Operative Obstetrics, 3rd edition, ofers a more detailed description of this Kielland forceps procedure (Yeomans, 2017).
With occiput transverse (OT) positions, rotation is required for delivery. With experienced operators, high success rates with minimal maternal morbidity can be achieved (Burke, 2012; Stock, 2013). Either standard forceps, such as Simpson, or specialized forceps, such as Kielland, are employed. With Kielland forceps, each handle has a small knob, and branches are placed so that this knob faces the occiput. he station of the fetal head must be accurately determined to be at, or preferably below, the level of the ischial spines, especially in the presence of extreme molding.
Kielland described two methods of applying the anterior blade. In our example, placement with a left OT (LOT) position is described. With the wandering method, the anterior blade is first introduced into the posterior pelvis (Fig. 29-15). The blade is then arched around the face to an anterior position. To permit this sweep of the blade, the handle is held close to the maternal left buttock throughout the maneuver. he second blade is introduced directly posteriorly, and the branches are locked.
After checking the application, the handles of the Kielland forceps are pulled slightly to the patient's right to increase fetal head lexion and create a smaller diameter for rotation. he irst and second fingers of the left hand are placed over the inger guards with the palm against the handles. his palm faces the maternal left. Concurrently, the first two ingers of the operator's right hand are placed against the anterior lambdoid suture. he fetal head is then destationed approximately 1 cm. For rotation in a counterclockwise direction, the wrist of the left hand supinates, to direct this palm upward. Simultaneously, two ingers of the right hand press on the edge of the right parietal bone that borders the lambdoid suture. This ensures that the fetal head turns with the blades and does not slip.
he second type of blade application introduces the anterior blade with its cephalic curve directed upward to curve under
A B c FIGURE 29-15 A. Application of the right branch of the Kielland forceps to a head in LOT position. The knob on this branch (colored blue) will ultimately face the occiput. B. The right branch is wandered to its final position behind the symphysis. C. Insertion ofthe left branch of the Kielland forceps directly posterior along the hollow of the sacrum. This branch is inserted to the maternal right of the anterior branch to aid in engaging the sliding lock. (Reproduced with permission from Yeomans ER: Operative vaginal delivery. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201•7.) the symphysis. After it has been advanced far enough toward the upper vagina, it is turned on its long axis through 180 degrees to adapt the cephalic curvature to the head.
With either application, after rotation completion, the operator may choose from two acceptable methods for delivery. In one, the operator applies traction on the Kielland forceps using a bimanual grip described previously for conventional forceps (p. 559). When the posterior fontanel has passed under the subpubic arch, the handles can be elevated to the horizontal. Raising the handles above the horizontal may cause vaginal sulcus tears because of the reverse pelvic curve (Dennen, 1955). Alternatively, the Kielland forceps can be removed after rotation and replaced with conventional forceps. With this approach, moderate traction is first employed to seat the head before switching instruments.