DOI: 10.1111/tog.

12649 2020;22:155–60
The Obstetrician & Gynaecologist
Tips and techniques
http://onlinetog.org

Articles in the Tips and techniques

Optimising non-rotational forceps: the section are personal views from
experts in their field on how to
undertake procedures in obstetrics
anterior ninety-degree elevation and gynaecology.

forceps (ANEF) approach

BSc MSc MBBS (Lon) MRCOG, *
a b c
Stylianos E Myriknas Konstantinos Papadakis MD, Kim Hinshaw MBBS FRCOG
a
Clinical Fellow in Obstetrics and Gynaecology, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, Chelsea, London
SW10 9NH, UK
b
Specialist Trainee in Obstetrics and Gynaecology, West of Scotland Deanery, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow
G51 4TF, UK
c
Consultant Obstetrician and Gynaecologist, Director of Research and Innovation, South Tyneside and Sunderland NHS Foundation Trust,
Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
*Correspondence: Stylianos E Myriknas. Email: [email protected]

Accepted on 23 October 2019. Published online 10 March 2020.

Please cite this paper as: Myriknas SE, Papadakis K, Hinshaw K. Optimising non-rotational forceps: the anterior ninety-degree elevation forceps (ANEF)
approach. The Obstetrician & Gynaecologist 2020;22:155–60. https://doi.org/10.1111/tog.12649

2. Continuous, slow, upward traction, moving the handles

Introduction
through an arc of at least 90° – following the J-shaped
Gradual reduction in the use of forceps worldwide has led to curve of the pelvic axis.
an overall decrease in operative vaginal deliveries, with a 3. Slow, controlled delivery of both the head and the
parallel increase in caesarean sections at full dilatation.1 shoulders – while applying manual perineal support
Although trainees in the UK are required to develop (MPS) throughout, with judicious use of episiotomy.
competency in both forceps- and vacuum-assisted births,
The role of episiotomy in instrumental deliveries is
the risk of maternal injury associated with the former is
explored in more depth in the Discussion section. This is
greater, rightfully causing concern among practitioners.
pertinent while awaiting the results and recommendations
At the same time, there is a higher failure rate with vacuum,
from the OASI Care Bundle Project, a package of peripartum
with the potential for increased maternal and neonatal
care aiming to reduce the rates of OASI.2
morbidity, linked to sequential instrumentation or second-
In addition to these technical aspects, maternal education,
stage caesarean section.1 Apart from reducing the options in the
patient involvement with open and clear communication,
obstetrician’s repertoire, abandoning the vital skill of forceps
critical decision making, maintaining situational awareness
delivery might be counterproductive in terms of ensuring safety
and multidisciplinary team-working are vital non-technical
and maintaining the vaginal birth rate in the longer term.
skills to incorporate in a human factors approach to forceps
While acknowledging the increased anxiety and risk of
delivery. In ANEF, we acknowledge that skilled obstetric
physical morbidity linked to forceps use (including obstetric
practice is a combination of art, science and hands-on skills.
anal sphincter injury [OASI]), in this article we describe our
thoughts about optimising forceps delivery. We report a
holistic approach, aiming to increase operator confidence Antenatal education
and enhance the experience for the mother and her partner,
Early education to help to reduce maternal fear and anxiety
while minimising physical trauma.
about forceps delivery is of paramount importance. Our
We describe the ‘anterior ninety-degree elevation forceps’
experience has shown that, going into labour, many women
(ANEF) technique in detail (ANEF, ἄmeυ; Greek for ‘without’,
are not adequately informed, particularly with regard to the
denoting the potential to reduce trauma). Technically, it
indications, techniques and safety of instrumental birth.
includes three vitally important components to minimise
While drawing up a birth plan, the expectant mother
perineal injury:
should be made aware that operative vaginal birth is very
1. Timely elevation of the forceps handles – starting as soon common, especially in first labours (12.8% of all births in
as the fetal occiput passes under the symphysis pubis (SP), England).3 Accessible information should be provided about
for the fetus in an occipito-anterior position. the types of assisted vaginal delivery, indications that

