Operative delivery

Question 1

Types of instrumental delivery

Answer 1

Ventouse suction cup or forceps

Question 2

What give after forceps delivery

Answer 2

Co-amoxiclav

Question 3

Indications for instrumental delivery

Answer 3

Failure to progress
Foetal distress
Maternal exhaustion
Control of head in various foetal positions

Question 4

What procedure increases the risk of need for instrumental delivery?

Answer 4

Epidural

Question 5

Risks of instrumental delivery to mother

Answer 5

PPH
Episiotomy
Perineal tears
Injury to anal sphinctre
Incontinence of bladder or bowel
Obturator or femoral nerve injury

Question 6

Key risks to baby with instrumental delivery

Answer 6

Cephalohaemoatoma = collection blood between scalp and skull - with a ventouse
Facial nerve palsy - forceps

Question 7

Rare serious risks to baby with instrumental delivery

Answer 7

Subgaleal haemorrahge - most dangerous
Intracranial haemorrhage
Skull fracture
Spinal cord injury

Question 8

What is a subgaleal haemorrhage?

Answer 8

Accumulation of blood in layers soft tissue head between
Galea aponeuritica and
Periosteum

Question 9

What is galea aponeuritica?

Answer 9

Tough fibrous connective tissue

Question 10

What is periosteum

Answer 10

Membrane tissue that covers the surface of a newborns skull

Question 11

What causes subgaleal haemoatoma?

Answer 11

When emissary veins passing thrpugh foramen seperate from the tissue and rupture during difficult vaginal delivery

Question 12

Why is subgaleal haemotoma so life threatening?

Answer 12

Baby can lost 20% to 40% blood volume as haemorrhage forms in their skull

Question 13

Management of subgaleal haemotoma

Answer 13

Blood and plasma transufion on NICU
Surgery to stop bleed if still clinically unwell
Normally resolves after 2-3 weeks

Question 14

What is a ventouse?

Answer 14

On babies head, doctor or midwife applies careful traction to cord

Question 15

What causes femoral nerve injury in forceps delivery?

Answer 15

Compressed against inguinal canal

Question 16

What does femoral nerve injury cause?

Answer 16

Weakness of knee extension
Loss of patella reflec and numbness of anterior thigh and medial lower leg

Question 17

What causes obturator nerve injury in forceps delivery?

Answer 17

Compressed by forceps or by foetal head in normal delviery

Question 18

What does obturator nerve injury cause?

Answer 18

Weak hip adduction and rotation and numbness of medial thigh

Question 18

What does obturator nerve injury cause?

Answer 18

Weak hip adduction and rotation and numbness of medial thigh

Question 19

Nerve injuries that can occur in birth

Answer 19

Normal or instrumental
Obturator
Femoral
Lateral cutaneous nerve of the thigh
Lumbosacral plexus
Common peroneal nerve

Question 20

What does damage to lateral cutaneous nerve of thigh in birth cause?

Answer 20

Prolonged flexion at hip while lithotomy position can result in injury -> numbness of anterolateral thigh

Question 21

How is the lumbosacral plexus injured in birth and what does it cause?

Answer 21

May be compressed by foetal head during second stage of labour
Injury causes foot drop and numbness of anterolateral thigh, lower leg and foot drop

Question 22

What causes common peroneal injury in birth and what does this cause?

Answer 22

Compressed on head of fibula
Injury -> foot drop and numbness in lateral lower leg

Question 23

Indications for elective C section

Answer 23

Prev caesarean
Symptomatic after prev significant perineal tear
Placenta previa
Vasa previa
Breech
Multiple pregnancy
Uncontrolled HIV infection
Cervical cancer

Question 24

Categories of emergnecy C section

Answer 24

Category 1 - 4 1 - immediate threat to life of mother or baby - 30 mins Category 2 - required urgently due to compromise - 75 mins 3 - delivery required, mother and baby stable 4 - elective C section

Question 25

Different types of incision

Answer 25

Pfannenstiel incision - curved, two fingers above pubic symphysis Joel-cohens incision - straight incision slightly higher - recommended Vertical incision - prem, anterior placenta previa Blunt incision

Question 26

Why is blunt dissection used

Answer 26

After initial incision with scalpel Seperate remaining layers of abdominal wall and uterus Less bleeding, shorter operating times and less risk of injury to baby

Question 27

Layers of abdomen need to be dissected during C section

Answer 27

Skin SC tissue Fascia/rectus sheath Rectus abdominis muslces Peritoneum Vesicouterine peritoneum Uterus Amniotic sac

Question 28

What is teh fascia/rectus sheath is

Answer 28

Aponeurosis of transversus abdominis and external and interal oblique muscles

Question 29

Layers of the uterus

Answer 29

Perimetrium, myometrium and endometrium

Question 30

What is the vesicouterine peritoneum

Answer 30

Bladder seperated from uterus bladder flap

Question 31

How is baby helped to be delivered

Answer 31

Assistance of pressure on the fundus

Question 32

What is exteriosrisation?

Answer 32

Uterus out of abdomen

Question 33

Risks ass with general anaesthetic

Answer 33

Allergic reactions or anaphylaxis Hypotension Headache URINARY retention -spinal anaesthetic Nerve damage Haematoma -General anaesthetic Sore throat Damage to teeth or mouth

Question 34

Meds to reduce risk during a C section

Answer 34

H2 recpetor antagonists eg ranitidine or proton pump inhibirors eg omeprazole before Prophylactiv antibiotics during Oxytocin during - reduce PPH risk VTE - prophylacis with LMW heparin

Question 35

What does H2 receptor antagonists or PPIs reduce the risk of in C section

Answer 35

Risk of aspiration penumonitis - acid reflux and aspiration during prolonged period lying

Question 36

Generic surgical risks C section

Answer 36

Bleeding Infection Pain VTE

Question 37

Complications in PP period

Answer 37

PPH Wound infection Wound dehiscence Endometriosis

Question 38

What local structures can be damaged in a C section

Answer 38

Ureter Bladder Bowel Blood vessels

Question 39

What effects can have on abdominal organs C section

Answer 39

Ileus Adhesions Hernias

Question 40

What eIncreased riskss on future pregnancies have with C section

Answer 40

Repeat caesarean Uterine rupture Placenta previa Stillbirth

Question 41

Effects on baby of C section

Answer 41

Lacerations Transient tachypnoea of newborn

Question 42

Contraindications for vaginal birth after C section

Answer 42

Prev uterine rupture Classical caesarean scar - vertical incision Other usual contraindications to vaginal delivery

Question 43

Prophylaxis for VTE after C section

Answer 43

VTE risk assessment Early mobilisation Anti-embolism stocking or intermittent pneumatic compression of legs LMW heparin