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1. Operative procedure in Obstetric
SUNNY ALVA KHARSHANDI

2. Introduction
Obstetric operation are surgical procedures
Requires aseptic precautions and
some protocols should be followed

3. Forceps delivery:
Forceps delivery is a means of extracting the fetus with the
aid of obstetric forceps when it is inadvisable or impossible for
the mother to complete the delivery by her own efforts.
Forceps are also used to assist the delivery of the after
coming-head of the breech and on occasion to withdraw the
head up and out the of the pelvis at caesarean section.

4. • Forceps deliveries were classified by the level of the head at
the time the forceps were applied, i.e. high-cavity, mid-cavity
and low-cavity. Low-cavity forceps is the one frequently
performed as caesarean section is usually preferred to the
more traumatic high and mid-cavity operations.
• Low-cavity forceps can be divided into rotational and non-
rotational. Rotational forceps delivery refers to a maneuver of
the fetal head from a malposition into a more favourable
position with the aid of specially design forceps usually
Kielland's.

5. Basic Construction of the Forceps
Obstetric forceps consist of two separate blades, each with a
handle. Each blade is marked 'L' (left) or 'R' (right). They are
inserted separately on either side of the fetal head and locked
together by English or Smellie lock (rotational forceps have a
sliding lock).

6. Types of Obstetric Forceps currently used
Only three varieties are commonly used in present day
obstetrics. They are:-
1. Long curved forceps with or without axis traction device.
• PARTS:
• Blade
• Shank
• Lock
• Handle
• Axis traction
2. Short curved forceps.
3. Kielland's forccps.

8. Classification according to the Level of the Fetal Head at
which the Forceps are Applied
1. High Forceps Operation
2. Mid-Forceps Operation
3. Low Forceps Operation
4. Outlet Forceps

9. Indications for forceps delivery
Relative indications (vacuum extraction or caesarean section
may be an alternative option)
• Delay or maternal exhaustion in the second stage of labour .
• Dense epidural block with diminished urge to push
• Rotational instrumental delivery for mal-positioned fetus
• Suspected fetal distress

10. Specific indications (forceps delivery is usually superior to vacuum
extraction or caesarean section in these to Circumstances)
• Delivery of the head at assisted breech delivery (Singleton or twin)
• Assisted delivery of preterm infant (< 34 weeks' gestation)
• Controlled delivery of head at caesarean section
• Assisted delivery with a face presentation
• Assisted delivery with suspected coagulopathy or thrombocytopenia in
fetus
• lnstrumental delivery for maternal medical condition that proclude
pushing
• lnstrumental delivery under general anaesthesia
• Cord prolapse in the second stage of labour.

11. Pre-requisites for Forceps Delivery
• There are certain conditions which must exist before forceps delivery
can be performed.
• The cervix must be fully dilated and effaced.
• membranes must be ruptured.
• Presentation and positions must be suitable to apply the blades
corrected to the sides of the head. The head must be engaged with no
parts of the head palpable abdominally.
• No appreciable cephalopelvic disproportion.
• The bladder must be emptied.
• Presence of good uterine contraction as a safeguard to postpartum
haemorrhage.

12. Preparation of the woman
Procedure of Low Forceps Operations
Manual Rotation of the Fetal Head followed by Mid Forceps
Operation

13. Appropriate method of application of forceps blade

14. Applying the left
blade of the
forceps
Applying the right
blade of the
forceps
After locking, apply
steady traction
inferiorly and
posteriorly with
each contraction
Locking and
applying traction
Failure of the
forceps

15. Difficulties in Forceps Operation
Difficulty in locking are caused by:-.
• Application on un-rotated head.
• Improper insertion of the blade (not for enough in).
• Failure to depress the handle against the perineum.
• Enlargement of the cord or fetal parts inside the blades.

16. Complications of Forceps Operation
In the Mother
Immediate
Late complications
• Chronic low backache due to tension imposed on softened
ligaments of lumbosacral or sacroiliac joints during
lithotomy position.
• Genital prolapse or stress incontinence
In the infant
Immediate

17. Prophylactic forceps (Elective)
It refers to forceps delivery only to shortened the second stage of labour
when maternal and or fetal applications are anticipated. The indications
are:
• Eclampsia
• Heart disease
• Previous history of CS
• Postmaturity
• Low birth weight baby
• Patients under epidural anaesthesia
• To curtail the painful second stage.

