Spatules de Thierry

Rotational Forceps: Which technique is superior for blade insertion? A simulation study comparing direct, first posterior, and wandering maneuvers

OBJECTIVE

The Kielland's forceps is the most used forceps for assisting rotational operative births. There are various maneuvers described for blade insertion. Among these, the most used ones are the direct, first posterior, and wandering maneuver. The objective of this study was to compare these three maneuvers using a simulator.

STUDY DESIGN

In this experimental study, 144 rotational forceps-assisted births were conducted using a simulation model, with 72 starting in a right occiput-transverse position and 72 in a left occiput-transverse position. Each of the three maneuvers (direct, first posterior, or wandering) for blade insertion was performed 48 times by a total of 6 operators, comprising 3 obstetricians with over 10 years of experience and 3 trainees. The assessment of forceps application included evaluating the placement of the blades in terms of asymmetry and the distance from the lock to the posterior fontanelle. Additionally, the study evaluated the number of reinsertions and relocations required, the perceived difficulty of the procedure, and the operator's level of experience.

RESULTS

There were no statistically significant differences in terms of asymmetry with the three maneuvers. Regarding the distance from the lock to the posterior fontanelle, the best results were obtained with the direct maneuver. There were no differences in the number of reinsertions, relocations, and the perceived difficulty by the operators among the three maneuvers. Experienced obstetricians had better outcomes in terms of the need for reinsertions.

CONCLUSION

The direct maneuver offer advantages in the insertion of blades for rotational forceps.

[Spatulas: A Franco-Colombian story or the slow rise of propulsion...]

The idea of using an instrument to assist natural childbirth is not new and it was in the 18th and 19th centuries that the forceps was developed. It is only after the Second World War that the suction cup provides an alternative to instrumental childbirth, but still based on prehension and traction. In 1950, Emile Thierry, in France, presented his spatulas based on the then original principle of propulsion. The diffusion of spatulas is almost non-existent in the Anglo-Saxon world but is not limited to France since its use was real by the Iberians and Latin Americans. There are currently three types of spatula, two of which are French and one Colombian. This review takes up the saga of this instrument for more than 70 years, develops its particularities and describes the present literature.

[Pathophysiology, diagnosis and management of occiput posterior presentation during labor]

Persistant occiput posterior (OP) positions are the commonest malpresentations of the fetal head during labor and their diagnosis remains challenging. They are associated to prolonged second stage of labor, prolonged expulsive efforts, labor augmentation, cesarean sections and instrumental deliveries. On the maternal side, severe perineal tears, post-partum hemorrhage or chorioamnionitis are more frequent. Currently, prevention of persistent OP positions is based on the maintain of precise maternal positions. Several positions have been evaluated but only lateral position on the same side of the fetal spine has proved its effectiveness. Fetal head rotation can also be achieved with extraction instruments though none has ever been evaluated by a randomized controlled trial. Obstetrical forceps seem more efficient than vacuum but are associated with severe perineal tears. Evaluation of rotation with Thierry's spatulas is scarce. Last, manual rotation is of routine use in many wards. This management is associated with a twofold reduction of operative delivery rate and rare adverse outcomes but has never been evaluated through randomized control trial.