Operative procedure

1. OPERATIVE
OBSETRICS
PRESENTED BY
V.KRISHNAPRIYA
MS.C(N)IIYEAR
SCON
SIMATS

2. INTRODUCTION
• Obstetric operations are surgical
procedures and as such irrespective of the
nature of operation (major or minor),
asepsis and antiseptic precautions are to
be taken as outlined in .
• Even an internal examination during late
pregnancy and labor requires utmost
asepsis. The proximity of the bladder and
rectum to the operative field should
deserve attention prior to any operative
procedure.

3. OVER VIEW
• Dilatation and evacuation
• Sucktion evacuation
• Menstral regulation
• Vacuum aspiration
• Hysterotomy
• Episiotomy

4. CONT…
• Operative vaginal delivery
• Forceps
• Ventouse
• Version
• Destructive operations
• Cesarean section

5. PRELIMINARIES:
• Anesthesia
• Lithotomy Position
• Full surgical asepsis
• Empty the bladder
• Vaginal examination

6. Anesthesia
• General/Local
• May be performed with IV Diazepam
sedation

7. Lithotomy Position

8. Full surgical asepsis
• Surgeon is to wear sterile mask, gown &
gloves
• Vulva & vagina is to be swabbed with
antiseptic solution
• Cervix is cleaned with povidone iodine
solution
• Perineum is to be draped by sterile towel
& the legs with leggings

9. Empty the bladder
• If the patient is ambulant, she
is asked to empty the bladder
before she is placed on the
table
• Otherwise, catheterization is to
be done

10. Vaginal examination
• Size of uterus
• Position of uterus
• State of dilatation of cervix

11. Dilatation and evacuation
• The operation consists of
dilatation of the cervix and
evacuation of the products
of conception from the
uterine cavity

12. CONT….

13. ONE STAGE operation
• Incomplete abortion (commonest)
• Inevitable abortion
• Medical termination of pregnancy (6-8
weeks)
• Hydatidiform mole in the process of
expulsion

14. TWO STAGE operation
• Induction of 1st trimester abortion
(commonest)
• Missed abortion (uterus 8-10 weeks)
• Hydatidiform mole with unfavorable cervix

15. INSTRUMENTS

16. CONT….

17. STEPS

18. First phase (slow dilatation of
cervix)
• Consists of introduction of laminaria tents
or lamicel (MgSO4 sponge) into cervical
canal to effect its slow dilatation
• May be effective by intravaginal insertion
of Misoprostol (PGE1), 400mcg 3 hrs
before surgery (less side effect)

19. CONT….

20. STEPS

21. Second phase
• Procedures:
• Patient is brought back to operation
theatre usually after 12 hours
• Patient should empty her bladder
beforehand.
• Preliminaries:
• As mentioned before
• Operation may be conducted under
• IV Diazepam sedation
• Local paracervical block

22. Steps of 2nd stage MTP
8WEEK

23. COMPLICATIONS
IMMEDIATE
• Excessive hemorrhage
• Injury
• Shock
• Perforation
• Sepsis
• Hematometra
• Increased morbidity
• Cont. of pregnancy (1%)

24. CONT…..
LATE
• Pelvic inflammation
• Infertility
• Cervical incompetence
• Uterine synechiae

25. MANAGEMENT PROTOCOL
OF UTERINE PERFORATION

26. SUCTION EVACUATION
• It is a procedure in which the products of
conception are sucked out from the uterus
with the help of a cannula fitted to a
suction apparatus.

27. INDICATIONS
(1)Medical termination of pregnancy during
first trimester (most common)
(2) inevitable abortion
(3) recent incomplete abortion
(4) Hadatidiform mole.

