Download Operative Obstetrics. Laceration of birth Canal

Operative Obstetrics.
Laceration of birth Canal
Doc. Stelmakh O.E.
Cesarean Delivery
Cesarean section means
delivery of a viable fetus
through an abdominal incision
(i.e., laparotomy) and a
uterine incision (i.e.,
hysterotomy). The terms
cesarean and section used
together are actually redundant, because both words
imply incision.
Labor Contraindicated
Under certain conditions, forceful uterine contractions, as in normal labor, constitute a real or
potential hazard to mother or fetus, or both.
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Conditions in which the forces of labor increase
the risk to the mother include central placenta
previa, previous classic cesarean section,
previous myomectomy transecting the uterine
wall, previous uterine reconstruction, and
previous repair of a vaginal fistula. In such
circumstances, normal labor and vaginal delivery
may result in uterine rupture, hemorrhage, or
serious lacerations of the birth canal, and may
endanger the life or future health of the mother.
Conditions that have traditionally been cited as threatening
the fetus and that may be worsened by
labor include placenta previa, velamentous insertion of the
cord or other forms of vasa previa, and cord presentation.
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The majority of cesareans are performed for fetal
indications; a few are solely for maternal
reasons, and some benefit both fetus and mother.
Repeat cesarean accounts for approximately 33%
of cesarean births in the United States, dystocia
is the indication for up to 30%, and fetal distress,
breech, and all other conditions are responsible
for the remaining cases. Unfortunately, there are
few data to suggest that the liberalized indications for cesarean section have reduced the
incidence of cerebral palsy and other long-term
disabilities
This is probably because most perinatal morbidity and
mortality are caused by premature births, fetal anomalies,
or antepartum events.
Failed Induction
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In conditions such as isoimmunization,
diabetes mel-litus, intrauterine growth
retardation, and hypertensive disorders,
which constitute an ever-increasing threat
to the fetus, preterm delivery may be
desirable. If attempts to induce labor are
inappropriate or unsuccessful, cesarean
section is the alternative
Common Indications for
Cesarean Delivery
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Failed induction
Cephalopelvic disproportion
Failure to progress in labor
Proven fetal distress
Placental abruption
Placenta previa
Umbilical cord prolapse
Obstructive benign and malignant tumors
Active genital herpes infection
Abdominal cerclage
Conjoined twins
Controversial (or Selective)
Breech presentation
Repeat cesarean
Immune thrombocytopenia
Severe Rh immunization
Congenital fetal anomalies, major
Cervical carcinoma
Prior vaginal colporrhaphy
Large vulvar condylomata
For example, fetal macrosomia occasionally causes CPD,
but most cesarean births for abnormal labor involve a
normal-sized infant. Dystocia also occurs because of soft
tissue tumors and abnormal fetal presentations
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Fetal Distress
Electronic fetal monitoring probably increases the
chances of detecting fetal distress and has
contributed to the increased number of cesarean
sections in the United States. Vaginal breech
deliveries have been abandoned by many
clinicians and replaced by cesarean delivery. In
this situation, cesarean birth avoids the potential
risk of intrapartum asphyxia or delivery-related
trauma from head entrapment and umbilical cord
prolapse
Classic incision in the upper
segment of the uterus.
Incisions in lower uterine segment.
(A) Low transverse incision. (B)
Low vertical incision.
On the other hand, reckless surgical techniques for rapid
delivery of the fetus should be condemned. An induction-todelivery time of 5 to 15 minutes is reasonable if maternal
oxygen-ation, blood pressure, and displacement of the uterus
are monitored and maintained with care
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Preparation of the abdomen includes
shaving the skin of the abdomen and
mons pubis when necessary, scrubbing the
area with an antiseptic soap, and preparing the skin with an antiseptic agent
such as non-organic iodide. The abdomen
is draped so that the area between the
umbilicus and the mons pubis is exposed.
The lower flap of peritoneum is elevated and the bladder is
gently separated by blunt or sharp dissection from the
underlying myometrium
The visceral peritoneum is grasped just above the
bladder and incised in the midline.
A. The incision in a well-developed (thin) lower uterine
segment is extended laterally and cephalad with the
fingers. B. The incision in a thicker lower uterine segment is
extended laterally with bandage scissors.
The fetal occiput is lifted toward the incision. Care
is taken not to use the lower uterine segment as a
fulcrum in order to avoid lacerations.
The body is delivered after the mouth and nares
have been suctioned thoroughly.
The placenta is delivered by shearing it manually
from its uterine attachment.
The second layer of closure imbricates the first; absorbable
suture is used in interrupted stitches in figures-of-eight, in
Lembert stitches, or in a continuous suture placed such that
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the first layer of closure is completely covered
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If, during the closure, any areas of
bleeding are still apparent in the
incision line, separate interrupted
absorbable sutures in figures-ofeight should be placed in the
bleeding area to secure hemostasis
A perplexing circumstance occurs in closing a transverse lower
uterine segment incision when the junction of the contractile
and noncontractile portion of the posterior wall presents the
appearance of the lower edge of the incision.
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Suturing this to the upper cut edge would
create a closure of the corpus, but the
error is usually recognized when the lower
cut edge presents when peritoneal closure
is attempted. The confusion can be
resolved by careful identification of the
upper and lower edges of the uterine incisions at both angles.
When the uterus and visceral peritoneum have been
reapproximated, the packs are removed from the
abdominal cavity and any residual blood or amniotic
fluid removed by suction.
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If meconium soilage or exposure to
infected amniotic fluid has occurred, the
pelvic cavity should be lavaged with
normal saline solution. Clinical studies
have demonstrated in high-risk patients a
reduction in postoperative infection rates if
the uterine cavity is lavaged by saline
solution
Operative delivery
1)forceps
operations
2)Vacuum
extractor
Simpson forceps
2)Vacuum
extractor
Laceration of birth canal
Laceration of birth canal