18. Trial Forceps
it is a tentative attempt of forceps delivery in a case of
suspected mid pelvic contraction with a preamble declaration
of abandoning it in favor of CS, if moderate traction fails to
overcome the resistance. The procedure is conducted in an
operating room keeping everything ready for CS. If moderate
traction leads to progressive descend of the fetal head, the
delivery is completed vaginally, if not, CS is done immediately.

19. Failed forceps
When a deliberate attempt in vaginally delivery with forceps
has failed to expedite the process, it is called failed forceps. It is
predominantly due to lack of obstetric skill with poor clinical
judgement. Failure in the operative delivery may be due to
improper application or failure of descent of the head even
with forcible contraction

20. Causes of Failed Forceps
• Incompletely dilated cervix
• Unrotated occipito-posterior position.
• Undiagnosed brow or hydrocephalus or fetal
ascites.
• Constriction ring
• Large baby with the shoulders impacted at the
brim.

21. Management
• Assess the effect on mother and fetus
• Start IV infusion with 5 percent dextrose if one is not
already in place.
• Administer parenteral antibiotic
• Exclude rupture of uterus and plan for other modes of
delivery.
• The woman should be shifted to an equipped hospital.

22. VENTOUSE DELIVERY/ VACCUM DELIVERY
A ventouse is a small instrument used to help pull a baby out
during the final moments of a vaginal birth. It consists of a soft
plastic cup which is placed on the crown of the baby’s head,
and a handle which is attached to a vaccum pump which gently
sucks to aid the mother’s pushing.
Meaning of Ventouse Delivery
Ventouse is an instrument device designed to assist delivery by
creating a vaccum between it and the fetal scalp.

23. When is ventouse delivery used
Indications:
• Maternal
• Fetal
Contraindications
Conditions to be fulfilled
• There should not be any bony resistance below the level of
head.
• The head of a single baby should be engaged.
• Cervix should be at least dilated.

24. Types : the main difference between vacuum extractors lies in
the cup.
Malmstrom cup: a metal cup to its centre attached a metal
chain passed through the rubber tube. The other end of the
chain is attached to a handle for traction.
Bird’s cup: the suction rubber tube is attached to the periphery
of the cup while the handle of traction is attached by a
separate short metal chain to the centre of the cup.
Soft cup: it is a bell-shaped 6.5 cm diameter soft cup which is
made of a firm but supple silastic material.

26. Advantage: it produces symmetric, less cosmetically alarming
caput succedaneum and less scalp abrasions.
Disadvantage: it slips more than the metal cup but with less
scalp injuries.
Equipments

27. Procedure
Applying the Malmstrom cup
Complications
- Fetal
- Maternal

28. Advantages of Ventouse Over Forceps
• It can be used in un-rotated or mal-rotated occipito-
posterior position of the head.
• It can be applied only through an incompletely dilated
cervix.
• It is not a space occupying device like the forceps blades.
Lesser traction force is needed (10kg)
• It can be used safely even when the head remains at a high
level in second baby of twins.
• It is comfortable and injuries to the mother are less.
• Requires less technical skill for the operator.

29. Advantages:
• Forceps operation can quickly expedite the delivery in the
case of fetal distress, where ventouse will be unsuitable as it
takes longer time.
• Forceps is safe for a premature baby. The fetal head is
remains inside the protective cage.
• It can be employed in anterior face or in after coming head
of breech.
• Insuspected pelvic contraction, where moderate traction is
required, ventouse will be effective.

30. CAESAREAN SECTION
It is an operative procedure whereby the foetuses after the
end of 28th week is delivered through an incision on the
abdominal and uterine walls. The first operation performed on
woman is referred to as a primary caesarean Section. when the
operation is performed in subsequent pregnancies, it is called
repeat caesarean section.
lncidence

31. Indications for caesarean section
Elective caesarean section: The term, elective, indicates that the
decision to deliver the baby by caesarean section has been made
during the pregnancy and before the onset of labor. While some
indications are absolute, others will depend on a combination of
factors.
b. Absolute (definite) indications include:-
• Cepalopelvic disproportion
• Major degrees of placenta previa
• Multiple pregnancy with three or more fetuses
• Advanced carcinoma of cervix .
• Pelvic tumors such as cervical fibroid

32. Relative (possible) Indications Include
• Mal-presentation
• Pregnancy Induced Hypertension
• Medical-Gynaecological Conditions
Emergency Caesarean Section
- This is performed when adverse conditions develop during
labour

33. Contraindications
In the absence of maternal interest, the following are the
contraindications for Cs.
• Dead fetus
• Baby, too premature to survive outside the uterus
• Presence of blood coagulation disorders.

