Caesarean sections Flashcards

1
Q

Discuss caesarean sections in NZ and Australia
-Rates in Australia
-Rates in NZ
-Elective repeat CS rate

A
  1. Aus rates - 33% 2015
  2. NZ rates 25% 2015
  3. Elective rates = 14% of all CS
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2
Q

What are the success rates for VBAC for the following
-VBAC following single previous CS
-VBAC after 2 previous CS
-VBAC with previous VB
-VBAC if no previous VB, Previous CS for FTP, Requiring IOL, BMI >30
-VBAC if BMI >40
-Preterm VBAC
-Twin VBAC

A
  1. VBAC following single previous CS - 75% (varied in the literature)
  2. VBAC after 2 previous CS - 65-75%
    (No difference in success rates for 1 or 2 CS)
  3. VBAC with previous VB - 85-95%
  4. VBAC if no previous VB, BMI >30, Previous CS for FTP, Requiring IOL = 40%
  5. VBAC if BMI > 40 = 39% (> double risk of uterine rupture)
  6. Preterm VBAC - same success rate as term VBAC (Less rupture)
  7. Twin VBAC - same as success rate as singleton VBAC
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3
Q

What are the factors which favour a successful VBAC (4)

A

-Previous safe VB
-Previous successful VBAC
-Spontaneous onset of labour
-Uncomplicated pregnancy without other risk factors

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4
Q

What are the factors which reduce success of a VBAC (11)

A

-Previous CS for dystocia
-IOL
-Co-existing fetal, placental or maternal conditions
-Maternal BMI >30
-Fetal macrosomia >4kg
-Advance maternal age
-Short stature
-More than one previous CS
-Risk factors associated with increase risk of scar rupture
-Gestation >41 weeks
-Fetal malpresentation

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5
Q

What are the contraindications to VBAC (5)

A
  1. Previous classical section
  2. Previous T or J extension
  3. Congenital uterine anomalies
  4. Inability to perform an EMCS
  5. Contraindications to VB
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6
Q

What are the risk and benefits of VBAC
-Neonate risks (5)
-Neonate benefits (2)

A
  1. Neonate risks
    -Increased uterine rupture 1:200 with 1:7 chance of death or brain injury
    -Increased perinatal mortality 0.4-0.7:1000 (Low and comparable to nullips)
    -Fetal acidosis <7.0pH 1.5:1000
    -Increased HIE 0.4: 1000
    -Increased Intracranial injury 1:1900
    -Increased birth injury
  2. Neonatal benefits
    -Reduced neonatal distress 2-3%
    -Higher breastfeeding rates
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7
Q

What are the maternal risks and benefits of VBAC
-Risks (6)
-Benefits (4)

A
  1. Maternal risks
    -Increased risk of emergency CS 1:4
    -Increased serious CS complication rate compared with ELCS 13% vs 7%
    -Increased risk uterine rupture 1:200
    -Increased womb infection 29:1000
    -Increased need for blood transfusion 2:1000
    -Hysterectomy 0.8:1000
    -Pelvic floor trauma - 5% 3rd and 4th
    -Instrumental delivery 39%
  2. Benefits
    -Avoid major surgery
    -Earlier mobilisation and DC from hospital
    -Reduce future pregnancy complication
    -Increase chance of future successful VBAC
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8
Q
  1. What are the neonatal risks and benefits for ELCS
    -Risks (3)
    -Benefits (4)
A
  1. Risks
    -Chance of EMCS prior to ELCS 118:1000
    -Increased neonatal respiratory distress 4-5% (No difference after 40/40)
    -Lower rates of breast feeding
  2. Benefits
    -Decreased uterine rupture <0.2:1000
    -Reduced perinatal mortality 1:100,000
    -Reduced HIE 0:1000
    -Reduced intracranial injury 1:2750
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9
Q

What are the maternal risks and benefits of ELCS
-Risks (2)
-Benefits (5)

A
  1. Risks
    -Increased surgical complications
    -Increased risk of complications in future pregnancies
  2. Benefits
    -Decreased womb infection 15:1000
    -Decreased need for blood transfusion 10:1000
    -Decreased uterine rupture <0.2:1000
    -Avoid pelvic floor trauma
    -Can plan time for birth
    -Avoid EMCS with increased complications (13 vs 7%)
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10
Q

What are the risk factors for uterine scar rupture (8)

