proceedures Flashcards
what is a C section?
The delivery of fetus through abdominal wall by incision to abdomen and uterus. can be elective or emergency
How can C sections be categorised?
4 categories (first 3 are classed as emergency sections)
1: urgent delivery is required due to fetal/maternal compromise that is an immediate treat to life. delivery within 30 mins
2: Emergency delivery where there is fetal/ maternal compromise that is NOT an immediate treat to life. delivery within 60-75 mins
3: no fetal/ maternal risk but needs early delivery
4: planned C section for >39 weeks
If C sections is planned for before 39 weeks, what should be done?
corticosteroids for fetal lung development
what are the indications for elective C section?
baby:
- IUGR and fetal distress such that don’t think fetus will cope with labour
- abnormal lie - transverse, oblique, breech, unstable
- twins where first twin is non cephalic
- maternal diabetes with macrosomia >4.5kg
- previous shoulder dystocia
mother:
- previous 3rd/4th degree tear
- HIV infection
- primary HSV infection (infection in 3rd trimester so not time for Ab to go to fetus)
- choice due to previous traumatic delivery
- maternal condition such that she may not deal with stress of labour e.g. cardiomyopathy
placenta:
- placenta praevia
what is done pre-operatively before C section?
FBC, GnS
H2 receptor antagonist (ranitidine) +/- metoclopramide (prevents aspiration)
VTE prophylaxis - anti-embolic stocking +/- LMWH
anaesthesia: spinal or epidural (can be general if real emergency or the other 2 fail)
left lateral tilt of 15 degrees and woman lies down
catheterise to drain bladder and avoid injury
aseptic solution to clean skin
Abx given just before incision
what is Mendelson’s syndrome and how is it prevented in pregnant women undergoing C section
Gastric contents can reflux and aspirate into lungs and cause pneumonitis.
this is due to flat lie in C section, relaxed LOS and pressure from gravid uterus in C section
prevented with ranitidine and anti-emetic
how is the woman positioned for a C section?
left lateral lie with a 15 degree tilt to prevent supine hypotension
describe the technique for conducting a C section
Skin incision
dissection of layers
incision through uterus
baby delivered with assistance of fundal pressure
oxytocin given IV to aid delivery of placenta by controlled cord traction by surgeon
close up layers
what incision is made in C section
pfannenstiel or Joel-Cohen - both transverse/ lower abdo incisions
what layers are dissected through in a C section?
skin, camper’s Fascia, Scarpa’s fascia, rectus sheath , rectus muscle, abdo perineum.
this then reveals the visceral perineum covering the uterus.
incision through uterus
what should be done post op after a C section?
record obs regularly
monitor lochia (vaginal discharge containing blood and mucus) - monitor for excess blood
early mobilisation, remove catheter
what are women who have a C section at increased risk of in future vaginal delivery?
placenta praevia +/- accreta
uterine rupture
(need to monitor fetal HR throughout in previous pregnancy as bradycardia can be a sign of rupture)
what are the advantages of a C section?
no perineal trauma
reduced risk of rectal, urinary or uterovaginal prolapse and thus incontinence
less risk of pain
less risk or late still birth or early neonatal infections
what are the immediate complications of a C section?
haemorrhage:
- PPH
- intrauterine
- wound haematoma (more likely in obese, DM)
bladder bowel trauma
neonatal:
- transient neonatal tachypnoea
- fetal lacerations
what are the intermediate complications of a C section?
VTE
infection - urinary, endometritis, respiratory
what are the late complications of a C section?
fistula - urinary tract trauma
subfertility - takes longer to recover and conceive in between
increased risk of placenta praevia, caesarean scar ectopic pregnancy, rupture of scar in next pregnancy
how is a ventouse carried out?
A cup is attached to the fetal head via a vacuum
this can be attached via:
- an electrical pump (can only be used in occipital anterior position)
- or hand held disposable device (can be used in any fetal position)
during uterine contractions, traction is applied perpendicular to the cup
what is more susccessful ventouse or forceps?
forceps
how does forceps compare to ventouse in terms of risk to mother and fetus
lower risk of fetal complications (cephalohaematoma, subgaleal haematoma or retinal haemorrhage) but higher risk of maternal complications (pain and perineal injuries) compared to ventouse
use of forceps is associated with
- higher rates of 3rd/4th tears
- less often used to rotate
- doesn’t require maternal effort
describe how forceps are used to delivery a baby?
