4. Operative obstetrics Flashcards
When is an operative delivery performed
If a spontaneous birth is judged to pose a greater risk to mother or child than an assisted one
What are the two types of operative delivery
Abdominal methods
Vaginal Assisted Deliveries
What is one type of Abdominal operative delivery method
Caesarean section
List two types of Vaginal assisted deliveries
Forceps Delivery
Vacuum Extraction
What is the definition of caesarean section
Removal of a fetus from the uterus by abdominal and uterine incisions, after 24 weeks of pregnancy
Term used to describe Removal of a fetus from the uterus by abdominal and uterine incisions, before 24 weeks of pregnancy
Hysterectomy
C- sections account for what percentage of deliveries
15-25%
List nine indications for C-Section
Cephalopelvic disproportion Relative Cephalopelvic disproportion Placenta Praevia Fetal Distress Prolapsed cord To avoid fetal hypoxia Malpositions Mal presentations Bad obstetric history
What does the term Cephalopelvic disproportion allude to
Obvious either antenatally or in early stages of labor that the fetus, presenting by the head, is not going to pass through the pelvis
What is meant by the term Relative Cephalopelvic Disproportion
Relative CPD (also known as FPD - Feto-Pelvic Disproportion) is the supposed inability of a baby to navigate through the mother’s pelvis, perhaps due to one of the following reasons: 1. Position of the baby’s head - The baby may have his head straight or tilted back instead of flexed with chin to chest.
What is Placenta Previa
This term is used describe when the baby’s placenta completely covers the mother’s cervix
What is the most common fetal malposition
Occiput posterior (OP) position
What are the grounds for allowing a repeat Caesarean Section
Repeat depends on the use for the 1st Csection
Ex: a recurrent indication such as small pelvis
What are the four Categories that indications for Caesarean Section are grouped under?
Category one: emergency
Category two: urgent
Category three: scheduled
Category four: elective
What classifies a C-section as emergency or category one
Immediate threat to mother or fetus
An emergency C-section should be done within which time span
30 mins
What classifies a Csection as Urgent / Category 2
Maternal/ Fetal compromise but not life threatening
Delivery of an urgent C section should be completed within what time span
60-75 mins
What classifies a C-section as scheduled or category three
Mother needed early delivery but no maternal or fetal compromise
What classifies a C-section as Category 4 or elective?
Delivery timed to suit the mother and staff
List some factors that increase the rate of Caesarean section
Inaccurate pregnancy dating Fetal monitoring Macrosomia Maternal request Advancing maternal age Socioeconomic factors Reduced parity Improved surgical techniques Health Insurance Choose the time and day of delivery Epidural anaesthesia
Which incision is used in a c section
Pfannenstiel’s incision
Transverse lower abdominal incision
Describe where the lower segment incision for c section is made
It is a gently curved Pfannenstiel’s incision following the Langer’s lines in the skin
Made 3cm above the pubis in the centre
Describe where the Classic upper segment operation incision for Caesarean section is done
A vertical right paramedian incision from level of umbilicus to 3cm above pubic symphysis
List the steps to the Caesarean Section
Drain bladder with in dwelling catheter Open abdomen Expose lower uterine segment Incise Visceral Peritoneum Push bladder down Open uterus with a transverse incision When bulge of membranes appears, pricked and open amniotic sac fully with a finger from each side Deliver baby if presentation is by the head
In C section
After
The bladder is drained with in dwelling catheter
Which step is next
Open abdomen
In C section
After opening the abdomen
Which step in next
Expose lower uterine segment
In c section
After exposing the uterine segment which step is next
Incise Visceral Peritoneum
In C section after you incise the visceral peritoneum, which step is next
Push bladder down
In c section after you push the bladder down, which step is next
Open uterus with a transverse incision
In C section after you open the uterus with a transverse incision
Which step is next
When bulge of membranes appears, pricked and open amniotic sac fully with a finger from each side
Deliver baby if presentation is by the head
Which drug is administered during and immediately after delivery of a baby to help the birth and to prevent or treat excessive bleeding
Syntometrine
How does Syntometrine work
It works by stimulating the muscles of the uterus (womb) to produce rhythmic contractions
When is a vertical uterine incision used in c section
If the lower segment is unapproachable because of fibroids
If Transverse fetal lie with the back inferior
If lower segment is not formed
What are the two types of regional block administered during a Caesarean Section
Spinal (fastest and densest block)
Epidural (allows postoperative top ups for continuing pain relief)
Why is general anaesthesia avoided for c section
incidence of complications postoperatively are higher than those of Regional blocks
What are some complications of General Anaesthesia during c section
Aspiration of stomach contents
Chest infections
Thrombosis
What are three main indications for General Anaesthesia
Maternal Anxiety
Operation likely to be complicated
Emergency, when insufficient time to establish epidural or spinal block
List four complications of c section
Haemorrhage
Infection
Ileus
Thrombosis
What is used to reduce risk of infection after C section
Prophylactic antibiotics
How do you treat ileus after c section
With IV fluids and no oral fluids until after the mother has passed flatus
The risk of a c section pt developing thrombosis is how much greater than than of a vaginal delivery pt
8x
Thrombosis after c section commonly occurs where
Leg or Pelvic Veins
What is used to prevent thrombosis in a c section patient (esp those older than 35, anemic, history of thrombosis, pre eclampsia, prolonged inactivity, obesity)
Prophylactic anticoagulant
List three types of forceps used in delivery
Kiellands forceps
Simpsons forceps
Short forceps (Wrigley’s)
Which forcep is used for ritationa and extraction in delivery
Kiellands Forceps
Which Forceps is used for midcavity assisted delivery without the need for rotation Max diameter (5-8cm) above vulva
Simpsons forceps
Which forceps is used for low extraction when the maximum diameter is about 2.5cm above vulva
Short Forceps (Wrigleys)
What are the four classifications of forceps application in delivery
Outlet forceps
Low forceps
Mid forceps
High forceps
What is the description for classification of outlet forceps application
Foetal scalp visible without separating vulva
Foetal skull has reached pelvic floor
Sagittal suture is in the A P diameter
Ritation does not exceed 45 degrees
What is the description for classification of low forceps application
Leading point of the skull is 2cm or more below ischeal spine but not on pelvic floor
What is the description for classification of mid forceps application
Leading point of the skull is 2 cm of less above the spine but head is engaged.