28. Preliminaries:
• GA is usually not needed
• If patient is apprehensive, IV Diazepam 5-
10 mg (conscious sedation) supplemented
by paracervical block is quite effective
• Patient is put on the table after bladder is
emptied

29. STEPS
• Sim’s posterior vaginal speculum is
introduced and hold by assistant
• Anterior lips of cervix is grasped by an
Allis forceps
• Cervical canal is gradually dilated by
graduated metal dilators up to one size
less than the suction cannula

30. Cont….
• Injection Methergin 0.2mg IV
• Appropriate suction cannula is fitted to the
suction apparatus.
• Introduced into the uterus, tip to be placed
in the middle of the uterine cavity.
• Pressure of suction is raised to 400- 600
mmHg.
• Cannula is moved up & down and rotated
360

31. Cont…
• Suction bottle is inspected for the products
of conception & blood loss.
END POINT OF SUCTION
• No more material is being sucked out
• Gripping of the cannula by the
• Contracting smaller size uterus
• Grating sensation
• Appearance of bubbles in the cannula

32. CONT…
• Vacuum should be broken before
withdrawing the cannula
• Better to curette the uterine cavity with
small flushing curette at the end of suction
• Cannula is reintroduced to suck out any
remnants

33. COMPLICATIONS
• Similar complications as mentioned in
D+E operation may occur
• Use of plastic cannula can minimize
uterine perforation
• Blood loss & incomplete evacuation are
less likely with pregnancy of 8 weeks or
less
• Use of USG during procedures shortens
the operative time and reduces
complications

34. MENSTRUAL REGULATION
• Operation is done as an out patient
• Aseptic precautions
• Sedation or paracervical block anesthesia
may be employed
• Introduction of posterior vaginal speculum
& Allis forceps
• Gentle dilatation of cervix using 4-5mm
size dilators
• Insertion of 5-6mm suction cannula
(Karman’s) & attached to 50mL syringe
• Cannula is rotated, pushed in & out with

35. CONT…
• The operator should examine the
aspirated tissue by floating it in a clear
plastic dish over a light source.
• Placental tissue appears fluffy and
feathery when floats in normal saline.
• This will help to detect failed abortion,
molar pregnancy or ectopic pregnancy.
The procedure is contraindicated in
advanced pregnancy and in the presence
of local pelvic inflammation.

36. CONT…
• There is risk of continuation of pregnancy
(0.5–2%) and ectopic pregnancy.
• When no chorionic villi are found on
tissue examination, ectopic pregnancy
should be excluded by estimation of hCG
levels and vaginal ultrasonography

37. VACUUM ASPIRATION
• This procedure is similar to menstrual
regulation and is done as outpatient basis
(p. 204).
• The procedure may be manual vacuum
aspiration (MVA) or electric vacuum
aspiration (EVA) and is highly effective
(98–100%).
• Termination of pregnancy is done up to
12 weeks with minimal cervical dilatation

38. CONT…
• The cannula is inserted transcervically into
the uterus and the vacuum is activated.
• A negative pressure of 660 mm Hg is
created. Aspiration of the products of
conception is done.
• This procedure takes less time (5–15
mins) and is less traumatic.
• Complications are similar to other surgical
methods (p. 644) but are less severe.

39. HYSTEROTOMY
• Hysterotomy is an operative
procedure of extracting the
products of conception out of the
womb before viability (28th week)
by cutting through the anterior
wall of the uterus.
• The operation is usually done
through the abdominal route.

40. INDICATIONS
(i) Midtrimester MTP where other methods
have failed or are contraindicated
(ii) fibroids in the lower uterine segment
obstructing evacuation
(iii) completely low lying placenta (placenta
previa)
(iv) uterine anomalies (uterine didelphys,
septate uterus)
(v) cervical cancer with pregnancy and
(vi) women with multiple previous cesarean

41. STEPS…
• Step I: The uterus is drawn out of the
incision. The abdominal cavity and the
abdominal wall are to be well packed to
prevent contamination by the products of
conception (to minimize scar
endometriosis). If there is difficulty in
delivering the uterus out of the abdomen, it
can be done with a finger hooked through
the uterine incision

42. CONT….
• Step II: Methergine 0.2 mg is given
intravenously. The loose peritoneum of the
uterovesical pouch is cut transversely and
pushed up and down (Fig. 37.4). The
myometrium is cut vertically for about 5 cm
(2") deep enough to make the membranes
visible. Alternatively, the uterine incision
may be vertical in the middle of the body
of the uterus as low down as possible.

