Operative Obstetrics and Tears Flashcards
Need for ASSISTED Vaginal Birth can be reduced by:
Dedicated and continuous support during labour
Oxytocin augmentation of inadequate labour
Delayed pushing in women with an epidural
Increased time pushing in nulliparous women with an epidural
Optimization of fetal head position through manual rotation where applicable.
Requirements for Assisted Vaginal Delivery (ex/ forceps, vaccum) RISECAD
Reasonable chance of success
Informed consent
Suitable contingency plan
Expertise in the chosen method
Comprehensive assessment of the clinical situation
Adequate analegisa
Documentation and debriefing afterwards with the care team, patient and family.
Indications for Assisted Vaginal Delivery:
HEDM
Abnormal fetal heart rate tracing
Delayed progress in the second stage of labour due to malposition or inadequate fetal descent
Maternal conditions precluding repetitive valsalva
Maternal exhaustion (subjective)
contraindications to assisted vaginal delivery
(nVIcSHDBCP)
Non-vertex presentation (exceptions forceps in face presentation or the after-coming head in vaginal breech delivery
Unengaged head (station above 0) → fetal head at or above the ischial spines.
Incomplete cervical dilation
Uncertainty of the fetal head position
Suspected cephalopelvic disproportion
Fetal conditions including coagulopathy, thrombocytopenia, or brittle skeletal dysplasia
Vacuum <34 weeks (relatively contraindicated)–> P= premature
Lack of patient consent.
subgaleal vs cephalohematoma
Cephalohematoma: Bleed in scalp that is confined to one side of the suture
Subgaleal hemorrhage: bleed that crosses the suture lines
outline tear degrees
First degree; injury to skin and vaginal epithelium. Perineal muscles are intact
Second degree; tear in vagina up into the hymen, but the perineal body musculature are also involved, including the transverse perineal muscles and bulbocavernosus muscles
Most common injury
Third degree; extends through fascia and musculature of the perineal body, and involves some of the internal anal sphincter
Fourth degree; most significant. Includes all the injuries in addition to an injury of the rectal mucosa.
most common type of tear
second degree
risks of C section
Infection
Endometritis
Wound infection
Hemorrhage
Surgical injury
Venous thromboembolism
Maternal mortality
Anesthetic complications
Fetal trauma
Transient tachypnea of the newborn.
“Wet lungs” that require admission to
TOLAC pros and cons
TOLAC Pros: potentially better recovery, avoids risks of C Section, decreased morbidly adherent placenta, patient may desire experience of labour
TOLAC Cons: risk of uterine rupture, planning/scheduling, risks of labour and delivery (lacerations, pelvic floor injury, uterine rupture), risk of emergency C Section (25%)
contraindications to TOLAC
Previous or suspected classical cesarean section
Previous inverted T or low vertical uterine incision
Previous uterine rupture
Previous major uterine reconstruction (full-thickness repair for myomectomy, mullerian anomaly repair)
Lack of consent to TOLAC
factors that increase risk for uterine rupture
Induction with cervical ripening agents
Use of oxytocin
2 or more prior C Sections
Short interpregnancy intervals (<18 months)
Thin lower uterine segment
Classical or low vertical incision
contraindications to TOLAC
Previous or suspected classical cesarean section
Previous inverted T or low vertical uterine incision
Previous uterine rupture
Previous major uterine reconstruction (full-thickness repair for myomectomy, mullerian anomaly repair)
Lack of consent to TOLAC