34. Types of Operations
• Lower Segment Caesarean Section (LSCS)
• Classical Caesarean Section
Indications

35. Preparation of the Mother
• Psychological Preparation
• Physical Preparation
• Anaesthesia
• Position
The anatomic layers incised are as follows
• Fat.
• Rectal Sheath
• Muscule (rectal abdominis)
• Abdominal peritoneum
• Uterine Muscule

36. Delivery of the head
The uterine cavity is then opened, the membranes are
ruptured and the amniotic fluid is aspirated. The head is
delivered by hooking the head with the fingers, which are
carefully inserted between the lower uterine flap and the d
head until the palm is placed below the head. As the head is
drawn to the incision line, the assistant is to apply pressure on
the fundus. Obstetric forceps (Wrigley's forceps) are often
used to extract the head from the pelvis.

37. Removal of the Placenta and Membranes
The placenta is extracted by traction on the cord with simultaneous
pushing on the fundus towards the umbilicus (controlled cord
contraction). The placenta and membranes are removed intact.
Suturing of the Uterine Wound
The margins of the wound are picked up by Allis tissue forceps or Green
Armitage hemostatic clamps. The uterine muscule is sutured in two layers
using continuos running sutures, the second of which tends to align the
cut edges of the pelvic peritoneum. Repair of the rectus sheath brings the
rectus abdominis into alignment. The Subcutaneous fat is sometimes
sutured and finally the skin is closed with sutures or clips.

38. PROCEDURE OF LOWER SEGMENT CAESAREAN SECTION
Narrow uterine incision
• Extension of the lower uterine segment incision may be
done by
• "J" shaped or hockey-stick incision: i.e. extension of one
end of the transverse semilunar incision upwards.
• "U"- shaped or trap-door incision: i.e. extension of both
ends upwards.
• An inverted T incision: i.e. cutting upwards from the middle
of the transverse incision. This is the worst choice because
of its difficult repair and poor healing

39. Advantages of the lower segment over the upper segment
operation

40. Caesarean Hysterectomy
• Hysterectomy is carried out after caesarean section in the
same sitting for one of the following reasons:
• Uncontrollable postpartum haemorrhage.
• Unrepairable rupture uterus.
• Operable cancer cervix.
• Couvelaire uterus.
• Placenta accreta cannot be separated.
• Severe uterine infection particularly that caused by Cl.
welchi.
• Multiple uterine myomas in a woman not desiring future
pregnancy although it is preferred to do it 3 months later.

41. Caesarean Sterilisation
Tubal sterilisation is usually advised during the fourth caesarean section
Postoperative Care
Immediate care
In the immediate recovery period, the blood pressure is recorded every l5
minutes. Temperature is recorded every every two hours. The wound
must be inspected ever. half hour to detect any blood loss. The lochia are
also inspected and drainage should be small initially. Following general
anaesthesia, the woman is nursed in the left lateral or recovery position
until she is fully conscious, since the risks of airway obstruction or
regurgitation and silent aspiration of stomach contents are still present.
Analgesia is given as prescribed

42. First 24 Hours
IV fluid (5% dextrose or Ringer’s lactate) are continued. Blood transfusion
is helpful in anemic mothers for speedy post operative recovery. Injection
methargin 0.2mg may be repeated intramuscularly. Parental antibiotic is
usually given for the first 48 hours. Analgesics in the form of pethidine 75-
100mg are administered as required. Ambulation is encouraged on the
day following surgery and baby is brought to her.
After 24 hours
The blood pressure, pulse and temperature are usually checked every
four hours. Oral feeding is started with clear liquids and then advanced to
light and regular diet IV fluids are continued for about 48 hours

43. Complications of Caesarean Section
• Postpartum haemorrhage
• Shock related to blood loss,
• Anaesthetic hazards
• Sepsis
• Thrombosis
• Wound complications

44. DESTRUCTIVE OPERATIONS
The destructive operations are designed to diminish the bulk of
the fetus to facilitate easy delivery through the birth canal. It
may occasional be necessary to destroy the fetus in the
interest of saving the mother’s life. There are four types of
operations:

45. CRANIOTOMY
It is an operation to make a perforation on the fetal head to
evacuate the contents followed by extraction of the fetus.
Indications
• Cephalic presentation producing obstructed labour with a
dead fetus. This is the commonest indication of craniotomy
in the referral hospitals of the developing countries.
• Hydrocephalus even in a living fetus, this is applicable to the
fore- coming and after coming head.
• Interlocking heads of twins.

