Operative Birth

Question 1

What are the different types of forceps?

Answer 1

Neville-Barnes
Simpsons
Haigh-Ferguson’s
Keilland’s
Wrigley’s

Question 2

What are the neville-BArnes forceps used for?

Answer 2

Presenting part is mid cavity in anterior occiput way (OA)

Question 3

What are Simpsons forceps used for?

Answer 3

Moulding/elongation of fetal head

Question 4

When are Haigh-Ferguson forceps used?

Answer 4

Mid cavity

Question 5

When are Keilland’s forceps used?

Answer 5

Rotation- transverse or direct OP

Question 6

When are Wrigley’s forceps used?

Answer 6

Lift out/low head/+2 or lower.

Question 7

What is the name of the suction/vacuum?

Answer 7

Ventouse

Question 8

What is the name of the abdominal operative delivery?

Answer 8

Caesarean section

Question 9

What is the historical purpose of an instrumental birth?

Answer 9

To retrieve the infant from a dead or dying mother. Sadly, the operation was not intended to preserve the mother’s life.

Question 10

What is the history behind the creation of forceps?

Answer 10

• The ‘modern’ incarnation of the forceps was developed by the Chamberlen family in 17th Century.
• The Chamberlens were innovators, opportunists and entrepreneurs who tried to promote various schemes for the public good, (and their own advancement).
• Dr Peter, in 1634, proposed a Sisterhood of Midwives of London.
• He would license midwives competence for which he would be paid a fee foreach delivery and would be called to all difficult cases.
• Developed the forceps c 1645, but kept the designs hidden until they were discovered in 1813!

Question 11

What was the advanced progress of forceps in the early C18th with William Smellie?

Answer 11

 Progress advanced in the early C18th with William Smellie.
 In 1751 he accurately described the mechanism of parturition and the curves of the birth canal.
 Set about designing his own instruments, with features which have endured to this day.
 ‘English lock’
 the pelvic curve
 shortened handles
 Late C19th and early C20th saw further innovation with manufacturing techniques and materials (steel) and the development of the forceps we have today (Neville Barnes, Kielland (rotational).

Question 12

What is the consent process for a operative delivery?

Answer 12

 Name of proposed procedure or course of treatment
. The proposed procedure.
 Intended benefits.
 Serious and frequently occurring risks.
 Any extra procedures which may become necessary during the procedure.
 What the procedure is likely to involve.
 The benefits and risks of any available alternative treatments, including no treatment.
 Statement of patient: procedures which should not be carried out without further discussion.
 Preoperative Information.
 Anaesthesia

Question 13

What are the two types of forcep births?

Answer 13

Non-rotational forceps:
-mid cavity forceps
-low cavity oulet/LSCS forceps
Rotational (Keillands) forceps:
-The reduced pelvic curve allows rotation.

Question 14

What are the maternal indications for forceps?

Answer 14

-Prolonged second stage of labour
-Maternal exhaustion
-Prophylactic shortening of the second stage (managing and OP position)

Question 15

What are the fetal indications for forceps?

Answer 15

Suspected fetal compromise in the second stage
-pathological CTG
-Abnormal FBS

Question 16

What is a pundenal nerve block analgesia (PNB)?

Answer 16

• Used as pain relief in the final stage of childbirth.
• An option during the second stage of birth (from 10 cm to birth)during the final descent of the fetal head and expulsion of the baby.
• An effective method of pain relief, providing analgesia to the vulva and anus by transvaginal infiltration of the pudendal nerve.
• It may be provided in spontaneous as well as in instrumental (vacuum and/or forceps extraction) vaginal births.
• Also used as analgesia for the suturing of perineal lacerations after birth

Question 17

What are the 3 p’s of examination?

Answer 17

Power, Passenger, Passage

Question 18

What is the 3p: power of examination mean?

Answer 18

 Strength / frequency of contractions (determined by abdominal palpation rather than looking at the CTG).
 An oxytocin infusion may be required. What to do if abnormal CTG

Question 19

What is the 3p: Passenger of examination?

Answer 19

Estimated size of baby
 USS / Customised Growth Chart.
 You should assess the presentation, position and station

Question 20

What is the 3p: passage of examination?

Answer 20

Abdominal and vaginal examination.
 <One-fifth palpable per abdomen
 Fully?
 Spines or below on vaginal examination (0 station).
 Moulding? May be disproportion

Question 21

what are some of the complications with forcep delivery?

Answer 21

• PPH* Perineal tears (1 in 10)
• Rare: persistent dyspareunia
• Third degree tears
• 2 - 20%
• 3.5% of women have long term faecal incontinence following forceps birth.
• Fetal bruising, grazing and chignon (Swelling generally caused by ventouse)
• Significant concern for women
• Jaundice
• Retinal and Intracranial haemorrhage
• Shoulder dystocia

Question 22

What are the caesarean categories?

Answer 22

• Elective LSCS
• Carried out after 39 weeks.
• Daytime hours with dedicated team (inc midwife).
• Emergency LSCS categories:
• Immediate threat to the life of the woman or fetus
• Maternal or fetal compromise that is not immediately life-threatening
• No maternal or fetal compromise but needs early delivery
• Delivery timed to suit woman or staff

Question 23

What are some indications for cesarean?

Answer 23

 Elective
 Fetal position eg Breech.
 Previous LSCS.
 Some twins, triplets.
 Placental. Maternal infection.
 Maternal – PET, active primary Herpes.
 Fetal – Suspected fetal compromise in any stage of labour (pathological CTG, abnormal FBS), fetal disease

Question 24

What needs to be done once a decision as been made?

Answer 24

• Note the decision time.
• Inform coordinator.
• Inform Anaesthetist.
• Inform Theatre team.
• Should be onsite, but backup team may be at home!
• Ensure blood tests.
• FBC, Clotting, G&S, (U&Es, LFTs).
• Inform Neonatal team (emergencies).
• Need to be present in theatre.
• Prepare the woman/birthing person to be moved to theatre.

Question 25

What are some frequent maternal risks of a caesarean section?

Answer 25

• Persistent wound and abdominal discomfort in the first few months after surgery (9 in 100; common).
• Increased risk of repeat caesarean section for subsequent pregnancies (1 in 4;extremely common).
• Readmission to hospital (5 in 100 (common).
• Haemorrhage (5 in 1000; uncommon).
• Infection (6 in 100; common).
• Emotional distress/regret.

Question 26

What are some serious maternal risks of a caesarean?

Answer 26

Emergency hysterectomy (7–8 in 1000; uncommon).
* Need for further surgery at a later date (5 in 1000; uncommon).
* Bladder injury (1 in 1000; rare).
* Ureteric injury (3 in 1000; rare).
* Death (approximately 1 in 12 000; extremely rare)

Question 27

What are some fetal risks for a caesarean?

Answer 27

• Fetal injury lacerations (2.0% or 1–2 in 100; common).
• Admission to intensive care unit (0.9%)

Question 28

What is the preparation needed for a caesarean

Answer 28

Team effort –Advocate women’s/birthing person’s wishes/requests
* The category will determine the urgency
* Cannula +/- Blood tests
* Antacid
* Catheter
* Essential before we can start the procedure
* May already be in situ or will need inserting in theatre
* Changing patient
* (And birthing partner)
* Notes/documentation
* Ongoing
* Moving to theatre
* May involve a lift or to another department.

Question 29

What are some difficulties of a caesarean?

Answer 29

• Understanding.
• Of procedure.
• Language barrier.
• Inability for patient to cope.
• Pain (May need to convert to GA)
• Partner will have to leave theatre!* Distressing for the woman!
• Baby born in poor condition.
• Complications