43. CONT….
• Step III: The products of conception are
gently coaxed out; the cavity is cleaned
with a gauze covered finger

44. CONT…
• Step IV: The uterine incision is closed in
three layers:
• (a) Deeper myometrium excluding the
decidua (difficult to exclude decidua) is
apposed by continuous sutures using No.
“0” catgut and round bodied needle;
• (b) similar second layer of continuous
suture is employed taking the entire
thickness of the muscle down to the first
layer of suture and

45. CONT….
• Step V: Packs are removed; peritoneal
toileting is done; another dose of
methergine 0.2 mg is administered
intramuscularly and the abdominal wall is
closed in layers

46. COMPLICATIONS
• COMPLICATIONS:
Immediate:
(1) Uterine bleeding
(2) peritonitis
(3) intestinal obstruction and
(4) anesthetic hazards. All these lead to
increased morbidity and an occasional
death.

47. CONT…
• Remote: (1) Menstrual abnormality—
menorrhagia or irregular periods (2) scar
endometriosis (1%) (3) scar rupture in
subsequent pregnancy. While concurrent
sterilization eliminates the hazards, but
those left exposed to future pregnancy
become a growing concern.

48. •VIDEO
PRESENTATIO
N

49. EPISIOTOMY
• A surgically planned incision on the
perineum and the posterior vaginal wall
during the second stage of labor is called
episiotomy (perineotomy).
• It is in fact an inflicted second-degree
perineal injury. It is the most common
obstetric operation performed.

50. CONT….

51. OBJECTIVES
• To enlarge the vaginal introitus so as
to facilitate easy and safe delivery of
the fetus: spontaneous or
manipulative.
• To minimize overstretching and
rupture of the perineal muscles and
fascia; to reduce the stress and strain
on the fetal head.

52. INDICATIONS
• In elastic (rigid) perineum:Causing arrest
or delay in descent of the presenting part
as in elderly primigravidae
Anticipating perineal tear:
(a)Big baby
(b) face to pubis delivery
(c) breech delivery and
(d) shoulder dystocia. Operative delivery:
Forceps delivery, ventouse delivery.

53. CONT…
• Operative delivery: Forceps delivery,
ventouse delivery.
• Previous perineal surgery: Pelvic floor
repair, perineal reconstructive surgery

54. CONT….
• Common indications are:
(1)Threatened perineal injury in
primigravidae
(2) rigid perineum and
(3) forceps, breech, occipitoposterior or face
delivery.

55. Timing of the episiotomy
• Timing of the episiotomy: The timing of
performing the episiotomy requires
judgment. If done early, the blood loss will
be more. If done late, it fails to prevent the
invisible lacerations of the perineal body
and thereby fails to protect the pelvic floor
– the very purpose of the episiotomy is
thus defeated.

56. CONT…
• Bulging thinned perineum during
contraction just prior to crowning (when 3–
4 cm of head is visible) is the ideal time.
During forceps delivery, it is made after
the application of blades

57. ADVANTAGES
• Maternal: It is controversial whether
routine episiotomy has got any major
benefits. The suggested benefits are:
(a)a clear and controlled incision is easy to
repair and heals better than a lacerated
wound that might occur otherwise
(b) reduction in the duration of second stage
and (c) reduction of trauma to the pelvic
floor muscles—that reduces the
incidence of prolapse and perhaps
urinary incontinence.

58. CONT….
• Fetal: It minimizes intracranial injuries,
especially in premature babies or after-
coming head of breech

59. TYPES
• Mediolateral:The incision is made
downwards and outwards from the
midpoint of the fourchette either to the
right or to the left. It is directed diagonally
in a straight line which runs about 2.5 cm
away from the anus (midpoint between
anus and ischial tuberosity).