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 Anterior ninety-degree elevation forceps (ANEF) approach

necessitate such delivery, risks and benefits, as well as the Move on to a careful and comprehensive vaginal
alternative options. Women and their partners may benefit examination. Allow adequate time to determine the clinical
from access to appropriate educational videos, to further adequacy of the pelvis, any signs of disproportion, cervical
demystify instrumental deliveries. dilatation, station and position, degree of caput, moulding
and any asynclitism. The fetal ear may be palpated alongside
the head; the pinna ‘folds forwards’, to allow confirmation of
Intrapartum communication
the position.
If an indication for instrumental delivery arises, ensure that As clinical assessment of fetal position can often be
the labour ward team is summoned and available to support incorrect, judicious use of ultrasound is a useful adjunct.
you, the expectant woman and her birth partner. Visualising the fetal orbits, falx and/or occiput is a
Reassure and clearly explain why assistance is necessary, relatively easy skill to learn and can be performed rapidly
outlining what is likely to happen during the procedure. Be and effectively.4
cognisant of concerns, invite questions and try to alleviate Careful assessment, along with the operator’s experience
any anxieties as much as you can. and consideration of the specific clinical situation, should
We cannot emphasise enough the active role that the determine whether an assisted vaginal delivery can be safely
mother is encouraged to play in the ANEF approach. undertaken. It will also determine whether this can be
Empower the woman by highlighting to her that you will performed in the room or as a trial of instrumental delivery
merely be assisting her to achieve a vaginal birth. It will still be in the obstetric theatre.
her own effort that will lead to a successful outcome. Maintain
supportive interaction, while offering clear instructions and
The traction technique
continuous feedback to her and her partner, as well as to the
rest of your team. Support and communication are vital: they Appropriate application and checks before traction are
must be maintained throughout delivery and are particularly described in detail in Box 1. In ANEF, the forceps
important when the indication for an assisted delivery consistently follow the natural shape of the birth canal
is acute. during traction, with movement always directed along the
line of the J-shaped pelvic axis.
Start traction with Pajot’s manoeuvre, encouraging
Analgesia
appropriate descent along the straight part of the pelvic
Aim to further alleviate anxiety by ensuring that the mother ‘J’. However, once descent to the outlet has occurred, it is
is comfortable and relatively pain-free. If there is an epidural vital that you start to elevate the handles just as the head
in situ, ensure a top-up is given before you start. passes under the SP. This should happen at the exact point
Alternatively, a pudendal block with perineal infiltration when the fetal head starts to extend, i.e. at the moment of
can be effective, although be aware that adequate time is crowning (Figure 1a). Timely elevation is key to reduce
required for it to take full effect (at least 5 minutes). pressure and the risk of injury from stretch of
Appropriate analgesia will reduce maternal distress, enabling the perineum.
the mother to work in collaboration with the obstetrician and Apply firm MPS with one hand, and continue gentle, slow,
participate actively in giving birth. constant traction in an ever-increasing upwards arc as the
In acute situations with less-than-adequate analgesia, the head delivers (Figure 1b). When the chin finally passes
operator must not only have excellent technical skills, but will through the introitus, the handles should have passed
also need to actively engage with the woman, constantly through the vertical plane (i.e. the handles should have
encouraging her as the delivery progresses. Maintaining moved through a minimum of 90° as they are raised), so that
direct eye contact while you actively reassure her can be a they lie a few degrees over the SP (Figure 1c). During
simple technique to distract from the discomfort or pain she elevation of the handles, lowering the bed or operating table
may be experiencing. allows this manoeuvre to be performed more easily.
Episiotomy should be considered and used judiciously.
Video S1 contains demonstrations of ANEF delivery.
Examination
In addition to timely elevation of the handles and
As part of a thorough clinical examination always start with maintaining upward traction, the ANEF approach further
an abdominal palpation. Apart from allowing for a clinical minimises impact on the perineum by aiming for a slow,
estimation of fetal size, it will assist you to safely ensure that controlled delivery. While the mother is encouraged to stop
the head is less than or equal to one-fifth palpable per active pushing, and pant or breathe gently instead, the
abdomen. A ‘scaphoid’ abdomen above the SP suggests an handles are used to balance traction with counter-traction, as
occipito-posterior position. necessary. The latter is particularly important to counter any

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 Myriknas et al.