A

-Very rare if unscarred uterus 0.5-2:10 000
-Multiparity
-Previous classical 90:1000
-Inverted T or J incision 19:1000
-Low vertical incision 20:1000
-IOL and augmentation esp with prostaglandins
-Pregnancy interval <18 months 2-3x risk
-Risk of recurrent rupture = >5%
-Previous uterine surgery with breech of cavity

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11
Q

What are the signs of uterine rupture (9)

A

-Abnormal CTG (65-75%)
-Haematuria 25%
-Loss of station
-Concave abdomen
-Shoulder tip pain or diaphragm irritation
-Constant pain persists between contraction 8%
-Blood stained liquor 4%
-Cessation of effective uterine activity
-Maternal tachycardia or hypotension

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12
Q

Discuss VBAC and induction of labour
-Risk of repeat CS
-Chance of successful VBAC
-Risk of rupture (5)

A
  1. Risk of repeat CS - 33% with IOL cf 18% if Spont labour
  2. Chance of successful VBAC = 65%
  3. Risk of rupture
    -2-3 times higher with IOL
    -Risk 10:1000 (Double spontaneous labour)
    -Risk increased 4 times with use of oxytocin (2:100)
    -Combined PG with oxy has highest risk
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13
Q

Discuss augmentation and VBAC
-Chance of VBAC success
-Risk of uterine rupture

A
  1. Chance of VBAC success 75%
  2. Chance of uterine rupture 8-9:1000
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14
Q

Discuss VBAC after >1 previous CS
-Success rate of VBAC
-Rupture rate
-Advice for VBAC after 3 CS

A
  1. Success rate for VBAC 70%
  2. Rate of rupture 1.6% (Note less than with oxy IOL)
  3. Advice for VBAC after 3 CS - don’t!!
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15
Q

Discuss evidence based CS technique
-Which techniques have high level evidence (5)
-Which techniques are not supported by the evidence (3)

A
  1. -Pre-skin incision antibiotics reduce maternal infection RR0.5
    -Blunt extension of the uterotomy in cephalad-caudad direction reduces blood loss and lateral extensions
    -Spontaneous removal of the placenta reduces infection and blood loss cf MROP.
    -Single layer closure in women who have completed their families
    -Suture closure of adipose tissue if more than 2cm RR 052 for haematoma / seroma formation
  2. Techniques not supported
    -Manual cervical dilation
    -Subcut drains
    -Supplemental oxygen
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16
Q

Discuss pre-operative steps for evidence based CS
-Antibiotics (3)
-IDC (3)
-Skin prep (1)
-Vaginal cleansing (2)

A
  1. Antibiotics
    -15-60 mins before skin incision.
    -First generation cephalosporin
    -Reduction in infection RR 0.5 compared to after skin incision
    -Avoid augmentin
  2. Indwelling catheter
    -Evidence is poor
    -NICE recommend
    -Catheterisation associated with increased UTI and no increase in bladder injury. Poor evidence
  3. Skin preparation
    -Chlorhexidine associated with reduced surgical site infection cf iodine (RR 0.7)
  4. Vaginal cleansing
    -Perform with providine iodine
    -Reduces post-CS endometritis esp. if in labour (RR 0.41) 7.1% vs 3.1%
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17
Q

Discuss incision type
-Pfannenstiel
-Joel-Cohen

A
  1. Pfannenstiel incision
    -2-3cm above superior aspect of SP slightly curved
  2. Joel-Cohen
    -Straight incision 3cm below the line that transects the ASIS. Blunt entry through into the peritoneum.
    -Joel-Cohen associated with less blood loss, faster operation time, less analgesia requirement, shorted post-op hospital stay cf pfannenstiel
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18
Q

Discuss evidence based CS
-Management of the fascial layer (3)
-Management of the bladder flap
-Hysterotomy method

A
  1. Management of the fascial layer
    -Insufficient evidence to dissect off rectus muscles
    -Low level evidence suggests not to dissect the lower rectus fascia
    -Sharp entry to fascia with blunt extension recommended
  2. Management of the bladder flap
    -Omission of a bladder flap reduces time to delivery 1.27 mins
    -No difference in bladder injury, blood loss.
    -Consider in repeat CS, CS at fully, Prelabour CS
  3. Hysterotomy method
    -J incision preferable to inverted T if extension required
    -Blunt extension of hysterotomy cephalo-caudal recommended - less blood loss, less angle extension cf sharp
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19
Q

