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MRCOG Part 2 > Management of Labour and Delivery including GT26 Operative Vaginal Delivery, GT29 3rd/4th Perineal Tears, GT42 Shoulder Dystocia > Flashcards

Management of Labour and Delivery including GT26 Operative Vaginal Delivery, GT29 3rd/4th Perineal Tears, GT42 Shoulder Dystocia Flashcards

1
Q

How much above background risk is the chance of a shoulder dystocia if a woman has had one previously?

A

x10

Background risk is 1 in 150

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2
Q

What is the incidence of breech presentation at term?

A

3-4%

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3
Q

What percentage of all live births were <37/40 in England and Wales in 2005?

A

7.6%

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4
Q

What is the mortality rate for babies born
@23/40?
@32/40?

A

23/40 >90%

32/40 2%

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5
Q

What is the incidence of 3rd/4th degree perineal tears associated with Shoulder dystocia?

A

3.8%

Background incidence in
primp is 6.1%
Multip is 1.7%

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6
Q

What is the rate of recurrence of shoulder dystocia?

A

15-25%

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7
Q

What is the overall rate of OASIS in the UK and what measure decreases risk?

A

3%

Hands poised on perineum

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8
Q

What is the recurrence rate of placental abruption?

A

4.4% (OR 7.8)

19-25% after 2 abruptions

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9
Q

What is the rate of dural headache followin accidental dural puncture and when do 90% develop by?

A

70%

within 3 days

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10
Q

What is the sensory supply to the uterus and cervix?

A

T11-L1 uterine via Frankenhauser’s plexus

Cervical dilatation perceived at T11-12

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11
Q

What are the UK rates of operative vaginal delivery?

A

10-13%

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12
Q

What are the measures to help avoid operative vaginal delivery?

A
  • Continuous support during labour (RR 0.82)
  • Upright/lateral positions, (RR 0.80)
  • Avoiding epirdural (OR 1.4 more likely to have OVD)
  • Delayed pushing in primips with epidural - decreased rotational/midcavity OVD
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13
Q

What are the gestational limits of vacuum extraction?

A

34/40

Safety unknown, insufficient evidence 34-36+0/40

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14
Q

What risk factors contribute to a high failure rate for OVD?

A
  • BMI >30
  • EFW >4kg/clinically big baby
  • OP position
  • Mid cavity
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15
Q

What are the differences between outcomes with soft and rigid ventouse cups?

A
  • Increase failure rate OR 1.6

- Less puerperal scalp trauma OR 0.4

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16
Q

What is the failure rate with Kiwi OmniCup?

A

13%

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17
Q

What is more likely with vacuum vs forceps…?

A
  • Cephalhaematoma OR 2.4
  • Maternal worries about baby OR 2.2
  • Retinal haemorrhage OR 2.0
  • Failed delivery OR 1.7
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18
Q

What is less likely with vacuum vs forceps…?

A

Significant maternal perineal and vaginal trauma OR 0.4

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19
Q

What is no more likely with vacuum vs forceps…?

A
  • Delivery by CS
  • 5 min Apgar scores being low
  • Need for phototherapy
20
Q

What % of women will have spontaneous VB after OVB?

A

80% even if complex instrumental in theatre

21
Q

What is the incidence of OASI in the UK?

A

2.9% (Range 0-8)

6% Pri, 1.7% Multip
Tripled from 2-6% from 2000-2012

22
Q

What are the risk factors for OASI?

A
  • Nullip (OR 6.97)
  • OP position (2.44)
  • Asian (2.27)
  • BW >4kg (2.27)
  • Shoulder dystocia (1.90)
  • Prolonged second stage (RR 2 if >4hrs)
  • Instrumental delivery - forceps no epis OR 6.5
  • Recurrent (5.51 - even higher if above RFs)
23
Q

What are preventive measures for OASI?