double bladed instrument introduced to pelvis and put around the fetal head, locked and then gentle traction is applied
when should the attempt to deliver with forceps or ventouse be stopped?
after 3 contractions with no progress
what are the indications of using forceps/ ventouse?
inadequate progress
maternal exhaustion
maternal medical condition meaning active pushing or prolonged exertion should be avoided
fetal:
- suspected fetal compromise in second stage
what are the absolute contraindications for ventouse/forceps (operative vaginal deliveries)
unengaged fetal head in singleton pregnancy
incomplete dilation of cervix
True cephalo-pelvic disproportion (pelvis is too small for fetal head)
breech or face presentation
ventouse only:
pre-term gestation (<34 weeks)
fetal coagulation disorder
what are the relative contraindications for ventouse/forceps (operative vaginal deliveries)
fetal distress with head above pelvic floor
delivery of second twin when head is not quite engaged or cervix has reformed
prolapse of umbilical cord with fetal compromise when cervix is fully dilated and station is mid cavity
what is physiological/ anatomy required before instrumental delivery
membranes ruptured cervix dilated cephalic presentation defined fetal position empty bladder fetal head at least the level of ischial spine and no more than 1/5 palpable per abdomen adequate pain relief adequate maternal pelvis
how are operative vaginal delivers classified?
by how low the fetal head has descended
Outlet = lowest one where the:
- fetal scalp is visible with labia parted
- OR fetal skull has reached the pelvic floor
- OR fetal head on perineum
Low:
- lowest part is +2 further down past ischial spines
- subdivided into :
> 45 degrees rotation needed
< 45 degrees rotation needed
midline:
- 1/5 palpable abdominally
- lowest part is higher than +2 but lower than ischial spines
- subdivided into :
> 45 degrees rotation needed
< 45 degrees rotation needed
what are the fetal complications of instrumental deliveries?
scalp laceration
Facial bruising
cephalohaematoma
subgaleal haematoma
retinal haemorrhage
facial nerve damage
skull fractures
neonatal jaundice
what are the maternal complications of instrumental deliveries?
vaginal tears 3rd/4th degree tears (more likely with forceps) VTE incontinence PPH shoulder dystocia infection
what are the indications to inducing labour?
prolonged gestation:
- offered at 40 weeks + to prevent still birth and fetal compromise
premature rupture of membrane
- offered in PROM or allow mum to wait for 24 hours to see if naturally goes into labour, otherwise IOL is advised due to risk of infection
- in P-PROM for those <34 weeks not offered (unless fetal distress), for those >34 weeks weight up risks and benefits
maternal diabetes, HTN, cholestasis
fetal growth restriction
intrauterine fetal death
what are the absolute contraindications to induction of labour?
transverse lie cephalopelvic disproportion shoulder dystocia cord prolapse placenta praevia vasa praevia previous classical C section (longitudinal incision) active primary genital herpes
what are the relative contraindications to induction of labour?
breech presentation
triplets
2 or more previous low transverse C sections
name 3 methods used to induce labour? (what is first line by NICE)
vaginal prostaglandins = first line
amniotomy
membrane sweep
how do vaginal prostaglandins work?
prepare cervix for labour by ripening it, help to stimulate uterine contractions
can be given orally, gel or controlled release pessary.
e.g. a pessary involves 1 dose over 24 hours
e.g. tablet or gel give 1 dose plus second dose if labour hasn’t started after 6 hours
how is an amniotomy performed? how does this work to induce labour?
amniotic membranes are ruptured artificially using an amnihook
waters break and the process of membranes rupturing releases prostaglandins which induces labour
offer infusion of syntocinon (oxytoxin) alongside - low dose and titrate up to aim for 4 contractions/ 10 mins
when should amniotomy be performed?
when cervix is ripe (assessed by bishop score)
when prostaglandins are contraindicated (high risk of uterine hyperstimulation
what is a membrane sweep? when is it offered?
digit inserted into vagina and swept across in attempt to separate chorionic membrane from decidua
the separation helps release of prostaglandins to induce labour.
offered at week 40-41 gestation in nulliparous women and 41 in multiparous women
what is the bishop score?
Assessment of cervical ripeness based on vaginal examination. checked prior to induction and during to check progress
dilation: <1cm, 1-2cm, 2-4cm, >4cm (scored 0-3)
length: >4cm, 2-4cm, 1-2cm, <1cm (scored 0-3)
station (relative to ischial spine):
-3, -2, -1/0, +1/2 (scored 0-3)
consistency : firm, average, soft (scored 0-2)
position: posterior, mid/anterior (scored 0-1)
what does a bishop score of
>/= 7 indicate?
