Use and Safety of Kiellands Forcepsin Current Obstetric PracticeNaomi Burke, MRCPI, Katie Field, MRCPI, Fakhra Mujahid, MRCOG, and John J. Morrison, MD, FRCOG

OBJECTIVE: We sought to evaluate the use and safety ofKiellands rotational forceps for delivery in current ob-stetric practice at a tertiary care obstetric unit.

METHODS: Data were obtained pertaining to all suchattempted deliveries from 1997 through 2011. The out-comes analyzed included maternal obstetric features,induction and duration of labor, use of analgesia, fetalposition and station, birth weight, seniority of the obste-trician, success and failure rates, and associated maternaland neonatal morbidity.

RESULTS: There were 144 cases, of which 129 resulted insuccessful vaginal delivery (89.6%) and 15 were unsuc-cessful (10.4%). A senior obstetrician was present at alldeliveries. The maternal morbidity was relatively low:third-degree or fourth-degree tear less than 1%, postpar-tum hemorrhage 12.4%, and urinary incontinence 7.8%.There were no cases of forceps-related neonatal traumaor hypoxicischemic encephalopathy.

CONCLUSION: Contrary to earlier reports, in these cir-cumstances, use of Kiellands forceps is associated with ahigh successful delivery rate and apparently low maternaland neonatal morbidity.(Obstet Gynecol 2012;120:76670)DOI: http://10.1097/AOG.0b013e3182695581

LEVEL OF EVIDENCE: III

In the past two decades there has been a majordecline in use of the obstetric forceps internation-ally in association with an increased clinician prefer-ence for use of the vacuum extractor, or ventouse, toperform assisted vaginal deliveries.15 For assisted

vaginal deliveries, when there is malposition of thefetal head, the use of rotational forceps has declinedeven more dramatically. Use of the Kiellands for-ceps, which is the most commonly used rotationalforceps, has been largely discontinued, or was neverinitiated, by many obstetricians6 because of the con-troversy that has surrounded its use. This controversyhas arisen because of reports, from relatively smallcase series, dated 2030 years ago, from both Euro-pean7 and U.S. groups,8 which described the adverseoutcomes associated with its use and, particularly, itspotential to cause fetal or maternal injury when usedinappropriately. In addition, it is possible that themedicolegal environment that has pertained to thisarea of obstetrics has influenced medical practice andoperator choice of instruments. Whether or not theKiellands forceps should be abandoned completelyremains an unsolved issue,8 and there are no real datafrom randomized controlled trials to outline bestpractice for midcavity rotational delivery, a relativelycommon clinical scenario in obstetric practice. Inter-estingly, the use of rotational forceps has been re-viewed and supported in the American College ofObstetricians and Gynecologists Practice BulletinNumber 17,9 which includes a recommendation thatit should be performed by only skilled health carepractitioners. The aim of this study was to evaluate theuse of the Kiellands forceps in current obstetricpractice at a tertiary care obstetric department over a15-year period from 1997 to 2011.

PATIENTS AND METHODSThe data for this study were obtained from an obstet-ric computerized database to which the informationhad been entered during the 15-year period from July1997 to December 2011 inclusive at the Departmentof Obstetrics and Gynecology, Galway UniversityHospital, Ireland. This study was deemed exemptfrom the institutional review board at our institution.The database used was the Euroking System Euro-pean Information Technology, Ottershaw, Surrey,

From the Department of Obstetrics & Gynaecology, Clinical Science Institute,National University of Ireland, Galway, Ireland.

Corresponding author: John J. Morrison, MD, FRCOG, Department of Obstet-rics & Gynecology, Clinical Science Institute, National University of Ireland,Galway, Ireland; e-mail: john.morrison@nuigalway.ie.

Financial DisclosureThe authors did not report any potential conflicts of interest.

