Pdf for operative procedure in obstetrics

1. Operative procedure in Obstetric
Fadzlina ZS (08201310006)

2. Introduction
Obstetric operation are surgical procedures
Requires aseptic precautions and
some protocols should be followed
Preliminaries :
1. Anesthesia
2. Lithotomy position
3. Full surgical asepsis
4. Empty the bladder
5. Vaginal examiination

3. Operative procedure in Obstetric
• Dilatation & evacuation
• Suction & evacuation
• Vacuum aspiration
• Life saving procedure – cervical
cerclage
Abortion
• Craniotomy
• Evisceration
• Decapitation
• Cleidotomy
Destructive

4. • Episiotomy
• Forceps delivery
• Ventouse
• Breech extraction
Vaginal
• Caesarean section
• Symphysiotomy
• Postpartum hysterectomy
Abdominal

5. Abortion
Expulsion or extraction from its mother of an
embryo/fetus weighing 500g or less when it is capable
of independent survival
500g of fetal development is attained
appx. – 22weeks

6. Abortion
Spontaneous
(miscarriage)
Isolated Recurrent
Induced
(deliberate)
Legal (MTP)
Illegal
(unsafe)
Missed
Inevitable Incomplete Septic
Complete
Threatened

7. Cervical incompetence
• Inability of the uterine cervix to retain a pregnancy in
the second trimester, in the absence of uterine
contractions
• This may cause threatened abortion or miscarriage
• Management  cervical cerclage operation (life
saving)

8. Cerclage operation
Principle – reinforces the weak cervix by non absorbable
tape, place around the cervix at the level of internal os
Timing of operation – Done when the cervix is dilated &
bulging of membrane
Types :
– Shirodkar
– Mcdonald

9. Cerclage operation—(A) McDonald’s technique; (B)
Shirodkar’s technique

10. Postoperative care
• Bed rest for 2-3 days
• Weekly injection of 17a-hydroxyprogestrone caproate
500mg IV
• Isoxsuprine 10mg thrice daily – avoid uterine irritability
• Advice on discharge – usual antenatal advise, avoid
intercourse, avoid rough journey
• Removal of stitch – 37th week or if labor pain
starts/features of abortion appears

12. Dilatation and evacuation
• Dilatation of the cervix and evacuation of the products of
conception from uterine cavity
One stage operation
– Dilatation of cervix and evacuation of uterus done in the same
sitting
Two stage operation
– First phase : slow method
– Second phase : rapid method

13. One stage operation
Steps ;
• Dilate the cervix to desired extent
• Products are removed by ovum forceps
• IV methergine 0.2mg to be given
• Uterus is massaged bimanually with both external and
internal hand
• Vagina and perineum is toileted, with sterile vulval pad
placed
Indication
Incomplete abortion
Inevitable abortion
MTP
Hydatidiform mole

14. Two stage operation
1. First phase
– Introduction of laminaria tent (MgSO4,sponge)
2. Second phase
– Further dilatation of cervix with metal dilators
followed by evacuation
Indication
Induction of 1st trimester abortion
Missed abortion
Hydatidiform mole
Patient is brought back to OT after 12 hours
Conducted under IV diazepam/GA sedation

16. Complication
– Excessive hemorrhage : due to incomplete evacuation or
atonic uterus
– Injury : cervical laceration, uterine perforation
– Shock
– Sepsis
– Hematometra
– Continuation of pregnancy (failure)

17. • Products of conception are sucked out from uterus
with the help of cannula fitted to a suction
• GA is usually not needed
Suction evacuation
Indication
MTP during 1st trimester
Inevitable abortion
Incomplete abortion
Hydatidiform mole

18. USG/TVS
Dilate the cervix
IV methergine0.2mg is administered
Cannula is introduced into uterus, tip should be in the middle
cavity
Firm uterus, minimal vaginal bleeding toileting, place a
sterile vulval pad

19. • Endpoint of suction is denoted by :
– No more material sucked out
– Gripping of cannula by the contracting small uterus
– Grating sensation
– Appearance of bubbles in cannula
Complication
• Similar to D&E

20. • Aspiration of endometrial cavity within 14 days of
missed period in woman with normal cycle
• Done as outpatient or office procedure
• cannula is inserted and attached to 50ml syringe for
suction
Menstrual regulation

21. • Similar to menstrual aspiration, Highly effective (98-
100%)
• It may be manual vacuum aspiration or electric vacuum
aspiration
Vacuum aspiration

