Bullet forceps

Role in surgical pregnancy termination

When performing an instrumental abortion (curettage of the uterine cavity), vulsellum forceps serve as the primary fixing instrument.

• They are part of the complete surgical set, which also includes vaginal specula, a uterine sound, a set of Hegar dilators, curettes of various sizes, and abortion forceps (ovum forceps for removing the conceptus).
• Fixation of the cervix with vulsellum forceps is an obligatory first step. It allows the organ to be held securely during cervical dilation using dilators.
• Once access is secured, the physician proceeds to destroy and remove the conceptus, followed by curettage of the uterine walls (starting with a blunt No. 6 curette and moving to smaller, sharper instruments as the uterus contracts).

Use in destructive obstetric operations

In obstetric practice, vulsellum forceps play a key role during the preparation phase for craniotomy (perforation of the fetal head).

• The primary task of the instrument at this stage is the rigid fixation of the presenting part. Through the vagina, the physician grasps the skin of the fetal scalp.
• To ensure maximum immobility, two pairs of vulsellum forceps are used simultaneously (Muziot forceps serve as an acceptable alternative).
• Only after such additional fixation is the scalp incised with a scalpel. The incision is always made in the anteroposterior direction.
• Securely holding the head with vulsellum forceps makes it possible to safely introduce the perforator (Phenomenov spear-shaped or Blo scissors-like perforator) with careful twisting movements. The insertion point depends on the presentation: through the anterior fontanelle, orbit, frontal bone, or fetal mouth.

Use in laparoscopic interventions

In operative gynecology, particularly during laparoscopy, vulsellum forceps are necessary for correct patient positioning and manipulation of the pelvic organs.

• The surgery is performed under endotracheal anesthesia; the patient is positioned with the perineum extending past the edge of the table (it is optimal to use a table with a cutout for vaginal manipulations).
• To create traction and countertraction during the procedure, a Cohen uterine sound is used. It is inserted into the uterine cavity and rigidly fixed with vulsellum forceps.
• This fixation allows the second assistant, positioned between the patient's abducted legs, to actively mobilize the uterus. This provides the surgeon, standing on the left, with an optimal view and convenience when working with instruments.
• Note: for hysterectomy, the Clermont manipulator is preferred as it allows the uterus to be positioned favorably for transecting the vaginal fornices, however, the Cohen sound with vulsellum forceps remains a classic solution for many procedures.

Non-standard use in obstetrics

The instrument can be used not only for grasping tissues but also for performing specific manipulations in complex obstetric procedures.

• A prime example is the combined obstetric version with incomplete cervical dilation (Braxton Hicks method). This procedure is performed extremely rarely (in case of fetal demise or life-incompatible anomalies) to press the detaching, low-lying placenta against the uterine wall via the fetal pelvic pole.
• The intervention is performed when cervical dilation reaches 5–6 cm. The obstetrician inserts a hand into the vagina and the index and middle fingers into the internal cervical os.
• It is at this stage that one blade of the vulsellum forceps is used for amniotomy to rupture the amniotic sac. Afterward, the fetal foot is grasped at the ankle joint, brought out through the vaginal introitus, and a 200 g weight is suspended from it.

Class and exam questions

What else to study on this topic

• Technique of fetal head perforation and types of perforators used (Phenomenov, Blo).
• Stages of surgical abortion: from cervical dilation to changing curettes.
• Organization of the operating field and positioning of the surgical team during laparoscopy.
• Indications, conditions, and technique of performing the Braxton Hicks version.
• Use of the Clermont uterine manipulator in hysterectomy.

Other topics in the "Obstetrics" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.