Operative Obstetrics• Interventions intrapartum I. Vaginal A. Forceps Delivery B. Breech Extraction C. Vacuum Extraction II. Abdominal A. Cesarean Section B. Postpartum Hysterectomy
Vaginal Operations: Forceps DeliveryForceps are a surgical instrument that resembles a pair oftongs and can be used in surgery for grabbing, maneuvering,or removing various things within or from the body. They canbe used to assist the delivery of a baby as an alternative tothe ventouse (vacuum extraction) method.Classification: 1. Outlet forceps 2. Low forceps 3. Midforceps 4. High Forceps
Forceps DeliveryOutlet forceps 1. Scalp is visible at the introitus without separating the labia. 2. Fetal skull has reached the pelvic floor. 3. Sagittal suture is in the A-P diameter or ROA,ROP, LOA, LOP 4. Fetal head is at or on perineum. 5. Rotation does not exceed 45 . O=occiput
Forceps Delivery• Low forceps delivery, when the babys head is at +2 station or lower. There is no restriction on rotation for this type of delivery.• Midforceps delivery, when the babys head is above +2 station. There must be head engagement before it can be carried out.• High forceps delivery is not performed in modern obstetrics practice. It would be a forceps-assisted vaginal delivery performed when the babys head is not yet engaged.
Techniques of Forceps DeliveryThe cervix must be fully dilated and retracted and the membranes ruptured.The urinary bladder should be empty.The station of the head must be atleast +2 in the lower birth canal. The woman is placed on her back, usuallywith the aid of stirrups or assistants to support her legs. A mild local orgeneral anesthetic is administered.Ascertaining the precise position of the fetal was accomplished by feelingthe fetal skull suture lines and fontanelles, in the modern era, confirmationwith ultrasound is essentially mandatory. At this point, the two blades ofthe forceps are individually inserted, the posterior blade first, then locked.The position on the babys head is checked. The fetal head is then rotated tothe occiput anterior position if it is not already in that position. Anepisiotomy may be performed if necessary. The baby is then delivered withgentle traction in the axis of the pelvis.
Uses of forceps1. Maternal or fetal indications2. Prophylactic3. Elective
Indications for Forceps DeliveryAny condition threatening the mother or fetus that is likely tobe relieved by delivery. Maternal Indications 1. Heart disease 2. Pulmonary compromise or Injury 3. Intrapartum infection 4. Certain neurological conditions 5. Exhaustion 6. Prolonged second stage Fetal Indications 1. Prolapse of umbilical cord 2. Premature separation of the placenta 3. Non-reassuring fetal heart rate pattern
Pre-requisites for application of Forceps Delivery1. head engaged2. presentation vertex or chin anterior3. position known4. cervix completely dilated5. membranes ruptured6. no disproportion between head & pelvis
Complications of forceps deliveryA. Maternal 1. episiotomy,lacerations & Injuries to the bladder or urethra 2. uterine rupture 3. urinary and rectal incontinence 4. febrile morbidityB. Fetal 1. trauma, Cuts and bruises 2. cephalo-hematoma 3. temporary facial nerve injury 4. clavicle fracture
Summary: Forceps Delivery1. Forceps delivery, when performed inappropriately, canresult in maternal and fetal adverse effects.2. Outlet & low-forceps operations of 45 or less can be safelyperformed if the basic guidelines are met.
Vaginal Operations: Breech Delivery A breech presentation is defined as the condition in which the baby is in longitudinal lie and the podalic pole presenting at the pelvic brim with the head occupying upper pole of uterus. Types of breech:1. Frank –lower extremities flexed at the hips & extended at knees2. Complete – one or both KNEES are flexed3. Incomplete – one or both HIPS are not flexed and one or both feet or knees lie below the breech
Methods of Breech Delivery1. Spontaneous breech delivery2. Partial Breech extraction, spontaneous up to umbilicus3. Total Breech Extraction
Maneuvers of Breech Delivery A) Pinard Maneuver in frank breech:• used to deliver a foot into the vagina• Two fingers are carried up along one extremity to the knee to push it away from the midline. Spontaneous flexion follows.