60. CONT…
• Median:The incision commences from the
center of the fourchette and extends
posteriorly along the midline for about 2.5
cm
• Lateral:The incision starts from about 1 cm
away from the center of the fourchette and
extends laterally. It has got many
drawbacks including chance of injury to
the Bartholin’s duct. It is totally
condemned.

61. CONT….
• J’ shaped:The incision begins in the center
of the fourchette and is directed posteriorly
along the midline for about 1.5 cm and
then directed downwards and outwards
along 5 or 7 O’clock position to avoid the
anal sphincter. Apposition is not perfect
and the repaired wound tends to be
puckered. This is also not done widely.

62. CONT….
• Preliminaries
• Incision
• Repair

63. CONT…
• Perineum is thoroughly swabbed with
antiseptic (povidone-iodine) lotion and
draped properly
• Local anesthesia
• The perineum, in the line of proposed
incision is infiltrated with 10mL of 1%
solution of lignocaine

64. Incision
• Fingers are placed in the vagina between
the presenting part & the posterior vaginal
wall
• Made by a curved/straight blunt pointed
sharp scissors
• One blade is placed inside, in between the
fingers & the posterior vaginal wall.
• The other is on the skin
• Incision should be made at the height of
an uterine contraction

65. CONT…
Timing
• Done soon after expulsion of placenta
• Oozing - controlled by pressure with a
sterile gauze swab Bleeding – artery
forceps
• Early repair prevents sepsis & eliminates
the patient’s prolonged apprehension of
‘stitches’

66. •VIDEO
PRESENTATION

67. Repair
• Preliminaries:
• Lithotomy position
• A good light source from behind is needed
• Perineum & wound area are cleansed with
antiseptic solution
• Blood clots are removed from vagina &
wound area
• Patient is draped properly repair should be
done under strict aseptic

68. CONT..
Done in 3 layers
Principles to be followed are:
1) Perfect hemostasis
2) To obliterate the dead space
3) Suture without tension
Orders:
1) Vaginal mucosa & submucosal tissues
2) Perineal muscles
3) Skin & subcutaneous tissues

69. DRESSING
• Dressing
• The wound is to be dressed each time
following urination & defecation
• To keep area clean & dry
• Swabbing with cotton swabs soaked in
antiseptic powder or ointment (Furacin or
Neosporin)

70. COMPLICATION
• Immediate
• Extension of the incision
• Vulval hematoma
• Wound dehiscence
• Incontinence

71. CON…
• Remote
• Dyspareunia
• Chance of perineal lacerations
• Scar endometriosis (rare)

72. OPERATIVE VAGINAL
DELIVERY

73. DEFINITION
• Operative vaginal delivery refers to any
delivery process which is assisted by
vaginal operations. Delivery by forceps,
ventouse and destructive operations are
generally included.

74. FORCEPS
• Obstetric forceps is a pair of instruments,
especially designed to assist extraction of
the fetal head and thereby accomplishing
delivery of the fetus.
• VARIETIES OF OBSTETRIC FORCEPS:
Ever since either Peter I or Peter II of the
Chamberlen family invented the forceps
around AD 1600, more than 700 varieties
were invented or modified. Most of them
are of historical interest only.

75. CONT…
• Long-curved forceps with or without axis-
traction device
• Short-curved forceps
• Kielland’s forceps

76. LONG-CURVED OBSTETRIC
FORCEPS
• Long-curved obstetric forceps is relatively
heavy and is about 37 cm (15") long andis
commonly used with advantages.
• It is comparatively lighter and slightly
shorter than its Western counterpart but is
quite suited for the comparatively small
pelvis and small baby of Indian women.

77. Cont…

78. Cont….
• Measurements: Length is 37 cm; distance
in between the tips is 2.5 cm and widest
diameter between the blades is 9 cm.
• BLADES: There are two blades and are
named right or left in relation to maternal
pelvis in which they lie when applied. Each
blade consists of the following parts:(1)
Blade (2) shank (3) lock and (4) handle
with or without screw.

