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TN Obstetrics > 13. Operative Obstetrics > Flashcards

13. Operative Obstetrics Flashcards

1
Q

Define: Operative Vaginal Delivery (1)

A

forceps or vacuum extraction

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2
Q

Name fetal indications: Operative Vaginal Delivery (2)

A
  • atypical or abnormal fetal heart rate tracing, evidence of fetal compromise
  • consider if second stage is prolonged, as this may be due to poor contractions or failure of fetal head to rotate
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3
Q

Name maternal indications: Operative Vaginal Delivery (2)

A
  • need to avoid voluntary expulsive effort (e.g. cardiac/cerebrovascular disease)
  • exhaustion, lack of cooperation, and excessive analgesia may impair pushing effort
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4
Q

Name: Prerequisites for Operative Vaginal Delivery (11)

A

ABCDEFGHIJK

  • Anesthesia (adequate)
  • Bladder empty
  • Cervix fully dilated and effaced with ROM
  • Determine position of fetal head
  • Equipment ready (including facilities for emergent C/S)
  • Fontanelle (posterior fontanelle midway between thighs)
  • Gentle traction
  • Handle elevated
  • Incision (episiotomy)
  • Once jaw visible remove forceps
  • Knowledgeable operator
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5
Q

Name contraindicaitons: Operative Vaginal Delivery (4)

A
  • unknown fetal head presentation
  • unengaged head
  • fetal bone demineralization disorder (e.g. osteogenesis imperfecta)
  • fetal bleeding disorder (e.g. hemophilia or vWD)
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6
Q

Describe: Outlet Forceps Position (3)

A
  • head visible between labia in between contractions
  • sagittal suture in or close to AP diameter
  • rotation cannot exceed 45°
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7
Q

Describe: Low Forceps Position (2)

A
  • presenting part at station +2 or greater
  • subdivided based on whether rotation less than or greater than 45º
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8
Q

Describe: Mid Forceps Position (1)

A
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9
Q

Name: Types of Forceps (4)

A
  • Simpson or Tucker-McLane forceps for OA presentations
  • Kielland (rotational) forceps when rotation of head or correction of asynclitism is required
  • Piper forceps for after-coming head in breech delivery
  • Wrigley’s for preterm babies
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10
Q

Describe: Vacuum Extraction (1)

A
  • traction instrument used as alternative to forceps delivery; aids maternal pushing
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11
Q

Name contraindications: Vacuum Extraction (4)

A
  • <34 wk GA (<2500 g)
  • fetal head deflexed
  • fetus requires rotation
  • fetal condition (e.g. bleeding disorder)
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12
Q

Name advantages and disadvantages: Forceps (3)

A
  • Advantages:
    • Higher overall success rate for vaginal delivery
    • Decreased incidence of fetal morbidity
  • Disadvantages: Greater incidence of maternal injury
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13
Q

Name advantages and disadvantages: Vacuum Extraction (6)

A
  • Advantages:
    • Easier to apply
    • Less anesthesia required
    • Less maternal soft-tissue injury compared to forceps
  • Disadvantages:
    • Suitable only for vertex presentations
    • Maternal pushing required
    • Contraindicated in preterm delivery
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14
Q

Name maternal complications: Forceps (6)

A
  • anesthesia risk
  • lacerations
  • injury to bladder
  • uterus, or bone, pelvic nerve damage
  • postpartum hemorrhage (PPH)
  • infections
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15
Q

Name fetal complications: Forceps (6)

A
  • fractures
  • facial nerve palsy
  • trauma to face/scalp
  • intracerebral hemorrhage
  • cephalohematoma
  • cord compression
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16
Q

Name complications: Vacuum Extraction (4)

A
  • Increased incidence of cephalohematoma and retinal hemorrhages, and jaundice compared to forceps
  • Subgaleal hemorrhage
  • Subaponeurotic hemorrhage
  • Soft tissue trauma
17
Q

Name: Limits for Trial of Vacuum (3)

A
  • After 3 pulls over 3 contractions with no progress
  • After 3 pop-offs with no obvious cause
  • 20 min and delivery is not imminent
18
Q

Classify: Lacerations

A
  • first degree: involves skin and vaginal mucosa but not underlying fascia and muscle
  • second degree: involves fascia and muscles of the perineal body but not the anal sphincter
  • third degree: involves the anal sphincter (partial IIIa or complete IIIb)
  • fourth degree: extends through the anal sphincter into the rectal mucosa
19
Q

What should be done for third and fourth degree tears? (2)

A
  • a single prophylactic dose of IV antibiotics (2nd generation cephalosporin, e.g. cefoxitin or cefotetan) should be administered to reduce perineal wound complications
  • laxatives should also be prescribed and constipation should be avoided
20
Q

