sdcsdcs

1. DAY X
Operative vaginal delivery
Cesarean section and postpartum hysterectomy

2. OPERATING OBSTETRICS
Interventions Intrapartum
1. Vaginal:
• Vacuum Extraction
• Forceps Delivery
2. Abdominal:
• Cesarean Section
• Postpartum Hysterectomy

3. INDICATION FOR FORCEPS DELIVERY
Mother Factors:
• Extragenital diseases (heart diseases, eye diseases)
• Preeclampsia, Eclampsia
• Failure to progress labor
Fetal Factors:
• Fetal dystress
• Premature abruption of placenta

4. THE MOST IMPORTANT FUNCTION OF BOTH DEVICES IS
TRACTION
FORCEPS ASSISTED VACUUM ASSISTED
All pre-requisites should be
fulfilled.
Rarely done nowadays due to
increased risk of complications.
Best to apply in fully dilated
cervix and rotated head, but
can be used if cervix is ≥ 6cm
and in non-rotated heads.
Alive Fetus
Cervix should be fully dilated
Amniotic sac should be ruptured
No cephalopelvic disproportion
Head engaged
Empty urinary bladder
Adequate anesthesia
Conditions for Forceps Delivery
The important step in
Vacuum Extraction is
proper cup placement
over the flexion point
Suction
Traction

5. CONTRA-INDICATIONS
• CPD
• Inadequate pelvis
• Known bony deformities of the
fetus (e.g., osteogenesis
imperfecta)
• Known coagulopathy of the fetus
• HIV +ve mother
• Prolonged 2nd stage of labour leading to fetal distress
(station ≥ +2)
• Maternal distress / exhaustion
• Prophylactic use of forceps/vacuum : To cut short the
2nd stage of labour in heart disease, or PIH patients.
INDICATIONS

6. FORCEPS OVER VACUUM:
Vacuum C/I :
- Preterm babies
- Intrauterine death ( d/t macerated head )
- After coming head of breech
- Face presentation ( in mentoanterior position)
Forceps preferred over vacuum :
- Heart disease in mother.

7. VACUUM DELIVERY : POSITION OF
APPLICATION
centre of the vacuum cup should be at ‘flexion point’ on
sagittal suture.
When correctly placed, edge of cup touches the posterior
fontanelle.
If the cup is placed anteriorly, can lead to extension of the
head leading to trauma.

8. FORCEPS DELIVERY : HOW TO
APPLY?

9. ● Station ≥ +2, but has not reached
perineum.
● Most forceps are low forceps
LOW FORCEPS APPLICATION
● When head at perineum. (Scalp
visible at introitus & skull on pelvic
floor)
● Ideally, sagittal suture should be in AP
diameter
● Outlet forceps : Wrigley forceps
FORCEPS DELIVERY : APPLICATION CRITERIA
OUTLET FORCEPS APPLICATION

10. DIRECTION OF PULL
WHEN APPLYING
FORCEPS :
• Ideal position of patient : LITHOTOMY position
• Take consent, give adequate analgesia, and
give episiotomy
Direction of pull in low
forceps
Direction of pull in outlet
forceps
1st pull Downward + Backward Downwards
2nd pull Downward Downward + Forward
3rd pull Downward + Forward

11. FORCEPS
● Facial nerve palsy
● Brachial plexus injury
● Corneal injury
● Requires good skill and training.
FLED Forceps/Vacuum Delivery = 3 Failed trials => managed by C-section
VACUUM
VIth nerve palsy
● Shoulder dystocia
● Cephalohematoma
● Subgaleal haemorrhages
● Retinal injury
● Easier to use and done more commonly.
FETAL COMPLICATIONS

12. CESAREAN SECTION
C-section is defined as delivery of the
fetus through incisions in the
abdominal wall (laparotomy) and
the uterine wall (hysterotomy). This
definition does not include removal
of the fetus from the abdominal
cavity in case of rupture of the uterus
or abdominal pregnancy

13. MATERNAL INDICATIONS
● Failed progress of labor
● Failed instrumental delivery
● CPD
● Transverse lie
● Brow or face presentation (where intrumental
delivery cant be done)
● Antepartum hemorrhage
● Pre-eclampsia
● Infection
● Repeated cesareans
● Maternal request
FETAL INDICATIONS
● Presentation of the fetus
● Macrosomia
● Higher order multiple pregnancies
● Preterm births
● Fetal distress
INDICATIONS

