Procedure: normal, complex and operative deliveries

Question 1

What are the advantages of vaginal delivery?

Answer 1

• shorter hospital stays
• less likely readmission
• less pain after birth
• recover more quickly from labour and birth
• better chance of starting to breastfeed their babies straight away
• are less likely to have medical problems in future pregnancies
• more physically able to care for baby and children soon after birth
• more likely to cuddle their babies and have skin-to-skin contact straight after birth

Question 2

What are the disadvantages of vaginal delivery?

Answer 2

• may need for stitches if perineal tears occur or episiotomy is done
• may need forceps or vacuum assistance
• increased chance of incontinence or prolapse.

Question 3

Which abdominal incision is used for C-section?

Answer 3

Either a Pfannenstiel or Joel-Cohen – both transverse lower abdominal skin incisions.

Question 4

What are the layers dissected during C-section?(7)

Answer 4

1. The skin,
2. Camper’s fascia (superficial fatty layer of subcutaneous tissue)
3. Scarpa’s fascia, (deep membranous layer of subcutaneous tissue)
4. Rectus sheath, (anterior and posterior leaves laterally, that merge medially)
5. Rectus muscle,
6. Abdominal peritoneum (parietal)
7. The gravid uterus.

Question 5

What is the only muscle in the body that ‘wants to’ stay contracted with stimulation?

Answer 5

Uterus

Question 6

Why is there often a lot of bleeding during C section?

Answer 6

Uterus receives a quarter of the blood supply in a pregnant woman

Question 7

Why have rates of C-section increased significantly in recent years?

Answer 7

The rate of caesarean section has increased significantly in recent years, largely secondary to an increased fear of litigation

Question 8

What are the two main types of caesarean section?

Answer 8

• lower segment caesarean section: now comprises 99% of cases
• classic caesarean section: longitudinal incision in the upper segment of the uterus

Question 9

What are the indications for caesarean section?

Answer 9

Antenatal:

• Maternal:
  
  • absolute cephalopelvic disproportion
  • pre-eclampsia
  • vaginal infection e.g. active herpes
  • cervical cancer (disseminates cancer cells)
• Fetal:
  
  • post-maturity
  • IUGR
• Placental:
  
  • placenta praevia grades 3/4

Intrapartum:

• Maternal:
  
  • failure of labour to progress
• Fetal:
  
  • umbilical cord prolapse
  • fetal distress in labour
  • malpresentations: brow
• Placental:
  
  • placental abruption: only if fetal distress; if dead deliver vaginally

Question 10

How are C-sections categorised?

Answer 10

Based on urgency from category 1-4 (1 being the most urgent and 4 being elective)

Question 11

What are the categories of C-section?

Answer 11

Category 1 = an immediate threat to the life of the mother or baby –> delivery within 30 mins of making the decision

Category 2 = maternal or fetal compromise which is not immediately life-threatening –> delivery within 75 minutes of making the decision

Category 3 = delivery is required, but mother and baby are stable

Category 4 = elective caesarean

Question 12

Give 4 examples of situations which may require category 1 caesarean section.

Answer 12

• suspected uterine rupture
• major placental abruption
• cord prolapse
• fetal hypoxia
• persistent fetal bradycardia

Question 13

How does RCOG advise clinicians to make patients aware of risks/complications of C section?

Answer 13

By mentioning the ‘serious’ and the ‘frequent’

Question 14

Give 5 examples of ‘frequent’ complications of C-section to the mother/baby.

Answer 14

Immediate:

• Fetal: lacerations, one to two babies in every 100
• haemorrhage

Short-term:

• readmission to hospital
• haemorrhage
• infection (wound, endometritis, UTI)

Long-term:

• discomfort in the first few months after surgery
• reduced success with subsequent VBACs

Question 15

Give 5 examples of serious complications of C-section.

Answer 15

Immediate:

• emergency hysterectomy
• bladder injury
• ureteric injury
• death (1 in 12,000)

Short-term:

• admission to intensive care unit
• thromboembolic disease
• need for further surgery at a later date, including curettage (retained placental tissue)
• prolonged ileus

Long-term:

• future pregnancies:
  
  • incrased risk of uterine rupture
  • increased risk of antepartum stillbirth
  • increased risk of placenta praevia and placenta accreta
• ​subfertility: due to postoperative adhesions

= Others not mentioned by RCOG.

Question 16

When can VBAC be done and what are the absolute contraindications?

Answer 16

• appropriate at >= 37 weeks gestation with a single previous Caesarean delivery
• contraindications include previous uterine rupture or classical caesarean scar

Question 17

What % of VBACs are successful?

Answer 17

around 70-75% of women with one previous C/S have a successful vaginal delivery

Question 18

Which malpresentations must be delivered by C-section?

