Intrapartum management Flashcards
(43 cards)
Contraindications to forceps delivery
Face presentation
Vertical transmission risks
Fracture risk
Relative: suspected fetal bleeding disorder
Vacuum vs forceps for preterm delivery
Higher risk of subgleal haematoma and scalp trauma with vacuum
- avoid vacuum if <32/40, caution if 32-36/40
Classification of fetal head position wrt OVD
Outlet:
-fetal scalp visible witout parting labia
- OA/ OP, ROA/P, LOA/P
- rotation doesn’t exceed 45 degrees
Low:
- vertex +2, not caput
- <45deg or >45 deg from OA/OP
Mid:
- fetal head no more than 1/5 palpable abdominally
- <45 deg or >45 deg from OA/OP
High:
- not recommended if head >/= 2/5
Placement of vacuum
3cm from post fontanelle
Halfway point = flexion point
Indications for OVD
Fetal compromise
Maternal:
- shorten second stage (eg med condition)
- fatigue/ exhaustion
Inadequate progress:
-P0: no progress 3 hours passive/ active w analgesia; 2 hours w/out analgesia
- P1: No progress w 2 hours passive/ active w analgesia; 1 hour w/out analgesia
Prerequisites for OVD
Verbal consent
Abdo/ VE:
- </= 1/5 palpable per abdo
- Vx presentation
- fully dilated and ROM
- need to know position for instrument placement
- assess caput/ moulding
- ? adequate pelvic
-? US
Preparation for OVD
Explain and consent (written consent if trial in OT)
Appropriate analgesia
Mat bladder empty
Aseptic technique
Staff - adequate facilities, lighting, staff, knowledge
Anticipate cx: failure, SD, PPH
Epis scissors: MLE to prevent OASIS, 60* angle
Failure risks with OVD
Increased failure risk with:
- BMI >30, EFW >4kg, OP, head >1/5
- vacuum > forceps
Risks assoc w OVD
OASIS
- 3rd deg w kiwi 8:100 w forceps
Incr risk of bleeding 4:100
If failure - increase risk of fetal head impaction
Vacuum - cepalohaematoma, retinal hge, maternal worries re baby
– dec risk vaginal/ perineal trauma
– no more likely assoc w CS, low Apgar or need for phototx
Aftercare following OVD
IV dose co-amox
Reassess VTE
NSAIDS and paracetamol
Document void
? retention - PVR, UC
Offer physio at 3/12 PN to reduce UI
Factors assoc w breech presentation
Prev breech birth
Premature labour
High parity
Multiple pregnancy
Polyhydramnios
Oligohydramnios
Uterine anomales
Pelvic tumour or fibroids
Placenta praevia
Hydrocephaly/ anencephaly
Fetal neuromuscular disorders
Fetal head and neck tumours
Complications breech delivery
Cord prolapse 1% (0.5% w cephalic)
Fetal head entrapment
PROM
Birth asphyxia
ICH
Intrapartum death
BPI
Rupture of liver/ kidneys/ spleen
Dislocation or fractures
Mx twin delivery after first twin delivered
Assistant to stabilise fetus in longitudinal lie
Continuous CTG
US - FH/lie
Oxytocin when lie confirmed
ARM only when fixed, best with contraction
Aim for birth within 30 min
Mx twin delivery if second twin transverse
ECV
Internal podalic version
- one or both feet grasped inside uterus –> breech extraction
- don’t ARM too early –> cord prolapse
- ** caution for head entrapment
Length of inter-twin birth interval
30 min
Prevention of OASIS
MLE considered for OVD
- 60 degrees from midline when perineum distended
Perineal protection at crowning
Warm compression during second stage
Pointers on OASIS repair
OT
Regional/ general anaesthesia
Good lighting
Vaginal pack for excessive bleeding
Avoid figure of 8s- good for haemostasis but cause ischaemia
PR before and after
Technique for repairing anal mucosa
Continous or interrupted
Technique for repairing IAS
Interrupted OR
mattress without any attempt to overlap IAS
Technique for repairing full thickness EAS
either overlapping OR
end to end
Technique for repairing partial thickness EAS
end to end
Suture choice for OASIS
Anorectal mucosa:
- 3-0 polyglactin (less irritation and discomfort than PDS)
IAS/ EAS:
- monofilament (3-0 PDS) OR
- modern braided (2-0 polyglactin)
- mattress without any attempt to overlap
Burying of knots beneath superficial perineal muscles recommended to minimise knot and suture migration to skin
Post-op mx OASIS
Broad spec Ab - reduce infection and dihiscence
Laxatives
Physio
R/V 6-12/52
Incontinence or pain at review –> refer gynae/ colorectal
Prognosis of OASIS
60-80% asymptomatic 12/12 after repair
