Operative Delivery

Question 1

What are the indications for instrumental delivery?

Answer 1

Failure to progress in 2nd stage
Foetal distress in 2nd stage
Maternal reasons – health emergencies and exhaustion e.g. pneumothorax, retinal detachments etc.

Question 2

What are the requirements for a instrumental delivery to be viable?

Answer 2

Trained operator, full dilation must be reached, absent membranes, cephalic presentation, clearly defined position, presenting part has engaged, no evidence of CPD (cephalopelvic disproportion), adequate analgesia, 1/5th or less palpable in the abdomen, neonatal doctor present and empty bladder. If any doubt, then undertake this in theatre under ‘trial’.

Question 3

Describe how a ventouse delivery works

Answer 3

Sucks foetal scalp tissue into a Ventouse creating a artificial caput called a chignon (this takes 1-2 days to go away).

Question 4

What are the advantages and disadvantages of a forceps delivery

Answer 4

Forceps – Less likely to fail as little maternal effort required. Cause significant genital tract trauma (as they add an extra 1cm).

Question 5

What are the advantages and disadvantages of a ventouse delivery

Answer 5

Ventouse – higher foetal complications but lower maternal. Requires maternal effort and more likely to fail.

Question 6

What are the 3 types of forceps

Answer 6

There are 3 types.

1. Low cavity forceps (Wrigley’s) – lift out deliveries when head is in the perineum
2. Mid-cavity non-rotational forceps – when sagittal suture lies in the AP diameter
3. Mid-cavity rotational forceps – suitable for rotation

Question 7

When should forceps delivery attempts be stopped?

Answer 7

No descent with each pull

Delivery not imminent after 3 attempts

Question 8

What steps should be taken after a forceps delivery

Answer 8

Give vitamin K to the baby
Assess maternal urine output and need for catheter
Assess need for thromboprophylaxis

Question 9

What are the complications from ventouse and forceps delivery?

Answer 9

Maternal
Maternal genital tract trauma, postpartum haemorrhage and urinary retention.
Spiral vaginal tears with rotational forceps

Foetal
Forceps: skull fractures, , facial bruising and intracranial haemorrhage (forceps can sometimes be misplaced and cause trauma – usually self-limiting).
Ventouse: cephalhaematoma, retinal haemorrhage and scalp laceration and avulsions.

Oedema from the forceps area is normal but this can bleed leading to a cephalic haematoma usually only spreads as far as sutures but if it spreads further – sub-glial haemorrhage – baby can in theory lose most of its circulating volume – rare but important.

Question 10

What are the indications for a caesarean section?

Answer 10

Indications 
Failure to progress
Foetal distress 
Malpresentation/malposition
Failed instrumental delivery
Maternal medical condition e.g. gestational diabetes, cardiomyopathy 
Placenta praevia

Question 11

What are the requirements for a caesarean section?

Answer 11

Trained operator
Adequate facilities
Adequate analgesia (usually regional anaesthesia spinal +/- epidural - usually if its going to take longer). GA sometimes required if speed necessary e.g. CAT1
Consultation with senior member of staff
Group and save
Bladder catheterised and/or drained
Omitted dose of thromboprophylaxis day before surgery

Question 12

Describe the complications from a caesarean section

Answer 12

Complications
Immediate:
Haemorrhage
Bladder/Bowl injury
TTN (transient tachypnoea of the new-born)
Foetal trauma - cut on the baby tends to heal very well
Requirement for blood transfusion

Intermediate:
Infection
Thromboembolic disease

Late:
Subfertility
Psychological – regret
Rupture/dehiscence of scar 
Placenta praevia
Caesarean scar ectopic

Question 13

What are the benefits of caesarean sections?

Answer 13

Benefits – no labour complications e.g. tears, shoulder dystocia etc., mother knows a date, predictable delivery.

Note reduced risk of perineal trauma, pain, urinary and anal incontinence, uterovaginal prolapse, late stillbirth and early neonatal infections.

