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)
What are the benefits of ERCS?
o No risk of rupture
o Able to plan recovery
most safe is successful VBAC, least safe is EMCS (not ERCS)
most safe is successful VBAC, least safe is EMCS (not ERCS)
What can you do for intrapartum management?
§ Induced and/or augmented labour -> increased risk of uterine rupture and C-section
§ Induction with mechanical methods (e.g. ARM) has a lower risk of scar rupture than prostaglandins
How do you plan ERCS?
§ ERCS should be conducted after 39 weeks (preterm VBAC has a lower risk of uterine rupture)
§ Antibiotics should be given before C-section
§ All women should receive thromboprophylaxis
How do you care for the C section scar?
· Keep it dry and get sutures taken out after 5 days
· No heavy lifting for 6 weeks
· No getting pregnant for 12-18 months
What precautions do you take for VBAC?
§ Cautious approach to VBAC if post-dates, twins, foetal macrosomia, antepartum stillbirth or >40 years
§ Preterm VBAC has a lower risk of uterine ruptur
How do you do PACES counselling for VBAC/ ERCS?
§ Explain that the options are either VBAC or ERCS
§ Explain the risks of VBAC (uterine rupture, needing EMCS)
§ Explain the risks of ERCS (future pregnancy waits, usual C-section risk factors)
Label the scars on this diagram:
