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A - MSRA Obstetrics [16] > [45] Operative Vaginal Delivery > Flashcards

[45] Operative Vaginal Delivery Flashcards

1
Q

What is operative vaginal delivery?

A

The use of an instrument to aid the delivery of the fetus

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2
Q

What % of deliveries in the UK are operative?

A

12-13%

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3
Q

What are the two main types of instruments used in operative vaginal delivery?

A
  • Ventouse

- Forceps

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4
Q

Which instrument is most likely to succeed in delivering the baby vaginally?

A

The one that is used first - the one used second is less likely to deliver regardless which is used first

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5
Q

Which instrument has a lower risk of fetal complications?

A

Forceps

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6
Q

Which instrument has a lower risk of maternal complications?

A

Ventouse

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7
Q

When should an attempt to deliver with an instrument be abandoned?

A

After 3 contractions and pulls and no reasonable progress

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8
Q

What is a ventouse?

A

An instrument that attaches a cup to the fetal head via a vacuum

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9
Q

What are the most common types of ventouse?

A
  • Electrical pump attached to a silastic cup

- Hand-held, disposable device commonly known as the Kiwi

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10
Q

When is an electrical pump ventouse suitable?

A

Only if the fetus is in an occipital-anterior position

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11
Q

When is a kiwi ventouse suitable? 🥝

A

All fetal positions and rotational deliveries

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12
Q

How is the ventouse used?

A

Cup is applied with centre over the flexion point of the fetal skull. Traction is applied perpendicular to the cup during contractions

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13
Q

What is the flexion point of the fetal skull?

A

In the midline 3cm anterior to the posterior fontanelle

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14
Q

What are the advantages of ventouse delivery?

A
  • Less maternal perineal injuries

- Less pain

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15
Q

What are the disadvantages of ventouse delivery?

A
  • Lower success rate
  • More cephalohaematoma
  • More subgaleal haematoma
  • More fetal retinal haemorrhage
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16
Q

What are forceps (obstetrics)?

A

Double bladed instrument that comes in different types for different scenarios

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17
Q

What scenarios may require different forceps for delivery?

A
  • OA positions
  • C-section
  • Rotational delivery
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18
Q

How are forceps used to deliver?

A

Introduced into the pelvis taking care not to cause trauma to maternal tissues and applied to fetal head with blades locked together. Gentle traction applied during contractions

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19
Q

What angle is used when applying traction to forceps?

A

Following the J shape of the maternal pelvis

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20
Q

What is the advantage of forceps delivery?

A

Don’t require maternal effort

21
Q

What is the disadvantage of forceps delivery?

A

Have a higher rate of 3rd and 4th degree tears

22
Q

When should a decision for operative vaginal delivery be made?

A

In the 2nd stage of labour

23
Q

What are the main considerations when deciding on operational vaginal delivery?

A
  • Is there a valid clinical indication

- Is the patient suitable

24
Q

What are the most common maternal indications for operative vaginal delivery?

A
  • Inadequate progress
  • Maternal exhaustion
  • Maternal medical conditions that mean active pushing should be limited
25
Q

When should delivery be expected in nulliparous women?

A

After 2 hours of active pushing

26
Q

When should additional time be allowed for pushing in nulliparous women?

A

If there is no urge to push at diagnosis of second stage (common in regional anaesthesia)

27
Q

When should delivery be expected in multi-around women?

A

Within one hour of active pushing

28
Q

What maternal medical conditions may limit active pushing in delivery?

A
  • Intracranial pathologies
  • Some maternal heart diseases
  • Severe hypertension
29
Q

What are some common fetal indications for operative vaginal delivery?

A
  • Suspected fetal compromise in second stage of labour

- Clinical concerns e.g. significant antepartum haemorrhage

30
Q

How are most fetal compromises diagnosed?

A
  • CTG monitoring

- Abnormal fetal blood sampling

31
Q

What are the pre requisites for operative vaginal delivery?

A
  • Fully dilated
  • Ruptured membranes
  • Cephalic presentation
  • Defined fetal position
  • Fetal head at least the level of the ischial spines and no more than 1/5 palpable per abdomen
  • Empty bladder
  • Adequate pain relief
  • Adequate maternal pelvis
32
Q

What are some absolute contraindications to operative vaginal delivery?

A
  • Unengaged fetal head in singleton pregnancy
  • Incompletely dilated cervix in singleton
  • True cephalo-pelvic disproportion
  • Breech and face presentation
  • Most brow presentation
33
Q

What is true cephalo-pelvic disproportion?

A

Where the fetal head is too large to pass through the maternal pelvis

34
Q

What are some specific absolute contraindications for ventouse delivery?

A
  • Preterm gestation (<34 weeks)

- High likelihood of any fetal coagulation disorder

35
Q

What are some relative contraindications for operative vaginal delivery?

A
  • Severe non-reassuring fetal status and scalp is not visible
  • Delivery of the second twin when head not quite engaged
  • Prolapse of umbilical cord with fetal compromise when cervix is completely dilated and the station is mid cavity
36
Q

How are operative vaginal deliveries classified?

A

By the degree of fetal descent

37
Q

What are the classifications of operative vaginal delivery?

A
  • Outlet
  • Low
  • Midline
38
Q

How does the risk of complications change with classification of operative vaginal delivery?

A

Decreases the lower the classification

39
Q

What is an outlet operative vaginal delivery?

A
  • Fetal scalp visible with labia parted OR
  • Fetal skull reached pelvic floor OR
  • Fetal head on perineum
40
Q

What is a low operative vaginal delivery?

A

Lowest presenting part (not caput) is +2 or further below the ischial spines

41
Q

What is a low operative vaginal delivery subdivided into?

A
  • > 45 degrees (rotation needed)

- <45 degrees (no rotation needed)

42
Q

What is a midline operative vaginal delivery?

A
  • 1/5 palpable abdominal

- Lowest part is above +2 but is lower than the ischial spines

43
Q

What is a midline operative vaginal delivery subdivided into?

A
  • > 45˚ - rotation needed

- <45˚ - no rotation needed

44
Q

What are the potential fetal complications of operative vaginal delivery?

A
  • Neonatal jaundice
  • Scalp lacerations
  • Cephalhaematoma
  • Subgaleal haematoma
  • Facial bruising
  • Facial nerve damage
  • Skull fractures
  • Retinal haemorrhage
45
Q

What are the potential maternal complications of operative vaginal delivery?

A
  • Vaginal tears
  • VTE
  • Incontinence
  • PPH
  • Shoulder dystocia
  • Infection
46
Q

What are the 3rd/4th degree vaginal tear rates in a normal vaginal delivery?

A

1/100

47
Q

What are the 3rd/4th degree vaginal tear rates in a ventouse delivery?

A

4/100

48
Q

What are the 3rd/4th degree vaginal tear rates in a forceps delivery?

A

10/100

49
Q

When is a lower complication rate likely in an operative vaginal delivery?

A
  • Lower classification
  • Less rotation needed
  • Fewer pulls

A - MSRA Obstetrics [16] (61 decks)

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