Question 14

What are the 4 categories of emergency caesarean sections?

Answer 14

1) Immediate threat to the life of mother or baby – delivery within 30 minutes
2) Maternal or foetal compromise that is not immediately life-threatening, delivery within the hour
3) No maternal or foetal compromise but needs early delivery
4) Elective – delivery timed to suit the woman or staff

Question 15

What 3 important things must be done pre operatively before a caesarean section?

Answer 15

FBC, VTE score and H2 receptor antagonist – women lying flat are at risk of Mendelson’s syndrome – aspiration of gastric contents into the lung due to pressure of gravid uterus) this can lead to chemical pneumonitis. If emergency CS give metoclopramide instead as it acts faster.

Question 16

How should Mendelson’s syndrome be managed?

Answer 16

Management of Mendelson’s Syndrome – Tilt head back, aspirate pharynx, give 100% oxygen, aminophylline and hydrocortisone.

Question 17

Describe the position and prep for a low transverse segment caesarean section

Answer 17

Position – left lateral tilt of 15 degrees (reduced risk of hypotension)
Catheter inserted and bladder drained
Skin prepped and antibiotics given

Question 18

Describe the process of a low transverse caesarean section

Answer 18

Skin incision- Pfannestiel or Joel-Cohen – both transverse lower abdominal skin incisions
Sharp or blunt dissection made through several layers:
• Skin
• Campers Fascia (superficial)
• Scarpa’s Fascia (Deep)
• Rectus Sheath
• Rectus Muscle
• Transversalis Fascia
• Abdominal peritoneum (parietal)
• Visceral peritoneum covering gravid uterus
• Uterine incision in lower uterine segment beneath the line of peritoneal reflection
Baby delivered cephalic or breech whilst assistant applies fundal pressure
Oxytocin given to aid delivery of the placenta by controlled cord traction by surgeon
Uterine cavity ensured empty and then closed with two layers.

Question 19

Describe a classic caesarean section and it’s indications

Answer 19

Vertical incision – rarely done but indications include 
Structural abnormality of the uterus
Fibroids or adhesions blocking access 
Post-mortem CS delivery 
Anterior placenta praevia
Elective caesarean hysterectomy 
Transverse lie with ruptured membranes

Question 20

What care should be provided post c section?

Answer 20

One to one support in recovery room
Aim for skin to skin contact ASAP
Check BP, pulse, RR and sedation levels: half hourly for first 2 hours then hourly for 24hrs
Use MEOWS to assess condition
After epidural remove catheter when mobile or 12hours after last top up
If GA give extra midwife support to help encourage breastfeeding
Give paracetamol and ibuprofen with morphine for any breakthrough pain

Question 21

How would retained products present?

Answer 21

The uterus does not contract down well as the products are still in the cavity, and the discharge is offensive suggesting that the products have become infected.

Question 22

How should retained products post caesarean section be managed?

Answer 22

Requires urgent examination under anaesthesia to remove the products. The products often pass by themselves without the need for anaesthesia, however after day 1 this is unlikely so intervention is needed. Can sometimes scan for the products but they don’t always turn up.

Question 23

Differentiate between a caput succedaneum, subgaleal haematoma and a cephalohaemaotma

Answer 23

Caput succedaneum is caused by pressure on the fetal scalp during the birthing process. It results in a large oedematous swelling and bruising over the scalp. Treatment is not required as the swelling reduces over a few days.

A cephalohaematoma may occur after a spontaneous vaginal delivery or following a trauma from the obstetric forceps or the ventouse. A haemorrhage results after the periosteum is sheared from the parietal bone. The tense swelling is limited to the outline of the bone. It reduces over a few weeks - months.

Subgaleal haematoma is between the aponeurosis of the skull and the peiosteum and can spread further than a cephalohaematoma. These are dangerous as neonates can theoretically lose their whole circulating volume into this space.