Obstetric Procedures Flashcards
What is Evacuation of Retained Products of Conception (ERPC)?
Surgical procedure to remove ‘retained products of conception’ after delivery, miscarriage or TOP
What are the indications for ERCP?
- Miscarriage (maternal preference or necessity)
- Persistent bleeding, haemodynamic instability
- Gestational trophoblastic disease (suspected)
- Infected products of conception after ABx
What are the complications of ERCP?
Generic: bleeding, infection, procedural failure, necessity to repeat
Specific: intrauterine adhesions, perforation of uterus (0.5%)
What is External Cephalic Version (ECV)?
External manipulation of foetus through maternal abdomen to achieve a cephalic presentation
What are the indications for ECV?
Breech presentation (persistent at 36 or 37 weeks)
- Nulliparous - offered at 36 weeks
- Multiparous - offered at 37 weeks + Tocolytics
Success rate = 50-60%
What are contraindications for ECV?
Absolute contraindications:
- Any requirement for C-section regardless
- Abnormal CTG
- APH <7 days
- Major uterine abnormality
- Ruptured membranes
- Multiple pregnancy
Relative contraindications: (ECV may be complicated)
- SGA
- Pre-eclampsia
- Oligohydramnios
- Major foetal abnormalities
- Scarred uterus
- Unstable lie
What are the complications of ECV?
There is a very low complication rate
- Generic: procedural failure, necessity to repeat
- Placental abruption
- Uterine rupture
- Foeto-maternal haemorrhage
What is CTG?
Cardiotocography – continuous monitoring of the foetal heart and uterine activity > used in labour
What are growth scans?
Booking scan at 12 (8-14) weeks, anomaly scan at 20 (18-21) weeks > monitor pregnancy
What is a foetal doppler?
Used to monitor FHR and should be placed over the anterior shoulder of foetus > monitor pregnancy
What is foetal blood sampling?
Blood withdrawn from umbilical vein to determine if severe anaemia caused by Rh sensitisation
What are the complications of foetal blood sampling?
- Bleeding from site
- Changes in FH
- Infection
- Leaking of amniotic fluid
- Death of foetus (1%)
What are the indications for an emergency CS?
- Terminal Bradycardia: FHR < 100 bpm for more than 10 mins
- Terminal Deceleration: FHR drops and does not recover for more than 3 mins
What are the indications for an IUS?
- Desire for long-term contraception
- Menorrhagia
- Endometriosis
- HRT
What are the complications of IUD / IUS insertion?
- Generic: bleeding, infection, procedural failure, necessity to repeat
- SE – heavier bleeding in first 2 weeks after insertion, pain, headache, nausea/vomiting, depression
- Perforation, infection, bleeding
What is a ventouse?
Vacuum extractor cup placed directly over flexion point (better for mum but may upset baby)
What are forceps?
Smooth metal instruments fit around baby’s head (doesn’t upset baby)
What are the birth options after a previous CS?
VBAC – Vaginal Birth After CS
- <34w GA > forceps
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 a CS?
- Malpresentation
- Foetal distress
- Multiple pregnancy
- Failure to progress
- Placenta praevia
- Severe IUGR
- Placental abruption
- Infections (HIV, HSV)
- Cord prolapse
- Previous CS
- APH
- Previous anal sphincter injury
What are the requirements for instrumental delivery?
(FORCEPS) – an episiotomy will often be done first:
- F Fully dilated cervix
- O OA position (OP delivery is possibly with Keilland forceps and ventouse)
- R Ruptured membranes
- C Cephalic presentation
- E Engaged presenting part (NOT palpable abdominally)
- P Pain relief
- S Sphincter (bladder) empty (usually requires catheterisation)
What are the CS categories?
- (Cat 1) Immediate threat to life of woman or foetus
- (Cat 2) No immediate threat to life of woman or foetus
- (Cat 3) Requires early delivery
- (Cat 4) Elective CS
What are the CS incisions?
- Pfannenstiel
- Joel-Cohen
- Midline vertical/classical
- Maylard
What are the complications of instrumental delivery?
Maternal: (more common forceps)
- Perineal tears (3rd degree)
- Cervical and vaginal lacerations
- PPH
- 80% achieve SVD in subsequent pregnancy
Foetal: (more common ventouse)
Ventouse
- Cephalohematoma
- Intracerebral haemorrhage
- Retinal haemorrhage
- Jaundice
- 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
What are absolute contraindications for VBAC?
