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Operative Interventions In Obstetrics

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Operative Interventions In Obstetrics - Mani Smk

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Operative Interventions In Obstetrics

  1. 1. Operative Interventions In Obstetrics - Dr.Mani Smk
  2. 2. Introduction Operative Interventions 1) Operative vaginal delivery 2) Caesarean section
  4. 4. 1) Operative Vaginal Delivery ▪ Definition : Delivery of a baby vaginally using an instrument (forceps/ vacuum device) for assistance. Indications Fetal Maternal *Fetal compromise * Exhaustion *Malposition of fetal head *Prolonged 2nd stage of labour *Valsalva maneuver is contraindicated * Pushing is ineffective because of maternal neurologic or muscular disease. - paraplegia/ tetraplegia / myasthenia gravis
  5. 5. CONTRAINDICATIONS ▪ ●Fetal demineralizing disease (eg, osteogenesis imperfecta) ▪ ●Unknown fetal position. ▪ ●Brow or face presentation. ▪ ● Suspected fetal-pelvic disproportion.
  6. 6. PREREQUISITES ▪ Fetus alive ▪ Cervix is fully dilated. ▪ Membranes are ruptured. ▪ Fetal head descended and is engaged. ▪ Fetal presentation, position, station known. ▪ Gestational age >33wks to use vacuum devices.
  8. 8. i)Forceps Delivery ▪ Parts of the forceps :
  9. 9. Types of Forceps
  10. 10. CLASSIFICATION OF FORCEPS DELIVERY ▪ It is based on station and amount of rotation which correlate with the degree of difficulty and risk of the procedure. ▪ Station is measured in centimeters, −5 to 0 to +5. Rotation </> 45 degrees. ▪ Deliveries are categorized as outlet, low, and midpelvic procedures.
  11. 11. Outlet forceps Low forceps Mid-forceps •The leading point of the fetal skull has reached the pelvic floor and at or on the perineum •The scalp is visible at the introitus without separating the labia. •Rotation does not exceed 45 degrees •The leading point of the fetal skull is ≥2 cm beyond the ischial spines, but not on the pelvic floor (ie, station is at least +2/5 cm ). •Low forceps have two subdivisions: -Rotation ≤45 degrees -Rotation >45 degrees •The head is engaged(ie, at least 0 station), but the leading point of the skull is <2 cm beyond the ischial spines (ie, station is 0/5 cm or +1/5 cm).
  12. 12. Application of the Forceps
  13. 13. Application of the Forceps The left branch is held Place the right hand on the The left blade is introduced Repeat the same manoeuvre in the left hand vertically left side, behind fetal head into the left side of the pelvis on the right side, using the right hand & right branch
  14. 14. Lock the forceps Traction - horizontal Vertical traction As the fetal head is reached, the forceps are removed
  15. 15. FORCEPS DELIVERY : COMPLICATIONS ▪ FETAL COMPLICATIONS – Injury to facial nerves – Lacerations & bruising of the face and scalp – Fractures of the face and skull ▪ MATERNAL COMPLICATIONS – Tears of the genital tract may occur – Trauma to soft tissue
  17. 17. ii) VACUUM DELIVERY
  18. 18. ii)Vacuum Extraction - Dr.Mani Smk ▪ The vacuum device consists of the – suction cup and the hand-pump. ▪ Check all connections before application. ▪ Assess the position of the fetal head. ▪ Identify the posterior fontanelle Suction cup Hand-pump
  19. 19. Application of the device ▪ Insert the cup into the vagina in an oblique angle ▪ Apply the cup, with the center of the cup over the flexion point. ▪ After applying the cup move a finger around the cup to ensure there is no maternal soft tissue (cervix or vagina) within the rim.
  20. 20. ▪ With the pump, create a vacuum of 0.2 kg/cm2 negative pressure and check the application. ▪ Increase the vacuum to 0.8 kg/cm2 and check the application. ▪ After maximum negative pressure, start traction in the line of the pelvic axis and perpendicular to the cup. ▪ Remove the cup when the fetal jaw is reachable.