Discuss evidence base CS
-PPH prophylaxis (4)
-Placental delivery (3)
-Uterine exteriorisation (3)
-Hysterotomy closure (4)

A
  1. PPH prophylaxis
    -5IU oxy with delivery of anterior shoulder
    -Routine oxy infusion
    -Misoprostol confers no advantage over oxy
    -TXA associated with reduced EBL >1000 and further use of uterotonics
  2. Placental delivery
    -Delivery spontaneously with CCT
    -Avoid manual removal - increased blood loss, endometritis, Rh sensitisation
    -Only do intra-uterine wiping if placental membranes seen - 1 x small RCT
  3. Uterine exteriorisation
    -New evidence suggests exteriorisation reduces blood loss
    -Surgeon’s preference
    -May be associated with increased discomfort.
  4. Hysterotomy closure
    -No difference in single or double layer closure for scar rupture / dehiscence / accreta / praevia
    -Single layer faster operation time and maybe less blood loss
    -Continuous and unlocked
    -No evidence for suture type
20
Q

Discuss evidence based CS
-Management of peritoneum (3)
-Intraperitoneal drain use (2)
-Sheath closure (1)
-Subcut closure (3)
-Skin closure (2)

A
  1. Management of peritoneum
    -Closure associated with increased post op pain
    -May be associated with reduced adhesions
    -Insufficient evidence to support closure
  2. Intraperitoneal drains
    -Consider if anticoagulated
    -Use large bore non suction
  3. Sheath closure
    -Continuous closure with absorbable suture
  4. Sub cut closure
    -Perform subcut irrigation - 1 x RCT
    -Close if >2cm of adipose
    -Reduction in haematoma/seroma formation RR 0.52
    -No difference for wound infection
  5. Skin closure
    -Subcut stitches
    -Stables associated with increased wound separation and no difference in wound infection
    -Use absorbable monofilament
21
Q

Discuss RANZCOG categories for CS urgency classification (4 categories)

A
  1. Category one: urgent threat to the life or health of mother or baby
  2. Category two: Fetal or maternal compromise but not immediately life threatening
  3. Category three: Requiring earlier than planned delivery but without current evidence of fetal compromise
  4. Category four: CS at a time that is acceptable to the woman and team
22
Q

Discuss the RANZCOG recommendations for classifying CS urgency (5)

A

-Supports a nuanced approach to determine urgency
-Recommends no specific time interval attached to categories
-Urgency must be re-evaluated and this communicated with team
-Centers with >4000 should have own obstetric OT
-Clear communication important to reduce decision to delivery interval

23
Q

Discuss classical caesarean section
-Indications (8)
-Technique (2)
-Risks (2)

A
  1. Indications
    -Poorly formed lower segment
    -Large uterine fibroids in lower segment
    -Transverse lie and PPROM esp if back down
    -Placenta praevia with large vessels in LUS
    -Severe adhesions limiting access to LUS
    -Planned CS hysterectomy
    -Morbidly adherent placenta
    -Perimortem CS
  2. Technique
    -Close in 3 layers
    -Use monfilament for third layer to reduce adhesions
  3. Risks
    -PPH
    -Increased risk of uterine rupture 9:1000
24
Q

What are the risks associated with CS at fully / impacted fetal head
-Risks to baby (2)
-Risks to mother (6)

A
  1. Risks to baby
    -Skull fracture
    -Intracranial haemorrhage
  2. Risks to mother
    -Angle extensions into lower segment / vagina
    -Bladder injury
    -Ureteric injury
    -Haemorrhage
    -Blood transfusion
    -Need for ICU
25
Q

Discuss delivery principles for impacted fetal head / CS at fully
-Pre-operative considerations (4)
-Intra-operative considerations
-Post delivery considerations

A
  1. Pre-operative considerations
    -Assess whether Vaginal or CS safest
    -Apply upward pressure to assist disimpaction
    -Consider fetal pillow (RR 0.23 for angle extension
  2. Intra-operative considerations
    -Perform hysterotomy higher to avoid going through vagina
    -Stand on step
    -Trendelenburg tilt
    -Relax uterus - between contraction/tocolysis
    -Turn to OT position
    -Try to disimpact head with opposite hand
    -Consider experienced assistant for vaginal disimpaction
    -Extend incision
    -Deliver breech
  3. Post delivery considerations
    -PPH prophylaxis
    -Examine bladder carefully
    -Examine carefully for hysterotomy extensions
26
Q