Box 1. Non-rotational forceps delivery: the anterior ninety-degree elevation forceps (ANEF) approach

Introduction and communication

Introduce yourself and maintain a calm environment throughout the procedure, informing all involved what to expect.

Explain to the expectant mother and any birth partner why you are there, and how you will help to deliver the baby.

Emphasise that you will do this together, giving her clear instructions of when to push and when to stop pushing, in order to deliver slowly and
minimise any tears she might sustain.

Consent

Obtain clear, verbal consent for an instrumental delivery in the room and written consent for a trial of instrumental in theatres, in accordance with
published guidance from the Royal College of Obstetricians and Gynaecologists.5

Discuss the maternal and fetal risks appropriately, providing reassurance that babies commonly get small marks overlying the cheekbones, which
soon settle.

Team participation

Inform the midwife or assistant that at some point you will ask them to lower the bed/operating table to its lowest possible position to help with
elevation of the forceps’ handles.

Inform a colleague/assistant that you may request their help with perineal support during head and shoulder delivery.

Ensure the presence of a practitioner skilled in neonatal resuscitation.

Patient position

Assist the expectant mother into the lithotomy position, with her buttocks 2 cm over the edge of the delivery bed and upper body maintained in a
semi-recumbent position so that you are able to clearly see one another. This position straightens the lumbosacral angle and rotates the maternal
pelvis, increasing the relative pelvic diameters.

Start with the bed/table at approximately the level of your waist.

Bladder

Empty the bladder just before you start. If an indwelling catheter is in situ, remove it to minimise the risk of periurethral tears (and, more rarely,
urethral or bladder trauma).

Application and safety checks

Discretely, assemble the forceps away from the direct view of mother and birth partner.

Confirm that the blades are a matching pair (i.e. they have the same numbers imprinted).

Ensure the forceps lock and lubricate them generously.

Between contractions, hold the left handle with the fingers of the left hand, using a light, pencil-like grip.

Start with the handle parallel to the opposite inguinal ligament. Slide the blade gently around the fetal head, with the index and middle fingers of the
right hand protecting the vaginal wall.

Place the right thumb on the heel of the forceps blade during insertion to help to guide it into place.

Change hands and repeat this process to insert the right blade. The blades should enter under their own weight and should never be forced into
position.

Once inserted, ensure that the two blades lock effortlessly. Minor adjustment may be needed.

Keep the blades unlocked between contractions to minimise compressive forces on the fetal head.

Before applying traction, check forceps application carefully.

Ensure the fetal sagittal suture runs in the midline, parallel to the blades.

The posterior fontanelle should be no more than one finger’s breadth above the forceps shanks and the fenestrations should not admit more than
one fingertip (from within the blade, near the heel).

Initial traction – Pajot’s manoeuvre

During a subsequent contraction, ask the woman to actively push.

Initiate traction using Pajot’s manoeuvre, which combines two forces: (1) horizontal (i.e. ‘outwards’) traction using the dominant hand, and (2)
vertical (i.e. ’downwards’) traction applied by the non-dominant hand placed on the shanks.

By carefully balancing the two forces, the head will descend along the line of the pelvic axis, eventually sitting under the pubic arch (Figure 1a).

Remember: the forceps’ handles must be kept horizontal during traction – avoid the temptation to drop the handles towards the floor.

Lowering the bed/table

Once the occiput has just passed under the symphysis pubis (SP), and the head starts crowning, ask the midwife/assistant to lower the bed/operating
table to its lowest possible position (50–70 cm from the floor).

Lowering the bed as the head crowns will allow you to move closer and encourages appropriate, timely elevation of the forceps handles.

Elevation and further traction

Aim to draw the forceps blades along the natural curve of the birth canal.

Maintain constant extension and upward traction by gradually elevating the handles until they are at a minimum of 90° to the maternal midpelvic
axis, eventually lying just over the SP (Figure 1b and c).

Manual perineal support

While continuing to elevate the forceps’ handles with your dominant hand, use the thumb and index fingers of your non-dominant hand to pull the
perineal tissues towards the midline, with the third and fourth fingers folded beneath and used to apply firm pressure to the central perineum.
Alternatively, ask an assistant to apply firm manual perineal support (MPS) while you deliver the head.