2012 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/12

766 VOL. 120, NO. 4, OCTOBER 2012 OBSTETRICS & GYNECOLOGY

United Kingdom. At the time of initial antenatal visitfor the woman, a series of medical and demographicdetails pertaining to each woman was entered on thedatabase by a midwife. Similarly, at the completion ofdelivery for every woman, and before discharge fromthe delivery suite, a further entry was made by theattending midwife, outlining the management of la-bor, mode of delivery, and neonatal details. In addi-tion to the data entered on this database, the maternaland neonatal case records for each pregnancy forwhom Kiellands forceps had been used were exam-ined to validate all of the database findings. Fromthese, the following outcome measures related to useof the Kiellands forceps were ascertained: 1) overallprevalence; 2) maternal age, parity, and body massindex (BMI, calculated as weight (kg)/[height (m)]2) atfirst antenatal visit for all mothers; 3) total duration oflabor; 4) duration of second stage of labor; 5) pres-ence of epidural analgesia; 6) position of the fetalhead before attempted delivery; 7) station of the fetalhead before attempted delivery; 8) indication forforceps delivery, ie, suspected fetal compromise ordelayed second stage of labor (as defined below); 9)location of attempted Kiellands forceps assisted de-livery (delivery suite room or operating room); 10)birth weight of neonates delivered; 11) degree ofperineal trauma observed (perineum intact, episiot-omy (mediolateral), first- or second-degree tear, third-or fourth-degree tear, or high vaginal laceration; 12)shoulder dystocia; 13) postpartum complications ofhemorrhage or incontinence (urinary or fecal); 14)neonatal Apgar scores less than 7 at 1 minute and lessthan 7 at 5 minutes; 15) umbilical cord blood pHvalues (less than 7.20, 7.207.25, greater than 7.25);16) the occurrence of forceps related neonatal trauma,neonatal encephalopathy, clavicular fracture, or bra-chial nerve palsy; 17) rate of admission to a neonatalspecial care baby unit; and 18) seniority of operatorand presence or otherwise of a senior attending(consultant) obstetrician at delivery.

All senior obstetricians participating in this studyhad completed the Royal College of Obstetriciansand Gynecologists, London, requirements for accred-itation, which involved a period of 10 years of post-graduate clinical training. The clinical practice usedwas 1 hour of passive second stage after the diagnosisof full dilatation followed by 1 hour of maternalpushing. The second stage of labor was deemeddelayed when delivery was not imminent after 1 hourof maternal pushing. Suspected fetal compromiseconsisted of evidence of a nonreassuring cardiotoco-gram. The technique used was that of direct applica-tion of the forceps blades when the fetal position was

occipitoposterior, and for the occipitotransverse posi-tion, the anterior blade was applied by a technique ofcareful wandering of the blade over the fetal faceinto position with direct application of the posteriorblade. After rotation, the delivery was completedusing the Kiellands forceps. During the time periodof the study (19972011), the overall operative deliv-ery rates in the institution were as follows: the averageforceps rate was 5.4% (1997, 10%; 2011, 5.5%); theaverage vacuum-assisted delivery rate was 13.2%(1997, 8.6%; 2011, 12%); and the average cesareandelivery rate was 24.8% (1997, 18.3%; 2011, 29.2%).

Microsoft Excel was used to tabulate and graph-ically summarize the data. The statistical packageSPSS 18 was used to perform descriptive statistics.Finally, a logistic regression analysis for trend wasperformed to examine for any potential variation inthe number of cases per year during the study.

RESULTSDuring the time period of the study there were 45,335neonates delivered, and Kiellands forceps was at-tempted in 144 cases (0.3%), leading to a successfulassisted delivery for 129 neonates, 89.6% (95% confi-dence interval [CI] 8394%), and a failed attempt in15 cases (10.4%) (95% CI 617%). The results con-cerning the 15 cases of failed attempt at delivery areoutlined separately at the end of this section.

For successfully assisted delivery with Kiellandsforceps, the number of cases per year during the timeperiod of the study varied from three to 21 with amean of 8.6 cases (Fig. 1). There was no significantlinear increase or decrease observed in the number ofcases per year for the duration of the study (95% CI0.931.02, P.266). The vast majority of women forwhom Kiellands forceps-assisted delivery took placewere nulliparous (n116; 89.9%), and the remainingwere parous women (n13; 10.1%). The mean age ofthe group was 31.9 years (3.9, standard error of themean [SEM]) with a range in age from 2043 years.The rate of induction of labor for this group was44.2% (n57), and the remaining 55.8% (n72) un-derwent spontaneous onset of labor. The indicationsfor forceps-assisted delivery were as follows: delayedsecond stage of labor (n94; 72.9%) and suspectedfetal compromise (n35; 27.1%).

