Instrumental Delivery (RCOG/RANZCOG) Flashcards
Methods for reducing need for assisted vaginal delivery?
continuous support during labour
upright or lateral positions in second stage
delayed pushing for 1-2 hours in nulliparous women with epidural
Incidence of assisted vaginal birth
10-15%
1/3 nulliparous women gives birth by vacuum or forceps.
Serious rare neonatal complications associated with assisted delivery
subgaleal haemorrhage
intracranial haemorrhage
skull fracture
spinal cord injury
More likely to occur with mid pelvic, rotational and failed attempts at assisted vaginal birth.
What is the association between epidural anaesthesia and incidence of assisted vaginal birth?
OR 1.42 9%% CI 1.28-1.57. However, lower concentrations of local analgesic or PCEA do not have this outcome.
What is the risk reduction of instrumental delivery associated with upright/lateral positions in second stage?
RR 0.75 95% CI 0.66-0.86
Define mid cavity delivery
no more than 1/5 palpable per abdomen
PP 0 or +1
non rotational <45 degrees from OA
rotational >45 degrees from OA
Give 5 safety criteria for assisted vaginal birth for a) examination b) preparation of mother c) preparation of staff
a) head 1/5 or less palpable,
cervix fully dilated,
membranes ruptured,
station at level of spines or below,
position of the fetal head has been determined,
caput or moulding is no more than moderate (+2),
pelvis is deemed adequate
b) clear explanation given and informed consent taken and documented, appropriate analgesia in place, bladder has been emptied, IDC removed/balloon deflated, aseptic technique
c) operator has knowledge, experience and skill, adequate facilities and access to OT,
back-up plan
anticipation of complications
neonatal resus team present
describe severe moulding
+3= parietal bones have overlapped and are irreducible indicating CPD`
What is the incidence of incorrect diagnosis of fetal position with +without USS
USS 1.6%
no USS 20.2%
What is the rate of vaginal delivery in subsequent pregnancy after a) assisted vaginal birth vs. b) LSCS
a) 80%
b) 30%
What factors are associated with a higher risk of instrumental delivery failure?
BMI >30, short maternal stature, EFW >4kg or clinically LGA, HC >95th, OP position, mid pelvic birth when 1/5 of head palpable per abdomen.
Discuss the Cochrane systematic review comparing assisted delivery modes and their complications
Both PPH 10-40% urinary or bowel incontinence improving over time fetal lacerations 10% jaundice 5-15% ICH 5-15 /10,000
Vacuum episiotomy 50-60% significant tear 10% OASI 1-4% cephalohaematoma 1-12% retinal haemorrhage 17-38% subgaleal haemorrhage 3-6/1000
Forceps episiotomy 90% tear 20% OASI 8-12% facial bruising skull fracture (rare) facial palsy (rare fetal death (rare)
When should vacuum assisted birth be discontinued
no evidence of progressive descent
more than three pulls to perineum
two pop-offs
15 minutes duration of application
When should forceps delivery be discontinued?
forceps cannot be easily applied or do not lock
lack of progressive descent
delivery not imminent after 3 pulls
What is the efficacy of episiotomy in prevention of pelvic floor morbidity?
ML episiotomy (60 degrees) at distension of perineum is protective in vacuum 9.4% vs. 1.4% (OR0.11) and forceps 22.7% vs. 2.6% (OR 0.28) delivery against OASI.