Discuss CS delivery of breech baby
-Risks to fetus (6)
-Delivery method (8)

A
  1. Risk to baby
    -Overall risk lower cf vaginal delivery
    -Dislocation of hip, shoulder
    -Cervical spine injury
    -Spinal cord injury
    -Vertebral artery injury
    -Brachial plexus injury
  2. Delivery method
    -Extend uterotomy cephalo-caudal
    -Elevate breech to hysterotomy
    -Delivery legs with Pinards manoeuvres
    -Delivery Shoulders with Lovsett’s manouevres
    -Delivery Head maintaining fundal pressure to keep head flexed.
    -If head not spontaneously delivered perform MSV manouvre
    -If head still not delivered use obstetric forceps
    -If head still not delivered consider tocolysis and inverted T incision
27
Q

Discuss emergency peripartum hysterectomy
-Definition (1)
-Incidence (2)
-Causative factors (4)
-Risk factors (6)

A
  1. Definition
    Hysterectomy performed immediately following or within 24hrs of delivery
  2. Incidence
    -0.2-5:1000
    -95% follow CS delivery
  3. Causative factors
    -Morbidly adherent placenta (55%)
    -Placenta praevia (20%)
    -Uterine atony
    -Uterine scar rupture
  4. Risk factors
    -Previous CS (9% risk if >6)
    -Previous uterine surgery
    -Advance maternal age
    -Placenta praevia
    -Multiparity
    -Multiple pregnancy
28
Q

Discuss emergency peripartum hysterectomy
-Considerations pre-hysterectomy(3)
-Surgical difficulties (5)
-Surgical considerations (3)

A
  1. Considerations
    -If Hysterectomy is inevitable then don’t delay
    -Should be decided on by senior clinician. Better if 2 SMO’s
    -Can do aortic compression to buy time for decision and senior help
  2. Difficulties
    -Distended cervix - hard to identify external os
    -Engorged and dilated pelvic blood vessels
    -Friable and oedematous tissue
    -Large bulky uterus
    -Unstable patient
  3. Surgical considerations
    -Reflect bladder to minimise injury and displace ureters distally
    -Use extra clamps on vessels to ensure haemostasis
    -Consider subtotal hysterectomy as faster, safer.
29
Q

Discuss PPH at CS
-Incidence (2)
-Maternal risk factors (6)
-Fetal risk factors (1)
-Situational risk factors (2)

A
  1. Incidence
    -7% of EMCS
    -5% of ELCS
  2. Maternal risk factors
    -Obstructed labour
    -APH
    -Placenta praevia/ morbidly adherent placenta
    -Prolonged labour
    -Obesity
    -Uterine fibroids
  3. Fetal risk factors
    -Macrosomia
  4. Situational risk factors
    -EMCS
    -GA
30
Q

Discuss PPH at CS
-Causes (4 categories)
-Prevention (4)

A
  1. Causes
    Uterine atony
    Tissue trauma
    -Angle extensions
    -Cervicovaginal injury
    -Bladder injury
    -Muscle and adhesion bleeding
    Placental
    -Placenta praevia
    -Morbidly adherent placenta
    Coagulopathy
  2. Prevention
    -Meticulous surgical technique (JCM best)
    -Correction of dextrose-rotation
    -Correct placement of hysterotomy incision
    -Delivery of placenta by CCT
31
Q

Discuss management of PPH in CS (6)

A

1.Direct treatment at cause
2.Consider TXA for all causes
3.Manage atony with ecbolics, B-Lynch
4.Manage trauma with prompt surgical repair
-Secure angles
-Haemostatic sutures or uterine artery ligation
5. Bleeding from placental bed
-Figure of 8 sutures into placental bed
-Bakri balloon

32
Q

Discuss rates of CS
-Incidence in NZ and Australia
-Reasons for increased CS rates (9)
-Evidence based ways to reduce CS rates (6)