46. Sites of Perforation
Vertex- On the parietal bone, on either side of the sagittal
suture.
Face- Through the orbit or hard palate.
Brow- Through the frontal bone.
Cranioclast Forceps
Cranioclast Forceps, 19th Century.
Metal forceps with cupped and grained jaws to improve grip
and have a blue tint (blued steel is the predecessor of plating).
One handle is a scissor-like circle, the other doubles as a hook.

48. Oldham's Perforator
Curved Oldham's Obstetric Perforator. Oldham was a surgeon
of Guy's Hospital
• This instrument was used to facilitate removal of the foetus
after an obstructed labour.
• The sharp point would pierce the foetal skull and closure of
the handle would macerate the skull bones which when
eventually removed would allow passage of the rest of the
body. Marked by the maker's name Maw London

49. Craniotomy Forceps
Simpson’s Improved Craniotomy Forceps

50. Procedure
• The obstetrician introduces two fingers (index and middle) into the
vagina and the fingertips are placed on the proposed site of
perforation. If the suture line cannot be defined because of a big caput,
the perforation is done through the dependent part.
• An assistant fixes the head supra-pubically while the operator
introduces the perforator with the blades closed, protecting the
anterior vaginal wall and the bladder with the fingers in the vagina.
When the tip reaches the site of perforation, the skull is perforated
using rotating movements. After the skull is perforated, the instrument
is advanced further and the handles are approximated so as to allow
separation of the sharp blades which will extend the perforation.

51. DECAPITATION
It is a destructive operation in which the fetal
head is severed from the trunk and the
delivery is completed with the extraction of
the trunk and then of the decapitated head
per vagina.
Indications
Neglected shoulder presentation with dead
fetus where the neck is easily accessible.
Interlocking head of twins.

52. Hook and Crochet
Decapitating Hook
Embryotomy scissors
Decapitation Hook with Knife

53. Procedure:

54. EVISCERATION
The operation consists of removal of thoracic and abdominal
contents piecemeal through an opening on the thoracic or
abdominal cavity at the most accessible site. The objective is to
diminish the bulk of the fetus, which facilitates the extraction.
Indications
• Gross fetal malformations such as fetal ascites or hugely
distended bladder.
• Neglected shoulder presentation with dead fetus and neck
is not easily accessible. The procedure is more feasible in a
breech presentation. Embryotomy scissors are used for the
procedure.

55. CLEIDOTOMY
The operation consists of reduction of the width of the
shoulder girdle by division of one or both the clavicles. ne
operation is done only in dead fetus with shoulder dystocia.
The clavicles are divided by the embryotomy Scissors or long
straight scissors introduced under the guidance of two fingers
of left hand placed inside the vagina.

56. Postoperative Care Following Destructive Operations
• A self-retaining (Foly's) catheter is inserted following
craniotomy and maintained for 3-5 days or until bladder-
tone is regained.
• Intravenous drip is to be continued until dehydration is
corrected. Blood transfusion may be given if required.
• Antibiotics is given either parenterally or orally.

57. Complications of Destructive Operations
• Injury to utero-vaginal canal
• Postpartum haemorrhage-atonic or traumatic.
• Shock due to blood loss and dehydration.
• Puerperal sepsis.
• Subinvolution of the uterus. Injury to the adjacent viscera-
vesico vaginal fistula or recto-vaginal fistula.

58. SYMPHYSIOTOMY
Definitions
Symphysiotomy: It is the process of division of the symphysis
pubis with a scalpel.
Pubiotomy: Is division of the pubic ramus half an inch from the
symphysis pubis with a Gigli saw to avoid injury to the urethra
and bladder. It is out of modern obstetrics due to higher
incidence of pubic pain and infection.

59. Indications
It is particularly indicated in women living in distant areas where
caesarean section cannot be done and even patient Will be left with a
caesarean scar is in a high risk of rupture in the next labour.
As symphysiotomy gives a permanent increase of the pelvic capacity, it
can be an alternative to C.S. and indicated in the following conditions:
• Moderate cephalopelvic disproportion.
• Contracted outlet in funnel shaped pelvis.
• Retained aftercoming head in breech delivery failed to be delivered by
other means.
• Shoulder dystocia with a living foetus cannot be delivered by other
means.

