, the obstruction of labour eventually results in an abnormal foetal heart rate which requires urgent delivery. Under severe pressure the obstetrician can be easily trapped into trying an unwise forceps delivery, usually Kjelland forceps because the head is always posterior so rotation is required. Labour has become long and painful so there is usually an epidural which weakens pushing so forceps are usually chosen over the vacuum cup. After applying the forceps the heart rate often plunges catastrophically, but the head does not fit so there is no descent with the usual force. At this point it seems that there is no alternative but to pull very hard and that is when the baby can be injured. The obstetrician is upset, trembling and with tears in their eyes as it dawns on them that they are now in the middle of an obstetric disaster which will never end.
That is why some hospitals simply don't use rotational forceps, but they are sweet when used with care.

So, very little sleep last night managing  a vaginal birth after previous Caesarian section. Then abnormal foetal heart rate, onset of vaginal bleeding and head in posterior position, probably due to her epidural,  but not quite suitable for delivery. Anxious parents, midwives and obstetrician. I slowly prepared for an instrumental delivery until the head was genuinely low enough, then applied the Kjelland forceps, rotated the head and delivered a healthy baby.

By this time the sun was rising and sleep unlikely when I finally got home.