Operative delivery

Question 1

indications for operative vaginal delivery

Answer 1

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

Question 2

Types of operative delivery

Answer 2

Forceps

Vacuum extraction

Question 3

Prerequisites for operative vaginal delivery

Answer 3

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

Question 4

Limits of trial of vacuum

Answer 4

After 3 pulls over 3 contractions with no progress
After 3 pop-offs with no obvious cause
20min and delivery is not imminent

Question 5

Advantages of vacuum extraction

Answer 5

easier to apply, less anaesthesia required, less maternal soft-tissue injury compared to forceps

Question 6

Disadvantages of vacuum extraction

Answer 6

contraindicated if fetus at risk for coagulation defect
Suitable only for vertex presentation
Maternal pushing required
Contraindication in-preterm delivery

Question 7

Complications of vacuum extraction

Answer 7

increased incidence of cephalohematoma and retinal haemorrhages compared to forceps
Subgaleal haemorrhage, subaponeurotic haemorrhage, soft tissue trauma

Question 8

Advantages of forceps

Answer 8

Higher overall success rate for vaginal delivery

Decreased incidence of fetal morbidity

Question 9

Disadvantages of forceps

Answer 9

Greater incidence of maternal injury

Question 10

Cx of Forceps

Answer 10

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.

Question 11

Muscles of the perineal body

Answer 11

superficial transverse perineal
Bulbocavernous
External anal sphincter

Question 12

Types of Lacerations

Answer 12

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

Question 13

Indications for episiotomy

Answer 13

to relieve obstruction of the unyielding perineum
Instrumental delivery
Controversial between making a cute or letting it tear

Question 14

Cx of episiotomy

Answer 14

Infection
Hematoma
extension into anal musculature or rectal mucosa
Fistula formation
Incontinence

Question 15

Indications for Caesarean delivery

Answer 15

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

Question 16

Types of cesarean incision

Answer 16

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.

Question 17

Common risk and complications of caesarean delivery

Answer 17

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

Question 18

Uncommon risk and Cx of caesarean delivery

Answer 18

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

Question 19

Rare risk and Cx of caesarean delivery

Answer 19

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.