Obstetrics Marrow Pg 555-564 (Labor & Puerperium)

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Questions and Answers

What is the primary indication for breech extraction?

Single pregnancy with breech presentation

Fetal distress in a singleton pregnancy

Maternal health complications

Twin pregnancy with first twin in cephalic presentation and second twin in transverse lie (correct)

Breech delivery involves maternal efforts during the procedure.

False

What method is utilized for the delivery of the second twin in a breech extraction?

Internal podalic version under general anesthesia

In breech extraction, the first twin is delivered vaginally and the second twin is delivered by __________.

breech delivery under GA Signup and view all the answers

Match the following components of breech extraction with their descriptions:

First Twin Delivery = Vaginal delivery Second Twin Delivery = Breech delivery under GA Preparation for Delivery = Internal podalic version Maternal Involvement = Performed without maternal efforts Signup and view all the answers

Which of the following maternal injuries can occur from forceps delivery?

Facial nerve palsy Signup and view all the answers

Only fetal injuries are associated with vacuum deliveries.

False Signup and view all the answers

What is the primary management for failed forceps or vacuum delivery?

C-section Signup and view all the answers

The correct application of forceps is along the ____________ diameter of the fetal head.

occipito-mental Signup and view all the answers

Match the following complications with their respective delivery method:

Facial nerve palsy = Forceps Delivery Shoulder dystocia = Vacuum Delivery Corneal injury = Forceps Delivery Cephal hematoma = Vacuum Delivery Signup and view all the answers

What is the best method for delivering the after coming head in breech presentations?

Piper's forceps Signup and view all the answers

Intracranial hemorrhage is the most common cause of death related to breech delivery.

True Signup and view all the answers

What maneuver is associated with the delivery of the shoulder in a breech presentation?

Dorso-anterior Signup and view all the answers

The __________ technique can be used when the entire body of the baby is pushed back into the uterus after delivering the breech.

Zavanelli Signup and view all the answers

Match the following complications of breech delivery with their descriptions:

Entrapped head = Management may include Duhressen's incision Fetal asphyxia = Insufficient oxygen supply to the fetus Hypoxic ischemic encephalopathy = Brain injury due to lack of oxygen Abdominal injuries = Damage to organs during breech delivery Signup and view all the answers

What is a primary indication for using the Omnicup?

OA & OP deliveries Signup and view all the answers

The English lock on forceps closes when the right blade is introduced first.

False Signup and view all the answers

What are two advantages of fenestrations of the blade in forceps?

Light weight and decreased risk of head compression Signup and view all the answers

The _______ delivery technique uses a device that is portable and disposable.

Omnicup Signup and view all the answers

Match the type of forceps lock with its description:

English Lock = Two sockets, closes with left blade first Sliding Lock = Single socket Signup and view all the answers

What is the vaginal delivery rate for women attempting a trial of labor after a previous Cesarean section?

70-72% Signup and view all the answers

The ideal inter-delivery gap after a Cesarean section is less than 18 months.

False Signup and view all the answers

What is the minimum time gap recommended between a cesarean and the next pregnancy?

6 months Signup and view all the answers

The risk of scar rupture during delivery is affected by the type of ________, previous number of c-sections, and the inter-delivery interval.

c-section Signup and view all the answers

Match the following scenarios with their corresponding risks:

Trial of labor = Increased risk of bleeding Elective cesarean section = Anesthetic and operative risks Short inter-delivery gap = Higher chance of complications Repeat c-section = Potential hysterectomy Signup and view all the answers

Which of the following conditions describes the use of low forceps?

Fetal head station at or above +2 Signup and view all the answers

The ideal position for forceps delivery is the supine position.

False Signup and view all the answers

What type of analgesia is recommended prior to forceps delivery?

Epidural or pudendal nerve block Signup and view all the answers

The direction of pull during outlet forceps delivery begins with pulling in the __________ direction.

downward Signup and view all the answers

Match the forceps type with its correct pull directions:

Low Forceps = Downward + backward; Downward; Downward + forward Outlet Forceps = Downward; Downward + forward Signup and view all the answers

What is an indication for the prophylactic use of instrumental delivery?

Maternal exhaustion Signup and view all the answers

Vacuum delivery can be applied in cases of incomplete cervical dilation at 5 cm.

False Signup and view all the answers

What are the two main types of instrumental delivery discussed?

Forceps delivery and vacuum delivery Signup and view all the answers

For forceps delivery, the cervix must be __________.

fully dilated Signup and view all the answers

Match the following prerequisites of instrumental delivery with their descriptions:

Favorable position = Sagittal suture in AP diameter, maximum rotation of 45° Os = Fully dilated Consent = Agreement from the mother to proceed Pelvis = Adequate size and shape for delivery Signup and view all the answers

Which type of forceps is primarily used for delivering the after-coming head of a breech baby?

Piper Forceps Signup and view all the answers

The Kielland Forceps are outdated but are designed for rotating the fetal head.

True Signup and view all the answers

What determines whether the forceps are classified as left or right?

Relation to the mother Signup and view all the answers

The __________ forceps have the shortest length at 27.5 cm and are designed as outlet forceps.

Wrigley Signup and view all the answers

Match each type of forceps with its description:

Wrigley Forceps = Outlet forceps, short and light Kielland Forceps = Long, able to rotate fetal head Piper Forceps = Longest forceps for breech delivery Tucker-McLane Forceps = Forceps with a solid blade Signup and view all the answers

What is the main advantage of a Pfannenstiel incision?

Less post-operative pain Signup and view all the answers

Kerr's incision is contraindicated for vaginal birth after cesarean (VBAC).

False Signup and view all the answers

What is the risk percentage of uterine rupture associated with Sanger's incision?

4-9% Signup and view all the answers

The incision type that offers improved cosmetic results is called the ________ incision.

Pfannenstiel Signup and view all the answers

Match the incision types with their corresponding sites and features:

Sanger's Incision = Classical C-section Kerr's Incision = Lower segment C-section (LSCS) Kronig Incision = Low vertical C-section Signup and view all the answers

What is the maximum pressure that can be generated by a silastic cup during vacuum delivery?

0.8 kg/cm² Signup and view all the answers

Silastic cups are indicated for use in cases of fetal stress.

True Signup and view all the answers

What is the initial pressure applied with a silastic cup in vacuum delivery?

0.2 kg/cm² Signup and view all the answers

Cupping is avoided in __________ when there is a mento anterior position.

face presentation Signup and view all the answers

Match the following placements with their descriptions:

Center of cup = 6 cm from anterior fontanelle Edge of cup = 3 cm from anterior fontanelle Correct placement = Rim touches posterior fontanelle Anterior placement = Cup placement extends the head Signup and view all the answers

Study Notes

Breech Extraction

Indication for breech extraction in twin pregnancy: First twin cephalic presentation with second twin in transverse lie
Method: Vaginal delivery of the first twin followed by internal podalic version under general anesthesia for breech delivery

Bracht Technique

Bracht technique is similar to the Burns-Marshall technique, but suprapubic pressure is not applied.
Mauriceau-Smellie-Veit technique involves shoulder traction and malar flexion

Piper's Forceps

Piper's forceps is the best method for delivering an after-coming head
It is a long forceps

Breech Delivery: Head Position

The head occupies the opposite oblique diameter to that of the shoulder/buttocks
Delivery of the head in breech: Dorso-anterior is the most common position
Dorso-posterior delivery requires the Prague maneuver

Breech Delivery: Complications

Entrapped head:
- Management:
  - Preterm breech: Duhressen's incision on the cervix at 2 o'clock and 10 o'clock positions
  - Term breech: Pushing the entire body of the baby back into the uterus and performing a C-section. Zavanelli Technique can also be used
Intracranial hemorrhage: Most common cause of death in breech delivery
Fetal asphyxia
Hypoxic ischemic encephalopathy
Abdominal injuries

Forceps Delivery: Maternal Injury

Facial (VIIth) nerve palsy
Brachial plexus injury
Corneal injury

Vacuum Delivery: Fetal Injury

VIIth nerve palsy
Shoulder dystocia
Cephal hematoma
Subgaleal hemorrhages
Retinal injury

Failed Forceps/Vacuum Delivery

Management: Cesarean section after 3 unsuccessful trials to deliver the fetal head

Forceps Application

Correct application of forceps is along the occipito-mental diameter of the fetal head.

Omnicup

Newer vacuum device
Smaller size: Portable and disposable
Indication: OA & OP deliveries

Forceps: Diagram Description

Illustration of forceps with handles, blade, lock mechanism, finger guards, heel, pelvic curve, cephalic curve, and different types of locks.

Forceps: Advantages of Fenestrations of the Blade

Light weight
Less traumatic
Decreased risk of head compression

Forceps: Types of Locks

English lock (most common): Two sockets, one on each handle. Closes only when the left blade is introduced first
Sliding lock: Single socket

Previous Cesarean Section: Vaginal Delivery Rate

Successful vaginal delivery rate: 70-72%

Previous Cesarean Section: Risks Associated with Trial of Labor

Increased risk of:
- Bleeding
- Blood transfusions
- Uterine rupture

Previous Cesarean Section: Risks Associated with Elective Cesarean Section

Obstetric history is affected
Increased chances of transient tachypnea of the newborn
Anesthetic and operative risks

Previous Cesarean Section: Risk of Scar Rupture

Depends on:
- Type of c-section:
- Previous number of c-sections
- Inter-delivery interval

Previous Cesarean Section: Inter-delivery Gap

Ideal: ≥ 18 months
Short: < 18 months (interval: 12 months)
Minimum time gap between cesarean and next pregnancy: 6 months

Cesarean Section: Considerations

Repeat C-section (36-37 weeks): Recommended for women who had a previous cesarean section and wish to try a vaginal delivery
Anesthesia Level: Painless labor is achieved with epidural anesthesia at the T10 level. Anesthesia for cesarean section should be T1
Ideal Position: Supine position with a left lateral tilt of 15° or a wedge placed under the right hip of the patient
Elective C-section for non-medical reason: 39 weeks

Cesarean Section: Potential Complications

Hysterectomy
Fetal distress
Fetal death
Hypoxic ischemic encephalopathy

Cesarean Section: Incisions

Transverse Skin Incision

Types:
- Pfannenstiel incision: A finger breadth above the pubic symphysis
- Joel Cohen incision: Not curved, above the Pfannenstiel incision

Cesarean Section: Uterine Incisions: Vaginal Birth After Classical C-section

Features	Sanger's Incision	Kerr's Incision	Kronig Incision
Site	Classical C-section	Lower segment C-section (LSCS)	Low vertical C-section
Diagram	(Diagram of a classical C-section incision on the uterus)	(Diagram of a lower segment C-section incision on the uterus)	(Diagram of a low vertical C-section incision on the uterus)
Risk of rupture	4-9%	+/-	1-7%
VBAC	Contraindicated	One previous LSCS: 0.2% to 0.9% Multiple previous LSCS: 0.9% to 1.8%	+/-
Other features	Repeat C-section in next pregnancy (36-37 weeks).After 37 weeks, contractions become prominent (increased risk of uterine rupture).Repeat C-section should be LSCS.	Recommendations: - ACOG: VBAC can be tried irrespective of the number of previous LSCS.- National guidelines: VBAC is C/1 if ≥ 2 previous LSCS	Indication: Presence of constriction ring

Forceps Application Criteria

Low Forceps (Most Common)