79. Cont…
Pelvic curve: The curve on the edge is to fit
more or less the curve on the axis of the
birth canal (curve of Carus). It forms a part
of a circle whose radius is 17.5 cm (7").
The front of the forceps is the concave
side of the pelvic curve. Pelvic curve
permits ease of application along the
maternal pelvic axis

80. Cont…
• Cephalic curve: It is the curve on the flat
surface which when articulated grasps the
fetal head without compression. The
radius of the curve is 11.5 cm (4.5").
• Shank: It is the part between the blade
and the lock and usually measures 6.25
cm (2.5"). It increases the length of the
instrument and thereby, facilitates locking
of the blades outside the vulva

81. Cont…
• Lock: The common method of articulation
consists of a socket system located on the
shank at its junction with the handle
(English lock). Such type of lock requires
introduction of the left blade first.

82. Cont…
• Handle: The handles are apposed when
the blades are articulated. It measures
12.5 cm (5"). There is a finger guard on
which a finger can be placed during
traction

83. HOW TO IDENTIFY THE
BLADES?
• Place the instrument in front of the pelvis
with the tip of the blades pointing upwards
and the concave side of the pelvic curve
forward. The blade which corresponds to
the left of the maternal pelvis is the left
blade and that to the right side is the right
blade

84. Cont….
• When isolated:
(1)The tip should point upwards
(2) the cephalic curve is to be directed
inwards and the pelvic curve forwards.

85. Short-Curved Obstetric Forceps
(Wrigley)
• The instrument is lighter, about a third of
the weight of an ordinary long-curved
forceps. The instrument is short which is
due to reduction in the length of the
shanks and handles (Fig. 37.7C). It has a
marked cephalic curve with a slight pelvic
curve.

86. Cont….
• Kielland’s Forceps It is a long almost
straight (very slight pelvic curve) obstetric
forceps without any axis-traction device. It
has got a sliding lock which facilitates
correction of asynclitism of the head. One
small knob on each blade is directed
towards the occiput.

87. CHOICE OF FORCEPS
OPERATION
• Outlet forceps: It is a variety of low forceps
where the head is on the perineum Thus,
all outlet forceps are low forceps but not all
low forceps are outlet forceps operations.
• Low forceps (90%): The head is near the
pelvic floor or even visible at the introitus.
It is commonly used nowadays with
advantages

88. Cont…
• Midforceps (10%): Prerequisites are: (i)
Must be associated with less maternal
morbidity than Cesarean section (ii) should
not cause any fetal damage. Unless the
prospect of successful vaginal delivery is
high midforceps delivery is best avoided.
Manual rotation may be needed before
traction. In a selective case, delivery by
rotational forceps by an expert is safe.

89. TYPES OF APPLICATION OF
FORCEPS BLADES
• Cephalic application: The blades are
applied along the sides of the head
grasping the biparietal diameter in
between the widest part of the blades. The
long axis of the blades corresponds more
or less to the occipitomental plane of the
fetal head. It is the ideal method of
application as it has got a negligible
compression effect on the cranium.

90. Cont..
• Pelvic application: When the blades of the
forceps are applied on the lateral pelvic
walls ignoring the position of the head, it is
called pelvic application. If the head
remains unrotated, this type of application
puts serious compression effect on the
cranium and thus must be avoided.

91. •VIDEO
PRESENTATION

92. VENTOUSE
• Ventouse is an instrumental device
designed to assist delivery by creating a
vacuum between it and the fetal scalp.
The pulling force is dragging the cranium
while in forceps, the pulling force is directly
transmitted to the base of the skull.

93. Cont…

94. Types
• Spontaneous: Version process occurs
spontaneously. The incidence of
spontaneous version in breech
presentation is nearly 55% after 32 weeks
and about 25% after 36 weeks. It is more
common in multiparous women.

95. Cont
• External: The maneuver is done solely by
external manipulation. Internal: The
conversion is done principally by one hand
introducing into the uterus and by the
other hand on the abdomen.
• Bipolar (Braxton-Hicks): The conversion is
done introducing one or two fingers
through the cervix and by the other hand
on the abdomen.

