Forceps were invented by a surgeon in the early 17th century and gained acceptance among man-midwives or accoucheurs during the 18th and early 19th centuries. Midwives, not surprisingly, argued strongly against their use, believing the hands were Nature’s best instrument. Today forceps are still used in the delivery room, but there are questions about their safety.
The Regency Era: That Was Then
Illustration of the use of forceps from Dr. Smellie’s book of anatomical tables, Plate 24 (1793) (Source: Wikipedia)
A man-midwife in Jane Austen’s time was perceived as something of a monster, partly because he was inclined to use forceps. (See Cruikshank’s famous 1793 satirical print of “A Man-Mid-Wife”.) Dr. William Smellie, an 18th-century Scottish man-midwife, had worked to improve the forceps and used them in his practice: “We must determine when we ought to wait patiently for the efforts of nature, and when it is absolutely necessary to come to her aid.”1 He also published a set of anatomical tables showing the fetus positioned within the womb and the appropriate placement of forceps. In some cases, he wrote, the forceps were “artificial hands,” as when it was necessary to ensure the safety of either mother or child. However, he cautioned: “The forceps, therefore, in general, should not be used, especially in the early part of a man’s practice, except only on the most urgent occasions.”2
Illustration of use of forceps from Dr. Smellie’s book of anatomical tables, Plate 16 (1793) (Source: Wikipedia)
The design of forceps improved little until the early 1800’s, when Dr. David Davis was appointed physician accoucheur at the Queen Charlotte Lying-In Hospital. He designed many pairs of forceps to reduce injuries to infants, while also pleading for better training of accoucheurs.3 After the discovery of ether as an anesthetic in the 1840’s, numerous improvements were made in forceps material (stainless steel instead of iron) and heat sterilization. With the advent of the 20th century, forceps continued to be used but the cesarean section became safer and a new method—the vacuum extractor or ventouse—began to replace the forceps.3,4
The 21st Century: This Is Now
The last 50 years have seen a steady decrease in the use of forceps. In 1990 about 1 in 20 neonates were delivered by forceps; in 2007, less than 1 in 100 were delivered so.5 In part this trend has resulted from the growing popularity of the cesarean section delivery, which increased in the United States population from 21% in 1996 to 32% in 2007,6 becoming the most common surgical procedure.7 In the United Kingdom the cesarean section rate was 4.4% in 1960 and increased to about 28% in 2010.8
1903-1904 photo of an all-male class of medical students attending a lecture on delivery techniques in Chattanooga, TN. The instructor (at left in a dark suit) holds forceps; a female mannikin is positioned on the table. (Source: U.S. National Library of Medicine)
The American College of Obstetricians and Gynecologists (ACOG) promotes the use of forceps as a means of decreasing the number of cesarean sections,9 even though their use has been linked with injuries to the mother during delivery. For example, women whose infants were delivered by forceps had more major injuries to the levator ani muscle than women who delivered without forceps.10 (The levator ani muscle supports the viscera in the pelvic cavity and forms the pelvic floor.) According to Dietz,7 30% to 65% of women who undergo a forceps delivery show subsequent evidence of damage to the levator ani muscle: “In lay terms, the pelvic floor muscle is torn off the pubic bone.”
Forceps have also been implicated in the development of pelvic floor dysfunction, including pelvic organ prolapse, stress incontinence, overactive bladder and fecal incontinence, which can occur several years after childbirth.10,11 Moreover, anal sphincter defects occur in about 50% of patients whose infants are delivered with rotational forceps.7 Forceps are not solely to blame for these issues: women who have had a spontaneous vaginal delivery are also at increased risk of pelvic floor disorders.12
Should the forceps continue to be used during delivery? Some practitioners support their use, claiming they are effective when used properly and their use helps avoid unnecessary cesarean sections. But good training is essential. Because forceps still serve a purpose in the obstetrical theatre, some obstetricians argue that the art of using them should not be lost.8
Sources:
1McClintock, Alfred H. Smellie’s Treatise on the Theory and Practice of Midwifery, Vol. I (London, 1876), pp. 248, 250 (PDF pp. 271, 273).
2Smellie, William. A Set of Anatomical Tables with Explanations and an Abridgment of the Practice of Midwifery, with a View to Illustrate a Treatise on that Subject, and Collection of Cases (Worcester, MA, 1793), pp. 34-35, 39. Available from the Medical Heritage Library here.
3Hibbard, Bryan. Milesones in the evolution of obstetric forceps. Available here.
4Ali UA, Norwitz ER. Vacuum-assisted vaginal delivery. Rev Obstet Gynecol. 2009;2(1):5-17. Available here.
5Werner EF, Janevic TM, Illuzzi J, et al. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol. 2011(Dec);118(6):1239-1246. Available here.
6Martin JA, Hamilton BE, Osterman MJK. Births in the United States, 2013. NCHS Data Brief, No. 175, December 2014. Available here.
7Dietz HP. Forceps: towards obsolescence or revival? Acta Obstet Gynecol Scand. 2015(Jan 27). Abstract of Dietz’s commentary is available here.
8Talukdar S, Purandare N, Coulter-Smith S, Geary M. Is it time to rejuvenate the forceps? J Obstet Gynecol India. 2013(Jul-Aug);63(4):218-222. Available here.
9American College of Obstetricians and Gynecologists. Obstetric care consensus: safe prevention of the primary cesarean delivery. Obstet Care Consensus No. 1, March, 2014. Available here.
10Kearney R, Fitzpatrick M, Brennan S, et al. Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery. Int J Gynaecol Obstet. 2010(Oct);111(1):19-22. Available here.
11Handa VL, Blomquist JL, McDermott KC, Friedman S, Muñoz A. Pelvic floor disorders after childbirth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol. 2012(Feb);119(2 Pt 1):233-239. Available here.
12Memon HU, Handa VL. Vaginal childbirth and pelvic floor disorders. Womens Health (Lond Engl). 2013(May);9(3). Available here.