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Operative Delivery / Vaginal Birth After Caesarean Section (VBAC) - Coggle…
Operative Delivery / Vaginal Birth After Caesarean Section (VBAC)
Operative Vaginal Delivery
Definition
Use of an instrument in 2nd stage of labour to facilitate vaginal delivery of foetus
Alternative names
Instrumental delivery
Assisted vaginal birth
Types of Instruments
Vaccum
Kiwi Omnicup - Vaccum delivery
Metal Cup
Requires external vaccum
More traction than Kiwi
Elastic Cup
Requires external vaccum
Forceps
Kielland's forceps
Uncommonly used - OA position
Rotational forceps
Neville Barnes
Most commonly used
Mid cavity deliveries
Wrigley's forceps
Outlet deliveries
CS head delivery
Indications for Instrumental Delivery
Maternal Indications
Prolonged second stage
Primi :
3hr with regional anaethesia
2hr w/o
Mutiparous:
2hr with regional anaethesia
1hr without
Maternal Exhaustion
Medical Conditions exacerbated by Valsalva
NYHA class II or IV cardiac dsease
Hypertensive crisis
CVD
Proliferative retinopathy
Myasthenia gravis
Spinal cord injury of autonomic dysreflexia
Foetal Indications
Suspected foetal compromised
Pathological CTG
Abnormal FBS - foetal blood sampling
Contraindications
Absoloute
Prerequisites not met
Relative
Foetal bleeding disorder (autoimmune thrombocytopaenia)
Foetal predisposition to fractures (osteogenesis imperfecta)
Certain maternal infection (hep b,c, HIV)
Specific to Vaccum
< 34 weeks gestation
Face presentation
Prerequisites for Instrumental Delivery
Fully dilated cervix
Ruptured membranes
Cephalic
Station at / below ischial spines
Foetal position defined
Adequate maternal pelvis
Foetal head no more than 1/5 palpable
Empty bladder
Adequate pain relief
Consent
Forcepts Vs Kiwi
Forceps
Advantages
More traction - Higher chance of successful delivery
Can be used on premature babies
Effective in caput / moulding
Can be used for head in breech delivery / face presentation
Effective if maternal conditions limit pushing
Disadvantages
Higher rate of maternal trauma
Requires more effective analgesia - epidural / pudendal block
Requires OA/OP position
Kiwi
Advantages
Less maternal trauma
Epidural / pudendal block not mandatory
Use in rotating foetus into OA/OP
Disadvantages
Relies more on maternal effort
Limited traction - more likely to fail
Increased risk of neonatal trauma - brain bleed
C/i premature babies
Caput/ scalp oedema limites effectiveness
Complications of Operative Vaginal Delivery
Maternal
PPH
Perineal tears
including high vaginal tears, cervical trauma
3.Obstetric anal sphincter injuries (OASIS)
Psychological trauma
Pelvic organ prolapse
Urinary incontinence
Urinary incontinence
Flatal / faecal incontinence
Foetal
Bruising
Caput succedaneum
Scalp / facial lacerations
Skull fracture
Intracerebral haemorrhage
Cephalohaematoma
Subgaleal haemorrhage - potentially fatal
Facial nerve palsy
Retinal haemorrhage
Extracranial haemorrhage
Caput succedaneum
Subgleal haemorrhage
Cephalohematoma
Postnatal care following OVD
Assess perineal trauma - vaginal and rectal exam
Suture perineal tears
Consider indwelling catheter for 12hr
Prescribe regular analgesia
Debrief - indications / complictions
Advise pelvic floor exercises
Postnatal follow up at 6weeks
Operative Vaginal Deliver vs Caesaren Section
OVD
Quicker recovery
Shorter hospital stay
Less analgesia needed
CS
Longer recovery
Longer hospital stay
More analgesia needed
Risk of surgical complications
CS Indications
Breech singleton / first twin breech
Maternal HIV with high viral load
Maternal DM with EFW >4.5kg
Postdate with transverse lie
Primary genital herpes in 3rd trimester
Placenta praevia
HIV and Hep C concurrently
Previous major shoulder dystocia
Not Routinely Offerred
Twins first twin cephalic
Preterm
SGA
HIV + on HAART with viral load <400 copies/ml
HIV + on any retroviral therapy with viral load <50 copies per ml
Maternal Request
Maternal hep B
Recurrent herpes infx at term
BMI>50 with no other RF
BMI is a risk for clots and its hard to do CS
Classification of Urgency of CS
Category 1
Immediate threat to life of foetus / mother
Timing
CS within 30 min
Examples
Maternal collapse
Uterine rupture
Massve APH
Cord prolapse
Persistent foetal bradycardia
Fetal scalp pH <7.10
Category 2
Maternal / foetal compromise that is not an immediate threat to life
Timing
CS within 75 min
Examples
Abnormal CTG and low scalp pH 7.10-7.20
Abnormal CTG and no pH
Failure to progres with fetal / maternal complications
Trial of instrumental
Breech advancing in labour
Category 3
No maternal / foetal compromise, but early delivery indicated
Timing
When theatre space available
Examples
Failure to progress no complications
Failed induction
Pre-eclampsia (maternal or foetal indication
Planned elective with signs of labour
5 IUGR
Category 4
Elective
Timing
To suit patient or staff
Examples
Planned elective CS
Breech not in labor
Anaesthesia for LSCS
Epidural top up
Spinal anaethesia
GA
Risks of CS
Common
Wound discomfort
Repeat CS
Postnatal readmission
Haemorrhage
Infection
Foetal laceration
Uncommon
VTE
Bladder injury
Ureterc injury
Emergency hysterectomy
Death
Vaginal Birth after Caesarean Section (VBAC)
AKA Trial of labour after caesarean section (TOLAC)
Definition
When a woman that has previously had a CS gives birth vaginally
Success rate
72-75%
85-90% if prior vaginal delivery
Risks
Uterine rupture 1/ 200-500
Emergency CS 30-40% risk
Contraindications
Classical uterine incision
Prior complex CS
eg Extension of uterine incision into cervix
3+ prior CS
C/I to vaginal delivery - Placenta praevia / Vasa praevia
Caution in piror myomectomy
Prognostic Factors
Positive
Uncomplicated pregnancy
Spontaneous onset of labour
Prior vaginal delivery / labour with 4cm dilation
Prior c-cestion for non-recurrent cause eg breech
Delivery interval >18 months
Negative
Birth weight > 4kg OR EFW > 90th centile
BMI >35
Advanced maternal age
No prior vaginal births
Interdelivery interval > 10 yrs
Prior c-section for shoulder dystocia
Optimisation
Upright position in labour and delviery
Delay epidural until 3-4cm
Do not limit 2nd stage labour unnecessarily - delay active part of 2nd stage to allow head to descend
Manual rotation of head in OP position
Epidural regimens with reduced motor block
Optimal management of labour - use oxytocin here appropriate