The BMI details of the 129 women deliveredusing Kiellands forceps are demonstrated in Table 1.It is evident that 48% (n59) were in the normal BMIcategory with 2% (n2) in the low-weight category,and 50% of the women (n61) were either over-weight or obese (in seven cases the BMI was notrecorded). The mean duration of labor was 10 hours

VOL. 120, NO. 4, OCTOBER 2012 Burke et al Kiellands Forceps and Current Obstetric Practice 767

9 minutes (32 minutes, SEM). The mean duration ofthe second stage of labor was 1 hour 48 minutes (4minutes, SEM). Epidural analgesia was in place in96.1% of women (n124), and five women (3.9%)received a pudendal nerve block with local anestheticagent.

The details pertaining to both malposition andstation of the fetal head, at the time of application ofKiellands forceps, are outlined in Table 1. A seniorobstetrician (consultant) was present at all of theKiellands forceps-assisted forceps deliveries, and thevast majority (n124; 96.1%) were performed by thisattending consultant obstetrician. In a small numberof cases (n5; 3.9%), the forceps-assisted delivery wasperformed by the junior obstetrician (residentspe-cialist registrar) under the supervision of the attendingconsultant. For 90.7% (n117) of these cases. thedelivery took place in the delivery suite room with asmall proportion (n12; 9.3%) performed in theoperating room.

The mean birth weight of all neonates deliveredwas 3, 563 g (44.2, SEM) ranging from 2,140 to4,620 g. The details in relation to perineal traumaobserved at delivery are presented in Table 1. Therewas one third-degree tear and no fourth-degree tear inthe women successfully delivered. There were nocases of cervical laceration and seven cases of exten-sion of high vaginal tears. For postpartum hemor-rhage, there were 16 cases (12.4%). For one of thesecases, there was massive hemorrhage, which wasdeemed to be the result of an atonic uterus. Thisultimately was managed with pharmacologic utero-tonic therapy, examination under anesthesia, and alaparotomy and the patient required 16 units ofblood. In this case there was no noteworthy vaginaltear and a hysterectomy was not performed. Forurinary incontinence in the immediate postpartum

period, there were 10 documented cases (7.8%).There were no cases of fecal incontinence.

Finally, the neonatal details are presented inTable 1, including Apgar scores and cord vessel pHvalues for the neonates. An Apgar score of less than 7at 1 minute was recorded in six cases (4.6%), and therewere no cases of an Apgar score less than 7 at 5minutes. Umbilical cord vessel blood gas pH valueswere recorded in 102 cases (79%) and were missing orunrecorded in 27 cases (21%). An acidotic pH (lessthan 7.20) was recorded in 13 of 102 cases (12.7%).The rate of admission to the neonatal intensive careunit was 8.5% (n11). The reasons for admission tothe neonatal unit were as follows: neonatal tachypnea,grunting, neonatal pyrexia, to rule out sepsis, or all ofthese, n6; low Apgar scores, n3; hypothermia,n1; and social admission (to facilitate the mother inhigh-dependency care as a result of hemorrhage),n1. There were no cases of neonatal trauma second-ary to use of the forceps and no cases of hypoxicischemic encephalopathy. There was one case ofErbs palsy deemed to be related to shoulder dystocia.

Of the 15 women for whom the attempt atassisted delivery with Kiellands forceps was unsuc-cessful, they were all ultimately delivered by cesar-ean. The reasons for failure were as follows: failedapplication, n3; failed rotation, n6; failed descentwith traction, n5; and unclear documentation n1.For 10 (66.6%) of these women, the attempt at forcepsdelivery was performed as a trial in the operatingroom, and for two of these latter 10 cases, there wasan additional attempt at vacuum delivery after theunsuccessful attempt with Kiellands forceps, ie, failedsequential instruments. One of these neonates wasadmitted to the neonatal intensive care unit withApgar scores of 3 at 1 minute and 8 at 5 minutes andan umbilical cord blood pH value of 7.04. All other

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Del

iver

ies

usin

g K

iella

nds

forc

eps

(n)

Fig. 1. Kiellands forceps deliveries peryear (n) over the duration of the study.Burke. Kiellands Forceps and CurrentObstetric Practice. Obstet Gynecol 2012.