A
  • Consider RMLE
  • Perineal protection at crowing
  • Warm compression 2nd stage RR 0.48
  • Perineal massage last 4/40 RR 0.91 of trauma requiring suturing
24
Q

Which suture is recommended for the anorectal mucosa?

A

3.0 polyglactin, continuous or interrupted

25
Q

Which sutures is recommended for the external anal sphincter?

A

3.0 PDS or 2.0 polyglactin
Overlapping or end to end
Bury under superficial perineal muscles

26
Q

What is the incidence of suture migration in OASI?

A

7%

27
Q

What is the risk of further 3rd/4th degree tear in subsequent pregnancies?

A

5-7%

17% will have worsening symptoms if they were symptomatic at 3-6 months postpartum

28
Q

What is the incidence of shoulder dystocia?

A

0.58-0.70%

29
Q

What % will have a PPH with shoulder dystocia?

A

11%

30
Q

What % will have 3rd/4th degree tear with shoulder dystocia?

A

3.8%

31
Q

What is the rate of brachial plexus injury with shoulder dystocia? And how many occurred after CS?

  • How many with permanent neurological dysfunction?
  • What % due to substandard care?
A

2-16% (0.43/1000)

At CS - 4%

Permanent dysfunction - <10%

Substandard - 46%

32
Q

What % of shoulder dystocias are predicted by conventional risk factors?

A

16%

33
Q

What are the pre-labour risk factors for shoulder dystocia?

A
  • Previous shoulder dystocia
  • Macrosomia >4.5kg
  • DM (x2-4 risk)
  • BMI >30
  • IOL
34
Q

What are the intrapartum risk factors for shoulder dystocia?

A
  • Prolonged 1st stage
  • Secondary arrest
  • Prolonged 2nd stage
  • Oxytocin augmentation
  • Assisted vaginal delivery
35
Q

When should IOL be considered for shoulder dystocia?

A

Term with women with GDM

Not for suspected macrosomia

36
Q

When should elective Caesarean section be considered to prevent brachial plexus injuries?

A

In diabetic women regardless of treatment with EFW >4.5kg

NNT 443 vs 3695 (non-diabetic)

ACOG recommend consideration if EFW >5kg

37
Q

What is the increase in risk of shoulder dystocia in someone with a previous history of shoulder dystocia?

A

10x that of general population

recurrence rate 1-25%

38
Q

Which factors should be considered in women with previous shoulder dystocia when planning mode of delivery?

A
  • Previous maternal or neonatal injury
  • Predicted size
  • Maternal choice
39
Q

What is the incidence of humeral fractures with delivery of the posterior arm?

A

2-12%

40
Q

What is the time cut off for hypoxic ischaemia in management of shoulder dystocia?

A

5 minutes

41
Q

What are the maternal complications of shoulder dystocia?

A
  • PPH
  • 3rd/4th degree tears
  • Vaginal/cervical lacerations
  • Bladder rupture
  • Uterine rupture
  • Symphyseal separation
  • SI joint dislocation
  • Lateral femoral cutaneous nerve dysfunction
42
Q

What are the fetal complications of shoulder dystocia?

A
  • Brachial plexus injury (Erb’s C5-6; Clumpke’s C8-T1)
  • Humeral and clavicular fracture
  • Pneumothorax
  • Brain damange
43
Q

What is the incidence of cord prolapse?

A

0.1-0.6%

1% of breech babies

44
Q

What is the mortality rate from cord prolapse?

A

91/1000

45
Q

What is the rate of SVD following IOL with prostaglandins alone?

A

61-70%

46
Q

How many births are there a year in England/Wales?

And what proportion are first babies and how many spontaneous labours?

A

700,000
40% first
2/3 spontaneous

90% cephalic singletons

47
Q

What is the increase in risk of adverse outcome for baby with a homebirth in a low risk nullip compared to other birth settings?

A

4/1000

MRCOG Part 2 (97 decks)

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