operative delivery alex williams beth bradley october 2013
DESCRIPTION
operativeTRANSCRIPT
Operative Delivery
Alex Williams
Beth Bradley
Definition
• Operative delivery is defined as any procedure undertaken to facilitate delivery of an infant.
• Operative delivery should be undertaken for specific indications and those indications should be specifically noted in labour record.
Definition
Vaginal Operations
• Episiotomy
• Vacuum extraction
• Forceps Delivery
Abdominal Operations
• Caesarean Section
Vaginal Operations: Episiotomy
Rates vary. In 2001 the National Childbirth Trust produced figures for the UK of 15% in England 13% in Scotland 10% in Wales 22% in Northern Ireland Internationally 8% in Holland, 14% in England, 50% in the USA 99% in Eastern Europe
Episiotomy: Indications • Where a tear seems imminent and an episiotomy is deemed
preferable.
• Where there is delay due to a rigid perineum, and cutting it will expedite delivery and probably prevent a tear.
• Instrumental delivery
– forceps Tear – Kielland's forceps rotation and delivery the episiotomy needs to be
quite generous or a tear will accompany the cut.
• Premature delivery
• It estimates that 85% of women who have a vaginal delivery will have some degree of perineal trauma and that 60 to 70% will require suturing.
Episiotomy
Episiotomy
It estimates that 85% of women who have a vaginal delivery will have some degree of perineal trauma and that 60 to 70% will require suturing.
Vaginal Operations: Vacuum extraction (Ventouse)
Ventouse: Indications Maternal
– Exhaustion – Prolonged second stage (>1hr pushing) – Need to avoid expulsive effort (e.g.
Cerebrovascular disease)
Foetal – Failure of the foetal head to rotate – Foetal distress *Should not be used for preterm, face or breech presentation or in the case suspected foetal coagulation disorder
Ventouse: Delivery
Suction Cup applied to flexion point (2-3 cm anterior to posterior fontanelle) Traction applied in mother’s push.
Ventouse: Complications
• Vaginal laceration
• Scalp injuries
– Chignon
– Abrasion/laceration
• Cephalohematoma
• Intracranial haemorrhage
Vaginal operations: Forceps
Forceps: Indications
• Maternal
– Exhaustion
– Prolonged second stage
– Need to avoid expulsive effort
• Foetal
– Failure if the foetal head to rotate
– Foetal distress
– Control of head in breech delivery
Forceps: Choice
• Related to station of foetal head
Forceps: Choice
• Outlet forceps – Wrigley’s
• Low / Mid-cavity forceps – Neville Barnes
• Rotational Forceps – Kielland’s
Forceps: Requirements
F – Fully dilated cervix
O - no Obstruction (head <1/5 palpable per abdomen)
R – Review (lack of descent/rotation despite 3 tries)
E – Epidural or pudendal nerve block
P – Presentation (Cephalic)
S – Station (presenting part must be below ischial spines)
Forceps: Complications
• Foetus – Brachial plexus injury – Facial nerve damage – Fracture (skull) – Facial trauma – Shoulder dystocia
• Mother – Vaginal trauma – Haemorrhage – Infection
Abdominal Operations: Caesarean Section
1879
Caesarean Section: Definition Delivery of the foetus through an incision in the maternal abdomen and uterus.
Uterine Incision
• Lower Uterine Segment Incision
– Straight incision 3 cm above pubic Symphysis Pubis with blunt dissection to the uterus (reduces blood loss)
• Classic Caesarean section
– Vertical incision
– Very early foetus, anatomical difficulties
Caesarean Section: Indications
• Malpresentation, eg breech, transverse lie. • Multiple pregnancy. • Severe hypertensive disease in pregnancy. • Foetal conditions: distress, iso-immunisation, very low birth
weight. • Failed induction of labour. • Repeat Caesarean section: two sections nearly always means
subsequent births should also be by Caesarean section. • Large or obstructing Pelvic cyst or fibroid. • Maternal infection, eg herpes (if active), HIV (if viral load high) • Cephalopelvic disproportion
Caesarean Section
Caesarean Section
Caesarean Section Complications
• Maternal – Intra operative
• Haemorrhage • Caesarean Hysterectomy • Placenta Previa • Damage : Bowel ,Urinary Tract, Bladder
– Post Operative • Infection and endometritis • Scarring • PE • Psychological
Caesarean Section Complications
Foetal
• Respiratory problems
• Lacerations (rare)
• bonding
Instrumental and operative delivery: Summary
• The aim is to prevent foetal and maternal morbidity associated with a prolonged second stage of labour.
References
• www.patient.co.uk
• http://www.rcog.org.uk/
• Impey L, Child T. Obstetrics & Gynaecology (2012), 4th ed. Wiley & Blackwell
Images • http://www.theage.com.au/articles/2007/04/14/1175971419538.html • http://en.wikipedia.org/wiki/Caesarean_section • http://www.healthyhippie.net/more-twins-delivered-via-c-section/