Assisted Vaginal Delivery & Perineal Injury Flashcards
What are the indications for assisted delivery? (categorise)
Maternal Indications:
- Exhaustion
- Inadequate expulsion efforts (Neuromuscular/spinal cord injury)
- Need to avoid maternal expulsion effort (cardiac/cerebrovascular disease)
Fetal Indications:
-Fetal Distress
Other:
-Prolonged stage 2 of labour:
Nulliparous = > 2hours
Multiparous = >1 hour
Note: if with regional analgesia increase by 1hr before abnormal
What are the requirements which must be met before assisted delivery can be undertaken?
Maternal: Consent Analgesia Emptied bladder Lithotomy position
Fetal:
Vertex presentation and engaged
Station >+2
Uteroplacental:
Cervix fully dilated
Membranes ruptures
No placenta previa
Note, placenta previa = a condition in which the placenta partially or wholly blocks the neck of the uterus, so interfering with normal delivery of a baby.
What are the different classifications of forceps and give examples?
Classic forceps which have a pelvic or cephalic curvature:
Tucker-Mclane
Simpson
Elliott
Rotational forceps which allow rotation to the OA position:
Kielland
Forceps designed to assist breech delivery:
Piper forceps
What are the potential complications associated with forceps delivery?
Increased maternal trauma (including anal sphincter)
Rotational forceps often cause vaginal tears
Fetal Injuries: CNVII palsy Skull fracture Orbital injury Inter cranial haemorrhage
What are the potential complications associated with Ventouse delivery?
Ventouse = suction
Fetal injury: Scalp lacerations Cephalohaematoma Temporary swelling on the head (chignon) Retinal haemorrhage Neonatal jaundice
Rarely inter cranial haemorrhage
What factors play a decision in the type of assisted delivery?
Position and descent of the head.
If head is OT/OP use either Kielland forceps or ventouse.
If the head is at or just below the IS aka station 0/+1 mother will need an epidural and spinal and there must be a theatre ready in case a emergency CS is needed.
What factors are predisposing for needing an assisted delivery?
Nulliparous (20%)
Epidural analgesia
An induced labour
Abnormal CTG
What are the risk factors for a failed assisted delivery?
BMI>30
Estimated fetal weight >4kg
OP
Mid cavity delivery/head is > 1/5 palpable abdominally
What is an episiotomy, what are the different types?
A surgical incision into the perineum to facilitate delivery.
Can be done by 2 incisions:
Mediolateral: Incision at 45 degree to the posterior forchette. Less perineal trauma but antidotally increase blood loss, wound infection and pain.
Midline: Vertical midline incision from the posterior forchette to the rectum. Associated with increased perineal trauma involving the anal sphincters.
What are the indications for episiotomy?
Breech if not going CS
Shoulder dystocia
Assisted delivery (forceps/ventouse)
Fetal Distress
Extensive lower genital tract scarring
Poorly healed 3/4th degree tears
What are the complications of episiotomy?
Bleeding and haematoma Pain Infection Scarring Dyspareunia (painful sex) Rarely fistula formation
What are the different classifications of perineal tear?
1st degree: Vaginal mucosa
2nd degree: Subcutaneous tissue
3rd degree: External anal sphincter involvement
4th degree: Internal anal sphincter involvement
What is the mangement of perineal tears and episiotomy?
1st and 2nd degrees/uncomplicated episiotomy:
Sutured under local anaesthetic. Continuous sutures for muscle and subcuticular for skin.
3rd and 4th degree tears:
- Repaired under epidural or spinal analgesia in theatre.
- Prophylactic Abx and laxatives are used.
- Anal manometry is used to check pressures exerted by anal sphincters.
- Review at 6 weeks
- 30% suffer form long term flatulence/urgency/incontinence
