Operative obstetrics by Dr muhammad bilal

2. OPERATIVE INTERVENTION
IN
OBSTETRICS

3. Operative
Obstetrics
Operative
Vaginal
deliveries
Episiotomy Cesarean
Section

4. Operative vaginal
delivery

5. Delivery of baby vaginally using
an instrument.

6. INDICATIONS FOR OVD
No indication is
absolute
• Prolonged 2nd
stage of labor
• Fetal
compromise
• Maternal benefit
to shortened 2nd
stage
Contraindications
• Gestation of
less than 35
week
• Breech
presentation

7. TYPES
A. Forceps Delivery
B. Vacuum Extraction

8. PREREQUISITES FOR OVD
 Informed consent
 Vertex
 Engaged
 ≥34 weeks (vacuum delivery)
 Fully dilated
 Membranes ruptured
 Adequate maternal pelvis
 Adequate anesthesia
 Maternal empty bladder
 Backup plan
 Ongoing fetal and maternal assessment

9. PREREQUISITES FOR OVD
 Informed consent
 Vertex
 Engaged
 ≥34 weeks (vacuum delivery)
 Fully dilated
 Membranes ruptured
 Adequate maternal pelvis
 Adequate anesthesia
 Maternal empty bladder
 Backup plan
 Ongoing fetal and maternal assessment

12. INDICATIONS OF
FORCEPS DELIVERY
• 1. Heart disease
• 2. Pulmonary compromise
or injury
• 3. Intrapartum infection
• 4. certain neurological
conditions
• 5. Exhaustion
• 6. Prolonged second stage
Maternal
Indications

13. FORCEPS DELIVERY
• 1. prolapse of
umbilical cord
• 2. premature
separation of the
placenta
• 3. non-reassuring fetal
heart rate pattern
Fetal
indications

14. B.VACUUM EXTRACTION
Principle
 Creation of an artificial caput by attaching a
traction device by suction to the fetal scalp

16. VACUUM EXTRACTION
Technique
 Center of the cup
should be over the
sagittal suture about 3
cm. in front of the
posterior fontanelle

17. Complication of forceps
delivery
• Maternal
• Lacerations to the
vagina , cervix,
perineum, and uterus.
• Fetal-neonatal:
• Soft tissue
compression or
cranial injury.
Complication of
vacuum extractor:
• Maternal:
• Vaginal lacerations
• Neonatal:
• Cephalohematoma
• Scalp laceration
• Intra cranial
hemorrhages

18. CESAREAN DELIVERY
 Birth of a fetus through incisions in
the abdominal wall (laparotomy) and
the uterine wall (hysterectomy).

19. THE FIVE MOST COMMON CAUSES OF
CESAREAN SECTION
CS on Request
Routine repeat cesareans .
Dystocia (non-progressive labor) .
Abnormal fetal presentation eg breech ,
transeverse , cord presentation .
Fetal distress .

20. CESAREAN DELIVERY
Criteria for timing of repeat cesarean:
1. FHT have been documented for 20 weeks by
fetoscope or 30 weeks by doppler.
2. 36 wks. Since a +serum or urine HcG
3. US with CRL at 6-11 wks compatible with 39 wks.
4. US at 12-20 wks compatible with 39 weeks
determined by clinical Hx & PE

21. Elective caesarian section
(Planned operation)
Advantages are:-
Patient with empty stomach and surgeon
usually with full breakfast
Best anesthetist available at that time
Best assistant and nursing staff.
Disadvantages are :-
If wrong judgment, premature child may be
born.
Cervix may not be dilated and hence poor
drainage of lochia
Lower segment is not formed and hence
uterine incision in lower part of upper
segment.
Emergency caesarian
section (Unplanned)
Working under adverse circumstances:-
Patient may be with full stomach and
surgeon may be with empty belly
Odd working hours either of day or
night
Anesthetist, assistant and nursing staff
may not be of your choice
Advantage is :-
Mature child as patient is in labor
Cervix is open, better drainage of
lochia.
Lower segment is well formed

22. CESAREAN DELIVERY
Abdominal Incisions
1. Vertical Incision
quickest to make
greater chance of dehiscence
2. Pfannenstiel Incision
cosmetically better, stronger
less chance of dehiscence
exposure not as good

23. CESAREAN DELIVERY
Types of uterine incisions
1. Classical
vertical incision into the body of uterus
Indications:
a. Lower segment cannot be exposed
b. transverse lie
c. placenta previa, anteriorly located
d. Lower segment not formed

24. ABDOMINAL OPERATIONS: CESAREAN
DELIVERY
2. Low Segment Transverse
 easier to repair
 located at a site least likely to rupture in a
subsequent pregnancy
 Does not promote adherence of bowel or omentum
to the incisional line

25. CESAREAN DELIVERY

26. COMPLICATIONS
•Bowel damage
•U T damage
•Placenta
previa
•hemorrhage
Intra
operative

27. COMPLICATIONS(CONTINUED..)
• 1.infection
• 2.endometriosis
• 3. embolism
• 4.psychological
Post
oprative

28. PURPOSE OF EPISIOTOMY:
“A surgical incision of the perineum
usually performed to enlarge the vaginal
opening and assist in childbirth.”
EPISIOTOMY:
The purpose is to increase the diameter of the soft
tissue pelvic outlet, thereby preventing perineal
lacerations, facilitating delivery, and reducing the time
for expulsion of the infant.

30. POSSIBLE INDICATION FOR EPISIOTOMY:
Shoulder dystocia
Vaginal breech delivery
Non-assuring monitoring tracing
Forceps or vacuum extractor vaginal delivery
Narrow birth canal.

31. COMPLICATION:
Perineal*
trauma
Infection
Dehiscence
Hematoma
Recto
vaginal
fistula
Recto
vaginal
fistula
Perineal
abscess

33. PREVENTION
 Avoid assisted delivery
 Vacuum if needed
 Restrictive use of episiotomy
 Support perineum during delivery
 Allow time for perineal thinning

34. THANK YOU
By
Muhammad Bilal
Roll no 08-111