96. • VIDEO PRESENTATION

97. EXTERNAL CEPHALIC
VERSION
• External cephalic version is done to bring
the favorable cephalic pole in the lower
pole of the uterus.
• INDICATIONS:
• Breech presentation
• Transverse lie Selection of time,
contraindication, difficulties and
complications have already been
described

98. Advantages
(i) Reduces the incidence of breech
presentation at term and of breech
delivery
(ii) reduces the number of Cesarean delivery
(iii) reduces maternal morbidity due to
Cesarean or vaginal breech delivery and
(iv) reduces the fetal hazards of vaginal
breech delivery

99. Preliminaries:
• The patient is asked to empty her bladder.
She is to lie on her back with the
shoulders slightly raised and the thighs
slightly flexed. Abdomen is fully exposed.
The presentation, position of the back and
limbs are checked and FHR is
auscultated.

100. Procedure
• Step I
• The breech is mobilized using both hands
to one iliac fossa towards which the back
of the fetus lies. The podalic pole is
grasped by the right hand in a manner like
that of Pawlik’s grip while the head is
grasped by the left hand.

101. Cont…
• The pressure (firm but not forcible) is now
exerted to the head and the breech in the
opposite directions to keep the trunk well
flexed which facilitates version. The
pressure should be intermittent to push the
head down towards the pelvis and the
breech towards the fundus until the lie
becomes transverse. The FHR is once
more to be checked.

102. Cont…
• The hand is now changed one after the
other to hold the fetal poles to prevent
crossing of the hand. The intermittent
pressure is exerted till the head is brought
to the lower pole of the uterus.

103. •VIDEO
PRESENTATION

104. INSTRUCTIONS
• (1)The patient is advised for follow up to
check the corrected position
• (2) to report to the physician if there is
vaginal bleeding or escape of liquor amnii
or labor starts and
• (3) Rh-negative nonimmunized women
must be protected by intramuscular
administration of 100 µg anti-D gamma
globulin

105. Cont….
• EXTERNAL VERSION IN TRANSVERSE
LIE: The version is much easier than in
breech. The association of placenta previa
or congenital malformation of the uterus
should be excluded.
• EXTERNAL PODALIC VERSION: The
external podalic version may be done in
cases when the external cephalic version
fails in transverse lie in case of the second
baby of twins

106. INTERNAL VERSION
• Internal version is always a podalic version
and is almost always completed with the
extraction of the fetus.
• INDICATIONS:
• Internal version is hardly indicated in a
singleton pregnancy in present day
obstetric practice. Its only indication being
the transverse lie in case of the second
baby of twins.

107. Cont,…
• CONDITIONS TO BE FULFILLED:
• (1) The cervix must be fully dilated
• (2) liquor amnii must be adequate for
intrauterine fetal manipulation and
• (3) fetus must be living.

108. Cont…
• CONTRAINDICATIONS: It must not be
attempted in neglected obstructed labor
even if the baby is living

109. Procedure
• Step I: Patient is placed in dorsal lithotomy
position. Antiseptic cleaning drapings and
catheterization are done.
• Introduction to head if the podalic pole of
the fetus is on the left side of the mother,
the right hand is to be introduced and vice
versa

110. Cont…
• Step II: The hand is to pass up to the
breech and then along the thigh until a foot
is grasped. The identification of the foot is
done by palpation of the heel. It is
advantageous to grasp the first foot which
one encounters.

111. Cont…
• Step III: While the leg is brought down by
a steady traction, the cephalic pole is
pushed up using the external hand.
• Step IV: After one leg is brought down,
there is no difficulty to deliver the other
leg. The delivery is usually completed with
breech extraction during uterine
contractions.
• Step V: Routine exploration of the
uterovaginal canal to exclude rupture of

112. Cont….
• COMPLICATIONS: Maternal risk includes
placental abruption, rupture of the uterus
and increased morbidity. The fetal risk
includes asphyxia, cord prolapse and
intracranial hemorrhage apart from all
hazards of breech delivery leading to a
high perinatal mortality of about 50%.

