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Toni's Obs and Gynae > Methods Of Delivery > Flashcards

Methods Of Delivery Flashcards

1
Q

Indications for instrumental delivery

A

Maternal exhaustion

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2
Q

Non rotational forceps

A

Neville-Barnes (cephalic + pelvic curve)
Max of 3 contractions to deliver
Ideally spinal/epidural
Also pudendal nerve block or local anaesthetic at perineum

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3
Q

Risks of forceps deliveries

A

Failure to deliver -> Caesarean section
Vaginal tears
Fetal trauma e.g. Bruising + abrasions

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4
Q

Indications for elective caesarean

A

Previous classic caesarean
Breech with failed ECV
Placenta praevia: grade 3/4
Multiple pregnancies (if first twin not cephalic)
To prevent transmission of infection e.g. HIV + primary HSV
Must be planned before onset of labour
Not usually performed before 39 wks

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5
Q

Indications for emergency Caesarean section

A

Fetal or maternal emergency

Decision to delivery = 30 mins

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6
Q

Rotational forceps

A

Kielland’s forceps:

cephalic curve, no pelvic curve

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7
Q

Ventouse

A

Suction cap attached to
Traction + maternal effort

Can also be used where rotation required

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8
Q

External cephalic version

A

Offer to nulliparous from 36 wks, multiparous from 37 wks
50% success
Complications: placental abruption, uterine rupture, fetomaternal haemorrhage,
CI: APH in last 7 days, abnormal CTG, major uterine abnormality, ruptured membranes, multiple pregnancy
Relative CI: SGA, proteinuric pre-eclampsia, oligohydramnios, major fetal abnormalities, scarred uterus, unstable lie

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9
Q

1st degree tear

A

Injury to perineal skin only

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10
Q

2nd degree tear

A

Injury to perineum involving muscles but not anal sphincter

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11
Q

3rd degree tear

A

A. 50% ext anal sphincter torn

C. Both ext + int anal sphincters torn

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12
Q

4th degree tear

A

Injury to perineum involving anal sphincter and anal epithelium

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13
Q

RF for 4th degree tears

A 
High birth weight
Persistent occipitoposterior position
Nulliparity
Induction of labour
Epidural
Prolonged 2nd stage (>1hr)
Shoulder dystocia
Midline episiotomy
Forceps delivery
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14
Q

Non indications for c sections

A 
Twin pregnancy, 1st = cephalic
Preterm birth
SGA 
Hep B or Hep C without HIV 
Recurrent genital herpes
Maternal request
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15
Q

Assessing fetal presentation using fetal head

A

Ant fontanelle = diamond
2 frontal, 2 parietal
Post fontanelle = Y shaped
Two parietal, occipital

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16
Q

Assessing station

A

0 = at ischial spines
-1 to -3 = above spines
1 to 2 = below spines

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17
Q

Induction of labour

A

Offered if > 40wks +12 days
Prostaglandins initiate contractions + encourage cervical ripening
3mg tablets, 6-8hrly, max 6 mg/day
Artificial rupture of membranes w. Amnihook
Oxytocin infusion

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18
Q

Complications of induction/augmentation of labour

A 
Failure -> req operative delivery
Uterine hyperstimulation >7/15 mins
can cause mat + fetal distress, stop oxytocin infusion, continuous monitoring, ?tocolysis, of fetal compromise suspected deliver asap!
Nausea, vom, diarrhoea: systemic SE
Water intoxication
Uterine rupture
19
Q

1st stage labour

A

Latent: cervical effacement, dilation to 3 cm
Slow hrs-days
Active phase: 3-10 cm dilation
Faster hrs

20
Q

2nd stage

A

Full dilation -> delivery

Passive: full dilation until urge to push
Active: pressure of head on pelvic floor = urge to push -> delivery

21
Q

3rd stage

A

Delivery of fetus -> delivery of placenta
Indicated by lengthening of cord assoc with rush of dark red blood
Contraction of uterus shears placenta from uterine wall

22
Q

Power

A

Contractions: 40-60s every 2-3 mins
Irreg contractions often seen in primips
Associated with dilation and shortening of cervix

23
Q

Passage

A

Bony pelvis and assoc soft tissues
Inlet: transverse diameter= 13cm, AP diameter= 11cm
Outlet: transverse= 11cm, AP=13cm

24
Q

Normal passage

A

Descent
Engagement: occipitoanterior position
Extension of head
Crowning
Restitution: external rotation on delivery of head
Lateral flexion: allows delivery of shoulders + trunk

25
Q

Prerequisites for instrumental delivery

A

Patient consent
Valid indication
Fully dilated cervix + ruptured membranes
No abdominally palpable head
Head at or below level of ischial spines
Empty mat bladder + adequate analgesia
Determined position of head with no excessive moulding