768 Burke et al Kiellands Forceps and Current Obstetric Practice OBSTETRICS & GYNECOLOGY

neonates had Apgar scores greater than 7 at 1 and 5minutes and umbilical cord blood gas pH readingsgreater than 7.10.

DISCUSSIONThe findings from this study indicate that use of theKiellands forceps for assisted rotational vaginaldelivery, in selected circumstances, in current ob-stetric practice, with the fetal head mainly at the

level of the ischial spines, or below, and in thepresence of, or performed by, a senior attendingconsultant obstetrician, is associated with a highrate of successful vaginal delivery and apparentlylow rates of maternal and neonatal morbidity. Thestrengths of this study include the large number ofrotational forceps procedures included, that theseries is recent in timing, that the data were allentered prospectively at the time of delivery, thatthe findings were all validated with the medicalcase notes and, finally, that the maternal andneonatal follow up are complete. The weaknesses ofthis study are that it is essentially observational andretrospective in nature, is nonrandomized, and theresults have all emanated from one tertiary carecenter.

The first notable observation from this study isthat the successful vaginal delivery rate for rotationaldeliveries in this study, using Kiellands forceps, was89.6% during the time period 19972011. This repre-sents a failure rate of 10.3%, which compares favor-ably with previously reported failure rates for use ofthis forceps, which varied between 5.9% and 17.5%,in a tertiary care referral U.K. obstetric unit, duringthe years 19922001.1 For vacuum-assisted deliveries,in comparison, the success rates reported using softcup instruments have been reported to be between66% and 79%9,10 and for the more traditional rigidvacuum cup to be between 79% and 81%.9,11 Thesereported success rates for vacuum-assisted deliveriespertain to cohorts of patients in which the position ofthe fetal head was occipitoanterior in the majority ofcases, ie, less than half of the deliveries were rota-tional. The data from our study clearly highlight thelow failure rate associated with use of the Kiellandsforceps for rotational deliveries and outline the estab-lished principle that use of the forceps is less likelyto fail to achieve a vaginal birth than use of thevacuum extractor.12 However, when failure is en-countered, it is recognized that persistent efforts toachieve a vaginal delivery using other instrumentsis not advisable and may be associated with ahigher degree of fetal or maternal injury.9,13 In ourcase series, such use of sequential instruments wasobserved in two of the 15 cases of failed instrumen-tal delivery. Finally, in view of the fact that five ofthe 15 failed delivery attempts in this study oc-curred in the delivery room, it is our view that amore liberal approach to forceps delivery in theoperating room should be recommended.

The other interesting finding from this study isthat the neonatal morbidity associated with use of theKiellands forceps was low. In 1979, analysis of a case

Table 1. Successful Kiellands Forceps Deliveries(n129): Maternal and Neonatal Features

Maternal outcomesAge (y) Mean 31.9 (range 2043)BMI (kg/m2)

Lower than 20 2 (1.6)2025 59 (48.4)2630 49 (40.2)Higher than 30 12 (9.8)Not recorded 7

ParityNulliparous 116 (89.9)Multiparous 13 (10.1)

Analgesia usedEpidural 124 (96.1)Pudendal block 5 (3.9)

Location of deliveryLabor ward 117 (90.7)Theatre 12 (9.3)

PositionOccipitoposterior 31 (24)Occipitotransverse 92 (71.3)Not documented 6 (4.7)

StationAbove spines 4 (3.1)At spines 69 (53.5)Below spines 42 (32.5)Not documented 14 (10.9)

Perineal injuryEpisiotomy 124 (96.1)High vaginal wall

lacerationn7

Anal sphincter injury Third- or fourth-degree tear,n1

Duration of second stage oflabor (h:min:sec)

01:48:53 (00:04:24 SEM)

Neonatal outcomesBirth weight 3,563 g (44.2 SEM)Apgar score

Less than 7 at 1 min 6 (4.6)Less than 7 at 5 min 0

Umbilical cord pH (n102)Less than 7.2 13 (12.7)7.27.25 14 (13.7)Higher than 7.25 75 (73.5)

Intensive care unit admission 11 (8.5)Neonatal trauma 0

BMI, body mass index; SEM, standard error of mean.Data are n (%) unless otherwise specified.

