Normal, complex and operative deliveries Flashcards
What are the types of delivery?
Spontaneous vaginal
Instrumental
Elective/ emergency C section (CS)
VBAC/ ERCS
What are the types of instrumental delivery?
o Ventouse – vacuum extractor cup placed directly over flexion point (better for mum but may upset baby)
o Forceps – smooth metal instruments fit around baby’s head (doesn’t upset baby)
What are the options after previous CS?
o VBAC – Vaginal Birth After CS <34w GA -> forceps
o ERCS – Elective Repeat CS >34w GA -> forceps OR ventouse
What are the indications for instrumental delivery?
§ Maternal exhaustion
§ Prolonged second stage of labour
§ Foetal distress
§ Maternal illness where bearing down is risky (cardiac conditions, HTN, aneurysm, glaucoma)
What are the indications for CS?
§ Malpresentation
Foetal distress
Multiple pregnancy
§ Failure to progress
Placenta praevia
Malpresentation
§ Severe IUGR
Placental abruption
Infections (HIV, HSV)
§ Cord prolapse
Previous CS
APH
§ Previous anal sphincter injury
What are the requirements for instrumental deliveries?
(HINT: use FORCEPS)
an episiotomy will often be done first:
o F Fully dilated cervix
o O OA position (OP delivery is possibly with Keilland forceps and ventouse)
o R Ruptured membranes
o C Cephalic presentation
o E Engaged presenting part (NOT palpable abdominally)
o P Pain relief
o S Sphincter (bladder) empty (usually requires catheterisation)
What are the CS categories?
o (Cat 1) Immediate threat to life of woman or foetus
o (Cat 2) No immediate threat to life of woman or foetus
o (Cat 3) Requires early delivery
o (Cat 4) Elective CS
What are the maternal complications of instrumental delivery?
Maternal (more common forceps) -> perineal tears (3rd degree), cervical and vaginal lacerations, PPH
· 80% achieve SVD in subsequent pregnancy
What are the foetal complications of instrumental delivery?
Foetal (more common ventouse)
· Ventouse – cephalohematoma, intracerebral haemorrhage, retinal haemorrhage, jaundice
o Prolonged ventouse delivery = greatest risk of haemorrhage in the newborn
· Forceps – facial nerve palsies
What are the complications of CS?
Generic: bleeding, infection, damage to local structures, procedural failure
Visceral damage – bladder (1 in 10,000), ureter, bowel
VTE
Foetal laceration
Hysterectomy – rare
When is VBAC offered?
o Appropriate and may be offered to most women with a singleton pregnancy of cephalic presentation at 37+ weeks who have had a single lower segment C- section, with or without a history of vaginal birth
§ Women ≥2 previous C-sections may be offered VBAC after counselling by a senior obstetrician
§ Discussion should include risk of uterine rupture, maternal morbidity and likelihood of successful VBAC
What are the absolute CIs to VBAC?
§ Previous uterine rupture
§ Classical (vertical) C-section scar
§ Other non-C-section contraindications (e.g. major placenta praevia)
What are the pros of VBAC compared to ERCS?
(success rate: 72-75%)
· Has the fewest complications compared to ERCS (elective repeat of C-section)
· Previous SVD is best predictor of successful VBAC (85-90%) and lower risk of uterine rupture
· Indications of Safe VBAC: singleton, cephalic, >37 weeks, 1 previous C-section
What are the risks of VBAC?
o Emergency C-section (EMCS)
o Planned VBAC has a 1 in 200 risk of uterine rupture (1 in 100 if syntocinon is used)
o Increased risk of instrumental delivery (39%)
o Infant: transient respiratory morbidity, still birth (very small
What are the risks of ERCS?
o Placenta praevia/accreta
o Pelvic adhesions
o Neonatal respiratory morbidity (can be reduced with antenatal corticosteroids)
o Longer recovery
o Risk of bladder/bowel injury (rare)
o Likely to need future LSCS (Lower Segment CS)
Label the scars on this diagram:
