52. Obstetric operations. Cesarean section (indications)

Question 1

when can forceps delivery be done?

Answer 1

during the 2nd stage of labor
in the case of any condition threatening the mother or fetus, that is likely to be relieved by delivery.

Question 2

what does forceps delivery for?

Answer 2

Facilitates delivery by applying traction to the fetal skull. The cephalic curve of the forceps conforms to the shape of the fetal head; the pelvic curve corresponds to the axis of the birth canal

Question 3

Prerequisites for forceps application

Answer 3

• Trained obstetrician in forceps procedures
• Fully dilated cervix
• Ruptured membranes
• Fetal head is engaged (the greatest transverse diameter in an occiput presentation passes through the pelvic inlet)
• Suitable size and shape of fetal head
• Living fetus
• No concern for cephalopelvic disproportion

Question 4

Prophylactic indications for forceps delivery/ vacum extraction

Answer 4

• Prolonged 2nd stage of labor
• Threatened intrauterine fetal asphyxia
• Maternal disease
• Previous uterine operation

Question 5

vital indications for forceps delivery/vaccum extraction

Answer 5

• Heart failure, pulmonary edema
• Eclampsia
• Severe hemorrhage, DIC
• Definite fetal hypoxia

Question 6

potential complications of forceps delivery

Answer 6

-Maternal injury → vaginal/bladder/perineal/rectal injuries.
-Fetal cephalohematoma, intracranial bleeding, skull traction.
-Fetal Bell’s palsy (CN VIII).

Question 7

types of forceps

Answer 7

1. outlet: the scalp is visible at the introitus without separating the labia
2. low: the leading part of the fetal skull is at station +2 cm or more.
3. mid: the fetal head is engaged, but the leading point of the skull is above station +2 cm

Question 8

what is The vacuum extractor (VE) ?

Answer 8

instrument that uses a suction cup that is applied to the fetal head

Question 9

when is vacuum extraction contraindicated?

Answer 9

the fetus presents by face or breech presentation, and in preterm deliveries.

Question 10

what is the most important determinant of the success of vacuum extraction?

Answer 10

proper cup replacement
the cup should be placed over the sagittal suture, 3 cm in front of the posterior fontanelle (anterior placement may result in cervical spine extension, asymmetrical placement may worsen asynclitism

Question 11

prophylactic maternal indications for C-section

Answer 11

• Maternal illness
• Previous operation on the uterus (myomectomy, C-section)
• Contracted pelvis (diminished pelvic capacity)
• Late primiparity

Question 12

prophylactic fetal indications for C-section

Answer 12

• Threatened fetal asphyxia (scalp pH 7.21-7.25)
• Placental dysfunction
• Fetal illness
• Pregnancy after fertility treatment

Question 13

prophylactic maternal- fetal indications for C-section

Answer 13

• Based on gestational history
• Dystocia, prolonged labor
• Cephalopelvic disproportion, malpresentation, malposition
• Twin pregnancies (not in all cases)

Question 14

vital maternal- fetal indications for C-section

Answer 14

• Eclampsia
• Uterine rupture
• Placenta previa
• Placental abruption

Question 15

vital maternal indications for C-section

Answer 15

• Heart failure, pulmonary edema
• Severe hemorrhage, DIC

Question 16

vital fetal indications for C-section

Answer 16

• Fetal asphyxia (scalp pH < 7.21)
• Umbilical cord prolapse
• Neglected transverse lie
• Ascending infection, fetal pneumonia

Question 17

Potential candidates of vaginal delivery after c-section

Answer 17

1. one cesarean delivery in the past
2. clinically adequate pelvis
3. no other uterine scars or previous rupture
4. physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean if needed.

Question 18

types of abdominal incision

Answer 18

• Vertical incision – lower median
• Low transverse incision (Pfannenstiel)

Question 19

types of uterine incision

Answer 19

• Classical (corporal longitudinal)
• Low vertical
• Low cervical-transverse

Question 20

which uterine incision is associated with low risk of future uterine rupture?

Answer 20

low transverse incision

Question 21

complication of C-section

Answer 21

• Bladder injury (0.3%)
• Ureter injury (< 0.1%)
• Bowel injury (0.2%)
• Postpartum hemorrhage
• Infection
• Pulmonary embolism post-operative

Question 22

what is cervical cerclage?

Answer 22

a circumferential suture placed into the cervix
the surgical treatment of cervical insufficiency (cervical incompetence).

Question 23

when is a cervical cerclage placed?

Answer 23

at 13-16 weeks gestation based on clinical diagnosis (history of cervical insufficiency),
or at 20-24 weeks gestation based on transvaginal US findings

the suture is typically removed before the onset of labor (transvaginal cerclage)

Question 24

definition of cervical insufficiency (cervical incompetence).

Answer 24

the inability of the uterine cervix to retain a pregnancy in the absence of contractions or labor (recurrent painless cervical dilation leading to 2nd-trimester pregnancy losses).

Question 25

types of cervical cerclage

Answer 25

1. McDonald-type cervical cerclage
2. Shirodkar-type cervical cerclage
3. Transabdominal cervical cerclage