Station of fetal head ≥ +2

Outlet Forceps (Wrigley Forceps)

Head: At perineum
Scalp: Visible at introitus
Skull: At pelvic floor
Sagittal suture: Along AP diameter

Forceps Application Criteria: Prior to Forceps Delivery

Consent
Adequate analgesia (epidural/pudendal nerve block)
Episiotomy

Forceps Application Criteria: Direction of Pull

Ideal position: Lithotomy
Direction of pull: Based on maternal abdomen

Low Forceps Pull Directions

Pull	Direction
1st	Downward + backward
2nd	Downward
3rd	Downward + forward

Outlet Forceps Pull Directions

Pull	Direction
1st	Downward
2nd	Downward + forward

Instrumental Delivery: Indications & Pre-requisites

Indications

Prolonged 2nd stage of labor
Fetal distress
Prophylactic use to expedite labor in cases of maternal exhaustion, heart disease, or PIH

Pre-requisites (FORCEP Mnemonic)

Favourable position: Sagittal suture in AP diameter, maximum rotation of 45° (DOA/DOP/ROA/LOA) + Station (2+2)
Os: Fully dilated
Rotate head + Ruptured membranes
Consent + Contracting uterus
Episiotomy + Engaged head + empty bladder
Pelvis: adequate + CPD: absent

Instrumental Delivery: Types

Forceps Delivery

All pre-requisites must be fulfilled

Vacuum Delivery

Applicable in cases of:
- Incomplete cervical dilation ≥ 6 cm
- Non-rotated head

Vacuum Delivery: Important Considerations

Best suited for vertex presentation with fully dilated cervix and rotated head
Maternal heart disease: Forceps (↓maternal efforts) > Vacuum

Vacuum Delivery: Silastic Cups

Safer: Less traumatic
Easy to apply
Shapes: Bell/mushroom shaped
Attached to: Suction machine
Initial pressure: 0.2 kg/cm²
Maximum pressure: 0.8 kg/cm² or 600 mmHg
Generated in: 2 minutes
Used in: Fetal distress

Vacuum Delivery: Application

Place the center of the cup: At the flexion point on the sagittal suture
Correct placement: The rim of the cup touches the posterior fontanelle
Anterior placement: Cup placement extends the head
Distance from anterior fontanelle:
- Center of cup: 6 cm
- Edge of cup: 3 cm

Vacuum Delivery: Important Considerations

Contraindications: Preterm babies, intrauterine death (macerated head requires increased pressure), face presentation (mento anterior position)
Absolute contraindications for instrumental delivery: CPD (Cephalopelvic disproportion), inadequate/contracted pelvis, bony deformities of the fetus (e.g., osteogenesis imperfecta), coagulopathy in the fetus
Avoidance in specific cases: Instrumental delivery is avoided in HIV+ve positive females

Forceps: Identifying Left/Right Forceps

Left/Right: Determined in relation to the mother
Placement: Pelvic curve facing upwards

Forceps: Correctly Held Forceps

	Left Forceps	Right Forceps
Socket	Facing upwards	Facing downwards

Forceps: Identification of Correctly Applied Forceps

Lock: Properly closed
Blades: Equidistant from the sagittal suture

Forceps: Types of Forceps

Wrigley Forceps

Type: Outlet forceps
Description: Short and light
Total Length: 27.5 cm
Shank: 2.5 cm

Kielland Forceps (Outdated)

Type: Long Forceps
Description: Only forceps able to rotate the fetal head.

Piper Forceps

Type: Longest forceps
Description: Used for delivering the after-coming head of a breech baby
Lock: English lock

Tucker-McLane Forceps

Type: Forceps with a solid blade

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

Test your knowledge on various breech delivery techniques, including the Bracht and Mauriceau-Smellie-Veit techniques. This quiz also covers indications for breech extraction in twin pregnancies and management of complications like an entrapped head. Dive into the nuances of breech deliveries and enhance your understanding.