7343376 Ob Operative Obstetrics

7/30/2019 7343376 Ob Operative Obstetrics

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Caesar D. Tongo M.D.,FPOGSAssociate Professor

DLS College of Medicine


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An operative vaginal delivery

is defined as the applicationof direct traction of the fetalhead with forceps or a

vacuum.


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The incidence of operative

vaginal delivery isapproximately 10 to 15%.


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Indications.An operative vaginal delivery

is performed to shorten thesecond stage of labor withcertain maternal or fetalindications.


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Nonreassuring fetalNonreassuring fetal

statusstatus

-- based on heart ratebased on heart ratepattern, auscultation, lackpattern, auscultation, lack

of response to scalpof response to scalp

stimulation, or scalp pH.stimulation, or scalp pH.


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Prolonged second stage ofProlonged second stage of

laborlabor

- secondary to- secondary tomalposition, deflexion, ormalposition, deflexion, or

asynclitism of the fetal head. Aasynclitism of the fetal head. A

prolonged second stage isprolonged second stage isdefined as follows:defined as follows:


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a. Nulliparous patienta. Nulliparous patientMore than 3 hours withMore than 3 hours with

a regional anesthetic ora regional anesthetic ormore than 2 hours withoutmore than 2 hours without

regional anesthesiaregional anesthesia


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CertainCertain maternal illnessmaternal illnesswhich make avoidance ofwhich make avoidance of

voluntary maternalvoluntary maternalexpulsive efforts desirable.expulsive efforts desirable.


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Poor voluntaryPoor voluntary

expulsion effortsexpulsion efforts

because of exhaustion,because of exhaustion,analgesia, oranalgesia, or

neuromuscularneuromusculardisease.disease.


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Prerequisites forPrerequisites for

Instrumental DeliveryInstrumental Delivery

1.1. The cervix must be fullyThe cervix must be fully

dilateddilated

2.2. The membranes must beThe membranes must berupturedruptured

3.3. The position and station mustThe position and station must

bebe known, and the head mustknown, and the head must


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4.4. The maternal pelvisThe maternal pelvis

must bemust be judgedjudged

adequate in size foradequate in size fordeliverydelivery

5. The bladder should be5. The bladder should be

empty.empty.


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6. A skilled operator must6. A skilled operator must

bebe present.present.

7. Adequate anesthesia is7. Adequate anesthesia is

needed before forcepsneeded before forceps

oror vacuumvacuum

application.application.


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ContraindicationsContraindications

1.1. Nonvertex presentation,Nonvertex presentation,

except forexcept for Piper forcepsPiper forceps ininthe breech delivery.the breech delivery.

2.2. NonengagementNonengagement of theof the

presenting partpresenting part


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3.3. Head that cannot beHead that cannot be

advanced withadvanced with

ordinaryordinary traction whentraction whenusing forcepsusing forceps oror thethe

vacuum extractor.vacuum extractor.

4.4. Prematurity, fetalPrematurity, fetal

bleedingbleeding disorder, ordisorder, or


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Classification ofClassification of

forceps deliveriesforceps deliveries

Outlet forcepsOutlet forcepsTo be categorized as anTo be categorized as an

outlet forceps delivery, theoutlet forceps delivery, the

following criteria mustfollowing criteria must

satisfied:satisfied:


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a.a. Scalp is visible at theScalp is visible at the

introitus withoutintroitus without

separating the labiaseparating the labia

b. Fetal skull has reachedb. Fetal skull has reached

the pelvic floorthe pelvic floor


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c.c. Sagittal suture is in theSagittal suture is in the

anteroposterioranteroposterior

diameterdiameter or right oror right orleft occiputleft occiput anterioranterior

or posterioror posterior position.position.


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d.d. Fetal head is at or onFetal head is at or on

the perineumthe perineum

e.e. Rotation doesRotation does

notnot exceed 45exceed 45

degree.degree.


