Operative delivery Flashcards
Types of instrumental delivery
Ventouse suction cup or forceps
What give after forceps delivery
Co-amoxiclav
Indications for instrumental delivery
Failure to progress
Foetal distress
Maternal exhaustion
Control of head in various foetal positions
What procedure increases the risk of need for instrumental delivery?
Epidural
Risks of instrumental delivery to mother
PPH
Episiotomy
Perineal tears
Injury to anal sphinctre
Incontinence of bladder or bowel
Obturator or femoral nerve injury
Key risks to baby with instrumental delivery
Cephalohaemoatoma = collection blood between scalp and skull - with a ventouse
Facial nerve palsy - forceps
Rare serious risks to baby with instrumental delivery
Subgaleal haemorrahge - most dangerous
Intracranial haemorrhage
Skull fracture
Spinal cord injury
What is a subgaleal haemorrhage?
Accumulation of blood in layers soft tissue head between
Galea aponeuritica and
Periosteum
What is galea aponeuritica?
Tough fibrous connective tissue
What is periosteum
Membrane tissue that covers the surface of a newborns skull
What causes subgaleal haemoatoma?
When emissary veins passing thrpugh foramen seperate from the tissue and rupture during difficult vaginal delivery
Why is subgaleal haemotoma so life threatening?
Baby can lost 20% to 40% blood volume as haemorrhage forms in their skull
Management of subgaleal haemotoma
Blood and plasma transufion on NICU
Surgery to stop bleed if still clinically unwell
Normally resolves after 2-3 weeks
What is a ventouse?
On babies head, doctor or midwife applies careful traction to cord
What causes femoral nerve injury in forceps delivery?
Compressed against inguinal canal
What does femoral nerve injury cause?
Weakness of knee extension
Loss of patella reflec and numbness of anterior thigh and medial lower leg
What causes obturator nerve injury in forceps delivery?
Compressed by forceps or by foetal head in normal delviery
What does obturator nerve injury cause?
Weak hip adduction and rotation and numbness of medial thigh
What does obturator nerve injury cause?
Weak hip adduction and rotation and numbness of medial thigh
Nerve injuries that can occur in birth
Normal or instrumental
Obturator
Femoral
Lateral cutaneous nerve of the thigh
Lumbosacral plexus
Common peroneal nerve
What does damage to lateral cutaneous nerve of thigh in birth cause?
Prolonged flexion at hip while lithotomy position can result in injury -> numbness of anterolateral thigh
How is the lumbosacral plexus injured in birth and what does it cause?
May be compressed by foetal head during second stage of labour
Injury causes foot drop and numbness of anterolateral thigh, lower leg and foot drop
What causes common peroneal injury in birth and what does this cause?
Compressed on head of fibula
Injury -> foot drop and numbness in lateral lower leg
Indications for elective C section
Prev caesarean
Symptomatic after prev significant perineal tear
Placenta previa
Vasa previa
Breech
Multiple pregnancy
Uncontrolled HIV infection
Cervical cancer
Categories of emergnecy C section
Category 1 - 4
1 - immediate threat to life of mother or baby - 30 mins
Category 2 - required urgently due to compromise - 75 mins
3 - delivery required, mother and baby stable
4 - elective C section
Different types of incision
Pfannenstiel incision - curved, two fingers above pubic symphysis
Joel-cohens incision - straight incision slightly higher - recommended
Vertical incision - prem, anterior placenta previa
Blunt incision
Why is blunt dissection used
After initial incision with scalpel
Seperate remaining layers of abdominal wall and uterus
Less bleeding, shorter operating times and less risk of injury to baby
Layers of abdomen need to be dissected during C section
Skin
SC tissue
Fascia/rectus sheath
Rectus abdominis muslces
Peritoneum
Vesicouterine peritoneum
Uterus
Amniotic sac
What is teh fascia/rectus sheath is
Aponeurosis of transversus abdominis and external and interal oblique muscles
Layers of the uterus
Perimetrium, myometrium and endometrium
What is the vesicouterine peritoneum
Bladder seperated from uterus bladder flap
How is baby helped to be delivered
Assistance of pressure on the fundus
What is exteriosrisation?
Uterus out of abdomen
Risks ass with general anaesthetic
Allergic reactions or anaphylaxis
Hypotension
Headache
URINARY retention
-spinal anaesthetic
Nerve damage
Haematoma
-General anaesthetic
Sore throat
Damage to teeth or mouth
Meds to reduce risk during a C section
H2 recpetor antagonists eg ranitidine or proton pump inhibirors eg omeprazole before
Prophylactiv antibiotics during
Oxytocin during - reduce PPH risk
VTE - prophylacis with LMW heparin
What does H2 receptor antagonists or PPIs reduce the risk of in C section
Risk of aspiration penumonitis - acid reflux and aspiration during prolonged period lying
Generic surgical risks C section
Bleeding
Infection
Pain
VTE
Complications in PP period
PPH
Wound infection
Wound dehiscence
Endometriosis
What local structures can be damaged in a C section
Ureter
Bladder
Bowel
Blood vessels
What effects can have on abdominal organs C section
Ileus
Adhesions
Hernias
What eIncreased riskss on future pregnancies have with C section
Repeat caesarean
Uterine rupture
Placenta previa
Stillbirth
Effects on baby of C section
Lacerations
Transient tachypnoea of newborn
Contraindications for vaginal birth after C section
Prev uterine rupture
Classical caesarean scar - vertical incision
Other usual contraindications to vaginal delivery
Prophylaxis for VTE after C section
VTE risk assessment
Early mobilisation
Anti-embolism stocking or intermittent pneumatic compression of legs
LMW heparin