Answer 18

Face presentation:

• If chin anterior (mento-anterior position) = vaginal delivery is possible with delivery by flexion
• If chin posterior (mento-posterior position) = delivery by C-section

Brow presentation = delivery by C-section

Question 19

How common is instrumental delivery in multips vs nullips?

Answer 19

Nullips = 20%

Multips = 2%

Question 20

What are the requirements for instrumental delivery to be considered?

Answer 20

• Position of head known
  
  • Head not palpable abdominally
  • Head at/below ischial spines on vaginal examination
• Cervix fully dilated
• Adequate analgesia
• Valid indication for delivery
• Bladder empty

Question 21

What are the indications for instrumental vaginal delivery?

Answer 21

Maternal:

• failure to progress in the second stage of labour (if 1-2hrs of pushing has failed or mother exhausted)
• prophylactically in some medical conditions e.g. severe cardiac or hypertension to prevent pushing

Fetal:

• fetal distress in the second stage of labour
• breech delivery

Question 22

What is meant by ventouse delivery?

Answer 22

Ventouse = vacuum cap connected to handle, fixed to fetal occiput by suction and allows traction during maternal pushing to delivery the OA head (normal position)

Question 23

What are obstetric forceps? What are the types?

Answer 23

Obstetric forceps = pair that fit together for use consisting of ‘blade’, shank, lock and handle. Lock prevents them from slipping apart when they fit on the fetal head.

Types:

• Non-rotational - Simpson’s, Neville-Barnes - only suitable for OA
• Rotational forceps - Keilland’s - no pelvic curve so allow malpoistioned head to be rotated by operator to the OA position before traction is applied

Question 24

What are the complications of instrumental delivery?

Answer 24

Failure - more common with venouse if cup is placed inaccurately

Maternal:

• Pain - greater need for analgesia
• Tears
• Vaginal lacerations

Fetal:

• Ventouse:
  
  • Chignon- swelling of the area of the scalp where the cup was attached by suction, disappears after a few days
  • Scalp lacerations
  • Cephalheamatomata
  • Neonatal jaundice - more common with ventouse
• Forceps:
  
  • Facial bruising
  • Facial nerve damage
  • Skull fractures

Changing instrument is associated with greater fetal trauma.

Question 25

If ECV is unsuccessful in breech, what are the options for delivery?

Answer 25

Vaginal breech vs elective C-section

Question 26

What are the risks and benefits of vaginal breech delivery vs elective caesarean section for breech?

Answer 26

C-section:

• Small reduction in foetal mortality and neonatal morbidity (0.5:1000 with CS compared to 2:1000 with vaginal breech birth)
• BUT
• Small increase in risk of immediate complications for the mother
• Implications on future pregnancy (VBAC, placenta praevia, uterine rupture)

Vaginal breech delivery:

• 40% risk of needing an emergency C-section
• BUT
• Factors associated with successful delivery = normal-size foetus, multiparity, positive mental attitude of woman
• Absolute contraindications = footling breech

Question 27

What factors are associated with a successful vaginal breech delivery?

Answer 27

• Normal sized foetus
• Multiparity
• Positive mental attitude of patient

Question 28

What is an absolute contraindication to breech vaginal delivery?

Answer 28

footling breech

Question 29

Describe the management of vaginal breech delivery.

Answer 29

IOL not recommended; advise to deliver in labour ward, with continuous CTG monitoring; maternal position: all fours

Technique of delivery

(1) Delivery of buttocks

• ‘Hands off’ approach
• If handling is needed, put thumbs on the sacrum and fingers on the ASIS of the baby

(2) Delivery of legs and lower body

• If the legs are flexed → they will deliver spontaneously
• If the legs are extended → Pinard’s manoeuvre – poke the baby in the popliteal fossa which will make them bend their knees

(3) Delivery of shoulders

• If the baby gets stuck once the body has delivered, you will see winging of the scapulae
• Loveset’s manoeuvre – rotate the baby into the transverse position and pull the anterior arm down
• If the second arm hasn’t delivered, rotate the baby into the opposite anterior position and pull the other arm down

(4) Delivery of head

• Mauriceau-Smellie-Veit manoeuvre – rest the baby on your forearm and pull the head downwards
• If this doesn’t work, use forceps

Other considerations: G&S, X-match, FBC, CTG, make sure theatre is ready.

Question 30

Define these maneouvres, used in breech vaginal delivery:

1. Pinard’s maneouvre
2. Loveset’s maneouvre

Answer 30

1. Pinard’s maneouvre - used in Frank breech where legs are extended; poking popliteal fossa of baby to make them bend their knees
2. Loveset’s maneouvre - rotate the baby into the transverse position and pull the anterior arm down