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Low forcepsLow forcepsIn low forceps delivery, theIn low forceps delivery, the

leading point of the fetal skull hasleading point of the fetal skull has

descended to at least +2 station butdescended to at least +2 station but

has not reached the pelvic floor.has not reached the pelvic floor.

The fetal head hasThe fetal head hasreached thereached the

perinealperineal floor and isfloor and is

visiblevisible


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1. Choosing the 2. Applying theleft left blade blade


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3. Applying the 4. Locking thebladesright blade


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5. Gentle traction 6. Thecorrectwith an episiotomy

cephalicat crowning application


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MidforcepsMidforceps

The station is aboveThe station is above+2 but the presenting part+2 but the presenting part

is engaged.is engaged.

Engagementhas taken placeand the leadingpart of the headis below the levelof the ischial

spines.


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1. Making a large 2. Applying

the leftepisiotomy blade.Hands before starting protectsvagina

from damageby

careless

insertions of blade


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3. Applying the 4. Locking thehandles

right blade


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5. Traction, maintaining 6. As the headdownward pressure crowns thehandleto keep in the line of the forceps

riseof the birth canal and thehead is

lifted over theperineum


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Types of forcepsTypes of forceps

1. Classic1. Classic

These forceps are usedThese forceps are usedprimarily for traction whenprimarily for traction when

there is to be little or nothere is to be little or no

rotation.rotation.

a. Simpsona. Simpson

b. Elliotb. Elliot


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2.2. SpecializedSpecialized

These forceps areThese forceps are

designed for rotation ordesigned for rotation orspecial indications.special indications.

a. Keillanda. Keilland

b. Bartonb. Barton

c. Piperc. Piper


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Delivery with Kiellands

Forceps

1. Holding forceps with the knobsdirected towards fetal occiput.


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2. The anterior blade is selected to

be applied first (someobstetricians prefer to apply the

posterior blade first).


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3. The Direct Method

The anterior blade is guardedby the finger and slipped into

the correct position on the side

of the head.


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4. The Wandering Method

The guarded blade is applied laterally(over the face) and then gentlyeased round to lie on top of the

head.


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5. It now lies with the concavity of

the blade applied to left(uppermost) side of the fetal

head.


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6. The posterior blade is applied

directly to the right (lower) side ofthe head. The vagina is protected

by the guiding hand.


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7. The forceps are locked. Notehow their position shows

asynclitism.


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8. Asynclitism is corrected and theforceps blades are opposite each

other.


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9. The head is gently rotated to the

OA position. Varying asynclitism andgentle traction help to rotate into the

pelvic axis. A large episiotomy is

needed.


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10. To prevent over compression ofthe babys head, a thumb is kept

between the handles.


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11. As the head extends, thedirection of pull must be altered

upwards.


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In a breech presentation theforceps can be applied to thehead once it has entered the

pelvis. Andersons blades arepreferred

because of their

length.


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In a face presentation(mento anterior)

the forceps may

be applieddirect.(Mento posterior

positions must berotated).


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Vacuum ExtractorsVacuum Extractors

There are two types ofThere are two types of

vacuum extractors, based onvacuum extractors, based onthe type of cup used forthe type of cup used for

application to the fetal head.application to the fetal head.

Each type has three parts: aEach type has three parts: acup, a rubber hose, and acup, a rubber hose, and a

vacuum pump.vacuum pump.


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The vacuum extractor is atraction instrument used as analternative to the obstetric

forceps. It adheres to the babysscalp by suction and is used inthe conscious patient to assist

maternal expulsive efforts. Thesuction cup obtains its grip byraising an artificial caput.


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The patient isusually in thelithotomy positionand the sameprecautions areobserved as forforceps operations.

Probably the mostconvenient anestheticis a pudendal block,but sometimes onlyinhalational analgesiaor sufficient localanesthetic for anepisiotomyis required.


