Assisted Delivery

Question 1

What are the indications for an instrumental delivery?

Answer 1

• Maternal exhaustion
• Prolonged second stage of labour
• Foetal distress
• Maternal illness where bearing down is risky - cardiac conditions, HTN, aneurysm, glaucoma

Question 2

What are the indications for a CS?

Answer 2

• Malpresentation
• Foetal distress
• Multiple pregnancy
• Failure to progress
• Placenta praevia
• Malpresentation
• Severe IUGR
• Placental abruption
• Infections (HIV, HSV)
• Cord prolapse
• Previous CS
• APH
• Previous anal sphincter injury

Question 3

What are the requirements for an instrumental delivery?

Answer 3

• Fully dilated cervix
• OA position (OP possible with Keilland forceps and ventouse)
• Ruptured membranes
• Cephalic presentation
• Engaged presenting part
• Pain relief
• Sphincter/Bladder empty - usually requires catheterisation
• An episiotomy will also often be done

Question 4

What are the CS categories?

Answer 4

• Cat 1 = Immediate threat to life of woman or foetus
• Cat 2 = No immediate threat to life of woman or foetus
• Cat 3 = Requires early delivery
• Cat 4 = Elective CS

Question 5

What incisions are made for a CS?

Answer 5

• Pfannenstiel
• Joel-Cohen
• Midline vertical/classical
• Maylard

Question 6

What are the complications of an instrumental delivery?

Answer 6

• Maternal - more common forceps
  
  • Perineal tears (3rd degree)
  • Cervical and vaginal lacerations
  • PPH
• Foetal - more common ventouse
  
  • Ventouse
    
    • Cephalohematoma
    • Intracerebral haemorrhage
    • Retinal haemorrhage
    • Jaundice
      
      • Prolonged ventouse delivery = greatest risk of haemorrhage in the newborn
  • Forceps
    
    • Facial nerve palsies

Question 7

What are the complications of a CS?

Answer 7

• Visceral damage – bladder, ureter, bowel
• VTE
• Foetal laceration
• Hysterectomy – rare
• Generic
  
  • Bleeding
  • Infection
  • Damage to local structures
  • Procedural failure

Question 8

What are the absolute contraindications for a VBAC?

Answer 8

• Previous uterine rupture
• Classical (vertical) C-section scar
• Other non-C-section contraindications - e.g. major placenta praevia

Question 9

What are the benefits and risks of VBAC?

Answer 9

• Success rate = 72-75%
  
  • Has the fewest complications compared to ERCS
  • Previous SVD is best predictor of successful VBAC (85-90%) and lower risk of uterine rupture
  • Indications of Safe VBAC
    
    • Singleton
    • Cephalic
    • >37 weeks
    • 1 previous C-section
  • Risks:
    
    • Emergency C-section (EMCS)
    • Uterine rupture (1 in 100 if syntocinon is used)
    • Instrumental delivery (39%)
    • Infant
      
      • Transient respiratory morbidity
      • Still birth (very small)

Question 10

What are the benefits and risks of ERCS?

Answer 10

• Risks
  
  • Placenta praevia/accreta in future pregnancies
  • Pelvic adhesions
  • Neonatal respiratory morbidity
  • Longer recovery
  • Risk of bladder/bowel injury (rare)
  • Likely to need future LSCS (Lower Segment CS)
• Benefits
  
  • No risk of rupture
  • Able to plan recovery

Question 11

How is an ERCS planned?

Answer 11

• ERCS should be conducted after 39 weeks
  
  • Preterm VBAC has a lower risk of uterine rupture
• Antibiotics should be given before C-section
• All women should receive thromboprophylaxis
• Care of the C-Section Scar:
  
  • Keep it dry and get sutures taken out after 5 days
  • No heavy lifting for 6 weeks
  • No getting pregnant for 12-18 months

Question 12

What counselling should be given to a women deciding between a VBAC and ERCS?

Answer 12

• Explain that the options are either VBAC or ERCS
• Explain the risks of VBAC (uterine rupture, needing EMCS)
• Explain the risks of ERCS (future pregnancy waits, usual C-section risk factors)