113. CESAREAN SECTION
• DEFINITION:It is an operative procedure
whereby the fetuses after the end of 28th
weeks are delivered through an incision on
the abdominal and uterine walls.
• The first operation performed on a patient
is referred to as a primary cesarean
section. When the operation is performed
in subsequent pregnancies, it is called
repeat cesarean section

114. Indications

115. PREOPERATIVE
PREPARATION
• Abdomen is scrubbed with soap and
nonorganic iodide lotion.
• Hair may be clipped.
• Premedicative sedative must not be given.
• Nonparticulate antacid

116. Cont..
• Ranitidine (H2 blocker) 150 mg is given
orally night before (elective procedure)
and it is repeated (50 mg IM or IV) 1 hour
before the surgery to raise the gastric pH.
• The stomach should be emptied, if
necessary by a stomach tube (emergency
procedure).
• Metoclopramide (10 mg IV) is given to
increase the tone of the lower esophageal
sphincter as well as to reduce the stomach

117. Cont..
• Bladder should be emptied by a Foley
catheter which is kept in place in the
perioperative period.
• FHS should be checked once more at this
stage.
• Neonatologist should be made available.
• Cross match blood when above average
blood loss (placenta previa, prior multiple
cesarean delivery) is anticipated.
• Prophylactic antibiotics should be given

118. Cont…
• IV cannula: Sited to administer fluids
(Ringer’s solution, 5% dextrose).
• Position of the patient:The patient is
placed in the dorsal position. In
susceptible cases, to minimize any
adverse effects of venacaval compression,
a 15° tilt to her left using a wedge till
delivery of the baby should be done..

119. Cont..
• Anesthesia—may be spinal, epidural or
general (see p. 593). However, choice of
the patient and urgency of delivery are
also considered. Antiseptic painting:The
abdomen is painted with 7.5% povidone-
iodine solution or savlon lotion and to be
properly draped with sterile towels.

120. Uterine incision
• Peritoneal incision: The loose peritoneum
of the uterovesical pouch is cut
transversely across the lower segment
with convexity downwards at about 1.25
cm (0.5”) below its firm attachment to the
uterus. The lower flap of the peritoneum is
pushed down a little

121. Cont….
• Muscle incision : The most commonly
used incision (90%) is low transverse.
Advantages are: Ease of operation; less
bladder dissection, less blood loss, easy to
repair, complete reperitonization, less
adhesion formation, less risk of scar
rupture when trial (VBAC) of labor (p. 384)
is given for subsequent delivery.

122. Cont…
• Other types of uterine incisions are
• (a) Lower vertical—may be extended
upwards when needed.
• classical incision (upper segment).
• “J” incision—upward vertical extension of
the initial transverse incision.
• inverted “T” incision—upward extension
from the mid-transverse incision

123. Cont....
• Delivery of the head The membranes are
ruptured if still intact. The blood mixed
amniotic fluid is sucked out by continuous
suction.
• The Doyen’s retractor is removed. The
head is delivered by hooking the head with
the fingers which are carefully insinuated
between the lower uterine flap and the
head until the palm is placed below the
head..

124. Cont..
• . The head is delivered by elevation and
flexion using the palm to act as a fulcrum.
As the head is drawn to the incision line,
the assistant is to apply pressure on the
fundus

125. Cont…
• Delivery of the trunk:As soon as the head
is delivered, the mucus from the mouth,
pharynx and nostrils is sucked out using
rubber catheter attached to an electric
sucker.
• After the delivery of the shoulders,
intravenous oxytocin 20 units or
methergine 0.2 mg is to be administered.

126. Cont..
• The optimum interval between uterine
incision and delivery should be less than
90 seconds. Interval > 90 seconds are
associated with poor Apgar scores.
• There is reflex uterine vasoconstriction
following uterine incision and
manipulation.