22. Extraamniotic instillation of 0.1% ethacridine lactate
– Done through Foley’s catheter
– Removed after 4 hours
Intrauterine instillation of hypertonic solution

23. Intra- amniotic instillation of hypertonic
saline
– Instilled through abdominal route
– Preliminary amniocentesis is done
– Amount of saline instilled = no. of weeks
gestation X 10mL
– Infused slowly at the rate of 10mL/min
– Induction-abortion interval : 32 hours

24. Liberation of postaglandin
following necrosis of the
amniotic epithelium and
decidua
Excites the uterine
contraction
Expulsion of fetus
Baby killed by a saline abortion. The saline injection
causes severe burns to the baby in the womb. (Priests
for Life)

25. • Extracting the products of conception out of the womb
before viability (28th week)
• Performed through abdominal route
Hysterotomy
Indication
Failed MTP
Cases where D&E are conraindicated –
fibroid,uterine anomalies

26. Destructive operation
Operation to diminish the bulk of fetus to facilitate easy
delivery through the birth canal
Types : craniotomy, evisceration, decapitation,
cleidotomy

27. • Operation to make a perforation on the fetal head,
evacuated the contents followed by extraction of the
uterus
• Indications
– Cephalic presentation producing √√
obstructed labor with dead fetus
– Hydrocephalus even in living fetus
– Interlocking head of twin
Craniotomy
Condition to be fulfilled
cervix fully dilated
baby must be dead
√
√
C/I
Severly contracted pelvis
Rupture of uterus

28. • Steps

29. • Head is severed from the trunk, delivery is completed
with extraction of trunk and that decapitated head per
vagina
Decapitation
Indication
Neglected shoulder presentation with dead fetus where neck is
easy accesible
Interlocking head of twins

30. • Removal of thoracic and abdominal contents piecemeal
through an opening at the most accessible site
• Together with spondylectomy
Evisceration
Indication
Neglected shoulder presentation
(deadfetus)
Fetal malformations

31. Cleidotomy
• Reduction in the bulk of the shoulder girdle by division
of one or both the clavicles
• Clavicle are divided by embryotomy scissor/long
straight scissor
Indication
Only in dead fetus with shoulder dystocia

32. • Injury to uterovaginal canal
• Postpartum hemorhage
• Shock – blood loss/dehydration
• Subinvolution
• Injury to adjacent viscera
Complication

33. Postoperative care for destructive operation
• Exploration of uterovaginal canal
• Self retaining Foley’s catheter to be put inside
following craniotomy
• Dextrose saline drip – to be continued
• Ceftriaxone IV 1g infusion

34. Vaginal
Planned incision on the perineum and posterior vaginal
wall during the second stage of labor
Episiotomy
Indication
Threatened perineal injury
Rigid perineum
Forceps, breech, OP or face presentation
Objective
– To enlarge the vaginal
introitus
– To minimize overstretch
and muscle rupture

35. Types
– Mediolateral : downward & outward diagonally from
midpoint of fourchette
– Median : center of fourchette  2.5cm posteriorly
– Lateral : condemned
– J shaped : not done widely

37. Steps
Step 1 – preliminaries
Thorough swabbed with antiseptic and draped.
Perineum is infiltrated with 10mL of
1%lignocaine
Step 2 – incision
Structures cut are :
– Posterior vaginal wall
– Sup. And deep transverse perineal muscle
– Fascia covering muscle
– Branch of pudendal vessels and nerve
– Sc tissue and skin

38. Step 3 – repair
Timing of repair – soon after expulsion of placenta
Preliminaries – lithotomy position, good lighting, wound area
cleansed with solution, blood clots removed, vaginal packs to
prevent blood oozes
Order of repair –
1. Vaginal mucosa and submucosal tissue
2. Perineal muscle
3. Skin and subcutaneous tissue

40. Postoperative care
Dressing : Swabbing with cotton swab soaked in
antiseptic solution
Comfort : MgSO4, compression, ice packs, analgesics
Ambulance : allow to move out of bed
Removal of stitches : on 6th day

41. Complications
Remote
• Dyspareunia
• Chance of perineal
laceration
• Scar endometriosis
(rare)
Immediate
• Extension of
incision
• Vulval hematoma
• Infection
• Wound dehiscence

42. Summary

43. REFERENCES
• Williams Obstetrics, 24th Edition
• DC Dutta’s Textbook of Obstetrics, 8th Edition
• Internet