Download Obstetric procedures

a
Caesarean section
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Is the operation that is performed to deliver a
baby via the trans abdominal route
Or refers to the delivery of a fetus,placenta &
membrane through an abdominal & uterine
incision.
History
First cesarean carried on a live woman in 16th
century to a Swiss farmer in early 20th
classical operation become wide spread
Types of C.S.
Classified according to the site of uterine incisions:
 Lower segment C.S.
Transverse incision in the lower uterine segment .
Advantage : reduced chance of rupture .
reduced risk of bleeding ,peritonitis ,
paralytic ileus and bowel adhesion.
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Upper segment (Classical C.S) :
Vertical incision in the upper uterine
segment .This incision may be made
in the lower segment (low vertical
incision) but It’ll invariably extend
into the upper segment .
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Indications
Obstructed labour, malpresentation,
malposition, multiple gestation
2. Foetal distress /prolapsed cord
3. Maternal medical conditions
4. Obstetric complications
5.Previous uterine surgery : Classical
C.S. /Previous 2 C.S./ Previous
myomectomy (Full thickness ) .
1.
Indications of Classical c\s
1.
2.
3.
4.
5.
6.
7.
Preterm labour
Placenta previa- abruptio
PROM, poor lower segment& transvers lie
Transvers lie with back inferior
Large cervical fibroid
Sever adhesion in lower segment
Post mortem cs
Cesarean hysterectomy
Incidence 0.01-0.05 percent
Indication
Hemorrhage
Relative risk;
Cesarean delivery, previous cs ,placenta previa,
placenta accreta& uterine atony
INDICATIONS FOR CS :- Based on the timing of CS at the
time of decision making are grouped in 4Categories
Category 1 or emergency CS – There is an immediate
threat to the mother or the fetus. Ideally the CS
should be done within the next 30 min. Some examples
are; abruption, cord prolapse, scar rupture, scalp
blood pH < 7.20 and prolonged FHR deceleration < 80
beats/min.
Category 2or urgent CS – There is maternal or fetal
compromise but was not immediately life threatening.
Here the delivery should be completed within 60-70min
Category 3 or scheduled CS – The mother needed
early delivery but there was no maternal or fetal
compromise, when continuation of pregnancy is
likely to affect the mother or fetus in hours or days
to come.
It may be a case of failure to progress where the CS is
planned within 1-2 hour
or preterm IUGR with absent end diastolic flow but a
normal CTG
or a case with pre-eclampsia where the liver or renal
function tests are gradually deteriorating where the
CS is planned for within hours to days. The timing
of the CS should be before further deterioration
Category 4 or elective CS – The delivery is timed
to suit the mother and staff. but there is no urgency
e.g. placenta praevia with no active bleeding;
malpresentations, (e.g. brow, breech); history of
previous hysterotomy or vertical incision CS; past
history of repair of vesico-vaginal or recto-vaginal
fistulae or stress incontinence; HIVinfection.
Elective cs is done around 39w as the incidence of
tachypnoea of newborn is much less after this
gestation.
However, the medical or obstetric condition determines the
gestation at which the elective CS is planned
Technique of C.S. now favors :
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Prophylactic antibiotics .
Cohen’s incision .
Delivery of the placenta by controlled cord
traction .
Leaving the uterus in during repair .
Not reperitonealizing .
Preparation for C.S. :
Left lat. Position .
 Empty the stomach and antacid .
 Thrombo prophylaxis .
 Prophylactic antibiotics .
 Catheterization .
 Skin preparation : shaving .
iodine , chrorhexidine
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Skin incision :
Low transverse suprapubic incision .(more
cosmotic , less dehiscence and hernia ).
 Cohen’s incision : less post operative febrile
morbidity , shorter operative time .
 Midline or paramedian incision better
exposure .
The skin wound is about 15 cm in length ,excise
the scar of previous C.S. operation .
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Uterine incision :
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Low transverse LSCS : less dissection of the
bladder ,blood loss is less ,lower incidence of
uterine rupture .
Low vertical incision .
Classical or upper segment incision .
Risk of C. S. :Maternal risk
Mortality after C.S. is 5-10X after normal vaginal delivery .
Risk is more after emergency than elective C.S..
Immediate complications :
1.
Anasthesia , aspiation (Mendelson’s syndrome)
2.
Haemorrhage (blood transfusion and shock)
3.
Injury to adjacent organs .
4.
Infection .
5.
Post operative ileus .
6.
Pulmonary embolism .
Remote : Rupture in pregnancy &labour , Placenta previa,
Intestinal obstruction and hernia, Risk of repeated C.S.
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Perinatal morbidity &mortality
Cs is safer to baby ?
1. Risk of anasthesia .
2. Respiratory problems (transient tachypnea)
3. Intracranial haemorrhage (difficult
delivery)
4. Prematurity ( inaccurate date ).
5. Fetal laceration is reported at rate 0.2-0.4%
Operative vaginal delivery or Assisted
Vaginal Delivery:
Instrumental vaginal delivery
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Vaccum (ventose) & Forceps
assisted vaginal delivery :- delivery of a
baby vaginally using an instrument for
assistanc when spontaneous vaginal
delivery does not occur within a
reasonable time.
Incidence:-6 -12% depends on institution &
the population
Indication for assisted delivery:
Maternal Indication :
1. Maternal distress during 2nd stage .
2. Prolonged 2nd stage .
3. Cardiopulmonary or vascular disease to
reduce the stress of the 2nd stage of labour .