<4 indicate?
> /= 7 : suggests cervix is ripe. high chance of response to induction of labour
<4: suggests labour is unlikely to progress naturally and prostaglandins will be required
what should be confirmed on CTG prior to induction?
reassuring fetal HR
what monitoring is required after induction of labour?
bishop score
CTG - after induction continually until a normal rate is confirmed then assess intermittently on auscultation
if oxytocin used, monitor CTG continuously.
what are the complications of inducing labour?
uterine hyperstimulation - fetal distress if contractions are too fast, too long, too frequent.
failure of induction - further cycle of prostaglandins or C section
cord prolapse - can occur at anytime of amniotomy, especially is fetal head is high
infection risk - because vaginal examinations are required to access progress
pain - IOL is more painful than spontaneous
uterine rupture is rate
how can uterine hyperstimulation be managed?
tocolytic agents - terbutaline
what are the benefits and risks of inducing labour for big babies?
big babies are at risk of shoulder dystocia, collar bone fracture, brachial plexus injury,
induction of macrosomic babies between 37 to 40 weeks reduced the occurance of the above
however risk of inducing too early and prematurity, but usually after 37 weeks this is not an issue
define abortion
the termination of a pregnancy by evacuation of fetus from the uterus prior to 24 weeks gestation (viability)
can an abortion be carried out beyond 24 weeks?
yes in certain circumstances e.g. if threat to mothers life
what are the laws in UK behind abortion?
- <24 weeks
- carried out at NHS/ approved location
- 2 practitioners must certify by signing HSA1 form
How is an abortion <7 weeks carried out?
medical management:
- mifepristone (antiprogesterone) and misoprostol (prostaglandin) given 24 -48 hours apart
how is an abortion between 7-15 weeks carried out?
medical management can be used up till 13 weeks but surgical management is offered before and recommended after 12 weeks
surgical methods include:
- vacuum aspiration
- dilation and evacuation
when is vacuum aspiration as a method of abortion available?
up to 14 weeks
which method of abortion is available up to the last date in
dilation and evacuation (USS guided)
can be used from 14 - 24 weeks
For surgical methods of abortion how can the cervix be prepared?
prostaglandins prior to surgery - vaginal / sublingual misoprostol 3 hours before
for those >10 weeks or <18yrs old
what are the contraindications for medical termination of pregnancy?
pregnancy >64 days suspected ectopic pregnancy hepatic/renal failure severe asthma/ COPD patients with long term CVS disease long term steroid therapy known allergy to mifepristone haemorrhage disorder / on anticoagulants
what are the complications of abortion?
haemorrhage uterine perforation cervical tears failure post abortion sepsis infection of uterus (this is minimal due to aseptic and antibiotic prophylaxis) psychological trauma
how are the complications of abortion avoided?
early referral - ideally within 5 days and max 2 weeks (earlier the safer)
counselling for emotional upset - before (to make sure correct decision i.e. discuss other options e.g. adoption) and after.
investigations - Hb, blood group, Rh, STI check, cervical smear
cervical ripening for surgical method
give analgesia - usually just NSAIDs
assess VTE risk
USS if gestational stage unclear
describe the after care for an abortion?
Rhesus negative get anti D prophylaxis
Abx - metronidazole 1g rectally at the time.
- doxycycline for 7 days oral OR azithromycin 1g oral once
verbal and written info about complications and what to do
no sex/ tampons for 2 weeks
follow up in 2 weeks
discuss future contraception
does abortion affect future pregnancy?
no - does not effect change of getting pregnant or complications of future pregnancies.
what is a HSA form
A form used prior to abortion to confirm that the law is being followed
It can be used if one of the following applies:
The abortion before 24 weeks will:
- reduce risk to womans life
- reduce risk to her physical/ mental health
- reduces risk to physical / mental health of baby
- the baby is at serious risk of being physically/ mentally handicaped
(usually due to the second criteria)
what are the indications on the HSA1 form for abortion post 24 weeks?
if risk to mothers life OR risk of permanent injury to mother health OR if child were both there is a great risk of mental/physical serious disability
what are the laws behind termination of pregnancy <16 yrs?
Can make informed decision without parental consent if they have capacity. Use Fraser criteria
