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GOSH > Obstetrics (Intrapartum care): Instrumental delivery > Flashcards

Obstetrics (Intrapartum care): Instrumental delivery Flashcards

1
Q

What is a Kiwi cap?

A

A disposable ventouse used in emergency situations

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2
Q

What is the purpose of a ventouse?

A

Provides mechanical traction by suction onto baby’s head

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3
Q

Whats more safe a rubber or metal cap for ventouse?

A

Rubber - less risk of foetal trauma

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4
Q

What are some of the common complications arising from ventouse?

A
  1. Chignon - swelling on the forehead from suction, will decrease over time
  2. Retinal haemorrhage
  3. Uterine lacerations
  4. Scalp lacerations
  5. Cephalohaematoma - more common in ventouse than forceps
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5
Q

What are the benefits of ventouse?

A

Provides traction to deliver OA presenting infants

May spontaneously rotate a malpositioned foetus to OA

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6
Q

What device would you use to rotate a foetus?

A

A Kieland forces (rotational) - can be used only in cephalic presentation

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7
Q

What are the two types of forceps and when are they used?

A

Kieland (rotational) - only used for cephalic

Simpson (non rotational) - used for cephalic or breech

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8
Q

What are the common complications arising from forceps?

A
  1. Facial nerve damage - Erbs (C5-6, waiters tip), Klumpke (C8-T1, claw hand)
  2. Uterine tear - more common with forceps than ventouse
  3. Facial bruising, skull and neck fractures - more common with forceps than ventouse
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9
Q

What is the checklist for use of forceps or ventouse?

A

FORCEPS

Full dilatation - cervix is dilate > 10cm
Obstruction excluded - head is <1/5th palpable at abdomen
Rupture of membranes - confirm and review
Consent
Catheter - remove
Check instrumentation
Explain procedure
Epidural analgesia
Examine genital tract - exclude trauma
Position - OA, OT, OP, Breech
Power - check uterine contractions adequate
Placement of forceps or ventouse
Station of presenting part - not above ischial spine

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10
Q

What is the difference between mid-cavity and low-cavity delivery? Which devices would you use?

A

Low cavity - head is below ischial spine, bony prominences are palpable on the lateral wall of the mid-pelvis
- OA usually - ventouse or forceps

Mid cavity - head not palpable abdominally, but it is just below the ischial spine

  • OA - ventouse or forceps
  • OT - venous (non-rotational kirkland forceps are CI)
  • OP - venous preferred, can use Kieland (if very competent)
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11
Q

Which instrument can you not use for a OT presenting foetus?

A

Must not use non-rotational forceps - contraindicated

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12
Q

What are the complications of C-Sections?

NB: divide complications into post-op, future pregnancies, maternal and foetal

A

Post-op

  • Infection - give prophylactic Abx
  • Endometritis
  • VTE
  • Pulmonary atelectasis

Long term (future pregnancies)

  • High risk of placenta praaevia, accrete, paccreta (future)
  • Uterine rupture
  • Dense adhesions if multiple CS

Maternal

  • Haemorrhage - if >1L requires urgent blood transfusion
  • Post-CS Hysterectomy
  • Death

Foetal

  • Poor pulmonary function
  • Reduced baby/mother bonding
  • Death
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13
Q

What are the benefits of C-Section

A

Reduced abdominal and post-natal pain
Reduced risk of foetal shock
Reduced PPH
Reduced injury to vagina - no instruments or episiotomy

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14
Q

What are the indications for emergency C-section

A

Acute foetal distress or compromise
Malposition or malpresentation
Prolonged 1st stage of labour - i.e. > 12hrs
Reduced uterine contractions

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15
Q

What are the indications for elective C-secion (absolute and relative)?

A

Absolute:

  • Placenta praaevia
  • Severe foetal compromise
  • Previous vertical CS
  • Gross pelvic deformity
  • Uncorrected foetal lie

Relative:

  • Breech
  • Severe IUGR
  • Pre-eclampsia
  • Twins - usually determined after 1st twin is born
  • DM
  • Older nulliparous women
  • Previous LSCS
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16
Q

What is the most common type of C-section?

A

LSCS - lower segment C section

Classic type i.e. vertical incision no longer used

17
Q

What is the main complication of traction of foetus during shoulder dystocia?

A

Erb’s palsy -

- C5-6 paralysed causes waiter’s tip presentation

18
Q

What is the main complication of traction of foetus during shoulder dystocia?

A

Erb’s palsy -

- C5-6 paralysed causes waiter’s tip presentation

19
Q

What are the causes of pre-term labour?

Tip: Castle analogy

A

Too many defenders
- Multiple pregnancy

Defenders jump out
- Foetal survival response - spontaneous labour more common when foetus at risk e.g. IUGR, placental abruption, pre-eclampsia

Castle design is weak
- Fibroid and polyps

Castle wall is weak
- Cervical incompetence

Attackers break through
- Infection due to UTI or STI (bacterial vaginosis most common)

20
Q

What are the signs of pre-term labour?

A

Pre-term labour signs

  • Painful uterine contractions
  • Antepartum haemorrhage or loss of liquor (indicates PROM)
  • Discharge

Cervical incompetence

  • Painless uterine contractions
  • Increased discharge
  • Vague supra-pubic abdominal pain
  • PROM
21
Q

What are the investigations for pre-term labour?

A

TVS

  • Measure cervical length
  • if >15mm delivery unlikely

Foetal fibronectin (FFN) assay

  • Calculates chances of delivery in 7-10d
  • +ve result indicates delivery is likely
  • -ve result indicates delivery unlikely

Vaginal swab MSU and sterile speculum

  • look for signs of infection
  • See if Os is open

Bloods
- Raised WCC and CRP (infection)

22
Q

What is the management of a pre-term labour?

A
  1. Monitor and assess mother
    - Observations
    - Obstetric exam
    - Speculum - see if os is open, infection signs
    - Assess likelihood of delivery - Os open, TVS < 15mm, FFN +ve
    - Monitor foetus - CTG, USS
  2. Steroids and Tocolysis
    - 2 doses Beclamethasone or Dexamethasone to promote pulmonary maturity
    - takes 24hrs so delay with tocolytics
    - IV Terbutaline, Nifedepine, Atosiban
  3. Delivery
    - Vaginal has less risk of foetal complications
    - Most premature babies are Breech so CS is more likely
  4. Prophylactic Abx
    - prevent risk of infection, usually group B strep

GOSH (14 decks)

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