127. Cot….
• And manipulation. Removal of the
placenta and membranes: By this time, the
placenta is separated spontaneously. The
placenta is extracted by traction on the
cord with simultaneous pushing of the
uterus towards the umbilicus per abdomen

128. •VIDEO
PRESENTATION.

129. SUTURE
• Suture of the uterine wound : The suture
of the uterine wound is done with the
uterus keeping in the abdomen. Some,
however, prefer to eventrate the uterus
prior to suture

130. • First layer: The first stitch is placed on the
far side in the lateral angle of the uterine
incision and is tied. The suture material is
No “0” chromic catgut or vicryl and the
needle is round bodied.
• A continuous running suture taking deeper
muscles excluding or including the
decidua.

131. CONT..
• Second layer: A similar continuous suture
is placed taking the superficial muscles
and adjacent fascia overlapping the first
layer of suture. Uterine muscles may be
closed using a continuous single layer
stitch taking full thickness muscle and
decidua

132. POSTOPERATIVE CARE
• Observation for the first 6–8 hours is
important. Periodic checkup of pulse, BP,
amount of vaginal bleeding and behavior
of the uterus.
• Fluid: Sodium chloride (0.9%) or Ringer’s
lactate drip is continued until at least 2.0–
2.5 L of the solutions are infused. Blood
transfusion is helpful in anemic mothers
for a speedy post-operative recovery.

133. CONT..
• Oxytocics: Injection oxytocin 5 units IM or
IV (slow) or methergine 0.2 mg IM is given
and may be repeated.
• Prophylactic antibiotics (cephalosporins,
metronidazole) for all cesarean delivery
(see p. 726) is given for 2–4 doses.
Therapeutic antibiotic is given when
indicated

134. CONT…..
• Analgesics in the form of pethidine
hydrochloride 75–100 mg is administered
and may have to be repeated.
• Ambulation: The patient can sit on the bed
or even get out of bed to evacuate the
bladder, provided the general condition
permits.

135. NURSING DIAGNOSIS
• 1.Acute pain related to surgical procedure
• INTERVENTION:
• i)Assess the general condition of mother
• iiProvide comfortable position
• iii)Provide iv antibiotics.
• iv)Provide analgesics
• v)Psychological support

136. CONT..
• 2.Fluid volume deficit related to blood loss
in surgical procedures.
• i)Assess the general condition of mother
• ii)Maintain i/o chart.
• iii) Encourage the mother to take more
fluids.

137. CONT…
• 3)Risk for infection related to surgical
procedure.
• INTERVENTION:
• i)Assess the general condition of mother
• ii)Use aseptic techniques while careing
mother
• iii)Perform surgical dressing care.

138. JOURNEL
• JOURNEL:
• International Journal of Health Sciences and
Research
• TOPIC: Efficacy of Adding Buprenorphine to the
Local Anaesthetics in Patients Undergoing
Lower Segment Caesarean Section (LSCS)
• AUTHOR:
• Haribabu R1 , Revathi P2
• PUBLICATION YEAR:2016.

139. CONT…
• Buprenorphine is a mixed agonist-
antagonist narcotic with high affinity at
both µ and k opiate receptors. The aim of
the study was to compare intrathecal
bupivacaine (0.5%) and buprenorphine
(3mcg/kg) with bupivacaine (0.5%) an
hour prior to surgery. One Hundred cases
of LSCS of ASA-I, between age group 25-
30 patients were taken for the study.

140. CONT….
• First Fifty patients were given, 2ml of plain
bupivacaine-Heavy 0.5%. Another fifty
patients were given 2ml of Bupivacaine-
heavy along with 0.5ml (3mcg/kg) of
Buprenorphine pre-operatively, for all
patients, BP, Pulse, SPO2 monitored

141. RESULT
• Among the subjects, 10% of Group B
having nausea and vomiting, 2% of Group
B had mild itching. Post operative
shivering was less in Group B. Duration of
analgesia was 4 hours in Group A, 16-18
hours in Group B. Mild Sedation was
observed in Group B.

142. THEORY APPLICATION

143. CONT…

144. CONT….

145. CONT….