14. TYPES OF INCISIONS

15. CLASSICAL CESARIAN SECTION [CCS]
Incision at upper uterine segment
[ Upper segment: Thick and contractile ]
Disadvantages:
1. Bleeding is more
2. Repair is difficult
3. Healing is not good
• If CCS done once → subsequent pregnancies → always
C-section
• High risk of rupture in subsequent pregnancy: 4-9%

16. KERR / PFANNENSTIEL INCISION
MOST COMMON
● For subsequent pregnancy- vaginal
birth after C-section (VBAC) can be
tried
● Very low risk of rupture in next
pregnancy: 0.2-0.9%
Lower segment stretches during labour & are non-contractile
ADVANTAGES : less bleeding, easy repair, better healing
KRONIG’S / DEE-LEE VERTICAL INCISION
IN LS
● Only indication is constriction ring.
● Subsequent pregnancies always do C-
section.
● There is risk of bladder injury if
incision is extended.
● Risk of rupture is 1-7%
LOWER SEGMENT CESARIAN SECTION
[LSCS]

17. ● Quick entry
● More exposure
● Less bleeding
● Minimal nerve damage
● Wound dehiscence more as less
blood supply
● Cosmetically not good
═► not preferred
● Stronger
● Cosmetically better
═► preferred
MIDLINE V/S PFANNENSTEIL

18. ANESTHESIA
PREFERRED : SPINAL ANAESTHESIA
INDICATIONS OF GA :
→SEVERE FETAL DISTRESS
→IN CERTAIN HEART CONDITIONS [ INTRACARDIAC SHUNTS, HYPERTROPHIC
CARDIOMYOPATHY
→,]
→IN SEVERE PRE-ECLAMPSIA [ WHEN THERE IS ABSENT OR REVERSED END-DIASTOLIC FLOW ]

19. PRE-OPERATIVE PREPARATION :
• Consent
• Foley’s catheterisation
• Parts preparation
• Shaving is not recommended
• Antibiotic prophylaxis
o Elective : 60 mins before cesarean
o Emergency : as soon as possible
o Antibiotics are given post-op only if :
 blood loss ≥ 1500ml
 Duration of patient ≥ 3 hrs
Position of the patient :
Supine with 15° left lateral tilt of table or place a wedge under the right
hip { to avoid IVC compression }

20. STEPS / LAYERS CUT :
1. Skin & Subcutaneous
tissue
2. External oblique muscle
3. Internal oblique muscle
4. Transverse abdominis
5. Fascia transversalis
6. Anterior rectus sheath
7. Rectus abdominis muscle
8. Posterior rectus sheath
9. Peritoneum
10. Abdominal cavity –
bladder, uterus

21. STEPS OF CLOSURE:
►Uterus = closed by single/double layered continuous absorbable sutures
►Examine tubes, ovaries, & broad ligament for any injury or hematoma formation.
►Peritoneum = May or may not be closed – based on surgeon preference.
►Rectus abdominis muscle = not closed
►Rectus sheath = closed by continuous absorbable sutures
►Skin = closed by interrupted/subcuticular suture/with help of staplers.
Suture Materials –
• Vicryl 1-0 : uterus, rectus sheath
• Monocryl sutures : subcuticular skin suture
• Silk / prolene sutures : interrupted skin suture

22. COMPLICATIONS
OPERATIVE
• Shock
• Anasthetic complications –
particularly mendelson’s syndrome
• Hemorrhage usually due to
extension of uterine incision to
uterine vessels, atony of uterus, or
DIC
• Injuries to bladder or ureter
• Fetal injuries
POST-OPERATIVE
Early :
• Thrombosis & PE
• Acute dilation of stomach &
paralytic ileus
• Wound infection, puerperal sepsis,
and burst abdomen
• Chest infection
Late :
• Scar rupture
• Incisional hernia

23. SCAR DEHISCENCE & UTERINE
RUPTURE:
• Uterine dehiscence is considered an
incomplete division sparing serosa, allowing
visibility of the foetus through the
perimetrium.
• Uterine rupture is a complete division of all
three layers of the uterus: the perimetrium,
myometrium, and endometrium

24. • Cesarean Hysterectomy.
Indications: Indications for cesarean hysterectomy are discussed in connection with the
various conditions for which the operation is indicated. A few of these include
• intrauterine infection;
• a grossly defective scar;
• a markedly hypotonic uterus that does not respond to oxytocin, prostaglandins and
massage ;
• laceration of major uterine vessels;
• large myomas; and severe cervical dysplasia or carcinoma
• Placenta accrete or increate often may best be treated by immediate hysterectomy if
cesarean section is performed.
Major derrents to cesarean hysterectomy are concern for increase blood loss and the
frequency of urinary tract damage. A major factor in the complication rate appears to
be whether the operation is performed as an elective procedure or as an emergency.
There are ; Supracervical Hysterectomy and Total Hysterectomy.