Rotation not considered
What are two indications for forceps delivery
Due to uterine inertia
Failure of progress of labour (if no progress occurs for more than 20-30 mins, with the head on the perineum)
What is the time used to declare prolonged second stage of labour in the nulliparous woman with regional anaesthesia?
<3 hrs
What is the time used to declare prolonged second stage of labour in the nulliparous woman without regional anaesthesia?
<2 hrs
What is the time used to declare prolonged second stage of labour in the multiparpus woman with regional anaesthesia?
<2hrs
What is the time used to declare prolonged second stage of labour in the multiparous woman without regional anaesthesia?
<1hr
List five fetal indications for forceps delivery
Foetal distress in second stage when prospect of vaginal delivery is safe
Cord prolapse in second stage
After coming head of breech
Low birth weight baby
Post maturity
What are six maternal indications for forceps delivery
Maternal distress Pre-eclampsia Post caesarean pregnancy Heart diseases Intra partum infection Neurological disorders (where voluntary efforts are contraindicated or impossible)
List the steps in the procedure for a forceps delivery
1) Explain to the patient what is about to happen
2) Bladder is catheterized
3) regional anesthesia is given
4) each blade is slipped beside the fetal head
5) The vagina is guarded by the operators hand
6) When correctly sited, the handles should lock
7) Gentle traction in the correct line of pull
8) once head is crowned, the blades can be removed and the rest of the baby delivered normally
When is Trial Forceps Delivery done?
Knowing that a certain degree of disproportion at mid pelvis may make the procedure impossible
Where is the the Trial Forceps Delivery Attempted
In the Operating Theatre
What type of forceps is used to attempt Trial Forceps Delivery
Low / mid forceps delivery
If the doctor sees that the Trial Forceps Delivery attempt will not be successful when should he abandon
At the earliest stage in favour of Caesarean Section
What are the six prerequisites for Forceps Delivery
Suitable presentation and position Cervix must be fully dilated Membranes must be ruptured Baby should be living Uterus must be contracting and relaxing Bladder must be empty No obvious bar exits to delivery Episiotomy Analgesia
What are the suitable presentations and positions for Forceps Delivery
Vertex
Aftercoming head
Anterior face
Which Analgesia is administered for the Forceps Delivery
Lignocaine pudendal block with infiltration to vulva (for mid cavity forceps )
Epidural or spinal (for rotation forceps)
List six Complications/dangers of Forceps Delivery
Injury Post partum hemorrhage Shock Sepsis Anaesthetic hazards Delayed or long term sequel
Which injuries might the mither succum during Forceps Delivery
Extension of Episiotomy involving anus and rectum or vaginal vault
Vaginal lacerations and cervical tear if cervix was not fully dilated
What are four Fetal Complications or Dangers after Forceps Delivery
Asphyxia
Trauma
Remote- cerebral palsy
Foetal death- around 2%
A vacuum extractor is rarely used for the first stage of labour
If, however, there was an indication to use it what would those indications be
Fetal distress after cervix is 8cm dilated in a multiparous woman
Lack of advance after 8cm dilation in a multiparous woman
A vacuum extractor is more commonly used during the second stage of labour
What are the indications
Lack of advance often with occipito-posterior or occipito transverse position
After an epidural has relaxed the pelvic floor
If the mother is tired
If the head of the second twin is high
List the steps in the procedure for a Vacuum Extraction Delivery
Use the largest possible cap
Should lie flat against fetal head
Check to ensure no part of the vaginal wall has been sucked in
The cap is held on to the head with the left hand as traction is applied with the right hand
Correct line of pull very important to prevent the cap coming off
Early episiotomy
List three complications of Vacuum Extraction Delivery
Damage to cervix of not fully dilated to vaginal wall
Haematoma of baby’s scalp
Scalp abrasions
List four Indications of episiotomy
Speed later part of the second stage of labour in presence of fetal distress
Open up posterior areas to allow correct line of traction at forceps extraction
Overcome a perineum that is rigid and delaying last part of delivery
If there is likely to be a major perineal tear
Describe stage 1 perineal tear
Skin of fourchette or vagina only
Describe Stage 2 Perineal Tear
Skin and Superficial Perineal Muscles
Describe Stage 3 perineal Tear
Anal and muscles and sphincter involved
Risks of Episiotomy
Substantially increases
- Maternal blood loss
- average depth of posterior perineal injury
- risk of anal sphincter damage and its attendant long term morbidity
- risk of improper perineal wound healing
- amount of pain in first several postpartum days
