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My MRCOG Part 2 > GTG Assisted Vaginal Delivery > Flashcards

GTG Assisted Vaginal Delivery Flashcards

1
Q

What proportion of all women will have an assisted vaginal delivery?

A

10-15%

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2
Q

What proportion of Primips will have an assisted vaginal delivery?

A

1:3 (33%)

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3
Q

In subsequent pregnancy, What happens to the chance of spontaneous vaginal delivery following an assisted vaginal delivery?

A

Increased chance of spontaneous vaginal delivery after assisted vaginal delivery.
80% chance of successful NVD in next delivery.

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4
Q

After what time period of second stage of labour has retrospective studies found a significant increase in maternal morbidity?

A

After 3 hours of second stage, there is a significant increase in maternal morbidity. With a further increase after 4 hours.

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5
Q

Define an ‘outlet’ assisted delivery.

A

Foetal scalp is visible without parting the labia.
Or foetal scalp has reached perineum.
<45 deg rotation.

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6
Q

Define a ‘low-cavity’ assisted delivery.

A

Foetal skull is station +2 but not yet on perineum.
Can be non rotational (<45deg) or rotational (>45deg).

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7
Q

Define a ‘mid-cavity’ assisted vaginal delivery.

A

Foetal head is no more than 1/5th palpable PA.
Foetal skull is station 0 or +1.
Can be non rotational (<45deg) or rotational (>45deg).

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8
Q

Name the 3 relative contra-indications to any assisted vaginal delivery.

A
  1. Suspected foetal bleeding disorders.
  2. Foetal pre-disposition to fractures.
  3. Maternal blood borne infections.
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9
Q

At what gestation can a vacuum delivery be carried out?

A

After 36 weeks.
(With caution between 32-36/40).
Avoid <32/40.

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10
Q

What risks are increased with vacuum deliveries compared to forceps?

A

Increased risk of subgleal haemorrhage or scalp trauma.

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11
Q

When should delay in second stage be suspected in nulliparous women?

A

After 3 hours (combined passive + active) if epidural in situ.
After 2 hours (combined passive + active).

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12
Q

When should delay in second stage be suspected in parous women?

Isn’t 30 mins suspected and 1 hour diagnosed?? Check this.

A

After 2 hours (combined passive + active) with an epidural in situ.
After 1 hour without an epidural in situ.

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13
Q

How can risk of assisted vaginal delivery be reduced (in women withOUT an epidural).

A
  1. Good intra-partum support.
  2. Upright position.
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14
Q

What effect does an epidural have on the rate of instrumental vaginal delivery?

A

Epidurals can increase the rate of assisted vaginal deliveries (although less likely with new anaesthetic techniques).

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15
Q

What difference does epidural placement have on rate of assisted vaginal delivery if placed in latent phase vs active labour?

A

Timing of epidural placement does not change rate of assisted vaginal delivery.

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16
Q

Why is passive time offered?

A

Study has shown significant reduction in rotational or mid-cavity deliveries, but later research does not show a difference).

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17
Q

What position reduces rate of assisted vaginal delivery in women with an epidural in situ?

A

Lying in lateral position.

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18
Q

Should TA or perianal US be used to assess foetal head position, flexion and descent in second stage?

A

Insufficient evidence for routine use.
But TA US recommended if uncertainty over foetal head position.
But, US is shown to significantly reduce incorrect foetal head position diagnosis.

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19
Q

What is the risk of episiotomy in vacuum delivery vs forceps delivery?

A

Vacuum delivery: 50-60%
Forceps delivery: >90%.

20
Q

What is the risk of a significant vulvo-vaginal tear in women who have a vacuum delivery vs forceps delivery?

A

Vacuum: 10%
Forceps: 20%

21
Q

What is the risk of PPH following vacuum vs forceps delivery?

A

10-40% for both.

22
Q

What is the risk of cephalohaematoma following vacuum delivery?

A

1-12%

23
Q

What is the risk of facial or scalp laceration following vacuum vs forceps delivery?

A

10% risk for both vacuum and forceps delivery.

24
Q

What is the risk of retinal haemorrhage after vacuum delivery?

A

17-38%

25
Q

What are the 3 risks associated with 2nd stage LSCS?

A
  1. Increased risk PPH.
  2. Increased risk NNU admission.
  3. Less likely to have NVD in next delivery (30%).
26
Q

What is the average decision to delivery time (DDT) for instrumentals carried out in the room?

A

15 mins.

27
Q

What is the average Decision to Delivery Time (DDT) for trials in theatres?

A

59 mins overall.
30 mins if foetal distress.

28
Q

What factors reduce the success rate of assisted vaginal deliveries?

A

BMI>30.
Short maternal stature.

EFW>4kg (or clinically big baby).
HC>95th centile.
OP or rotation required.

Mid-pelvic deliveries.
Biparietal diameter above ischial spines.

29
Q

What is the reported rate of failure for vacuum delivery?

A

17-36%.
But 3x higher if malposition.

30
Q

What risks are higher with vacuum delivery compared to forceps delivery?

A

Failure (OR 1.7).
Cephalhaematoma (OR 2.4).
Retinal haemorrhage (OR 2.0).
Maternal concern for baby (OR 2.2).

But less likely to cause perineal trauma (OR 0.4).

31
Q

What is the risk of low APGAR after vacuum delivery compared to forceps delivery?

A

Equal risk of low APGARs regardless of mode of assisted vaginal delivery.

32
Q

When should a ventous delivery be discontinued?

A
  1. No descent with moderate traction.
  2. Not delivered after 3 pulls (plus 3 additional gentle pulls to deliver out of the perineum).
  3. After 2 pop offs (less experienced doctor get help after 1 pop off).
33
Q

How many tractions can be applied during a ventous delivery before this should be abandoned?

A

3 pulls to bring head to perineum + 3 additional gentle pulls to deliver head from perineum.

34
Q

After how many ‘pop-offs’ should help be called or ventous be abandoned?

A

After 2 pop offs
(but less experienced doctors should get help after 1 pop off).

35
Q

How should the ventous cup be removed?

A

By rapidly decreasing the pressure (to reduce duration of application).

36
Q

What are the 2 main concerns of using sequential instruments?

A
  1. Increased risk of foetal trauma.
  2. Increased risk of OASI.
37
Q

When should forceps delivery be abandoned?

A
  1. Not easily locked.
  2. Lack of progressive descent.
  3. After 3 pulls be experienced operator.
  4. Excessive time of application (>12 mins).
38
Q

During trail of forceps delivery, what aspect causes the bulk of complaints?

A

Failure to discontinue at the appropriate time.

39
Q

What is the evidence for or against routine use of episiotomy during instrumental deliveries?

A

There is no robust evidence for or against the use of routine episiotomy during instrumental delivery.
But supporting evidence is stronger in nulliparous women.

40
Q

Outcome of ANODE trial in post- instrumental care

A

Single dose of IV Co-Amoxiclav significantly reduces risk of maternal infection.

41
Q

When should physiotherapy be offered after instrumental delivery?

A

3 months post partum, directed strategies to reduce the risk of urinary incontinence.

42
Q

When should women with persistent PTSD symptoms after delivery be referred?

A

At 1 month

43
Q

Do debrief sessions help with prevention of PTSD?

A

Debrief sessions neither help, no make it worse. They do not change the effect on developing psychological problems.

44
Q

What is the chance of having a NVD following a ventous delivery?

A

90%

45
Q

What is the chance of a NVD following more complex assisted vaginal deliveries in theatres?

A

80%

My MRCOG Part 2 (37 decks)

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