Operative Delivery Flashcards
26 year old G1 at 40 4/7 weeks gestation admitted to labor and delivery with rupture of membranes.
Cervix is 4cm/100%/-2 station on admission
Estimated fetal weight 4400 gms
PNC has been complicated by gestational diabetes with marginal control and an LGSIL pap smear. Otherwise PMH and PSH negative.
She progressed to completely dilated after 14 hours and has been pushing for 3 hours.
- how should the baby be delivered?
c section
2 year old G2P1 at 38 1/7 weeks gestation presents to labor and delivery with complaints of contractions.
She changes her cervix from 3 cm to 4 cm dilation after one hour of monitoring and she was admitted in active labor.
Estimated fetal weight 3300 gms.
Her prenatal care was uncomplicated and her past medical history is significant for asthma and past surgeries include a laparoscopic cholecystectomy after her last baby.
Her last baby was born vaginally at 37 weeks and weighed 2832 gms.
She changed to 6 cm and has not changed her cervix for the last 6 hours despite adequate contractions.
what does operative mean?
Not spontaneous
Two categories:
Vaginal: forceps assisted, vacuum extracted
Cesarean delivery
Method of choice is clinician dependent based on preference and experience
operative vaginal delivery- when is this performed? (two things)
vacuum extractor and forceps
safe if practitioner is comfortable using them
Should also only be performed when there is immediate ability to do a cesarean section if procedure fails
MATERAL indications for operative vaginal delivery vs
FETAL indications
other indications (nullparity/multiparity indications)
-
Maternal indications
- maternal exhaustion
- inability to expel baby due to neurological/spinal causes
- unsafe for mom to expel baby due to cardiovascular threats
- aortic stenosis
- CVD (aneursm, brain tumors)
-
Non-reassuring fetal status
- bradycardia
- repetitive heart rate decelerations
-
Other indications:
- Prolonged second stage of labor
- nulliparous:
- >2 hours without regional anesthesia or
- >3 hours with regional anesthesia
- multiparous:
- >1 hour without regional anesthesia or
- > 2 hours with regional anesthesia
op-vag delivery pre-req criteria (maternal vs fetal)
maternal: adequate analgesia, lithotomy position, bladdy empty, written/verbal consent
fetla: vertex presentation, engaged-fetal head (biparietal diameter @ 0 station)
op vag delivery: uteroplacental criteria + other criteria
uteroplacental: cervix fully dilated, membranes ruptured, no placenta previa
other criteria: experienced operator, capability to perform an emergency c-section
CLINICAL PEARLS FOR APPLICATION OF FORCEPS (5)
- If you aren’t positive of position: DON’T APPLY
- If they don’t articulate easily then reapply. If they still don’t articulate well DON’T APPLY.
- Always check to assure that no vaginal tissues or the the cervix are caught in the forceps
- Always check placement before applying traction
- blades should fit the fetal head evenly
- should lie against the fetal head so that they cover the space between the orbits and ears
- Traction is applied in the plane of least resistance and follows the pelvic curve-if it doesn’t come easy-STOP
complications of forceps delivery: maternal and fetal
Maternal: laceration of the vagina/cervix , episiotomy extension, pelvic hematomas, urethral and bladder injuries, uterine rupture
Fetal: minor facial lacerations, forceps marks, facial and brachial plexus injuries, cephalohematomas, skull fractures, intracranial hemorrhage, seizures
VACUUM ASSISTED VAGINAL DELIVERY INDICATIONS and CONTRAINDICATIONS
VACUUM ASSISTED VAGINAL DELIVERY INDICATIONS
- Indications and requirements exactly the same as for forceps
- Advantage: delivery can be achieved with little maternal analgesia
CONTRAINDICATIONS TO VACUUM ASSISTED VAGINAL DELIVERY
- Gestational age less than 34 weeks
- Suspected fetal coagulation disorder
- Suspected fetal macrosomia
- Breech presentation
CLINICAL PEARLS FOR USE OF VACUUM EXTRACTOR
CLINICAL PEARLS FOR USE OF VACUUM EXTRACTOR: SAME RECOMMENDATIONS FOR PLACEMENT AS WITH FORCEPS
- 3 checks should be undertaken:
- no maternal tissue trapped in the cup
- cup should be placed in the midline of the saggital suture
- the vacuum port of the suction cup should point toward the occiput
- Release suction between contractions
- No more than 2 “pop offs”
- Should not be applied more than 20 minutes
- No torsion or twisting of device during use
Vaccum EXTRACTOR COMPLICATIONS
Comparison of vacuum complications to forceps:
- More failed deliveries with vacuums (failure rate of about 12% versus 7% for forceps)
- Fewer perineal injuries
- Increased incidence of fetal cephalohematoma
- More scalp lacerations and bruising
CESAREAN DELIVERY: what it is, and why the rate of C sections are rising
CESAREAN DELIVERY
Used to describe the delivery of a fetus through a surgical incision of the anterior uterine wall
Most common based operative procedure in the United States
C-section rate is climbing. Why?: repeat c-section, continuous electronic fetal monitoring, macrosomia, decreased use of operative vaginal delivery methods, assisted reproductive technology, fear of litigation
INDICATIONS FOR C-SECTION, fetal and maternal
INDICATIONS FOR C-SECTION
- Fetal:
- non-reassuring fetal heart rate
- breech presentation/transverse presentation
- Very low birth weight (less than 1500gms)
- active herpes simplex virus infection
- immune thrombocytopenia purpura
- congenital anomalies (i.e. gastroschisis, spina bifida)
- Maternal-fetal:
- cephalopelvic disproportion
- failure to progress
- placental abruption
- placenta previa (other placental position abnormalities like vasa previ
- obstructive benign and malignant tumors
- large vulvar condyloma
- abdominal cervical cerclage
- prior vaginal colporrhaphy
- conjoined twins
- maternal request ??