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Malmstrom vacuumMalmstrom vacuum

extractorextractor

This device consists ofThis device consists ofaa metal cup that is appliedmetal cup that is applied

to theto the fetal scalp. The pumpfetal scalp. The pump

is then usedis then used to create ato create avacuum, notvacuum, not exceeding 0.7 toexceeding 0.7 to

0.8 kg/cm0.8 kg/cm.. Traction is thenTraction is then

applied to bringapplied to bring the infantsthe infants


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Plastic cup extractorPlastic cup extractorThis device is consistsThis device is consists

of aof a flexible Silastic cup thatflexible Silastic cup thatisis applied to the fetal scalpapplied to the fetal scalp

moremore easily and with lesseasily and with less

trauma thantrauma than the Malmstromthe Malmstromextractor. Theextractor. The vacuumvacuum

pressures attained arepressures attained are aboutabout

the same, but they can bethe same, but they can be


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ComplicationsComplications Maternal complicationsMaternal complications

are usually of minor clinicalare usually of minor clinicalconsequence and includeconsequence and include

lacerationslacerations

of the cervix, vagina, andof the cervix, vagina, and

perineum;perineum; episiotomyepisiotomy

extensions; andextensions; and

associated hemorrhage. Moreassociated hemorrhage. More

serious complications includeserious complications include


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Neonatal injuryNeonatal injury

a. Scalp abrasions ora. Scalp abrasions or

lacerationslacerations are theare themostmost common injurycommon injury

associatedassociated with vacuumwith vacuum

extractionextraction


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b. Soft tissue injuryb. Soft tissue injuryis the most common injuryis the most common injury

associated with forcepsassociated with forcepsdelivery.delivery.


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d. Subgaleald. Subgaleal

hemorrhageshemorrhages

occurs in 26 in 1000occurs in 26 in 1000to 45 in 1000 of vacuumto 45 in 1000 of vacuum

deliveriesdeliveries


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e. Intracraniale. Intracranial

hemorrhagehemorrhage

is a rare complication,is a rare complication,occurring in 0.75% ofoccurring in 0.75% of

instrumental deliveriesinstrumental deliveries..


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Definition:A suture placed in

the cervix to treat cervicalincompetence.


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A cervical incompetence isA cervical incompetence is

characterized by gradual,characterized by gradual,

progressive , painless dilationprogressive , painless dilationof the cervix, usually leadingof the cervix, usually leading

to spontaneous pregnancyto spontaneous pregnancy

loss early in theloss early in the secondsecondtrimestertrimester..

A minority of second-A minority of second-

trimester losses aretrimester losses are


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Cervical incompetenceCervical incompetencemaymay bebe acquired oracquired or

congenitalcongenitala.a.Acquired causesAcquired causes

areare primarily result fromprimarily result fromobstetric orobstetric orgynecologicgynecologic trauma totrauma to

the cervixthe cervix


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b. Congenital causesb. Congenital causesinclude anomaliesinclude anomalies

caused bycaused bydiethylstilbestrol (DES)diethylstilbestrol (DES)

exposure in utero andexposure in utero and

otherother reproductive tract.reproductive tract.


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Cervical incompetence isCervical incompetence is

diagnosed by adiagnosed by a

characteristiccharacteristic history ofhistory ofsecond-trimestersecond-trimester

spontaneous lossesspontaneous losses

associated with painlessassociated with painlesscervical dilation. Thecervical dilation. The

role ofrole of ultrasound as aultrasound as a


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TechniquesTechniquesCervical cerclage involvesCervical cerclage involves

placing an encircling sutureplacing an encircling suturearound thearound the cervical oscervical osusingusing

aa heavy, nonabsorbable sutureheavy, nonabsorbable sutureoror Mersilene tape. The suturingMersilene tape. The suturing

prevents protrusion of theprevents protrusion of theamniotic sac and consequentamniotic sac and consequentrupture by correcting therupture by correcting the

abnormal dilation of the cervix.abnormal dilation of the cervix.


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1. Shirodkar technique1. Shirodkar techniqueIn the more complicated ofIn the more complicated of

the two procedures using athe two procedures using avaginal approach, thevaginal approach, the

suture issuture is almost completelyalmost completely

buriedburied beneath thebeneath thevaginal mucosa atvaginal mucosa at thethe

level of the internal os. Itlevel of the internal os. It

can be left in placecan be left in place forfor


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2. McDonald techniqueThis procedure is a

simple purse-string

suture of thecervix and is simpler,

incurring less trauma tothe cervix and less bloodloss than the Shirodkar

procedure.


