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Women's Health > Emergency Caesarean Section > Flashcards

Emergency Caesarean Section Flashcards

1
Q

What women is operative vaginal delivery more common in?

A
  • Primpiparous women
  • Supine and lithotomy positions
  • Epidural anaesthesia
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2
Q

What do you look for when assessing a CTG?

A

DR C BRAVADO

  • Define Risk: low risk pregnancy, spontaneous labour at term, epidural in labour, adequate progress in 1st stage labour
  • Contractions e.g. 3-4:10
  • Baseline RAte
  • Variability
  • Accelerations
  • Decelerations
  • Overall e.g. suspicious
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3
Q

What are the outlet classifications for operative vaginal delivery?

A
  • Fetal scalp visible without separating the labia
  • Fetal skull has reached the pelvic floor
  • Sagittal suture is in the anterior-posterior diameter or left or right occiput anterior or posterior position (rotation does not exceed 45 degrees)
  • Fetal head is at or on the perineum
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4
Q

What are the low classifications for operative vaginal delivery?

A
  • Leading point of the skull (not caput) is at station plus 2cm or more and not on the pelvic floor
  • Two subdivisions: rotation of 45 degrees or less from occipito-anterior position, rotation of >45 degrees including occipito-posterior position
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5
Q

What are the mid classifications for operative vaginal delivery?

A
  • Fetal head is no more than 1/5 palpable per abdomen
  • Leading point of the skull is above station plus 2cm but not above ischial spines
  • Two subdivisions: rotation of 45 degrees or less from occipito-anterior position, rotation of >45 degrees including occipito-posterior position
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6
Q

What are the high classifications for operative vaginal delivery?

A

Not included in the classification as operative vaginal delivery is not recommended in this situation where the head is 2/5 or more palpable abdominally and the presenting part is above the level of the ischial spines.

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7
Q

What is the basic criteria for operative vaginal delivery?

A

Operative vaginal delivery can be performed as long as there is no more than 1/5 of the head palpable abdominally and the leading point of the skull is not above the ischial spines.

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8
Q

What are the fetal and maternal indications for operative vaginal delivery?

A
  • Fetal: presumed fetal compromise
  • Maternal: to shorten and reduce the effects of the 2nd stage of labour on medical conditions (e.g. cardiac disease class III and IV, hypertensive crisus, myasthenia gravis, spinal cord injury patients at risk of autonomic dysreflexia, proliferative retinopathy)
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9
Q

What are the indications of inadequate progress for operative vaginal delivery?

A
  • Nulliparous women: lack of continuing progress for 3hrs (total of active and passive second stage labour) 17 with regional anaesthesia or 2hrs without regional anaesthesia
  • Multiparous women: lack of continuing progress for 2hrs (total of active and passive second stage labour) 17 with regional anaesthesia or 1hr without regional anaesthesia
  • Maternal fatigue/exhaustion
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10
Q

What is rotational delivery?

A

The options available for rotational delivery include Kiellands forceps, manual rotation followed by direct traction forceps or rotational vacuum extraction. Rotational deliveries should be performed by experienced operators, with the choice depending on the expertise of the individual operator.
Failed delivery with selected instrument is more likely with vacuum extraction.

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11
Q

What is vacuum extraction like compared with forceps?

A
  • More likely to fail delivery with the selected instrument
  • More likely to be associated with cephalhaematoma
  • More likely to be associated with retinal haemorrhage
  • More likely to be associated with maternal worries about baby
  • Less likely to be associated with significant maternal perineal and vaginal trauma
  • No more likely to be associated with delivery by CS
  • No more likely to be associated with low 5 min APGAR scores
  • No more likely to be associated with the need for phototherapy
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12
Q

When should vacuum extraction not be used?

A

A vacuum extractor should not be used at gestations of <34 weeks + 0 days. The safety of vacuum extraction between 34 weeks + 0 days - 36 weeks + 0 days of gestation is uncertain and should therefore be used with caution.

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13
Q

What needs to be looked for in a full abdominal and vaginal examination before operative vaginal delivery?

A
  • Head is
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14
Q

How does the mother need to be prepared before an operative vaginal delivery?

A
  • Clear explanation should be given and informed consent obtained
  • Appropriate analgesia is in place for mid-cavity rotational deliveries. This will usually be a regional block. A pudendal block may be appropriate, particularly in the context of urgent delivery.
  • Maternal bladder has been emptied recently, in-dwelling catheter should be removed or balloon deflated
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15
Q

When should operative vaginal delivery be abandoned?

A

Where there is no evidence of progressive descent with moderate traction during each contraction or where delivery is not imminent following 3 contractions of a correctly applied instrument by an experience operators.

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16
Q

What risk factors are associated with operative vaginal delivery failure?

A
  • Maternal BMI >30
  • EFW >400g or clinically big baby
  • OP position
  • Mid-cavity delivery or when 1/5 of head palpable per abdomen
17
Q

What are the complications of a CS in the 2nd stage of labour?