- Previous uterine rupture
- Classical (vertical) C-section scar
- Normal non-C-section contraindications (e.g. major placenta praevia)
What are relative contraindications for VBAC?
- 2 or more previous CS
- The need for IOL
- Previous labour suggestive of cephalopelvic disproportion
What are the risks of VBAC?
- Emergency C-section (EMCS) - 25%
- Planned VBAC has a 1 in 200 risk of uterine rupture (1 in 100 if syntocinon is used)
- Increased risk of instrumental delivery (39%)
- Infant: transient respiratory morbidity, still birth (very small)
What are the indications for safe VBAC?
Singleton, cephalic, >37 weeks, 1 previous C-section
What are the risks of ERCS?
- Placenta praevia/accreta
- Pelvic adhesions
- Neonatal respiratory morbidity (can be reduced with antenatal corticosteroids)
- Longer recovery
- Risk of bladder/bowel injury (rare)
- Likely to need future LSCS (Lower Segment CS)
What are the benefits of ERCS?
- No risk of rupture
- Able to plan recovery
How should ERCS be planned?
- 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 should a CS scar be cared for?
- 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 is CVS?
- Performed 10-13 wks (i.e. week 12)
- 1% miscarriage rate
- USS-guided needle aspirate of placental tissue
- Foetal viability confirmed and anti- RHD given to Rh- women (sensitising event)
What is amniocentesis?
- Performed ≥15/40
- 1% miscarriage rate
- USS guided needle, avoid entry of placenta, small aspirate of amniotic fluid
- Foetal viability confirmed and anti-RhD given to Rh-neg women (sensitising event)
What are the indications for CVS / amniocentesis?
- Demonstrated risk at antenatal screening
- Suspected foetal anomaly on USS
- FHX of inherited disorder
- Known carrier status for inherited disorder
- Previous pregnancy with chromosomal disorder
- Increased maternal age
What are the complications of CVS / amniocentesis?
- Generic: bleeding, infection, damage to local structures, procedural failure
- Abdominal pain
- Miscarriage (both CVS and amniocentesis at 1%)
- Chorioamnionitis
- Limb abnormalities if CVS performed before 10/40
What is sterilisation?
Surgical ligation or obstruction of both fallopian tubes as method of contraception:
- Hysteroscopic sterilisation – expanding springs inserted into tubal ostia via hysteroscope induce fibrosis
- Tubal occlusion (laparoscopic procedure) – occlude fallopian tubes with Filshie clips
What advice should be given to women considering sterilisation?
- Method is irreversible (reversal requires high skilled and is difficult)
- Vasectomy is safer, quicker and associated with less morbidity
- High proportion of women regret sterilisation
- Does not protect against STIs
What is required prior to sterilisation?
- Abstain from UPSI for 3 weeks and have a pregnancy test before the procedure
- If the patient has had UPSI, the procedure should be deferred
- Protected sex is ok
Is contraception still required after sterilisation?
- Laparoscopic procedure: the next menstrual period
- Hysteroscopic procedure: 3 months
Can you get pregnant after sterilisation?
- Pregnancy following female sterilisation is rare but has an increased risk of ectopic pregnancy:
- If missed period > immediate pregnancy test
- If +ve > immediate USS to check location
What are the indications for sterilisation?
- Desire for permanent contraception (>99% effective)
- Requires thorough counselling about nature of the procedure, risks, SE, irreversibility, alternative contraception
What are the complications of sterilisation?
- Generic: bleeding, infection, damage to local structures, procedural failure (1 per 200, 1% peripartum)
- Increased risk of future ectopic pregnancy
- Anaesthetic complications
- VTE damage to other organs (bladder, bowel, vessels)
- Risk of conversion to open procedure
Normal parameters for CTG?
Br = 110-160
A = 15bpm above baseline for 15s
Va = 5-25bpm
D = 15bpm below baseline for 15s
What is a pathological CTG?
1 abnormal feature, or
2 non-reassuring features
What are abnormal features on a CTG?
- Br <100 or >180
- Va <5 for 50 mins or >25 for 25 mins
- Single prolonged deceleration >3 mins
- Late decelerations for 30mins (less if RFs)
- Variable decelerations with any concerning characteristics in >50% for 30 mins (less if RFs)
What are non-reassuring features of a CTG?
- Br 100-109 or 161-180
- Va >25 for 15-25 mins
- Va <5 for 30-50 mins
