MODERN FORCEPS DESIGN DR SUBHASH NARGOLKAR PUNE INDIA

MODERN FORCEPS DESIGN DR SUBHASH NARGOLKAR PUNE INDIA 47 TH ISPP WORLD CONGRESS TBILISI GEORGIA 21 ST NOV 2015 March 18 smn-PENHAM 1

Prof Ian Donald “ Time was when many obstetricians, as a part of their rise to fame, designed a new type of obstetric forceps to suit their fad or fancy “ March 18 smn-PENHAM 2

DR DAVID HAY ‘ A prophet is not without honor except in his own country and among his own kin ‘ Pune – Western Indian Trials - India March 18 smn-PENHAM 3

HAY – NARGOLKAR universal OBSTETRIC FORCEPS 5 O+ years of counter-current research with safety SUBHASH M NARGOLKAR 1277 A JANGLI MAHARAJ ROAD PUNE 411004 INDIA subhash. nargolkar@gmail. com

SUNSET ? Reasons for diminished use • Feto-maternal trauma in some forceps operations • Development, safety , extended usage of CS • Hostile medico-legal climate • Lack of tuition – experience, peer pressures • Failure to update design • Economic considerations? March 18 smn-PENHAM 5

Question 1 Vaginal delivery : What is the governance of 2 nd stage if the obstetrician has not already performed a CS? March 18 smn-PENHAM 6

Forceps and VE Grip Traction-elevation-propulsion-compression Independent rotation / active - passive rotation Wandering & cephalic grip – pivot point Correctly applied VE does slip, forceps never! Rapid improvement in VE designs MODERN FORCEPS DESIGN ? ? March 18 smn-PENHAM 7

Question 2 Abdominal delivery : What is the ideal technique for delivery of head from different stations and positions? March 18 smn-PENHAM 8

Question 3 Abdominal delivery : The blades of the thickest forceps are thinner than the thinnest lady’s hand…. . right or wrong? Elective forceps use at CS March 18 smn-PENHAM 9

The Parry Jones Principles : ideal forceps 1 2 3 4 5 6 7 8 9 be simply constructed be suitable for all presentations, positions, stations need only one application ( always cephalic ) be applicable with minimal vaginal manipulations do not diminish available pelvic space be capable of rotating the head allow axial traction at any level make use of excessive force impossible require no specialist training for their use March 18 smn-PENHAM 10

Instrument Design single instrument for all applications? Principle of Parallelism…. Shute Parallel – Divergent…. Hay-Nargolkar (fixed dimension - cross-locking) March 18 smn-PENHAM 11

The Hay’s Forceps March 18 smn-PENHAM 12

HISTORY & DEVELOPMENT regularly reported nationally, in international journals, congresses, FIGO meetings The color atlas monograph HAY’s FORCEPS, with theory, practice, reports, tuition including unique true dimension color CAD drawings of feto-maternal relationships, was published in 1991, reviewed in Asian, Canadian journals March 18 smn-PENHAM 13

USE with safety & advantage Individual (author & others in India), collaborative as Western Indian Trial, in UK, USA, Israel, Malaysia, Mexico In all known vaginal presentations & positions From +5 to -1 stations, almost exclusively with local anaesthesia Paradoxically, routinely, electively at LSCS for floating, deep or after-coming head, using both blades and locking March 18 smn-PENHAM 14

FORCEPS at LSCS routine elective ‘ The blades of the thickest forceps are thinner than the thinnest lady’s thickest hands ’ ……… author Technique of Application of Forceps for Delivering Head at Caesarean Section Subhash M Nargolkar : Practical Obstetrics March 18 smn-PENHAM 15

blades • 14 cms……to lie on mento-vertical (14 cms)…. but from sub-zygoma to vertex…. allowing 3 cms for caput • No protruding cutting tips • Fenestrated, differently curved • Retro-pelvic curve useful at rotation & LSCS, • Divergent-parallel for larger BPDs • Firm, strong, very light • Rounded smooth with special treatment March 18 smn-PENHAM 16

shanks q Flattened & specially treated for ‘springing’ with Pajot’s manoeuvre for pelvic-axis traction. • Rotations always performed with short shanks • Extra length hidden in handles, controlled by screws • useful for higher stations & after-coming head • ‘Springing’ increases with lengthening • Shank insertion widened to facilitate rotation March 18 smn-PENHAM 17

screws q For occipital orientation q Loosening, withdrawal of handles and retightening lengthens the forceps for ‘springing’ & pelvic-axis traction March 18 smn-PENHAM 18

handles q palm-fit grip for wrist movements q Comfortable finger-rests for middle inter -phalangeal joints q Unique “spud-in-groove “ lock q Accommodate hidden shanks with open ends for cleansing q Incorporates unique asynclitism considerations and specific safe locking q Composite alloy / polymer / aesthetics March 18 smn-PENHAM 19

asynclitism ü Evident at ALL stations ü BOTH types encountered ü always with incompletely rotated head, however minimally so ü Seen even at normal delivery ü So, instrument design must cater for application to asynclitic head and its automatic correction by sliding during traction ü THIS INSTRUMENT PROVIDES for these aspects March 18 smn-PENHAM 20

ock L q ‘spud-in-groove’. . To cater to asynclitism, equal and opposite over two stations q Specific. Unless the second (or wandered) blade lies exactly opposite the first, locking is not possible. (forewarning) q Unlike the cross-locking forceps, this forceps cannot be ‘wrenched’ into locking. q Lock is secure but will widen with blades and shanks for larger babies, adapting to the larger BPD March 18 smn-PENHAM 21

q To highlight BP zone (rather than BP diameter) , LBP, stations, types of operations (for comparative assessment and improvement) ACOG markings q Some will help for pre-op assessment, some for corroboration, with or without adjustment, some for abandonment or for cautious or re-confirmed continuation March 18 smn-PENHAM 22

Hay – Nargolkar Design Asynclitism provisions opposite and equal ; ‘palm-fit grip’ with finger-rests; blades – handles with superior, specially treated materials and finish, special markings for evaluation & comparison ; larger series and published reports etc March 18 smn-PENHAM 23

Design………lightest ever? Shute… 850 gms Hay…. . 400 gms H-N. . … 230 gms minus Lightest forceps can be inserted and locked with advantage under ’local & vocal’ Better feel & avoidance of force March 18 smn-PENHAM 24

ETHICAL, LEGAL, ECONOMIC issues • Ethical issues: studies scientifically conducted ; consents obtained ; acknowledgements made ; no infringement or willful transgression • IPR registration obtained • Legal climate must be changed • Commercial availability is now a distinct possibility March 18 smn-PENHAM 25

Plea Break the Vicious Cycle Banned or occasional use = infrequent use = bad use = abuse hurled at forceps Establish a Cycle Training, learning, practicing, evaluating, modifying, teaching March 18 smn-PENHAM 26

in verse One cannot teach, what one does not know, Some know little, some know more, Those who do not know, do not teach or train So, many or most do not learn or gain! One cannot know everything, but all must teach what they know for benefit of students, practitioners and patients! This will not be in vain ! Everyone should gain ! March 18 smn-PENHAM 27

PROSPECTS & CONCLUSIONS Availability of this instrument by standardized commercial production and feed-back, will provide insight to affirm that FORCEPS ARE USEFUL IN THE GOVERNANCE OF THE 2 ND STAGE OF LABOUR AND PARADOXICALLY, ELECTIVELY AT MODERN LSCS ! March 18 smn-PENHAM 28

DHANYAVAAD Terima kasih March 18 smn-PENHAM 29