A
  1. Incidence
    -31% Australia
    -27% NZ
  2. Reasons for increased CS rates
    -Increasing maternal BMI
    -Increasing maternal advanced age
    -Increasing multiple pregnancy
    -Reduction in rotational instrumental deliveries
    -Increase in CS for breech
    -Increase in placenta praevia and morbidly adherent placenta
    -Increase rates of neonatal survival at earlier gestation
    -Increased maternal co-morbidities
    -Increased anxiety regarding litigation
  3. Means to reduce CS rates
    -One to on continuous care
    -IOL after 41/40
    -Partogram with 4 hr action line
    -Consultant obstetrician to make decision
    -Fetal blood sampling
    -Increase VBAC and ECV
33
Q

Discuss vaginal seeding
-Definition (1)
-Reasons for doing (4)
-Benefits
-Risks
-What to do if mother is requesting

A
  1. Definition
    -Innoculating a cotton swab with vaginal flora and exposing mouth, nose and skin of neonate
  2. Reasons for doing
    -Microbiome determined by mode of delivery.
    -CS delivered infant have microbiome of maternal skin not vaginal mucosa
    -Thought these differences may influence atopy and autoimmune diseases
    -Children born by CS have increased rates of obesity, diabetes asthma and autoimmune disease.
  3. Benefits
    -AS yet unproven
  4. Risks
    -GBS, Chlamydia, HSV, Gonorrhoea
  5. What to do if requested
    -Risk of harm not justified without evidence of benefit
    -If women wants to perform herself then consider testing for vaginal pathogens
    -Make sure woman is well informed
    -Ensure paeds and MW are aware
34
Q

Discuss elective caesarean sections
-Indications for CS (9)
-When should a CS not be offered
-What are the increased risks of ELCS cf planned VB (7)

A
  1. Indications for CS
    -Malpresentation: Breech / transverse
    -Twins: MCMA or leading twin breech
    -Placenta praevia
    -Previous CS: declining VBAC, previous classical, J or T incision
    -High HIV viral load >400 copies/mL
    -Primary genital herpes
    -HIV with concurrent Hep C
    -Maternal diabetes with EFW >4.5kg
    -EFW >5kg without maternal diabetes
  2. When should ELCS not be offered
    -Preterm birth - effect of ELCS unknown
    -SGA - Effect of ELCS unknown
    -Hep B or Hep C - unnecessary
  3. Increase in ELCS risks cf planned VB
    -Maternal death 5 times risk
    -Peripartum hysterectomy 2 x risk
    -Wound infection 3 x risk
    -Endometritis 12% increase
    -Less urinary and prolapse issues with ELCS
    -Pain same between groups at 4 months
    -Increased Neonatal mortality, asthma, GI infections, respiratory infections
35
Q

Discuss approach of ELCS for maternal request (5 points)

A
  1. No RCT to help guide evidence
  2. Explore reasons why requested
  3. Discuss risks and benefits of VB vs CS
  4. Offer support / intervention depending on reason for request
  5. As per RANZCOG can either:
    -Agree to provide once satisfied woman is well informed of choice
    -If declines to provide must refer to another obstetrician for second opinion
36
Q

Discuss timing of ELCS
-When should it be performed (5)
-Risk of pre-CS labour
-Should steroids be given for ELCS (4)

A
  1. Timing
    -39 weeks of after to avoid: increase in neonatal respiratory disorders, behavioural and neurodevelopmental issues associated with birth before 39/40
    Increased metabolic disorders, increased adult mental illness
    -Small increase risk in still birth related to increase of SB with increasing gestation
  2. Risk of labour pre-CS
    -10% if booked at 39 weeks
  3. Should steroids be given for ELCS
    -RCOG recommend steroids until 38+6 for ELCS
    -C Steroid study aimed to answer this question
    -ASTECS non-blinded RCT found Babies who had steroids from 37 weeks for ELCS had less SCBU admissions but very high NNT as admissions were rare
    -RANZCOG say consider giving if you can’t defer CS until after 39/40
37
Q

Discuss complications of CS
-Incidence of complications at EMCS and ELCS (2)
-Factors that increase risk of complications (6)

A
  1. Incidence of complications
    -ELCS - 7%
    -EMCS 16%
  2. Factors that increase complication risk
    -Obesity
    -Cat 1 CS
    -Previous surgery
    -Pre-existing medical conditions
    -Dilation 9-10cm 33:100
    -EMCS
38
Q

Discuss risks of CS complications
-Maternal (11)
-Fetal (3)

