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Questions and Answers
What is the primary indication for breech extraction?
What is the primary indication for breech extraction?
Breech delivery involves maternal efforts during the procedure.
Breech delivery involves maternal efforts during the procedure.
False
What method is utilized for the delivery of the second twin in a breech extraction?
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 __________.
In breech extraction, the first twin is delivered vaginally and the second twin is delivered by __________.
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Match the following components of breech extraction with their descriptions:
Match the following components of breech extraction with their descriptions:
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Which of the following maternal injuries can occur from forceps delivery?
Which of the following maternal injuries can occur from forceps delivery?
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Only fetal injuries are associated with vacuum deliveries.
Only fetal injuries are associated with vacuum deliveries.
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What is the primary management for failed forceps or vacuum delivery?
What is the primary management for failed forceps or vacuum delivery?
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The correct application of forceps is along the ____________ diameter of the fetal head.
The correct application of forceps is along the ____________ diameter of the fetal head.
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Match the following complications with their respective delivery method:
Match the following complications with their respective delivery method:
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What is the best method for delivering the after coming head in breech presentations?
What is the best method for delivering the after coming head in breech presentations?
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Intracranial hemorrhage is the most common cause of death related to breech delivery.
Intracranial hemorrhage is the most common cause of death related to breech delivery.
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What maneuver is associated with the delivery of the shoulder in a breech presentation?
What maneuver is associated with the delivery of the shoulder in a breech presentation?
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The __________ technique can be used when the entire body of the baby is pushed back into the uterus after delivering the breech.
The __________ technique can be used when the entire body of the baby is pushed back into the uterus after delivering the breech.
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Match the following complications of breech delivery with their descriptions:
Match the following complications of breech delivery with their descriptions:
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What is a primary indication for using the Omnicup?
What is a primary indication for using the Omnicup?
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The English lock on forceps closes when the right blade is introduced first.
The English lock on forceps closes when the right blade is introduced first.
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What are two advantages of fenestrations of the blade in forceps?
What are two advantages of fenestrations of the blade in forceps?
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The _______ delivery technique uses a device that is portable and disposable.
The _______ delivery technique uses a device that is portable and disposable.
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Match the type of forceps lock with its description:
Match the type of forceps lock with its description:
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What is the vaginal delivery rate for women attempting a trial of labor after a previous Cesarean section?
What is the vaginal delivery rate for women attempting a trial of labor after a previous Cesarean section?
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The ideal inter-delivery gap after a Cesarean section is less than 18 months.
The ideal inter-delivery gap after a Cesarean section is less than 18 months.
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What is the minimum time gap recommended between a cesarean and the next pregnancy?
What is the minimum time gap recommended between a cesarean and the next pregnancy?
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The risk of scar rupture during delivery is affected by the type of ________, previous number of c-sections, and the inter-delivery interval.
The risk of scar rupture during delivery is affected by the type of ________, previous number of c-sections, and the inter-delivery interval.
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Match the following scenarios with their corresponding risks:
Match the following scenarios with their corresponding risks:
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Which of the following conditions describes the use of low forceps?
Which of the following conditions describes the use of low forceps?
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The ideal position for forceps delivery is the supine position.
The ideal position for forceps delivery is the supine position.
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What type of analgesia is recommended prior to forceps delivery?
What type of analgesia is recommended prior to forceps delivery?
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The direction of pull during outlet forceps delivery begins with pulling in the __________ direction.
The direction of pull during outlet forceps delivery begins with pulling in the __________ direction.
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Match the forceps type with its correct pull directions:
Match the forceps type with its correct pull directions:
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What is an indication for the prophylactic use of instrumental delivery?
What is an indication for the prophylactic use of instrumental delivery?
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Vacuum delivery can be applied in cases of incomplete cervical dilation at 5 cm.
Vacuum delivery can be applied in cases of incomplete cervical dilation at 5 cm.
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What are the two main types of instrumental delivery discussed?
What are the two main types of instrumental delivery discussed?
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For forceps delivery, the cervix must be __________.
For forceps delivery, the cervix must be __________.
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Match the following prerequisites of instrumental delivery with their descriptions:
Match the following prerequisites of instrumental delivery with their descriptions:
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Which type of forceps is primarily used for delivering the after-coming head of a breech baby?
Which type of forceps is primarily used for delivering the after-coming head of a breech baby?
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The Kielland Forceps are outdated but are designed for rotating the fetal head.
The Kielland Forceps are outdated but are designed for rotating the fetal head.
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What determines whether the forceps are classified as left or right?
What determines whether the forceps are classified as left or right?
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The __________ forceps have the shortest length at 27.5 cm and are designed as outlet forceps.
The __________ forceps have the shortest length at 27.5 cm and are designed as outlet forceps.
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Match each type of forceps with its description:
Match each type of forceps with its description:
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What is the main advantage of a Pfannenstiel incision?
What is the main advantage of a Pfannenstiel incision?
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Kerr's incision is contraindicated for vaginal birth after cesarean (VBAC).
Kerr's incision is contraindicated for vaginal birth after cesarean (VBAC).
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What is the risk percentage of uterine rupture associated with Sanger's incision?
What is the risk percentage of uterine rupture associated with Sanger's incision?
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The incision type that offers improved cosmetic results is called the ________ incision.
The incision type that offers improved cosmetic results is called the ________ incision.
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Match the incision types with their corresponding sites and features:
Match the incision types with their corresponding sites and features:
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What is the maximum pressure that can be generated by a silastic cup during vacuum delivery?
What is the maximum pressure that can be generated by a silastic cup during vacuum delivery?
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Silastic cups are indicated for use in cases of fetal stress.
Silastic cups are indicated for use in cases of fetal stress.
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What is the initial pressure applied with a silastic cup in vacuum delivery?
What is the initial pressure applied with a silastic cup in vacuum delivery?
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Cupping is avoided in __________ when there is a mento anterior position.
Cupping is avoided in __________ when there is a mento anterior position.
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Match the following placements with their descriptions:
Match the following placements with their descriptions:
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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
- Management:
- 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
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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.
