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O&G > Emergency C-section > Flashcards

Emergency C-section Flashcards

1
Q

C-section: Overview

A

The rate of caesarean section has increased significantly in recent years, largely secondary to an increased fear of litigation

There are two main types of caesarean section:

  • Lower segment caesarean section: now comprises 99% of cases
  • Classic caesarean section: longitudinal incision in the - upper segment of the uterus
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2
Q

Vaginal birth after caesarean (VBAC)

A
  • If a women has had a previous caesarean section due a factor such as fetal distress the majority of obstetricians would recommend a trial of normal labour
  • around 70-75% of women in this situation have a successful vaginal delivery
  • contraindications include previous uterine rupture or classical caesarean scar
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3
Q

C-section: CATEGORIES

A

CAT 1: immediate threat to the life of the women or foetus.
CAT 2: maternal or foetal compromise which is not immediately life-threatening.
CAT 3: no maternal or foetal compromise, but needs early delivery.
CAT 4: delivery time to suit women or staff

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4
Q

When to abandon OPERATIVE delivery (2)

A

Operative vaginal delivery should be abandoned where:

  1. There is no evidence of progressive descent with moderate traction during each contraction.
  2. Where delivery is not imminent following three contractions of a correctly applied instrument by an experienced operator.
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5
Q

COMPLICATIONS of a c-section in the 2nd STAGE of LABOUR - MATERNAL

A
  • Uterine/cervical/high vaginal injury
  • Postpartum haemorrhage
  • Blood transfusion
  • Sepsis, admission to intensive care
  • Length of stay.
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6
Q

COMPLICATIONS of a c-section in the 2nd STAGE of LABOUR - NEONATAL

A
  • Admission to neonatal intensive care.
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7
Q

Foetal pillow: Definition

A

C- section carries an increased risk of trauma for both the mother and her baby (this is related to a deeply impacted head).

​Fetal Pillow is a balloon device designed to elevate a deeply impacted fetal head atraumatically out of the pelvis during a cesarean section, making the delivery safer, easier and less traumatic for the mother and baby.

↓ risk of complications from c-section @ full dilation.

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8
Q

Other METHODS for disimpaction of the FOETAL head from the PELVIS

A
  • Use of non-dominant hand
  • Walking towards anaesthetist
  • Vaginal disimpaction
  • Reverse breech extraction
  • Tocolytics
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9
Q

OPERATIVE vaginal delivery: Overview

A

An operative vaginal delivery (OVD) is defined as the use of an instrument to aid delivery of the fetus.

C-section in the 2nd stage of labour is associated with ↑ morbidity. Instrumental delivery helps to avoid an emergency c-section. Thus decreasing maternal and perinatal morbidity/mortality.

In the UK, operative vaginal delivery rates have remained stable at 12-13%; yielding safe and satisfying outcomes for the majority of the women and babies

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10
Q

INDICATIONS for INSTRUMENTAL delivery - Maternal (4)

A
  • Exhaustion
  • Prolonged 2nd stage
    (Active pushing: >1hr multip, >2hr primip)
  • Medical indications for avoiding Valsava manouevre
    • severe cardiac disease
    • hypertensive crisis
    • uncorrected cerebral vascular malformations
  • Pushing is not possible (paraplegia, tetraplegia)
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11
Q

INDICATIONS for INSTRUMENTAL delivery - Foetal (2)

A
  • Foetal compromise
    (abnormal CTG, foetal blood sample)
  • Clinical concerns
    (significant APH)
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12
Q

OPERATIVE delivery: INSTRUMENT types (2)

A

There are two main instruments used in operative deliveries – the ventouse and the forceps.

In general, the first instrument used is the most likely to succeed. The choice is operator dependent, but forceps tend to have a lower risk of fetal complications, and a higher risk of maternal complications.

The general rule is, if after three contractions and pulls with any instrument there is no reasonable progress, the attempt should be abandoned.

TYPES:

  • Forceps
  • Ventouse
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13
Q

Instrument types: FORCEPS

A

FORCEPS consist of curved blades that sit around the foetal head and allow traction to be applied along the ‘flexion point’ of the head (3cm in front of the occiput). This is usually to speed up delivery, but may be used to slow rate of the head in a breech delivery.

The forceps are double bladed instruments. Types include:

  • Rhodes, Neville-Barnes or Simpsons – used for OA positions.
  • Wrigley’s – used at Caesarean section.
  • Kielland’s – used for rotational deliveries.
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14
Q

Instrument types: VENTOUSE (Vacuum extraction)

A

The ventouse is an instrument that attaches a cup to the fetal head via a vacuum. There are many different systems used, but the most common are:

An electrical pump attached to a silastic cup.
This is only suitable if the fetus is in an occipital-anterior position.
A hand-held, disposable device commonly known as the “Kiwi”.
This is an omni-cup – it can be used for all fetal positions, and rotational deliveries.