25. Subsequent Care
Vital Signs. The patient is not evaluated at least hourly for 4 hours ate
ate the minimum, and blood pressure , pulse, urine flow, amount of
bleeding and status of the uterine fundus are checked at these times.
Thereafter , for the first 24 hours, these are checked at intervals of 4
hours along with the temperature.

26. • In the absence of extensive intra-abdominal manipulation or sepsis ,
the woman nearly always should be able to tolerate oral fluids or
even a regular diet the day after surgery. By the second day after
surgery, the great majority of women tolerate a general diet.
• Bladder and Bowels. The bladder catheter most often can be
removed by 12 hours after operation or , more conveniently, the
morning after surgery.
• Ambulation. In most instances , by the day after surgery the patient,
with assistance , should get out of bed briefly at least twice.
Ambulation can be timed so that a recently administer analgesic will
minimize the discomfort.

27. • Wound care. The incision is inspected each day, and the skin sutures
(or clips) are removed on the 7-8 th day after surgery . By the third
postpartum day, bathing by shower is not harmful to the incision.
• Laboratory. The hematocirt is routinely measured the day after
surgery. It is checked sooner when there was unusual blood loss or
when there is oliguria or other evidence to suggest hypovolemia. If
the hematocrit is decreased significantly from the preoperative level,
it is repeated and a search is instituted to identify the cause of the
decrease. If the lower hematocrit is stable , the mother can
ambulate without any difficulty and if there is little likelihood of
further blood loss, hematological repair is response to iron therapy
is preferred to transfusion.

28. • Breast Care. Breast feeding can be initiated by the day after surgery.
If the mother elects not to breast feed, a breast binder that supports
the breasts without marked compression will usually minimize
discomfort.
• Discharge from the hospital; Unless there are complications
the puerperium , the mother may be safely discharged from the
hospital on the third or fourth postpartum day. Her activities
during the following week should be restricted to self-care and
care of her baby with assistance. It is advantageous to perform the
initial postpartum evaluation during the third week after delivery
rather than at the more traditional time of 6 weeks.

29. • Prophylactic Antimicrobial Therapy .Febrile morbidity is rather
frequent after cesarean section and appears to be more common
among indigent than affluent women. The literature is replete with
reports of reduced febrile morbidity with antibiotics administered
prophpylactically. Without prophylactic antimicrobials 85% of
women in labor with membranes ruptured for longer than 6 hours
who underwent CD may developed serious infections . The
incidence was much less in women who underwent C-section after
laboring with membranes intact.
• Moreover associated complications such as wound abscesses and
pelvic phlegmons were encountered in less than 1% of women
with intact membranes, compared with 30 % of women whose
membranes ruptured more than 6 hours before cesarean section.

30. • Finally , bacteremia was four times more common in those women
whose membranes ruptured longer than 6 hours before surgery and
who subsequently demonstrated infection. Subsequently
therapeutic intervention was evaluated for this high-risk group of
nulliparous women who underwent CD because of cephalopelvic
disproportion. The administration of an antibiotic as soon as the
cored was clamped , followed by two more doses of the same
medications give at intervals of 6 hours , resulted in a reduction in
postoperative metritis from 85 to 20 %

31. Associated compilations , such as pelvic phlegmons, incisional
abscesses and pelvic thrombophlebitis also decrease dramatically.
It is emphasized that the woman with clinically diagnosed
chorioamnionitis should be given continuous antimicrobial therapy
postoperatively until she is a febrile .

32. • Trial of labor after cesarean (TOLAC) - is associated with a small
but significant risk of uterine rupture with poor outcome for
mother and infant:
• Classical uterine incision : 10% risk
• Low-transverse incision : 1% risk
• Maternal and infant complications are higher with a failed trial of
labor followed by cesarean delivery
• Candidates for TOLAC
• One LTCS
• Clinically adequate pelvis
• No other uterine scars or previous rupture
• Physician immediately available throughout active labor capable of
monitoring labor and performing and emergency CD
• Availability of anesthesia and personnel for emergency CD