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Flashcards in Methods Of Delivery Deck (44):
1

Indications for instrumental delivery

Maternal exhaustion

2

Non rotational forceps

Neville-Barnes (cephalic + pelvic curve)
Max of 3 contractions to deliver
Ideally spinal/epidural
Also pudendal nerve block or local anaesthetic at perineum

3

Risks of forceps deliveries

Failure to deliver -> Caesarean section
Vaginal tears
Fetal trauma e.g. Bruising + abrasions

4

Indications for elective caesarean

Previous classic caesarean
Breech with failed ECV
Placenta praevia: grade 3/4
Multiple pregnancies (if first twin not cephalic)
To prevent transmission of infection e.g. HIV + primary HSV
Must be planned before onset of labour
Not usually performed before 39 wks

5

Indications for emergency Caesarean section

Fetal or maternal emergency

Decision to delivery = 30 mins

6

Rotational forceps

Kielland's forceps:
cephalic curve, no pelvic curve

7

Ventouse

Suction cap attached to
Traction + maternal effort

Can also be used where rotation required

8

External cephalic version

Offer to nulliparous from 36 wks, multiparous from 37 wks
50% success
Complications: placental abruption, uterine rupture, fetomaternal haemorrhage,
CI: APH in last 7 days, abnormal CTG, major uterine abnormality, ruptured membranes, multiple pregnancy
Relative CI: SGA, proteinuric pre-eclampsia, oligohydramnios, major fetal abnormalities, scarred uterus, unstable lie

9

1st degree tear

Injury to perineal skin only

10

2nd degree tear

Injury to perineum involving muscles but not anal sphincter

11

3rd degree tear

A. 50% ext anal sphincter torn
C. Both ext + int anal sphincters torn

12

4th degree tear

Injury to perineum involving anal sphincter and anal epithelium

13

RF for 4th degree tears

High birth weight
Persistent occipitoposterior position
Nulliparity
Induction of labour
Epidural
Prolonged 2nd stage (>1hr)
Shoulder dystocia
Midline episiotomy
Forceps delivery

14

Non indications for c sections

Twin pregnancy, 1st = cephalic
Preterm birth
SGA
Hep B or Hep C without HIV
Recurrent genital herpes
Maternal request

15

Assessing fetal presentation using fetal head

Ant fontanelle = diamond
2 frontal, 2 parietal
Post fontanelle = Y shaped
Two parietal, occipital

16

Assessing station

0 = at ischial spines
-1 to -3 = above spines
1 to 2 = below spines

17

Induction of labour

Offered if > 40wks +12 days
Prostaglandins initiate contractions + encourage cervical ripening
3mg tablets, 6-8hrly, max 6 mg/day
Artificial rupture of membranes w. Amnihook
Oxytocin infusion

18

Complications of induction/augmentation of labour

Failure -> req operative delivery
Uterine hyperstimulation >7/15 mins
can cause mat + fetal distress, stop oxytocin infusion, continuous monitoring, ?tocolysis, of fetal compromise suspected deliver asap!
Nausea, vom, diarrhoea: systemic SE
Water intoxication
Uterine rupture

19

1st stage labour

Latent: cervical effacement, dilation to 3 cm
Slow hrs-days
Active phase: 3-10 cm dilation
Faster hrs

20

2nd stage

Full dilation -> delivery

Passive: full dilation until urge to push
Active: pressure of head on pelvic floor = urge to push -> delivery

21

3rd stage

Delivery of fetus -> delivery of placenta
Indicated by lengthening of cord assoc with rush of dark red blood
Contraction of uterus shears placenta from uterine wall

22

Power

Contractions: 40-60s every 2-3 mins
Irreg contractions often seen in primips
Associated with dilation and shortening of cervix

23

Passage

Bony pelvis and assoc soft tissues
Inlet: transverse diameter= 13cm, AP diameter= 11cm
Outlet: transverse= 11cm, AP=13cm

24

Normal passage

Descent
Engagement: occipitoanterior position
Extension of head
Crowning
Restitution: external rotation on delivery of head
Lateral flexion: allows delivery of shoulders + trunk

25

Prerequisites for instrumental delivery

Patient consent
Valid indication
Fully dilated cervix + ruptured membranes
No abdominally palpable head
Head at or below level of ischial spines
Empty mat bladder + adequate analgesia
Determined position of head with no excessive moulding