There are also cups that can be used with the electrical pump that are suitable for OP positions. These are generally metal cups with the tubing attached to the side of the cup as opposed to the middle – the Bird cup.

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15
Q

FORCEPS: How are they used?

A

The blades are introduced into the pelvis, taking care not to cause trauma to maternal tissue, and applied around the sides of the fetal head, with the blades then locked together. Gentle traction is then applied during uterine contractions, following the J shape of the maternal pelvis.

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16
Q

VENTOUSE (vaccum extraction): How is it used?

A

Works on the principle of creating ‘negative pressure’ to allow scalp tissues to be sucked into the cup. The cup is held in place by the atmospheric pressure on the cup against the negative pressure created.

To use the ventouse, the cup is applied with its centre over the flexion point on the fetal skull (in the midline, 3cm anterior to the posterior fontanelle). During uterine contractions, traction is applied perpendicular to the cup.

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17
Q

VENTOUSE deliveries: complications

A

Ventouse deliveries are associated with:

  • Lower success rate
  • Less maternal perineal injuries
  • Less pain
  • More cephalhaematoma
  • More subgaleal haematoma
  • More fetal retinal haemorrhage
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18
Q

FORCEPS deliveries: complications

A

Use of the forceps is associated with:

  • Higher rate of 3rd/4th degree tears
  • Less often used to rotate
  • Doesn’t require maternal effort
19
Q

CEPHALOHAEMATOMA: Definition

A

A traumatic subperiosteal haematoma that occurs underneath the skin in the periosteum of the infants skull bone.

20
Q

INSTRUMENTAL delivery: CONTRAINDICATION - Absolute

A
  • Unengaged fetal head in singleton pregnancies.
  • Incompletely dilated cervix in singleton pregnancies.
  • True cephalo-pelvic disproportion (where the fetal head is too large to pass through the maternal pelvis).
  • Breech and face presentations, and most brow presentations.
    Note: Forceps can be used for the after coming head in complex breech deliveries.
  • Preterm gestation (<34 weeks) for ventouse.
  • High likelihood of any fetal coagulation disorder for ventouse.
21
Q

INSTRUMENTAL delivery: CONTRAINDICATION - Relative

A
  • Severe non-reassuring fetal status (‘acute fetal distress’), with station of the head above the level of the pelvic floor – i.e. fetal scalp not visible.
  • Delivery of the second twin when the head has not quite engaged, or the cervix has reformed.
  • Prolapse of the umbilical cord with fetal compromise when the cervix is completely dilated and the station is mid cavity.
22
Q

OPERATIVE vaginal delivery: CRITERIA -

FOR(2)C(3)E(3)P(4)S(2)

A
  • (F)ully dilated cervix
  • (O)bstruction should be excluded
  • (R)uptured membranes
  • (R)eview the procedure
  • (C)onsent
  • (C)atheterize bladder (‘in and out’ technique)
  • (C)heck instrument prior to application
  • (E)xplain procedure to patient
  • (E)pidural (or pudenal) analgesia
  • (E)xamine the genital tract - to exclude genital tract trauma
  • Check (P)resentation and (P)osition of the head
  • (P)ower: are the contractions effective?
  • Correct (P)lacement of forceps/ventouse cup?
  • (S)tation of the presenting part
  • (S)enior help should be called if needed
23
Q

COMPLICATIONS of an instrumental delivery - FOETAL

A
  • Neonatal jaundice
  • Scalp lacerations
  • Cephalhaematoma
  • Subgaleal haematoma
  • Facial bruising
  • Facial nerve damage
  • Skull fractures
  • Retinal haemorrhage
24
Q

COMPLICATIONS of an instrumental delivery - MATERNAL

A
  • Vaginal tears
  • 3rd/4th degree tears:
    (1: 100 in normal vaginal delivery)
    (4: 100 in ventouse)
    (10: 100 in forceps)
  • VTE
  • Incontinence
  • PPH
  • Shoulder dystocia
  • Infection
25
Q

Operative vaginal delivery: TRIAL

A

This term is used when it is not possible to determine with sufficient confidence that an instrumental delivery will be successful. It should, therefore, take place in theatre, where it is possible to move to an immediate CS.

This avoids failed delivery in delivery room and subsequent delay in performing CS, which may complicate foetal well being.