60. Procedure

61. Postoperative
• Rest for 2 weeks.
• A tight binder of "Elastoplast" is strapped around the pelvic
girdle and hips.
• Bladder drainage is continued for 3-4 days.
• A prophylactic antibiotic may be given.
Complications
• Haemorrhage, compression for few minutes usually stop it.
• Injury to the urethra or bladder.
• Vesico-vaginal or urethro-vaginal fistula.
• Stress incontinence.

62. VERSION
Definition
It is manipulative procedure designed to change the lie or to bring the
comparatively favourable pole to the lower pole of the uterus.
Types of Version
EXTERNAL CEPHALIC VERSION
External cephalic version is a procedure used to turn a fetus from a
breech position or side-lying (transverse) position into a head-down
(vertex) position before labor begins. When successful, version makes it
possible for you to try a vaginal birth. This version is done to bring the
favourable cephalic pole in the lower pole of the uterus.

63. Version may be attempted when
• The mother is 36 to 42 weeks pregnant. Before 36 Weeks, a fetus is
likely to turn back into a head-down position on its own. But version
may be more Successful if it is done as early as possible after 36 Weeks
because the fetus is smaller and is surrounded by more amniotic fluid
and space to move in the uterus.
• The mother is pregnant with only one fetus.
• The fetus has not dropped into the pelvis (has not engaged). A fetus
that has engaged is very difficult to move.
• There is enough amniotic fluid surrounding the fetus for turning the
fetus. If the amount of amniotic fluid is below normal
(oligohydramnios),. the fetus is more likely to be injured during a
version attempt.
• The fetus is in the frank, complete breech, or footling breech position.
• No clinical evidence of contracted pelvic.

64. Version is usually not done when
Patient preparation for External Cephalic Version
• Explain the procedure.
• The patient is asked to empty her urinary bladder.
• Maintain privacy.
• Keep her on back with the shoulder slightly raised and thigh slightly flexed.
• Abdomen is fully exposed

65. Procedures
External cephalic version in breech presentation
External version in Transverse lie
the version is much easier than in breech. The association of
placenta or congenital malformation or the uterus should be
excluded.
The external podalic version
the external podalic version may be done in cases When the
external cephalic version fails in transverse Iie in case of the
second baby of twin.

66. INTERNAL CEPHALIC VERSION
Definition
Maneuver performed by means of one hand within the uterus.
Internal version is always a podalic version and is almost
completed with the extractor of the fetus.
Indications
Internal version is hardly indicated in a singleton pregnancy n
present day obstetric practice. Its only indication being
transverse lie in case of the second baby of twins.

67. Conditions to be fulfilled
• The cervix must be fully dilated
• Liquor amni must be adequate for intrauterine fetal
manipulation
• Fetal must be living.
Contraindications
It must not be attempted in neglected obstructed labour even
if the baby is living.

68. Procedures

69. Hazards
• Placental abruption.
• Rupture of the uterus.
• Increased maternal morbidity and mortality.
• Fetal asphyxia.
• Intracranial haemorrhage.

70. BIPOLAR VERSION
Bipolar version, a method for changing the position of a fetus
in which one hand is placed on the abdomen of the mother
and two fingers of the other hand are inserted into the uterus

71. DILATATION AND EVACUATION
The procedure consists of dilatation of the cervix and
evacuation of the procedures of conception from the uterine
cavity.
One- stage Operation
Indications
- Incomplete abortion (commonest)
-Inevitable abortion
-Medical termination of pregnancy (6-8weeks)
-Hydatidiform mole in the process of expulsion.

72. Preparation for the operation
Local preparation, perineal care and catherization are done
once the decision is made for evacuation the woman and her
spouse are given adequate explanation and psychological
support.

73. Procedure

74. Two Stage Operation
Indications
• First trimester abortion.
• Missed abortion (8-10 weeks uterus).
• Hydatidiform mole with unfavourable cervix (l0 firm and
closed os).

75. Procedure

76. Dangers of Dilatation and Evacuation Operation
Immediate Dangers
• Haemorrhage due incomplete evacuation or atonic uterus.
• Injury such as cervical laceration or uterine perforation.
• Shock due to excessive blood loss, uterine perforation or
anaesthetic complications.
• Increased morbidity.

