By: 29 April 2020
Optimising non‐rotational forceps: the anterior ninety‐degree elevation forceps (ANEF) approach

Dr Stelios Myriknas and colleagues recently demonstrated the Anterior Ninety-degree Elevation Forceps (ANEF) technique

In the latest edition of The Obstetrician and Gynaecologist, the Anterior Ninety-degree Elevation Forceps (ANEF) technique is described in an article, and demonstrated in the accompanying video (1). ANEF analyses how, by optimising the human factor (technical and non-technical skills) in instrumental deliveries, we could enhance the participants’ experience, whilst at the same time minimise injury on maternal tissue, and reduce the need for episiotomy.

Non-technical skills, such as early maternal participation, open and clear communication, operator’s critical decision-making and multidisciplinary team-working, enable an empowered, supportive environment, with active participation of everyone involved.

The technical aspects of timely elevation of the forceps handles, as the fetal occiput passes under the symphysis pubis, upward traction away from the perineum, aiming for an eventual handle position of at least 90° from midpelvic maternal axis, and the conscious effort of slowing down head delivery, over at least one to two minutes, are vital for achieving a controlled, assisted delivery with minimal trauma.

Such holistic approach has been implemented on forceps deliveries, though its key principles can be applied during ventouse extraction and spontaneous vaginal births. Bettering the experience of an instrumental delivery, as well as perineal integrity, appear to be in direct association with the human factor, and formal training should be re-visiting and addressing both technical and non-technical aspects of an assisted birth.


Dr Stelios Myriknas, Clinical Fellow in Obstetrics and Gynaecology, Chelsea and Westminster Hospital NHS Foundation. Email:

Dr Konstantinos Papadakis, Specialist Trainee in Obstetrics and Gynaecology, Queen Elizabeth University Hospital

Dr Kim Hinshaw, Consultant Obstetrician and Gynaecologist, Director of Research and Innovation, South Tyneside and Sunderland NHS Foundation Trust


  1. 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.