Obstetrics (Intrapartum care): Instrumental delivery Flashcards
What is a Kiwi cap?
A disposable ventouse used in emergency situations
What is the purpose of a ventouse?
Provides mechanical traction by suction onto baby’s head
Whats more safe a rubber or metal cap for ventouse?
Rubber - less risk of foetal trauma
What are some of the common complications arising from ventouse?
- Chignon - swelling on the forehead from suction, will decrease over time
- Retinal haemorrhage
- Uterine lacerations
- Scalp lacerations
- Cephalohaematoma - more common in ventouse than forceps
What are the benefits of ventouse?
Provides traction to deliver OA presenting infants
May spontaneously rotate a malpositioned foetus to OA
What device would you use to rotate a foetus?
A Kieland forces (rotational) - can be used only in cephalic presentation
What are the two types of forceps and when are they used?
Kieland (rotational) - only used for cephalic
Simpson (non rotational) - used for cephalic or breech
What are the common complications arising from forceps?
- Facial nerve damage - Erbs (C5-6, waiters tip), Klumpke (C8-T1, claw hand)
- Uterine tear - more common with forceps than ventouse
- Facial bruising, skull and neck fractures - more common with forceps than ventouse
What is the checklist for use of forceps or ventouse?
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
What is the difference between mid-cavity and low-cavity delivery? Which devices would you use?
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)
Which instrument can you not use for a OT presenting foetus?
Must not use non-rotational forceps - contraindicated
What are the complications of C-Sections?
NB: divide complications into post-op, future pregnancies, maternal and foetal
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
What are the benefits of C-Section
Reduced abdominal and post-natal pain
Reduced risk of foetal shock
Reduced PPH
Reduced injury to vagina - no instruments or episiotomy
What are the indications for emergency C-section
Acute foetal distress or compromise
Malposition or malpresentation
Prolonged 1st stage of labour - i.e. > 12hrs
Reduced uterine contractions
What are the indications for elective C-secion (absolute and relative)?
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
What is the most common type of C-section?
LSCS - lower segment C section
Classic type i.e. vertical incision no longer used
What is the main complication of traction of foetus during shoulder dystocia?
Erb’s palsy -
- C5-6 paralysed causes waiter’s tip presentation
What is the main complication of traction of foetus during shoulder dystocia?
Erb’s palsy -
- C5-6 paralysed causes waiter’s tip presentation
What are the causes of pre-term labour?
Tip: Castle analogy
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)
What are the signs of pre-term labour?
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
What are the investigations for pre-term labour?
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)
What is the management of a pre-term labour?
- 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 - Steroids and Tocolysis
- 2 doses Beclamethasone or Dexamethasone to promote pulmonary maturity
- takes 24hrs so delay with tocolytics
- IV Terbutaline, Nifedepine, Atosiban - Delivery
- Vaginal has less risk of foetal complications
- Most premature babies are Breech so CS is more likely - Prophylactic Abx
- prevent risk of infection, usually group B strep