  21. 21. VACUUM EXTRACTION : COMPLICATIONS ▪ FETAL COMPLICATIONS – Localized scalp oedema – Cephalohematoma – Retinal haemorrhage – Scalp abrasions and lacerations – Intracranial bleeding ▪ MATERNAL COMPLICATIONS – Tears of the genital tract may occur due to entrapment of vaginal mucosa between suction cup & fetal head
  23. 23. Forceps Vs Vacuum ▪ More likely to cause maternal genital tract trauma. ▪ Doesn’t need the help of the mother, so done under anaesthetics ▪ Can be used on premature fetuses & to actively rotate the fetal head ▪ More likely to cause fetal trauma like: cephalohaematoma & retinal haemorrhage ▪ Need the mothers assistance during delivery. So anaesthetics are not given ▪ Fetal age:>33weeks of ges.
  24. 24. New Devices ▪ Odon device : ▪ Was introduced by theWHO for use in areas that have limited or no access to cesarean birth. ▪ Made of film-like polyethylene material that creates a sac filled with air that surrounds the entire fetal head and enables extraction when traction is applied.
  25. 25. CAESAREAN SECTION Dr.Mani Smk
  26. 26. 2) Caesarean Section ▪ Definition : Surgical procedure in which a viable fetus is delivered through the incisions of the mothers abdominal wall and uterus.
  27. 27. Indications for C-section ▪ It is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk. MATERNAL FETAL FETO-MATERNAL INDICATIONS INDICATIONS INDICATIONS
  28. 28. Maternal Indications
  29. 29. Fetal Indications
  30. 30. Contraindications ▪ Intrauterine fetal death ▪ Coagulation defects
  31. 31. Classification according to Urgency 1CS – Emergency/crash Immediate threat to the life of the mother and fetus 2CS – Urgent Maternal/fetal compromise which is not immediately life threatening 3CS- Scheduled No maternal/fetal compromise but needs early delivery 4CS – Elective At optimal time for the mother and the maternity team Classification according to Urgency Placental abruption with abnormal FHR Cord prolapse Failure to progress with pathological CTG Severe pre- eclampsia IUGR with poor fetal function tests Twin pregnancy with non- cephalic first twin
  32. 32. Types of Abdominal Incisions
  33. 33. Low Segment Caesarean SectionPfannestielincision • Slightly curved horizontal incision 2- 3cm above the pubic symphysis. • Good cosmetic result & less incidence of herniation • Less exposure Joel-Cohenincision • Straight horizontal incision, 3 cm below the line that joins the anterior superior iliac spines, and slightly more cephalad than Pfannenstiel • Rely mostly on blunt dissection to open the abdomen MaylardIncision • Derived from Pfannestiel incision. • Rarely used • Used when more exposure is needed. • Rectus muscle incised
  34. 34. Classic Incision ▪ This involves a vertical incision into the upper uterine segment. ▪ Rarely performed ▪ Incision allows rapid delivery. ▪ This incision is made when incision-to-delivery time is critical, as well as when a transverse incision may not provide adequate exposure or may be too prone to hematoma formation. ▪ Higher incidence of infection & herniation. Poor cosmetic result.
  35. 35. LSCS Vs Classic CS
  36. 36. Procedure ▪ Regional anesthesia - spinal is preferred. In some instances, use of general anesthesia may be indicated. ▪ Position – supine with a 15 degree tilt of the theatre table ▪ A catheter is placed in the bladder ▪ Abdomen cleaned and surgically draped
  37. 37. ▪ The uterine incision can be low transverse, classic vertical, low vertical, J shaped or T shaped. 1 2 3 4 5 6
  39. 39. ▪ Some obstetricians repair the uterus by uterine exteriorization, and some repair it while it is still in the abdomen. ▪ The uterus is closed with one or two layers of suture ▪ The layers of the abdominal wall are sutured and then the skin closed
  40. 40. Complications of Caesarean Section  Uterine lacerations  Heavy blood loss.(>1L)  Bladder injury.  Post anesthetic complications – respiratory difficulty  Wound Infection.  Deep venous thrombosis  Risk of incisional hernia  Rupture of uterus at the site of the scar in future pregnancies
  41. 41. Thank You … Mom !!!