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 Anterior ninety-degree elevation forceps (ANEF) approach

Box 1. Continued

Completing head delivery

Apply gentle upward traction, aiming for slow delivery of the head through the perineum (expect this to take at least 1–2 minutes).

Encourage the mother to stop pushing and to breathe or pant gently instead.

Episiotomy

As the perineum slowly stretches, continuously assess the need for an episiotomy.

Perform an episiotomy judiciously, particularly if the perineum appears to start tearing early. A right mediolateral episiotomy should be at a minimum
of 60° from the vertical (i.e. towards 8 o’clock).

Ideally, the perineum will already have stretched up when the episiotomy is made to avoid excessive bleeding.

With practice, the need for episiotomy can reduce, as you will learn to elevate the handles early, at the appropriate point, to reduce posterior pressure
on the perineum.

Slowing the pace of head delivery by applying counter-traction when necessary allows the perineal tissue to stretch up gradually and accommodate
the widening diameter of the head as it passes through the introitus.

Removing the blades

Once the head is delivered, remove your forceps blades in the reverse order of application (right blade first).

Slide them off gently around the fetal head. Avoid ‘levering’ them off.

Delivering the shoulders and body

Ask your assistant to apply MPS during delivery of the shoulders and body, as several cases of obstetric anal sphincter injury occur at this point rather
than at head delivery.

Once the anterior shoulder is dislodged, deliver the body by gentle lateral flexion upwards, onto the mother’s abdomen (if that is her wish).

In most circumstances, deferred cord clamping (1–3 minutes after birth) should be encouraged.

Deliver the placenta and complete the third stage.

Trauma assessment and post-delivery care

Ensure good light and analgesia, and systematically assess for any trauma (cervix, vaginal walls, labia, clitoris, urethra, vulva and perineum).

Per vaginum and per rectum examinations should be performed before and after suturing.

Ensure swab and instrument counts are correct and recorded.

Estimate and record the blood loss.

Document comprehensively, leaving clear post-delivery instructions for analgesia, bladder and wound care, and pelvic floor exercises.

Ensure a dose of intravenous co-amoxiclav (or intravenous clindamycin in the case of penicillin allergy) is given within 6 hours of delivery, to reduce
the risks of maternal perineal infection and related severe sepsis.6

Debriefing

Make every effort to debrief the mother and her birth partner before they leave the hospital.

Summarise events and indications for instrumental delivery, highlight the likelihood of a normal vaginal delivery in future labours, answer any
questions and receive feedback.

(a) (b) (c)

Figure 1. The ANEF technique (left to right). (a) Pajot's manoeuvre leads to head descent under the symphysis pubis (SP), and should stop as soon
as the occiput (red dot) appears. (b) At that precise point, start elevating the handles and move them slowly upwards in a steady arc. Lower the
delivery bed/operating table to its lowest possible position to assist this manoeuvre. Advise mother to 'pant', firmly support the perineum and use
episiotomy judiciously. (c) As the head and chin deliver, the handles should have moved through a minimum of 90° as the head extends, so that
they eventually lie just over the SP.

unintentional strong, expulsive maternal effort. In the An assistant may be instructed to maintain MPS
absence of acute fetal compromise, we strongly endorse throughout head and shoulder delivery, which may further
slow, controlled delivery of the head and body. reduce perineal trauma.

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 Myriknas et al.