VOL. 120, NO. 4, OCTOBER 2012 Burke et al Kiellands Forceps and Current Obstetric Practice 769

series of 86 Kiellands forceps deliveries reported thatthe neonatal mortality rate was 3.5%, associated birthtrauma was 15.1%, and abnormal neonatal neurologicbehavior was 23%.7 In 2001, a Scottish study, whichincluded 93 women delivered by Kiellands rotationalforceps, reported a 2% risk of physical trauma to theneonate.14 In this study of 129 women similarlydelivered, there were no neonatal deaths, 12.7% ofneonates demonstrated a cord pH value less than7.20, and the rate of admission to the neonatal unitwas 8.5% for all neonates delivered with use of theKiellands forceps. There were no cases of forceps-related fetal trauma and no neonates were classified ashaving hypoxicischemic encephalopathy.

It is difficult to speculate, or understand, why theneonatal morbidity, and mortality, associated with theuse of this forceps are lower than reported fromearlier series7,8 on consideration of the findings pre-sented in this study. There are many possible expla-nations. Case selection may have improved in currentpractice. There may be a lower threshold for perform-ing a cesarean delivery in current practice, and hencethe forceps deliveries described in this study mayhave been easier or more amenable for assistedvaginal delivery than earlier reported cases. Thepresence of a senior and experienced obstetrician atall of these deliveries was likely to have had a positiveinfluence on outcome.

In summary, the data from this study support acontinuing use of rotational forceps in current obstet-ric practice. It is apparent that in well-selected cases,and using the expertise of a senior obstetrician withexperience in using the instrument, that it achieves arelatively high rate of successful delivery with lowneonatal and maternal morbidity. Although use ofthis instrument remains controversial, the challengefor the future is that of training junior obstetricians in

the skill of rotational forceps after many decades ofdecreasing use.

REFERENCES1. Loudon JAZ, Groom KM, Hinkson L, Harrington D, Paterson-

Browne S. Changing trends in operative delivery performed atfull dilatation over a 10-year period. J Obstet Gynaecol 2010;30:3705.

2. Kozak LJ, Weeks JD. US trends in obstetric procedures,19902000. Birth 2002;29:15761.

3. Patel RR, Murphy DJ. Forceps delivery in modern obstetricpractice. BMJ 2004;328:13025.

4. Bailey PE. The disappearing art of instrumental delivery: timeto reverse the trend. Int J Gynaecol Obstet 2005;91:8996.

5. Yeomans ER. Operative vaginal delivery. Obstet Gynecol2010;115:64553.

6. Meager C, Griffiths A, Penketh R. The use of Kiellandsforceps and obstetricians anxiety trait. J Obstet Gynaecol2008;38:7002.

7. Chiswick ML, James DK. Kiellands forceps: association withneonatal morbidity and mortality. Br Med J 1979;1:79.

8. Hankins GD, Rowe TF. Operative vaginal deliveryyear 2000.Am J Obstet Gynecol 1996;175:22582.

9. American College of Obstetricians and Gynecologists. Oper-ative vaginal delivery. Practice Bulletin 17. Washington, DC:ACOG; 2000.

10. Attilakos G, Sibanda T, Winter C, Johnson N, Draycott T. Arandomised controlled trial of a new handheld vacuum extrac-tion device. BJOG 2005;112:15105.

11. Groom KM, Jones BA, Miller N, Paterson-Browne S. Aprospective randomised controlled trial of the Kiwi Omnicupversus conventional ventouse cups for vacuum-assisted vaginaldelivery. BJOG 2006;113:1839.

12. O Mahony F, Hofmeyr GJ, Menon V. Choice of instrumentsfor assisted vaginal delivery. The Cochrane Database of Sys-tematic Reviews 2010, Issue 11. Art. No.: CD005455. DOI:10.1002/14651858.CD005455.pub2.

13. Edozien LC, Williams JL, Chattopadhyay I, Hirsch PJ. Failedinstrumental delivery: how safe is the use of a second instru-ment? J Obstet Gynaecol 1999;19:4602.

14. Hinton L, Ong S, Danielian PJ. Kiellands forceps delivery-quantification of neonatal and maternal morbidity. Int JGynaecol Obstet 2001;74:28991.

770 Burke et al Kiellands Forceps and Current Obstetric Practice OBSTETRICS & GYNECOLOGY