4. Vaginal birth after previous lower segment
C.S. to reduce the stress on the scar .
5. Significant vaginal bleeding .
Fetal Indications :
1. Malposition of the fetal head (OP, OT)
2. Fetal distress ( bradycardia or
deceleration )
and cord prolapse .
3. Preterm baby (1500 – 2500 Kg )
4. Vaginal delivery of breech : forceps for
after coming head to avoid traction on
the trunk and the cervical spine and
produce controlled flexion of the head .
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Ventouse delivery
The vacuum extractor works by allowing
the external traction force applied to fetal
scalp to be transmitted to the head. The
metal cups have a central traction chain
and a separate vacuum pipe .it is anterior
cups(4, 5, 6cm) or posterior cups.
The silicone-rubber cup the soft cups are
smoothly applied to the contour of the
head and do not develop a ‘chignon’
Types of vacuum:
1.Rigid vaccum:
O’neil
Bird
Malmstrom
2.Soft vacuum:
Funnel
cause less fetal injury ,
higher failure rate .
mushroom
Ring
Indications and contraindications
for delivery with the ventouse
Indications
 Delay in the second stage
 Fetal distress in the second stage
 Maternal conditions requiring a short second stage
Contraindications
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Face presentation
Gestation less than 34 weeks
Marked active bleeding from a fetal blood sampling
site
Prerequisites for delivery with the ventouse
• Dilatation of the cervix and full engagement of the head
• Co-operation of the patient
• Good contractions should be present
Basic rules
• The delivery should be completed within 15 minutes of
application
• The head,not just the scalp , should descend with each
pull.
• The cup should be reapplied no more than twice.
• If failure with the correctly placed ventouse occurs
despite good traction, the forceps should not be tried as
well
Forceps delivery
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Types of obstetric forceps
 Short curved forceps
Used for Outlet forceps
operation or for delivery
of the head during C.S. ,
it has short shank (2.5 cm),light in
weight.
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Long curved forceps
Used for delivery of the head from the
midcavity,long shank
(6.5 cm),heavy weight .
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Kielland’s forceps
-It has a sliding lock allows Sliding of one blade
on the other so it allows accurate placement at
any position or station of the head.
-the pelvic curve is initially backward then
sweeps forward but never reach the plane of the
shank and handle make a safe rotation in labour.
Classification of forceps
application
1.outlet forceps:- when the scalp is
visible ,fetal skull reached the pelvic
floor
 2.low forceps:-when leading point of
fetal skull is at +2 station or more but
not reached pelvic floor
 3.mid forceps:- fetal skull above +2
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Before application of forceps :
1. Engaged head .
2. Position and attitude of the head .
3. Clinically adequate pelvis (mid ,outlet )
4. Empty bladder .
5. Ruptured membrane .
6. Cervix is fully dilated .
7. Appropriate anaesthesia (vacuum without )
8. Experience of the doctor .
9. Well informed patient .
10. working equipment .
Complication of assisted delivery :
Maternal complication : is more common with
forceps than vacuum .
Soft tissue injuries includes :
Genital : uterine ,cervical ,vaginal ,perineal
lacerations .
Entrapment of the cervix is specific to the vacuum
Bladder and urethral injury : retention ,fistula .
Rectal injuries : laceration ,fistula ,defecation
problems .
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Fetal complication :
With forceps : 1. Transient facial marks.
2. Facial palsy .
3. Fracture of skull or facial bones .
4. Sever cervical cord damage .
With vacuum :
1. Scalp injury .
2. Cephalhaematoma .
3. Subgleal haematoma .
4. Intracranial haemorrhage ..
5. Tentorial tears .
6. Fracture of skull .
7. Neonatal jaundice
8. Retinal haemorrhage
9. Brachial plexus injury .
10. cerebral palsy .
EPISIOTOMY
Episiotomy is an intentional surgical
incision of the perineum after informed
consent with the aim of increasing the
soft tissue outlet dimensions to help with
childbirth.
Episiotomy is advocated when
 anterior tears with bleeding or multiple
perineal tears appear.
 fetal distress it is carried out to expedite
delivery.
 It facilitates instrumental vaginal deliveries
 If the delivery process is delayed and it is
thought to be due to rigid perineum.
. Whenever there are vaginal
manipulations needed such as in some
assisted breech deliveries
 and in cases of shoulder dystocia an
episiotomy may be useful.
 Those women who had a previous pelvic
floor or perineal surgery may also
benefit by an episiotomy.
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Types of episiotomy:
 Midline episiotomy :vertical incision towards
the anus , less blood loss ,easier repair ,quicker
healing , less pain in the postpartum period
,less dysparunia.
-risk of extension to the anus.
 Medio lateral episiotomy : start at midline then
laterally to avoid the anal sphinctor .
 Lateral episiotomy .
Complication:
1.Difficult repair.
2.heavy bleeding.
3.extention to the anus.
4.infection.
5.pain and dyspareunia.
6.weak point in the perinium-tear.
7.Dryness from injury to bartholine
gland.
After care:
1.analgesia,oral or suppositories.
2.prophylactic antibiotics.
3.washing with water and soap.
4.hot sitz bath.
Symphysiotomy
Considered in cases of cephalo-pelvic
disproportion with vertex presentation & living
fetus
Indicated for traped aftercoming head& shoulder
dystortia
Destructive operations
Required when the fetus is dead where
vaginal delivery is is either the only
occur or the mother wish to deliver
1-crniotomy
2-perforation of after-coming head
3-decapitation