Operative delivery

doi:10.1136/bmj.318.7193.1260

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Geoffrey Chamberlain,
Philip Steer

In Britain all operative deliveries are now performed in a hospital. Caesarean sections must take place in hospital, but the National Birthday Trust's 1994 survey of home births reported that all ventouse and low forceps deliveries also took place in hospital (Chamberlain, 1997). However, not only obstetricians have to know about these deliveries—general practitioners and midwives need to know too, so that they can brief women and prepare to deal with any complications that may arise.

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NHS hospital deliveries England, 1980-94 (from NHS Maternity Statistics England, 1997)

An operative delivery is performed if a spontaneous birth is judged to pose a greater risk to mother or child than an assisted one. Operations are divided into abdominal methods (caesarean section) and vaginal assisted deliveries (forceps delivery and vacuum extraction).

Preparations for operative delivery

Discuss operative delivery with the woman and her partner (if time is short, at least outline what will happen)
Follow the woman's wishes—no operative delivery can proceed without her consent even if the doctors think that the baby will die if it is not done
Get written consent for elective procedures
A paediatrician should attend any delivery where problems are anticipated; local guidelines should be drawn up and followed for all operative deliveries

Indications for caesarean section

Cephalopelvic disproportion—When it is obvious either antenatally or in the early stages of labour that the fetus, presenting by the head, is not going to pass through the pelvis
Relative cephalopelvic disproportion—The fetus descends initially during labour but is then arrested, possibly due to a malposition such as occipito-posterior
Placenta praevia—Particularly if it is overlapping the internal os
Fetal distress—In the first stage of labour
Prolapsed cord
To avoid fetal hypoxia—When there is poor perfusion of the placental bed (for example, pre-eclampsia)
Malpositions—For example, brow
Malpresentations—For example, transverse lie, breech
Bad obstetric history …