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3. Abdominal placementThis uncommon,

permanent procedure is

used women with ashort or amputatedcervix or in those in whom a

vaginal procedure hasfailed. Cesarean birth is

necessary for delivery.


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TimingCerclage is usually

performed between twelfth andsixteenth weeks of gestation

but can be performed as lateas the twenty-fourth week.

Fetal viability and the absenceof anomalies should bedocumented before performing

the procedure.


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Effectiveness.

There have been norandomized trials to define the

efficacy and benefit of

cerclage; this benefit is probablyoverstated. Except in women

with a strong history consistent

with cervical incompetencethe benefit of cerclage has notbeen proven.


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Complications

1. Cervical lacerationsoccur

in 1 to 13% ofdeliveries after aMcDonald cerclage

2. Cervical dystocia withfailure to dilate,

re uirin a cesarean


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3. Displacement of the sutureoccurs in 3 to 12%

of cases.A second cerclage is then

attempted, which hasa lower success rate.

4. Premature rupture of themembranes

complicates cerclage 1

to 9% of cases.


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5. Chorioamnionitis

complicates 1 to7% of cases.

6. Early, elective cerclagehave a low rate (1%) ofinfection; cerclage

placement with dilationof the cervix has a much

higher risk (30%) of

infection.


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The termination ofpregnancy before viability,

usually designated as 20weeks gestation is known as

abortion.


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A. Spontaneous abortionIs expulsion of the

products of conceptionwithout medical ormechanical intervention.


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1. Incidence

Spontaneous lossoccurs

in 15% of clinically

recognized pregnancies;the risk increases directlywith maternal age,

advancingpaternal age, minority race,increasing gravidity, and

history of previous


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2. Etiology

Chromosomalabnormalities are the mostcommon reason for first-

trimester losses,occurring at a 60%frequency. Mostchromosomal abnormalities

are sporadic defects; in asmall percentage of cases, one

of the parent carries a balanced

translocation.


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3. ClassificationSpontaneous

abortion are classifiedinto five types.


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Threatened abortion

This term is traditionalused when bleeding occursin the first half of gestation

without cervical dilation orpassage of tissue.Twenty-five percent of

pregnant womenexperience spotting orbleeding early in gestation; 50%

of these proceed to lose the

re nanc


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Inevitable abortionthis type of pregnancyloss is diagnosed when

bleeding or rupture of themembranes occurs withcramping and dilation of the

cervix. Suction curettage isperformed to evacuate theuterus.


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Incomplete abortionThis type of pregnancy

loss occurs when there hasbeen partial but

incomplete expulsion ofthe products ofconception from the uterine

cavity. Therapy is evacuationof remaining tissue by

suction curettage.


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Missed abortion Death of the fetus or

embryo may occur

without the onset of labor orthe passage of tissue for aprolonged period. Suction

curettage is used toevacuate the firs-trimester

uterus.


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4. Workup for spontaneousabortion. Detailed history and physical

examination.

Chromosomal evaluation of

the couple


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Endometrial biopsy to excludeluteal phase defect

Thyroid function test andscreening for diabetesmellitus

Cervical cultures forUreaplasma urealyticum


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Hysterosalpingogram orhysteroscopy to evaluate

uterine cavity

Screening test for lupus

anticoagulant andanticardiolipinantibody


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B. Induced (elective)abortion.

Abortion became legal in1973 and can be induced up to

approximately 24 weeks gestation,depending on state laws.Therapeutic abortions areterminations of pregnancy that are

performed when maternal risk isassociated with continuation of thepregnancy or fetal abnormalities

associated with genetic or


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Techniques ofpregnancytermination.

techniques usedeffectively to empty the

uterus of the products of

conception fall under thecategories of surgicalevacuation or induction of

labor


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A. