Operative delivery Flashcards
indications for operative vaginal delivery
fetal
- atypical or abnormal FHR tracing
- Consider if second stage is prolonged as this may due to poor contractions or failure of fetal head to rotate
Maternal
- need to avoid voluntary expulsive effort e.g. cardiac/cerebrovascular disease
- exhaustion, lack of cooperative and excessive analgesia may impair pushing effort
Types of operative delivery
Forceps
Vacuum extraction
Prerequisites for operative vaginal delivery
Anesthesia
Bladder empty
Cervix fully dilated and effaced with ROM
Determine position of fetal head
Equipment ready - including facilities for emergent C/S
Fontanelle - posterior fontanelle midway between thighs
Gentle traction
Handle elevated
Incision - episiotomy
once Jae visible remove forceps
Knowledgeable operator
Limits of trial of vacuum
After 3 pulls over 3 contractions with no progress
After 3 pop-offs with no obvious cause
20min and delivery is not imminent
Advantages of vacuum extraction
easier to apply, less anaesthesia required, less maternal soft-tissue injury compared to forceps
Disadvantages of vacuum extraction
contraindicated if fetus at risk for coagulation defect
Suitable only for vertex presentation
Maternal pushing required
Contraindication in-preterm delivery
Complications of vacuum extraction
increased incidence of cephalohematoma and retinal haemorrhages compared to forceps
Subgaleal haemorrhage, subaponeurotic haemorrhage, soft tissue trauma
Advantages of forceps
Higher overall success rate for vaginal delivery
Decreased incidence of fetal morbidity
Disadvantages of forceps
Greater incidence of maternal injury
Cx of Forceps
Maternal: anaesthesia risk, lacerations, injury to bladder, uterus or bone, pelvic nerve damage, PPH, infections.
Fetal: fractures, facial nerve palsy, trauma to face/scalp, intracerebral haemorrhage, cephalohematoma, cord compression.
Muscles of the perineal body
superficial transverse perineal
Bulbocavernous
External anal sphincter
Types of Lacerations
First degree: skin and vagina mucosa only
2rd degree: fascia and muscles of perineal body
3rd degree: anal sphincter
4th degree: extends through the anal sphincter into the rectal mucosa
Indications for episiotomy
to relieve obstruction of the unyielding perineum
Instrumental delivery
Controversial between making a cute or letting it tear
Cx of episiotomy
Infection Hematoma extension into anal musculature or rectal mucosa Fistula formation Incontinence
Indications for Caesarean delivery
Maternal obstruction active herpetic lesion on vulva Invasive cervical cancer Previous uterine surgery Underlying maternal illness eg eclampsia, HELLP syndrome Heart disease Maternal - Fetal Failure to progress, placental abruption or Previa, vasa previa Fetal: abnormal fetal heart tracing Malpresentation Cord prolapse Certain congenital anomalies
Types of cesarean incision
Skin
- transverse eg Pfannensteil. Decrased exposure and slower entry and improved strength and cosmetics.
- Vertical midline: rapid peritoneal entry and increased exposure and increased dehiscence
Uterine
- Low transverse: most common, in non contractile segment, decreased chance for rupture in subsequent pregnancies
- Low vertical: used for very preterm infants, poorly developed maternal lower uterine segment
- Classical: rare, in thick, contractile segment. used for transverse lie, fetal anomaly, greater 2 fetuses, lower segment adhesions, obstructing fibroid, morbidly obese patients.
Common risk and complications of caesarean delivery
greater then 5%
Infections of site, pelvis or urinary tract. Tx wound dressing or ABX
Bleeding. tx with ABX and a drain into wound
Uterus not contracting properly. Leads to excess vaginal bleeding. Tx with hormone injection to contract uterus or hysterectomy
Adhesion
increase risk to Obese people of wound infection, chest infection, heart and lung complications and thrombosis
Uncommon risk and Cx of caesarean delivery
1-5%
Lung collapse tx with ABX and Physiotherapy
Minor cutes to baby.
Injury to other organs eg uteter’s, bladder or bowel.
Keloid
heart attack or stroke
VTE
Rupture in future pregnancies or during labour
may get reduced fertility
Rare risk and Cx of caesarean delivery
slightly higher risk of placenta previa or acretia
severe bleeding from lg vessel
Bowel blockage either temporary or long term requirement bowel surgery
poor wound healing or hernia formation
Death.