26

RF for shoulder dystocia

Macrosomia
Hx of dystocia
Mat obesity
Prolonged 1st stage
Secondary arrest >8cm dilated
Mid-cavity arrest
Forceps/ventouse delivery

27

Signs suspicious of shoulder dystocia

Slow/difficult delivery of head
Neck does not appear
Turtle sign: chin retracts against perineum

28

Complications of shoulder dystocia

Compression of umbilical cord betw mat pelvis and fetal trunk hypoxia= fetal morbidity + mortality
Downward traction on head -> Erb's/Klumpke's palsy
Deliberate fracture of fetal humerus or clavicle
Maternal
Birth canal injury, femoral nerve injury, incr blood loss

29

Emergency management of shoulder dystocia

H: elp
E: valuate for episiotomy
L: egs into McRoberts -flex+ abduction
P: suprapubic pressure 'mazzanti's'
E:nter pelvis to perform manoeuvres - Rubin or Woods
R: emove posterior arm
R: oll mother over and repeat manoeuvres
Attempt each for 20-30s
Last resort= symphisiotomy, deliberate clavicle fracture, zavanelli

30

Cord prolapse

Assoc with artificial rupture of membranes (especially where no close fit betw presenting p and pelvic inlet), long cord, 2nd twin
Mechanical compression of cord by presenting part
Spasm of umbilical vessels due to cooling, drying, pH change and handling
CTG: deep decelerations, prolonged bradycardia

31

Management of cord prolapse

Help
Deliver ASAP
Stop any oxytocin infusion
Head down position, lift presenting part PV/fill bladder
Fully dilated-> attempt instrumental
Not fully-> emergency Csection

32

Bishop score for cervical 'favourability'

Higher = shorter + easier
Subject to examiner variation, same person should assess progress
Dilation: 4
Consistency: firm : average : soft
Length: >4 : 2-4 :1-2 : 1

33

Uterine inversion

Rare
Fundus passes through cervix into vagina
Stretch on round ligament-> vagal stimulation-> profound shock
Shock out of proportion with blood loss, fundus not abdominally palpable - blue grey mass in vagina
RF: fundal placenta, atomic uterus, prev inversion
don't attempt to remove placenta prior to signs of placental separation, gentle traction + counter pressure on uterus

34

Consenting for c section

Serious risks: hysterectomy 0.7-0.8%, further surgery at later date 0.5%, ICU admission 0.9%, bladder injury 0.1%, ureteric injury 0.03%, fetal laceration 2%, incr risk uterine rupture in subsequent pregnancies 0.4%, antepartum stillbirth 0.4%, incr risk placenta praevia or acreta in subsequent pregnancies 0.4-0.8%
Frequent risks: persistent wound and abdominal discomfort in first few months following surgery, incr risk of further c section in future
Other procedures: blood transfusion, repair of bladder/bowel damage, surgery on major vessels, ovarian cystectomy/oophorectomy,mif unsure cited pathology is found, hysterectomy

35

Urgency of c section

Grade 1: immed threat to life of women or fetus
Grade 2: maternal/fetal compromise, not immediately life threatening
Grade 3: no maternal or fetal compromise but needs early delivery
Grade 4: timed delivery to suit woman or staff

36

Uterine rupture

Scar tenderness between contractions, cessation o contractions
Abdo pain ++ mat tachycardia, CTG abnormalities, PV bleeding
RF: prev uterine surgery, use of prostaglandins and oxytocin, prev classical c section!!! ECV, uterine malformation, obstructed labour, shoulder dystocia, forceps

37

3rd stage >30 mins

Manual removal of placenta in theatre may be required

Conservation: leave placenta in situ to be absorbed
Haemorrhage with manual removal -> suction curretage
Massive haemorrhage -> hysterectomy

38

Risks of Caesarean section

VTE: 4-16/10,000
Significant haemorrhage: 5/100
Damage to bladder: 1/1000
Req hysterectomy: 8/1000
Death 1/12000
1-2% babies suffer lacerations
Infection: 6%
2x risk of stillbirth in subsequent preg
Incr risk placenta praevia

39

Remifentanil

Infusion pump
When epidural/spinal CI

40

Pethidine/Diamorphine

?

41

Entonox

Adjunctive analgesia

42

Epidural

?

43

CI to epidural

Absolute: allergies, systemic infection, skin infection at site, bleeding disorders, plt

44

Branches of pudendal nerve

Inferior anal
Inferior haemorrhoidal
Dorsal nerve of clitoris