77. Late Complications
• Pelvic inflammation
• Infertility
• Cervical incompetence
• Uterine adhesions.

78. SUCTION EVACUATION
If 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.
Indications
• Medical termination of pregnancy during first trimester
(commonest).
• Inevitable abortion.
• Recent incomplete abortion.
• Hydatidiform mole.

79. Procedures

80. Complications
Immediate Dangers
• Haemorrhage due incomplete evacuation or atonic uterus.
• Injury such as cervical laceration or uterine perforation.
• Shock due to excessive blood loss, uterine perforation or
anaesthetic complications.
• Increased morbidity.

81. Late Complications
• Pelvic inflammation
• Infertility
• Cervical incompetence
• Uterine adhesions

82. MANNUAL VACCUUM ASPIRATION
Manual vaccuum procedure is the aspiration of the
endometrial cavity within 7 menstrual weeks of missed period
in a woman with previous normal cycle
Clinical uses
Vacuum aspiration may be used as a method of induced
abortion, as a therapeutic procedure after miscarriage, to aid in
menstrual regulation, and to obtain a sample for endometrial
biopsy. It 1s also used to terminate molar pregnancy

83. Procedure

84. Advantages
Complications
When used for uterine evacuation, vacuum aspiration is 98%
effective in removing all uterine contents. Retained products of
conception require a second aspiration procedure. This is more
common when the procedure is performed very early in
pregnancy, before 6 weeks gestational age.
Other complications occur at a rate of less than I per 100
procedures and include excessive blood loss, infection, injury
to the cervix or uterus, and uterine adhesions.

85. EPISIOTOMY
An episiotomy is a surgical incision through the perineum
made to enlarge the vagina and assist childbirth. The incision
can be midline or at an angle from the posterior end of the
vulva, is performed under local anaesthetic (pudendal
anesthesia), and is sutured closed after delivery.
Purposes
• To enlarge the vaginal orifice to facilitate easy and safe
delivery of the fetus.
• To minimize overstretching and rupture of the perineal
muscles and fascia.
• To minimize stress and strain on the fetal head.
• To shorten the second stage of labour.

86. Indications

87. Types of episiotomies.
Median Episiotomy: This is midline incision which follows the
natural line of insertion of the perineal muscles. This incision
reduces blood loss and but higher incidence of damage to the
anal sphincter. The incision made about 2.5cm long.
Advantages of median episiotomy
• Muscules are not cut.
• Blood loss is least.
• Easy to repair.
• Post incisional comfort is maximum.
• Wound healing is superior and disruption is rare.
• Dysparenuia is rare.

88. Disadvantages of median episiotomy
Extension of episiotomy is limited due to chance of rectal
involvement.
This episiotomy is not suitable for manipulative delivery e.g.
abnormal presentation and position and assisted delivery.

89. Lateral Episiotomy :This incision is made about 1cm away from
the center of fourchette and extends lateraly. There is more
chance of injury to the Bartholin's duct. This incision is not
used and totally condemned.
J- shaped Episiotomy: This incision begins in the center of the
fourchette and is directed posterily along the midline for about
1.5cm and then directed downwards and outwards along 5 or 7
o'clock position to avoid the anal sphincter

90. Medio - Lateral Episiotomy: A mediolateral episiotomy
involves cutting into more muscle tissue and does not follow
the natural way a woman would tear. This can mean they are
harder to repair, have increased bleeding, the cut may not heal
as well, it may produce more scarring, and possibly more pain
in the weeks following the birth.

91. Advantages
• It is less likely to extend to a 3rd or 4th degree tear.
• Rectal involvement from episiotomy extension is less.
• Incision can be extended if necessary.
Disadvantages
• Apposition of the tissues is not so good. Blood loss is little
more.
• Postoperative discomfort is more.
• Wound disruption is higher.
• Dysparenuia is more

92. Procedure

93. Complications
Immediate:
Extension of the incision to invole the return, likely in median
episiotomy.
Vulval haematoma.
Infection
Wound dehiscence.
Remote
Dyspareunia due to narrow introitus, painful perineal Scar.
Chance of perineal lacerations in subsequent labour, if not
managed properly.
Scar endometriosis.

94. Care of the episiotomy repair

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

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

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

99. 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

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

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

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

103. • Steps

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

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

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

108. 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

109. 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

111. 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

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

113. Summary

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