Define: Episiotomy (4)

A
  • incision in the perineal body at the time of delivery
  • essentially a controlled second degree laceration
  • midline: incision through central tendinous portion of perineal body and insertions of superficial transverse perineal and bulbocavernosus muscles
    • heals better, but increases risk of 3rd/4th degree tears
  • mediolateral: incision through bulbocavernosus, superficial transverse perineal muscle, and levator ani
    • reduced risk of extensive tear but more painful
21
Q

Name indications: Episiotomy (5)

A
  • to relieve obstruction of the unyielding perineum
  • to expedite delivery (e.g. abnormal FHR pattern)
  • instrumental delivery
  • controversial between practitioners as to whether it is preferable to make a cut or let the perineum tear as needed
  • current evidence suggests letting perineum tear and then repair as needed (restricted use)
22
Q

Name complications: Episiotomy (5)

A
  • infection
  • hematoma
  • extension into anal musculature or rectal mucosa
  • fistula formation
  • incontinence
23
Q

Describe epidemiology: Cesarean Delivery (1)

A
  • overall 28% rate in Canada (range 18.5-35.3% by province/territory)
24
Q

Name indications: Cesarean Delivery (3)

A
  • maternal: obstruction, active herpetic lesion on vulva, invasive cervical cancer, previous uterine surgery (past C/S is most common), and underlying maternal illness (eclampsia, HELLP syndrome, heart disease)
  • maternal-fetal: failure to progress, placental abruption or previa, and vasa previa
  • fetal: abnormal fetal heart tracing, malpresentation, cord prolapse, and certain congenital anomalies
25
Q

Name types of SKIN Cesarean Incisions in Cesarean Delivery (6)

A
  • transverse (Pfannenstiel)
  • decreased exposure and slower entry
  • improved strength and cosmesis
  • vertical midline
  • rapid peritoneal entry and increased exposure
  • increased dehiscence
26
Q

Name types of UTERINE Cesarean Incisions in Cesarean Delivery (1)

A
  • low transverse (most common): in non-contractile lower segment
27
Q

Name types Cesarean Incisions that decrease chance for rupture in subsequent pregnancies (4)

A
  • low vertical
  • used for very preterm infants or poorly developed maternal lower uterine segment
  • classical (rare): in thick, contractile segment
  • used for transverse lie, preterm breech, fetal anomaly, >2 fetuses, lower segment adhesions, obstructing fibroid, and inaccessible lower uterine segment (e.g. morbid obesity)
28
Q

Name layers to dissect in cesarean (7)

A
  • Skin
  • fatty layer
  • fascia
  • muscle separation (rectus abdominis)
  • peritoneum
  • bladder flap
  • uterus
29
Q

Name Layers of the Rectus Sheath in cesarean (10)

A
  • Above the arcuate line:
    • external oblique
    • external internal oblique
    • internal oblique
    • rectus abdominis
    • internal internal oblique
    • transversus abdominis
  • Below the arcuate line:
    • external oblique
    • internal oblique
    • transversus abdominis
    • rectus abdominis
30
Q

Name of the Obliterated Umbilical Ligament

A

Urachus

31
Q

Name risks/complications (7)

A
  • anaesthetic complications (e.g. aspiration)
  • hemorrhage (average blood loss ~1000 cc)
  • infection (UTI, wound, and endometritis)
    • single dose prophylactic antibiotic should be used (e.g. cefazolin 1-2 g)
  • injury to surrounding structures (bowel, bladder, ureter, and uterus)
  • thromboembolism (deep vein thrombosis DVT, pulmonary embolism PE)
  • increased recovery time/hospital stay
  • maternal mortality (<0.1%)
32
Q

Describe: Trial of Labour after Cesarean Section (TOLAC) (3)

A
  • should be recommended if no contraindications after previous low transverse incision
  • success rate varies with indication for previous C/S (generally 60-80%)
  • risk of uterine rupture (<1% with low transverse incision), increased by interval <18 mo and one layer closure
33
Q

Name contraindications: Trial of Labour after Cesarean Section (TOLAC) (5)

A
  • previous classical, inverted T, or unknown uterine incision, or complete transection of uterus (6% risk of rupture)
  • history of uterine surgery (e.g. myomectomy) or previous uterine rupture
  • multiple gestation
  • non-vertex presentation or placenta previa
  • inadequate facilities or personnel for emergency C/S
34
Q

Describe: Safety of vaginal birth after Cesarean (VBAC) (4)

A
  • Rate of successful VBAC ranges from 60-82%
  • No significant difference in maternal deaths or hysterectomies between VBAC or C/S
  • Uterine rupture more common in VBAC group
  • Evidence regarding fetal outcome is lacking

TN Obstetrics (16 decks)

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