Operative O&G

Question 1

Types of operative vaginal delivery

Answer 1

-Forceps delivery
=Haig-Ferguson
=Kiellands
=Wrigleys
-Episiotomy (perineal skin incision in high risk of tear/ to expedite delivery)
-Vacuum assisted delivery
=Kiwi cup
=Ventouse

Question 2

Indications for operative vaginal delivery

Answer 2

-Delayed active 2nd stage labour
-Foetal distress in 2nd stage (bradycardia)
-Maternal exhaustion
-Pre-existing conditions= complications
-Small baby

Question 3

Criteria for operative vaginal delivery vs caesarean

Answer 3

-Signs of obstructive birth; caput, moulding?

-Fully dilated cervix
-Cephalic presentation
-Station (how low the occiput is compared to maternal ischial spines): at/below ischial spines
-Position: any direction but need to know (determines instrument)- if not known caesarean. Rotational forceps if OP
-Adequate anaesthesia: epidural, pudendal never block, spinal
-Maternal consent

Question 4

Contraindications for operative vaginal birth

Answer 4

-Breech presentation
-Premature (for suction delivery): before 32 weeks absolute, 32-36 weeks relative. Scalp delicate susceptible to haematoma, low circulating iron: anaemia
-Maternal bleeding diathesis, haemophilia
-Maternal von Willebrand’s

Question 5

Location of operative vaginal birth

Answer 5

-Labour ward room: less distressing, reduces delay (pudendal if foetal distress)
-Theatre: conversion to caesarean, needs epidural/ more than epidural

Question 6

Types of caesarean sections

Answer 6

-Elective (planned/scheduled), for example, for previous caesarean section, breech presentation or asymptomatic placenta praevia
-Emergency (immediate/urgent), for example, following a placental abruption or severe pre-eclampsia
- In labour (i.e., emergency), usually for the reasons listed under ‘forceps’. However, the cervix is not fully dilated or the cervix is fully dilated but circumstances are unsuitable for instrumental vaginal delivery

Question 7

Risks of caesarean section

Answer 7

-Maternal mortality is higher for emergency than for elective caesarean section.
-There is also greater morbidity from haemorrhage, infection and thromboembolic disease.
-Deaths from thromboembolism have been dramatically reduced by the widespread use of appropriate thromboprophylaxis (low-molecular-weight heparin, early mobilisation, hydration)

Question 8

Complications of caesarean sections

Answer 8

-Infection (wound, urinary, uterine)
-PPH (which may occur during the course of surgery or afterwards)
-Thromboembolism or bowel or bladder injury.
-For the fetus, there is an increased risk of transient tachypnoea of the new born (TTN) and transfer to the neonatal unit, although this is more likely with pre-labour procedures and at earlier gestational ages.
- Following a caesarean section, there are implications for any subsequent deliveries, as there is a scar on the uterus with an increased risk of uterine rupture during labour

Question 9

Incidence of caesarean section

Answer 9

-Over the past couple of decades, the rates of caesarean sections have increased significantly in western countries.
-In the United Kingdom, 25-30% of births were delivered by caesarean section in 2015.
-In women who have had at least one previous caesarean section, the rate of deliveries by this method increases to 67%

Question 10

Classification of caesarean section

Answer 10

-Category 1 – immediate (“crash”): these are performed when there is an immediate threat to the life of the woman or fetus. Delivery should take place as soon as possible. The Royal College of Obstetricians and Gynaecologists recommends that a category 1 section should be performed within 30 minutes of making the decision for caesarean delivery.
-Category 2 – urgent: these are indicated when there is maternal or fetal compromise, which is not immediately life-threatening. To be performed as soon as possible, and within 75 minutes of decision for delivery.
-Category 3 – scheduled: this category of C-section is indicated where there is no maternal or fetal compromise, but early delivery is required.
-Category 4 – elective: the timing of this delivery is planned to suit the woman and staff.

Question 11

Indications for Category 1 (crash) caesarean section

Answer 11

-Cord prolapse
-Sustained fetal bradycardia
-Fetal hypoxia (scalp pH < 7.20)
-Placental abruption
-Uterine rupture

Question 12

Indications for a category 2 (urgent) C section

Answer 12

-Failure to progress in labour with pathological CTG

Question 13

Indications for a category 3 (scheduled) C section

Answer 13

-Intrauterine growth restriction with poor fetal function tests
-Failed induction of labour
-Breech in labour

Question 14

Indications for category 4 (elective) caesarean section

Answer 14

-Previous caesarean section
-Breech presentation
-Other malpresentations
-Twin pregnancy where the first twin is not a cephalic presentation
-Placenta praevia
-Maternal HIV
-Primary genital herpes in the third trimester
-Previous hysterotomy or “classical” caesarean section
-Maternal diabetes with an estimated fetal weight >4.5kg in cases where vaginal delivery is unlikely to be successful
-Maternal request

Question 15

When are elective sections usually planned for?