A
  1. Maternal risks
    -ICU admission 9:1000
    -Emergency hysterectomy 8:1000
    -Return to OT 5:1000
    -Bladder injury 1:1000
    -Ureteric injury 3:10 000
    -Bowel injury - Rare
    -Death 1: 12 000
    -Repeat CS 1:4
    -Wound infection 10:100
    -Endometritis 18:100
    -Ileus 10%
  2. Fetal Risks
    -IVH 1:900
    -Fetal laceration 2:100
    -Increased TTN, Pulmonary HTN, surfactant def (2-7 times increase)
    -Still birth in future pregnancies 1-4:1000
39
Q

How do CS impact future pregnancies (10)

A

-Delayed conception
-Increased ectopic pregnancy
-Uterine rupture
-Placenta praevia
-Placenta accreta
-Adhesions complicating future pregnancies
-Unexplained still birth >34 weeks
-IUGR
-PTB
-Unexplained still birth

40
Q

Discuss Ogilvie syndrome
-Definition
-Pathophysiology
-Management

A
  1. Definition
    -Acute large bowel obstruction without mechanical cause
  2. Pathophysiology
    -Imbalance in the autonomic innervation of the colon leading to atony and proximal dilation
    -May occur due to PNS during CS
    -Caecum becomes dilated leading to ischemia, perforation and peritonitis
  3. Management
    -If Caecum <10cm consider conservative management. Avoid lactulose and opiates
    If Caecum >10-12cm
    -Consider neostigmine
    -Urgent colonic decompression with rectal flatus tube
    -If perforation urgent laparotomy
41
Q

Discuss RANZCOG recommendations for managing VBAC in labour (6)

A
  1. In a site with neonatal and OT access
  2. Continuous fetal monitoring
  3. IV access
  4. Clear fluids only
  5. VE at least every 4 hrs until 7cm then every 2 hours
  6. Epidural is not contra-indicated
42
Q

In what circumstances is the risk of fetal injury at CS increased (3)

A

-Deep impaction of fetal head in pelvis - skull fracture, ICH
-Fetal macrosomia -brachial plexus injury
-Breech presentation - cervical spine, spinal cord and vertebral injury

43
Q

Discuss recommendations (RANZCOG) for delivery of an impacted fetal head in second stage
-Pre-operative delivery (4)
-Intra-operative (3)
-Post-operative (1)

A
  1. Pre-operative
    -A vaginal examination should be done by a senior doctor prior to CS commencing to exclude whether a VB is safer and easier
    -Steady pressure to the fetal head to assist disimpaction should be applied (Hand or fetal pillow)
    -Have experiences OB and paeds in the room
    -Alter anaesthetics about need for acute tocolysis and PPH
  2. Intra-operative
    -Elevate the head into the abdomen by either - upward pressure from below or elevation of the fetal fetal by the accoucheur by passing the hand over the head and elevating
    -Consider a tocolytic GTN
    -Delivery by breech extraction
  3. Post-operative
    -Prepare for PPH secondary to atony, trauma, infection
44
Q

How should shoulder dystocia in a CS be managed (3)

A
  1. Anticipate macrosomia and make a larger incision. Extend as required
  2. Consider delivery of the posterior arm
  3. Consider a J or T incision
45
Q

Discuss the ASTECS trial
-Aim (1)
-Study methodology
-Primary outcomes
-Secondary outcomes

A
  1. Aim
    -To see if steroids reduce respiratory distress in babies born by ELCS
  2. Study design
    -Pragmatic RCT
    -10 maternity units
    -2 x IM doses of 12mg betamethasone 48hrs before delivery
    -Included women >37/40
    -Not blinded
  3. Primary outcome
    -NICU admission for respiratory distress
  4. Secondary outcomes
    -Level of respiratory distress
    -Level of care required
46
Q

Discuss ASTECS trial
-Number included in the study (1)
-Results of the primary outcome (2)
-Results of the secondary outcome (3)
-Recommendations

A
  1. Number included in the study
    n = 950
  2. Primary outcome results
    RR of respiratory distress if treated with steroids 0.46 (SS)
    -Reduction in respiratory distress in ELCS from 1.1 to 0.2%
  3. Secondary outcome results
    -Severity of respiratory distress was similar in both groups
    -Babies in the control group required higher level of care
    -Increased need for NICU associated with earlier gestation in both groups but more pronounced in control group in all categories
  4. Recommendations
    -Give steroids for ELCS
    -Try to avoid ELCS before 39/40