Discussion The ANEF approach was developed and used by SM as a

means of improving maternal experience, reducing trauma
The incidence of OASI in the UK is rising with rates of 6.1% and minimising the need for episiotomy in forceps
in nulliparous women delivering vaginally, and up to 14% in deliveries.13 Over 6.5 years, 516 unselected, non-rotational
forceps delivery.7 Although some of this increase may be forceps deliveries were performed by SM, KP and selected
associated with improved recognition and reporting, it colleagues under supervision on nulliparous women using
highlights the need for obstetricians to consider and use a the ANEF approach. No episiotomies were performed and
variety of preventive measures. the OASI rate was 1.9% (SM, unpublished data). The OASI
rate of 1.9% in this group of nulliparous women undergoing
Manual perineal support forceps delivery is similar to the rate expected in spontaneous
In Norway, where the OASI rate is relatively low, MPS is now a vaginal delivery in multiparous women.
core skill and is actively encouraged for all vaginal deliveries. In This early pilot work should not drive formal clinical
2012, Laine et al.8 recommended four interventions to reduce practice without confirmatory evidence from larger
the incidence of OASI: (1) slowing delivery with counter- published trials. We recognise that, along with fetal safety,
pressure from one hand, (2) adequate MPS, (3) maintaining the most important endpoint in instrumental delivery should
clear communication with the woman, ensuring she is be to reduce the incidence of OASI to the lowest possible
instructed to stop active pushing in a timely manner and (4) level. Therefore, in recommending the ANEF approach, we
restrictive use of episiotomy, made at an appropriate angle fully acknowledge that the obstetrician must adopt an
(60° away from the vertical) when necessary. individualised approach and should continue to use
A specific method of MPS has been described with firm episiotomy judiciously, as dictated by the individual and
pressure applied to the perineum as the head is crowning, particular circumstance.
while the thumb and index fingers are spread across the
perineum. By drawing the tissue medially with the thumb Reducing force through the perineum: timely
and index finger, stretching forces in the central perineum elevation, upward traction and slow delivery
are reduced. After formal training, the incidence of OASI The cornerstones of the technical aspects of ANEF are
was reduced by 50%, from 4% to 1.9%.7 Systematic timely elevation of the handles at the point of crowning
reviews have further supported the use of MPS, confirming (maintaining slow, upward traction away from the perineum,
a significant reduction in the risk of OASI (three studies; with an eventual handle position of at least 90° from
n = 74 744; risk ratio 0.45; 95% confidence interval midpelvic maternal axis) and a conscious effort to achieve
0.40–0.50).9 a slow, controlled delivery.
Slowing delivery minimises the forces applied to the perineal
Episiotomy tissues and pelvic floor. The fetal head negotiates the SP, and
Instrumental deliveries (and forceps in particular) are follows a near circular path as it ascends in an arc. In physics,
associated with an increased risk of OASI. As a result, the force-velocity relationship is seen in the centrifugal
many practitioners recommend routine use of episiotomy in (= – centripetal) force formula. Interestingly, in this formula,
forceps-assisted births. Evidence from randomised trials the force (F) is proportional to velocity (v) squared:
indicates no statistically significant difference in the mv2
F¼
incidence of OASI with a policy of routine or restrictive r
episiotomy in forceps deliveries (8.1% versus 10.9%, where m = mass, r = radius.
respectively).10 Similarly, a Cochrane review of the evidence This highlights the compound effect that speed of delivery
for routine use of episiotomy in instrumental births can have on maternal tissue, and the potential benefit in terms
concluded that further research was necessary.11 of reducing trauma by encouraging a slow delivery. We highly
Data from several large observational and cohort studies recommend that the obstetrician intentionally slows down
conflict with the findings of randomised trials, and suggest delivery through the perineum, whenever possible.
that episiotomy reduces the incidence of OASI associated In our clinical experience, a considerable amount of
with operative vaginal deliveries.12 However, the potential for perineal trauma seen with forceps delivery (including OASI)
bias in these trials must be remembered. The results from the results from delayed and/or insufficient elevation of the
OASI Care Bundle, a collaboration between the Royal College forceps handles, often accompanied by a hasty delivery.
of Obstetricians and Gynaecologists, the Royal College of
Midwives and the London School of Hygiene and Tropical
Summary and learning points
Medicine that aims to develop a consistent approach among
healthcare professionals, will contribute further to the Ultimately the purpose of this article is to encourage
ongoing debate.2 obstetricians to pause and consider the technique that they

ª 2020 Royal College of Obstetricians and Gynaecologists 159

 Anterior ninety-degree elevation forceps (ANEF) approach

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Supporting Information Obstet Gynaecol Physiother 2018;122:50–5.

Additional supporting information may be found in the

online version of this article at http://wileyonlinelibrary.com/
journal/tog
Video S1. Demonstrations of ANEF delivery.

160 ª 2020 Royal College of Obstetricians and Gynaecologists