Answer 15

Elective caesarean sections are normally planned around 39 weeks gestation. This is to reduce the risk of the neonate developing respiratory distress in neonates born at earlier gestations, known as transient tachypnoea of the new born

Question 16

Steps to reduce morbidity associated with the procedure

Answer 16

-Pre-operative haemoglobin check and correction of anaemia. A group & save should also be taken.
-H2-receptor antagonists or proton pump inhibitors (currently off license) +/- anti-emetics like metoclopramide. Metoclopramide is a prokinetic anti-emetic agent, and this can help reduce the risk of aspiration of gastric contents.
-Women should be risk-assessed and appropriate thrombo-prophylaxis should be prescribed. This includes compression stockings, hydration, early mobilisation and low-molecular-weight heparin as appropriate.
-Prophylactic antibiotics should be given immediately prior to the skin incision.
-In cases of ruptured membranes, an iodine-based vaginal wash is recommended pre-operatively to reduce the risk of endometritis

Question 17

Position of pregnant lady for anaesthesia

Answer 17

All types of anaesthetic require a left lateral tilt of up to 15 degrees for uterine displacement to prevent maternal hypotension (e.g. via insertion of a wedge cushion).

Question 18

Describe the lower uterine segment incision

Answer 18

-There are two types of skin incisions for this type of caesarean section: the Pfannenstiel incision (Figure 2) and a Joel-Cohen incision.

-NICE recommends a Joel-Cohen incision, defined as a straight horizontal incision above the symphysis pubis. Subsequent layers are opened bluntly. This allows for a shorter operating time and reduces the incidence of postoperative febrile illness.

Question 19

Abdominal wall layers in C section

Answer 19

-Skin
-Subcutaneous tissue (including Scarpa’s fascia)
-Rectus sheath
-Rectus muscle
-Parietal peritoneum
-Uterus including visceral peritoneum

Question 20

Indications for classical C section

Answer 20

-Structural abnormality of the uterus
-Difficult access to the lower uterine segment due to adhesions or fibroids
-Where hysterectomy will follow caesarean delivery (e.g. in cases of morbidly adherent placenta)
-Post-mortem caesarean section where the fetus is viable
-Cervical cancer
-Anterior placenta previa with abnormally vascular lower uterine segment
-Transverse lie with ruptured membranes
-Very preterm fetus where the lower uterine segment is poorly formed

Question 21

Cons of classical C section

Answer 21

-Classical caesarean sections are associated with greater rates of adhesions and infections compared to lower uterine segment incisions.

-The closure of a classical caesarean section is more complicated and takes longer to complete.

Question 22

Complications of C section vs vaginal delivery

Answer 22

-When compared to vaginal delivery, caesarean section has lower rates of perineal trauma and pain.
-However, primary caesarean section has a higher incidence of abdominal pain, venous thromboembolism, bladder or ureteric injury and hysterectomy.

Question 23

Intraoperative complications of C section

Answer 23

-Intraoperative complications occur in 12-15% of caesarean sections and are more common in women undergoing an emergency caesarean section. These may include:

=Anaesthetic side effects (e.g. hypotension, nausea)
=Haemorrhage sometimes requiring blood transfusion and, rarely, hysterectomy (7-8/1000)
=Uterine or uterocervical lacerations
=Bladder or bowel lacerations +/- repair
=Ureteral injury

-The risk of haemorrhage is increased in women with a high BMI, placenta praevia or placental abruption or in cases of very high or low birthweight.

Question 24

Postoperative complications of C section

Answer 24

-Postoperative complications can occur in up to one-third of women. These include:

=Pain: opioid analgesia is used first-line +/- laxatives. This is stepped down to paracetamol and non-steroidal anti-inflammatory drugs (NSAID) use once pain is adequately controlled.
=Infection: endometritis, wound infection and urinary tract infections. Occurs in approximately 8% of women undergoing caesarean section. Where the woman’s body mass index is greater than 35, negative pressure dressings may be considered to decrease the risk of wound infection.
=Venous thromboembolism
=Pulmonary atelectasis
=Return to theatre for another procedure
=Longer hospital stay compared to vaginal delivery

Question 25

Complications for future pregnancies in C section

Answer 25

-Abnormal placentation (e.g. accreta spectrum/praevia)
-Uterine rupture
-Repeat caesarean section
-There is also a higher risk of antepartum stillbirth in subsequent pregnancies and this risk increases with each successive caesarean section performed

Question 26

Fetal neonatal complications of C section

Answer 26

-Fetal laceration risk of 2%
-Transient tachypnoea of the new born
-Admission to a neonatal unit

Question 27

When can you have vaginal birth after C section?

Answer 27

Vaginal birth after caesarean section is an appropriate option and may be offered to women who have a singleton pregnancy with a cephalic presentation at 37 weeks who had a single lower uterine segment caesarean section in the past, with or without previous vaginal deliveries

Question 28

Contraindication for vaginal birth after caesarean section

Answer 28

VBAC is contraindicated in women who have had a previous uterine rupture or classical caesarean section, or for women where vaginal delivery is contraindicated irrespective of the presence of a scar (e.g. in major placenta praevia).

A planned VBAC is associated with a 0.05% risk of uterine rupture.