26
Q

Risk factors for FAILED operative vaginal delivery

A
  • BMI >30
  • EFW >4000g or clinically big baby
  • OP (occiputposterior) position
  • Mid-cavity delivery
27
Q

Episiotomy: Definition

A
  • More than 85% of women delivering vaginally in the UK will sustain some degree of perineal trauma.
  • Episiotomy is a surgical incision to enlarge vaginal introitus.
  • The decision to perform an episiotomy is made by the birth attendant.
28
Q

When should an EPISIOTOMY be performed: WHO recommendations

A 
- Complicated vaginal delivery:
  • breech
  • shoulder dystocia
  • forceps
  • ventouse.
- If there is extensive lower genital tract scarring:
  • female genital mutilation
  • poorly healed 3rd or 4th degree tears.
- When there is fetal distress.
29
Q

TYPES of episiotomy (2)

A
  • MEDIOLATERAL episiotomy extends from the fourchette laterally (thus reducing the risk of anal sphincter injury).
  • MIDLINE episiotomy extends from the fourchette towards the anus (common in the USA, but not recommended in the UK).
30
Q

How to perform an EPISIOTOMY

A
  • If the woman does not have a working regional block (epidural) then the perineum should be infiltrated with lidocaine (lignocaine).
  • Two fingers should be placed between the baby’s head and the perineum (to protect the baby).
  • Sharp scissors are used to make a single cut in the perineum about 3–4cm long (ideally this should be at the height of the contraction when the perineum is at its thinnest).
31
Q

General complications of PERINEAL TRAUMA including episiotomy

A
  • Bleeding.
  • Haematoma.
  • Pain.
  • Infection.
  • Scarring, with potential disruption to the anatomy.
  • Dyspareunia.
  • Very rarely, fistula formation.
32
Q

PERINEAL tears: Classification (4)

A
  • 1st-degree: injury to the skin only.
  • 2nd-degree: injury to the perineum involving perineal muscles (includes episiotomy).
  • 3rd-degree: injury to the perineum involving the anal sphincter complex
  • 4th-degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and the anal/rectal epithelium.
33
Q

Factors associated with increased risk of anal sphincter trauma (9)

A
  • Forceps delivery.
  • Nulliparity.
  • Shoulder dystocia.
  • 2nd stage >1h.
  • Persistent OP position.
  • Midline episiotomy.
  • Birth weight >4kg.
  • Epidural anaesthesia.
  • Induction of labour.
34
Q

C-section: Definition

A

CS involves delivery of the fetus through a direct incision in the abdominal wall and the uterus.

35
Q

C-section is associated with a HIGHER incidence of: (5)

A
  • Abdominal pain.
  • Venous thromboembolism.
  • Bladder or ureteric injury.
  • Hysterectomy.
  • Very rarely maternal death.
36
Q

C-section is associated with a LOWER incidence of: (3)

A
  • Perineal pain.
  • Urinary incontinence.
  • Uterovaginal prolapse.
37
Q

C-section: Main indications (4)

A
  • Repeat CS.
  • Fetal compromise.
  • ‘Failure to progress’ in labour.
  • Breech presentation.
38
Q

Indications for category 1 CS (5)

A
  • Placental abruption with abnormal FHR or uterine irritability.
  • Cord prolapse.
  • Scar rupture.
  • Prolonged bradycardia.
  • Scalp pH <7.20.
39
Q

Indications for category 2 CS (1)

A

• Failure to progress with pathological CTG.

40
Q

Indications for category 3 (scheduled) CS (3)

A
  • Severe pre-eclampsia.
  • IUGR with poor fetal function tests.
  • Failed induction of labour.
41
Q

Indications for category 4 (elective) CS (6)

A
  • Term singleton breech (if ECV is contraindicated or has failed).
  • Twin pregnancy with non-cephalic 1st twin.
  • Maternal HIV.
  • Primary genital herpes in the 3rd trimester.
  • Placenta praevia.
  • Previous hysterotomy or classical CS.
42
Q

C-section: INTRAoperative complications

A

Occur in 12-15% of women, include:

  • Uterine or uterocervical lacerations (5–10%).
  • Blood loss >1L (7–9%).
  • Bladder laceration (0.5–0.8%).
  • Blood transfusion (2–3%).
  • Hysterectomy (0.2%).
  • Bowel lacerations (0.05%).
  • Ureteral injury (0.03–0.09%.).
43
Q

C-section: POST-operative complications

A

Occur in 1/3 of women, include:

  • Endometritis (5%).
  • Wound infections (3–27%).
  • Pulmonary atelectasis.
  • Venous thromboembolism.
  • Urinary tract infections.
44
Q

LONG term effects of c-section

A
  • Uterine rupture
  • Placenta praevia
  • Placenta accreta.
  • Antepartum stillbirth

O&G (13 decks)

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