26
Q

RF for shoulder dystocia

A 
Macrosomia
Hx of dystocia
Mat obesity
Prolonged 1st stage
Secondary arrest >8cm dilated 
Mid-cavity arrest
Forceps/ventouse delivery
27
Q

Signs suspicious of shoulder dystocia

A

Slow/difficult delivery of head
Neck does not appear
Turtle sign: chin retracts against perineum

28
Q

Complications of shoulder dystocia

A

Compression of umbilical cord betw mat pelvis and fetal trunk hypoxia= fetal morbidity + mortality
Downward traction on head -> Erb’s/Klumpke’s palsy
Deliberate fracture of fetal humerus or clavicle
Maternal
Birth canal injury, femoral nerve injury, incr blood loss

29
Q

Emergency management of shoulder dystocia

A

H: elp
E: valuate for episiotomy
L: egs into McRoberts -flex+ abduction
P: suprapubic pressure ‘mazzanti’s’
E:nter pelvis to perform manoeuvres - Rubin or Woods
R: emove posterior arm
R: oll mother over and repeat manoeuvres
Attempt each for 20-30s
Last resort= symphisiotomy, deliberate clavicle fracture, zavanelli

30
Q

Cord prolapse

A

Assoc with artificial rupture of membranes (especially where no close fit betw presenting p and pelvic inlet), long cord, 2nd twin
Mechanical compression of cord by presenting part
Spasm of umbilical vessels due to cooling, drying, pH change and handling
CTG: deep decelerations, prolonged bradycardia

31
Q

Management of cord prolapse

A 
Help
Deliver ASAP
Stop any oxytocin infusion 
Head down position, lift presenting part PV/fill bladder
Fully dilated-> attempt instrumental
Not fully-> emergency Csection
32
Q

Bishop score for cervical ‘favourability’

A

Higher = shorter + easier
Subject to examiner variation, same person should assess progress
Dilation: 4
Consistency: firm : average : soft
Length: >4 : 2-4 :1-2 : 1

33
Q

Uterine inversion

A

Rare
Fundus passes through cervix into vagina
Stretch on round ligament-> vagal stimulation-> profound shock
Shock out of proportion with blood loss, fundus not abdominally palpable - blue grey mass in vagina
RF: fundal placenta, atomic uterus, prev inversion
don’t attempt to remove placenta prior to signs of placental separation, gentle traction + counter pressure on uterus

34
Q

Consenting for c section

A

Serious risks: hysterectomy 0.7-0.8%, further surgery at later date 0.5%, ICU admission 0.9%, bladder injury 0.1%, ureteric injury 0.03%, fetal laceration 2%, incr risk uterine rupture in subsequent pregnancies 0.4%, antepartum stillbirth 0.4%, incr risk placenta praevia or acreta in subsequent pregnancies 0.4-0.8%
Frequent risks: persistent wound and abdominal discomfort in first few months following surgery, incr risk of further c section in future
Other procedures: blood transfusion, repair of bladder/bowel damage, surgery on major vessels, ovarian cystectomy/oophorectomy,mif unsure cited pathology is found, hysterectomy

35
Q

Urgency of c section

A

Grade 1: immed threat to life of women or fetus
Grade 2: maternal/fetal compromise, not immediately life threatening
Grade 3: no maternal or fetal compromise but needs early delivery
Grade 4: timed delivery to suit woman or staff

36
Q

Uterine rupture

A

Scar tenderness between contractions, cessation o contractions
Abdo pain ++ mat tachycardia, CTG abnormalities, PV bleeding
RF: prev uterine surgery, use of prostaglandins and oxytocin, prev classical c section!!! ECV, uterine malformation, obstructed labour, shoulder dystocia, forceps

37
Q

3rd stage >30 mins

A

Manual removal of placenta in theatre may be required

Conservation: leave placenta in situ to be absorbed
Haemorrhage with manual removal -> suction curretage
Massive haemorrhage -> hysterectomy

38
Q

Risks of Caesarean section

A 
VTE: 4-16/10,000
Significant haemorrhage: 5/100
Damage to bladder: 1/1000
Req hysterectomy: 8/1000
Death 1/12000
1-2% babies suffer lacerations
Infection: 6%
2x risk of stillbirth in subsequent preg
Incr risk placenta praevia
39
Q

Remifentanil

A

Infusion pump

When epidural/spinal CI

40
Q

Pethidine/Diamorphine

A

?

41
Q

Entonox

A

Adjunctive analgesia

42
Q

Epidural

A

?

43
Q

CI to epidural

A

Absolute: allergies, systemic infection, skin infection at site, bleeding disorders, plt

44
Q

Branches of pudendal nerve

A

Inferior anal
Inferior haemorrhoidal
Dorsal nerve of clitoris

Toni's Obs and Gynae (27 decks)

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