A
  • Maternal morbidity: uterine/cervical/high vaginal injury, PPH, blood transfusion, sepsis, admission to ICU and length of stay
  • Neonatal morbidity: admission to NICU
18
Q

What is a fetal pillow?

A

A balloon device designed to gently lift the baby’s head out from the pelvis, making the delivery easier and safer for the doctor to perform and reducing the risks of complications for both mother and baby.

19
Q

What methods are available fro disimpaction of fetal head from pelvis?

A

Use of non-dominant hand, walking towards anaesthetist, vaginal disimpaction, reverse breech extraction, tocolytics

20
Q

What are the normal movements of the fetal head in labour?

A
  • Engagement: foetal head enters pelvic inlet in occipitotransverse (OT) position
  • Descent and flexion: the head descends into the mid-cavity and flexes as the cervix dilates (flexed direct occipito-anterior - DOA)
  • Internal rotation: in the mid-cavity the foetal head rotates through 90 degrees into an occipito-anterior (OA) position, remaining flexed. It is when this process does not occur or if the baby rotates into the occipitoposterior (OP) position that prolonged or obstructed labour can occur > operative VD or CS.
  • Further descent: the head continues to descend along the ischial spines and the perineum distends
  • Extension and delivery: head extends as it delivers
  • External rotation (restitution): following delivery of the head, the foetus rotates back to an OT position along with its shoulders. Axial traction is applied to allow delivery of the anterior shoulder and then posterior shoulder.
21
Q

What are the stages of labour?

A
  • Stage 1: from onset of true labour to when cervix is fully dilated
  • Stage 2: from full dilation to baby delivery
  • Stage 3: delivery of baby to when placenta and membranes have been fully delivered
22
Q

What occurs in stage 2 of labour?

A
  • Passive 2nd stage - without pushing (normal)
  • Active 2nd stage - mum actively pushing
  • Less painful than 1st (pushing masks pain)
  • Lasts around 1hr
  • If >1hr (can be left longer if epidural), consider ventouse extraction, forceps delivery or CS
  • Episotomy (small cut in posterior wall of vagina to make more space for baby to come out) may be needed after crowning
  • Associated with transient foetal bradycardia
23
Q

What is moulding?

A

Extent of overlap of foetal skull bones (moulding and caput both scored from 0 to +3 respectively):

  • +1: adjacent skull bones are touching but not overlapping
  • +2: one skull bone overlapping another but when you gently push the overlapped bone it goes back easily
  • +3: one skull bone overlapping another but when you try to push overlapped bone it doesn’t go back - +3 moulding with poor progress of labour > increased risk of labour obstruction
24
Q

What is caput?

A

Swelling of the foetal skull - it is normal if it develop centrally, but not if it’s displaced to 1 side (0 means no caput, +3 means large caput).
The more caput there is, the harder it is to do a ventouse delivery as the suction will not always retain suction.

25
Q

What do decelerations mean on a CTG?

A
  • Typical variable decelerations: indicative of transient cord compression
  • Late decelerations: fetal hypoxia
26
Q

What is the significance of the baby’s head position?

A

If the head is not rotated through 90 degrees in the mid cavity, then the position will remain occipito-transverse (OT) and the occiput will face either maternal left or right. The head may rotate through 90 degrees in the wrong direction to an occipitoposterior (OP) position. Malposition gives rise to larger fetal diameters and these deliveries often require rotation and operative vaginal delivery.

27
Q

How can the fontanelles be used to identify baby’s position?

A

In a direct occipitoanterior position, the posterior fontanelle (a triangular structure with 3 suture lines running off from it, 2x lamboidal and 1x sagittal, just in front of the occipital bone will be facing anteriorly. Often there can be caput over this area, or approximation or overlap of the sutures (moulding) which can make it difficult to identify.
Another landmark used would be the anterior fontanelle (diamond-shaped structure with 4 suture lines running from it, 2x coronal, 1x frontal and 1x sagittal).

28
Q

What are the indications for a category 1 (crash) CS?

A
  • Cord prolapse
  • Sustained fetal bradycardia
  • Fetal hypoxia (scalp pH < 7.20)
  • Placental abruption
  • Uterine rupture
29
Q

What are the indications for a category 2 (urgent) CS?

A

Failure to progress in labour with pathological CTG

30
Q

What are the indications for a category 3 (scheduled) CS?

A
  • Intrauterine growth restriction with poor fetal function tests
  • Failed induction of labour
  • Breech in labour
31
Q

What are the indications for a category 4 (elective) CS?

A
  • Previous caesarean section
  • Breech presentation
  • Other malpresentations
  • Twin pregnancy where the first twin is not a cephalic presentation
  • Placenta praevia
  • Maternal HIV
  • Primary genital herpes in the third trimester
  • Previous hysterotomy or “classical” caesarean section
  • Maternal diabetes with an estimated fetal weight >4.5kg in cases where vaginal delivery is unlikely to be successful
  • Maternal request

Women's Health (19 decks)

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