Kiellands forceps, a timely reminder

Christian Kielland (1871–1941) designed his forceps to facilitate delivery from the mid-pelvis in cases of malrotation: occipito-transverse and occipito-posterior positions of the fetal head. It was also used for high transverse arrest, today a certain indication for cesarean section. From the very beginning there were professional objections to the use of his forceps. It was considered too difficult to apply and there were too many risks of considerable maternal and fetal damage. This criticism was not, however, unanimous. It became an instrument widely used, and many obstetricians welcomed it enthusiastically. In his textbook on practical obstetric problems, Ian Donald (1910–1987) characterized it as a “really wonderful instrument” (1). In the past decades there has been a major shift in techniques of operative vaginal delivery, from application of the obstetric forceps to preference for the ventouse. The use of Kielland’s forceps, the most widely used rotational forceps, has declined even more dramatically, often justified by relatively small case series, published some decades ago. As a result many obstetricians either discontinued or never learned the use of rotational forceps. However, rates and methods of operative delivery vary strikingly between different countries, hospitals and consultants. This cannot be wholly explained by different patient populations, but reflects the scarcity of published data about the outcome of operative delivery and the wide range of opinions about the best mode of delivery. The commentary by Nash and co-workers (2) focuses on the renewed interest in Kielland’s forceps in recent years. The authors cite studies where a high rate of success is paired with rather few complications. The results from the relatively large number of cases are reassuring. But, as the authors emphasize, there are great problems associated with introducing or re-introducing Kielland’s forceps for rotation. This is also highlighted in the discussion in medical journals after these series were published. It is not only a question of teaching and learning the use of rotation forceps. Just as important is the way the older generation teaches younger colleagues how to assess the factors for safe vaginal operative delivery in general, the position of the fetal head in the maternal pelvis and its proximity to the pelvic outlet. A recent UK study showed that decisions made by consultant obstetric staff are important in determining whether a second stage cesarean section is the optimum method of delivery for women with delay in advanced labor (3). There were substantial differences between consultants’ and specialist registrars’ opinions on factors affecting safe vaginal delivery. A consultant obstetrician who performed a vaginal assessment was more likely to reverse a decision made by an obstetric trainee for a cesarean and proceed to a safely conducted instrumental delivery. From the women’s perspective, receiving a senior opinion might lead to a successful vaginal birth after hours of labor. Widespread re-introduction of rotational forceps delivery would of course be challenging and depend on a program of training and support by obstetricians experienced in forceps delivery. This might be particularly difficult where those with true experience in forceps delivery are in short supply, but there are strong arguments for trying. Women are considerably more likely to have a failed trial of instrumental delivery and need cesarean section if rotational ventouse is selected rather than Kielland’s forceps (4). Cesarean section in the second stage of labor can be a technically demanding procedure with a high rate of maternal complications, especially when performed at 9– 10 cm cervical dilation. Programs for learning vaginal operative delivery including rotation forceps may have the potential to reduce maternal complications associated with cesarean delivery, both in the short term and in subsequent pregnancies. It is easy to support Professor John M. Thorp Jr, Deputy Editor-in-Chief of BJOG, who in a recent commentary on Kielland’s forceps wrote: “Before this valuable tool in the work box of the accoucheur is relegated to the ‘dustbin of history’ we must actively bring it back into practice” (5).