Maneuvers of Breech DeliveryB)Mauriceau Maneuver (back anterior)• Delivery of the after coming head• index & middle finger applied over the maxillae to flex the head
Maneuvers of Breech DeliveryC)Prague Maneuver (back posterior)• 2 fingers grasping shoulders of the back- down fetus
Maneuvers of Breech Delivery D)Pipers forceps• For the aftercoming head
Maternal risks of Breech Delivery• Maternal infection• Uterine rupture• Cervical lacerations• Extensions of episiotomy• Deep perineal tears• Postpartum hemorrhage from uterine relaxants
Fetal risks of Breech Delivery• Trauma• Cord prolapse• Fracture of humerus or clavicle• Separation of the epiphysis of the scapula, humerus or femur• Paralysis of the arm• Spoon depressions or skull fracture• Broken fetal neck• Testicular injury
Vaginal Operations: Vacuum Extraction Ventouse is a vacuum device used to assist the delivery of a baby when the second stage of labour has not progressed adequately. It is an alternative to a forceps delivery and caesarean section. It cannot be used when the baby is in the breech position or for premature births. This technique is also called vacuum- assisted vaginal delivery or vacuum extraction (VE).Principle• Creation of an artificial caput by attaching a traction device by suction to the fetal scalpIndications & pre-requisites• Same as in forceps delivery
Indications for use of vacuumThere are several indications to use a ventouse to aid delivery:• Maternal exhaustion• Prolonged second stage of labor• Foetal distress in the second stage of labor, generally indicated by changes in the fetal heart-rate• Maternal illness where prolonged "bearing down" or pushing efforts would be risky (e.g. cardiac conditions, blood pressure, aneurysm, glaucoma).
Techniques of Vaccum ExtractionThe woman is placed in lithotomyposition and assists throughout theprocess by pushing.A suction cup is placed onto thehead of the baby and the suctiondraws the skin from the scalp intothe cup.Correct placement of the cup directly over the flexion point, about3 cm anterior from the occipital (posterior) fontanelle, is critical to thesuccess of a VE. Ventouse devices have handles to allow for traction.When the babys head is delivered, the device is detached, allowing theaccoucheur and the mother to complete the delivery of the baby.
Summary : Vaccum ExtractionPositive aspects• An episiotomy may not be required.• The mother still takes an active role in the birth.• No special anesthesia is required.• The force applied to the baby can be less than that of a forceps delivery, and leaves no marks on the face.• There is less potential for maternal trauma compared to forceps and caesarean section.Negative aspects• The baby will be left with a temporary lump on its head, known as a chignon.• There is a possibility of cephalohematoma formation, or subgaleal hemorrhage.
Abdominal Operations: Cesarean Delivery A Caesarean section is a surgical procedure in which one or more incisions are made through a mothers abdomen(laparotomy) and uterus (hysterotomy) to deliver one or more babies.
Abdominal Incisions1.Vertical Incision• Vertical incisions are very rare.• quickest to make• greater chance of dehiscence2. The horizontal or Pfannenstiel Incision• It it placed at the top of to pubic hair or just over the hair line as the c-section is started.• cosmetically better & stronger• less chance of dehiscence• exposure not as good
Indications for Cesarean Delivery• Prolonged labour• Dystocia or failure to progress in labor• Breech presentation• Those performed out of concern for fetal well-being• Failed labour induction• failed instrumental delivery (by forceps or ventouse)• Uterine rupture• Multiple births• Previous transverse Caesarean section
Abdominal Operations: Postpartum Hysterectomy A hysterectomy is the surgical removal of the uterus , usually performed by a gynecologist. Hysterectomy may be:• Total• Partial It is the most commonly performed gynecological surgical procedure.
Techniques1. Total Hysterectomy more extensive mobilization of the bladder medially and laterally is necessary2. Supracervical Hysterectomy amputate the body of the uterus above the level of the cervix
Indications for Postpartum Hysterectomy• Intrauterine infection• Grossly defective scar• Markedly hypotonic uterus• Laceration of major vessels• Large myomas• Severe cervical dysplasia• Carcinoma in situ• Placenta previa, accreta