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OBGYN 4MB > C-Section/VBAC/Instrumental Deliveries > Flashcards

C-Section/VBAC/Instrumental Deliveries Flashcards

1
Q

Define caesarean section

A

A surgical procedure by which the fetus is delivered through abdominal and uterine incisions

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2
Q

What is the rate of C-section in Ireland?

A

Approx. 30%

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3
Q

Which guideline is used in these scenarios?

A

NICE guidelines CG132

Irish HSE guidelines - Delivery After Caesarean Section

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4
Q

List the indications for an elective c-section

A
  1. Malpresentation e.g. breech
  2. Multiple pregnancy where first twin not cephalic
  3. Placenta praevia
  4. Severe IUGR
  5. Infections e.g. HIV, active primary HSV
  6. Previous classical C-section (increased risk of scar rupture with vaginal delivery)
  7. Previous anal sphincter injury
  8. > /=2 previous C-sections
  9. Certain maternal conditions
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5
Q

List the indications for an emergency c-section

A
  1. Fetal distress
  2. Failure to progress
  3. Maternal conditions for which delay in delivery may compromise her safety (e.g. severe pre-eclampsia)
  4. Malpresentation
  5. Placental abruption
  6. Cord prolapse
  7. APH
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6
Q

What preparation is needed for a C-section?

A
  • Anaesthetic = usually spinal or epidural, occasionally GA
  • Placed on left tilt to prevent caval compression
  • Urinary catheter inserted
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7
Q

How can the abdomen be entered in a C-section?

A
  • Transverse incision 2 finger breadths above pubic symphysis (rarely midline vertical incision)
  • Subcut tissues divided followed by rectus sheath
  • Peritoneum identified and entered high to avoid bladder
  • Bladder is reflected from lower uterine segment
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8
Q

How can we enter the uterus in a C-section?

A
  • > 95% transverse incisions to the lower segment:
  • Reduced blood loss
  • Reduced postnatal morbidity
  • Decreased morbidity in future pregnancies
  • Classical (vertical) incision used in select cases:
  • Lower uterine fibroids
  • Placenta praevia
  • Prematurity
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9
Q

How is the baby delivered during a C-section?

A
  • Presenting part delivered through the incision with assistance of firm fundal pressure
  • Wrigley’s forceps may be used
  • Placenta is then delivered and the uterus checked to ensure the cavity is empty
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10
Q

How do we close the patient after a C-section?

A
  • Uterus closed in two layers
  • Rectus sheath is closed
  • Camper’s fascia is approximated if >2cm subcutaneous fat
  • Skin is closed with either subcuticular sutures or staples
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11
Q

What are the advantages of C-section?

A

Important for avoiding maternal/neonatal morbidity and mortality when used appropriately

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12
Q

List the complications of C-section

A
  1. Bleeding +/- need for transfusion
  2. Infection
  3. Damage to surrounding structures:
    - Maternal = bladder, ureter
    - Fetal = laceration
  4. VTE
  5. Hysterectomy (rare)
    - Increased with multiple pregnancy, fibroids, placental site abnormalities
  6. Anaesthetic complications
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13
Q

What is the prognosis after a C-section delivery?

A
  • Chance of future vaginal delivery with one uncomplicated previous C-section = 75%
  • Increased risk of placental site abnormalities in future pregnancies (0.4-0.8%)
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14
Q

What does the HSE guideline say about delivery after previous C-section?

A
  1. All women with 1 C-section need repeat ultrasound at 32wks to check placental location
  2. Risk of uterine rupture = 0.5-1%
  3. There is an increased risk of uterine rupture with induction (e.g. PGE or oxytocin), so use with caution
  4. If had 2 C-sections, need elective C-sections for subsequent pregnancies
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15
Q

Define assisted delivery

A

Delivery of a baby vaginally with the aid of ventouse or forceps

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16
Q

List the indications for assisted delivery

A

Fetal:
1. Fetal distress in second stage of labour

Maternal:

  1. Prolonged second stage
  2. Maternal exhaustion
  3. Maternal conditions that preclude pushing (e.g. cardiac disease, intracerebral aneurysm, myasthenia gravis, spinal cord disorders)
17
Q

What are the contraindications to assisted delivery?

A
  1. Suspected fetal bleeding disorders

2. Ventouse CI <34wks

18
Q

What pre-requisites need to be met for an assisted delivery to take place?

A
  1. Cervix fully dilated
  2. Cephalic presentation
  3. Membranes ruptured
  4. 1/5 palpable abdominally
  5. Vertex at/below ischial spines
  6. Adequate maternal analgesia
  7. Empty maternal bladder
19
Q

What are the steps in performing an instrumental delivery?

A
  1. Gain maternal consent
  2. Assess position of cervix
  3. Ensure adequate analgesia (epidural, spinal, pudendal block, perineal infiltration with LA)
  4. Lithotomy position
  5. Empty bladder
  6. Perform instrumental delivery - choice of instrument depends on the clinical situation and experience of the operator
20
Q

How is a ventouse delivery performed?

A

Can have Kiwi cup (disposable handheld device) or Metal cup (attached by tubing to suction device)

  1. Apply cup to the flexion point of the fetal vertex
  2. Check maternal tissues clear of cup
  3. Apply suction
  4. Apply traction with contractions and maternal effort
21
Q

List the different types of forceps

A
  1. Outlet forceps = Wrigley’s (vertex at outlet)
  2. Low or mid-cavity = Simpsons/Neville-Barnes
  3. Rotational = Kjellands
22
Q

How is a forceps delivery performed?

A
  1. Apply forceps blades
  2. Check positioning
  3. Apply traction
  4. Requires episiotomy
23
Q

List the complications of assisted delivery

A

Maternal (more common with forceps):

  1. Perineal tears
  2. Cervical or vaginal lacerations
  3. PPH

Fetal (more common with ventouse extraction):
1. Cephalhaematoma (subperiosteal bleed)
2. Intracerebral haemorrhage
3. Retinal haemorrhage
4. Neonatal jaundice
Forceps:
5. Facial nerve palsies

24
Q

What is the prognosis after assisted delivery?

A

80% achieve SVD in subsequent pregnancy

OBGYN 4MB (25 decks)

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