Emergency C Section

Question 1

When is operative delivery more common?

Answer 1

Primiparous women
Supine and lithotomy positions
Epidural anaesthesia

Question 2

What is the fetal station?

Answer 2

Relationship of presenting part (head, buttocks, feet) to the ischia spines (assessed vaginally). Measured in cm above or below the ischial spines

Question 3

What is caput succedaneum?

Answer 3

Diffuse swelling of the scalp caused by pressure of the scalp against the dilating cervix during labour. Associated with moulding

Graded subjectively from 0 (none) to +3 (marked)

Question 4

What is moulding?

Answer 4

The bones of the fetal head move closer together or overlap to help the head fit through the pelvis. Parietal bones overlap occipital and frontal bones

Up to +2 occipito-parietal moulding may be normal in later stages of labour.

+2 parietal bones overlap but easily reduced
+3 irreducible. Never normal. Sign of relative or absolute cpd

Question 5

Why is it advised that primiparous women who have epidurals should have 2 hours of passive second stage?

Answer 5

Meta-analysis have shown more likely to have fewer rotational or mid-cavity operative interventions when pushing is delayed for 1-2 hours or until they had a strong urge to push

Question 6

How do you assess CTG?

Answer 6

DR C BRAVADO

Define Risk
Contractions - 3:10 = 3 every 10 minutes
Baseline RAte - 110-160bpm
Variability - 5-25
Accelerations - generally a sign the baby is healthy 
Decelerations*
Overall

Question 7

Classification for operative vaginal delivery

Answer 7

Outlet - scalp visible/ skull reached pelvic floor
Low - skull at station +2 or more and not on pelvic floor
Mid - skull above station +2 but ≥0 no more than 1/5 palpable per abdomen
High - not suitable for operative vaginal delivery. >2/5th palpable, presenting part above ischial spines

Question 8

Indications for operative vaginal delivery

Answer 8

Fetal compromise
Shorten stage II due to maternal medical conditions
Inadequate progress
- nulliparous lack of progress for 3 hours with, 2 hours without anaethesia
- mulitiparous 2 hours with, 1 without
-maternal fatigue/exhaustion

Question 9

Types of forceps

Answer 9

Simpsons/Neville Barnes (non-rotational)

Kiellands forceps rotional

Question 10

Vacuum extraction compared with forceps delivery

Answer 10

More likely to fail
More like to be associated with cephalhaematoma or retinal haemorrhage
Less likely associated with perineal and vaginal trauma making (making vacuum delivery as instrument of first choice)
No more likely associated with c section
No more likely associated with low 5 minute APGAR score

Question 11

When should operative vaginal delivery be abandoned?

Answer 11

When no evidence of progressive descent with moderate contraction and delivery is not imminent following three contractions

Question 12

Operative vaginal delivery - higher rates of failure:

Answer 12

BMI 30
EFW over 4kgvor clinically big baby
OP position
Mid-cavity delivery or when 1/5th of head palpable per abdomen

Question 13

Complications of c-section in stage II of labour?

Answer 13

Maternal: uterine/cervical/high vaginal injury, postpartum haemorrhage, blood transfusion, sepsis, admission to ITU, engrossing of stay

Neonate: ITU

Question 14

What is a fetal pillow?

Answer 14

Balloon device designed to gently lift the baby’s head, making the delivery easier and safer, reducing risks and complications

Question 15

Methods, other than the fetal balloon available for disimpaction of fetal head from pelvis

Answer 15

Use of non-dominant hand
Walking towards anaesthetist
Vaginal disimpaction
Reverse breech extraction
Tocolytics

Question 16

Describe engagement

Answer 16

Fetal head enters the pelvic inlet in an occipitotransverse position

Transverse diameter of the inlet is greater than the anteroposterior diameter

Question 17

Describe descent and flexion

Answer 17

The head descends into the mid-cavity and flexes as the cervix dilates

Question 18

Describe internal rotation

Answer 18

In mid-cavity the fetal head rotates through 90° into occipitoanterior (OA) position, remaining flexed.

When this doesn’t happen, or the head rotates OP prolonged or obstructed labour can occur.

Might require rotation of the baby, operative vaginal delivery or c section

Question 19

Further descent, extension and delivery

Answer 19

Head descends beyond ischial spines and the perineum descends

The head descends as it is delivered

Question 20

Describe external rotation

Answer 20

Following the delivery of the head, the fetus rotates back to an OT position along with its shoulders. Axial traction is applied to allow delivery of the anterior shoulder, and then posterior soldier

Question 21

Decelerations on a CTG

Answer 21

Reassuring

• none or early
• variable decelerations with no concerning features for <90 mins

Non-reassuring

• above >90 mins
• variable with concerning characteristics for up to 30 minutes (or more if present in <50% contractions)
• late decelerations <30mins

Abnormal

• late >30 mins
• variable >50% for 30 mins
• acute bradycardia or single prolonged deceleration for 3 mins or more

Question 22

Indications for emergency c section

Answer 22

Cord prolapse
Failure to progress 
Foetal distress in 1sr stage
Anteparting haemorrhage 
Transverse lie in labour