Instrumental Delivery Flashcards

1
Q

Purpose of instrumental delivery

A

Helps avoid Maternal and Perinatal Morbidity and Mortality, and avoiding Emergency Caesarean section (CS in second stage is associated with higher risk)

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2
Q

Indications for instrumental delivery

A

10 – 15% of deliveries; Indications include Maternal Exhaustion, Prolonged Second Stage
(>1hr of active pushing in Multiparous and >2hr in Primiparous), Medication indications for
avoiding Valsalva (E.g. Severe Cardiac, HTN, AVM), Pushing not possible (Para/Tetraplegia),
Foetal Compromise or Control of head of Breech Presentation

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3
Q

What should be done prior to attempting instrumental delivery

A

Confirm Second stage (Full Cervical Dilatation) and
station (Should be below Ischial spine); Obstruction should be excluded; Membranes should
be ruptured; Bladder Cath In-and-out, Epidural/Pudendal Analgesia
o Check Presentation and Position before apply instrument; Ensure maternal tissues are not caught in instruments during application

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4
Q

Risk Factors for Failed Instrumental Delivery

A

– High Maternal BMI, EFW>4kg, OP position,

Mid-cavity Delivery or if head >1/5ths palpable

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5
Q

Forceps Assisted Delivery

A

Curved Blades that sit around foetal head and allow traction to be applied around Flexion point of the
head (3cm in front of Occiput)

o Low Cavity (Wrigley’s), Mid-cavity Non-
Rotational, Mid Cavity Rotational

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6
Q

Risk associated with Forceps Assisted Delivery

A

increased Maternal
Trauma; Foetal injuries rare but include Facial
nerve palsy, Skull fractures, Orbital Injury and
Intracranial Haemorrhage

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7
Q

Vacuum Assisted Delivery

A

Scalp tissues sucked into cup; Artificial Caput
(=Chignon); Should not be used in <34/40
• Metal Cups, Soft Cups and Kiwi Omnicup

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8
Q

Risk of Vacuum Assisted Delivery

A

More likely to fail compared to Forceps; More associated with Foetal Trauma
• Vacuum Extraction associated with Foetal Injuries including Scalp Lacerations and Avulsions,
Cephalohaematoma, Retinal Haemorrhage; Subgaleal and Intracranial Haemorrhage rarely

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9
Q

Caesarean Section

A

Delivery of the Foetus through Direct Incision in Abdominal Wall and Uterus

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10
Q

How common is a C section

A

For Primiparous, has increased to 24%

in the UK; For Multiparous without previous CS, <5%; If at least one previous CS about 67%, mostly Elective

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11
Q

CS Risks

A

CS associated with higher incidence of Abdominal Pain, VTE, Bladder or Ureteric Injury, Hysterectomy, very rarely Maternal Death
o Lower rates of Perineal Pain, Urinary Incontinence and Prolapse

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12
Q

How are the risks of CS reduced?

A

Risks reduced with Hb Check and Correcting Anaemia, Intraoperative Abx before Skin Incision, VTE Thromboprophylaxis, Catheterisation, Antacid precautions

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13
Q

What kind of anaesthesia is used in CS?

A

Regional rather than General Anaesthesia if possible; Reduce Risk of Hypotension
with Intravenous Vasopressors and Volume Preloading, and Left Lateral Tilt

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14
Q

Main indications for CS

A

Repeat CS, Foetal Compromise, Failure-to-Progress, Breech

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15
Q

Crash CS

A

(within 30 mins) – Placental Abruption with Abnormal FHR or Uterine Irritability, Cord Prolapse, Scar Rupture, Prolonged Bradycardia, Foetal Acidosis

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16
Q

Urgent CS

A

Failure to Progress with Pathological CTG

17
Q

Scheduled CS

A

Severe Pre-Eclampsia, IUGR with poor Foetal Function, Failed Induction

18
Q

Elective CS

A

Term Singleton Breech (Failed or CI ECV), Twin Pregnancy with Non-
Cephalic First Twin, Maternal HIV, Primary HSV in Third Trimester, Placenta Praevia,
Previous Uterine Surgery; Elective usually carried about after 39/40 t reduce risk of
Respiratory Morbidity

19
Q

What types of incisions are used in CS?

A
Lower Uterine Segment Incision – Pfannenstiel Incision (2cm above Symphysis Pubis) or Joel-
Cohen Incision (3cm above level of ASIS, quicker entry into Abdomen)

o Layers – Skin, Subcutaneous Fat, Camper’s, Scarpa’s, Anterior Rectus Sheath, Rectus
Abdominis, Transversalis Fascia, Peritoneum

20
Q

Complications of CS

A
  • Intraoperative Complications occur in 12 – 15% of women
  • Uterine/Uterocervical Lacerations, Blood Loss >1L, Bladder, Bowel, Ureter Injury
  • Post-Op Complications in 1/3; Endometritis, Infections, Pulmonary Atelectasis, VTE, UTI
  • Subsequent Pregnancies – Uterine Rupture, Placenta Praevia and Accreta, Antepartum Stillbirth, Excessive Blood Loss, Adhesions; Higher complications with number of CS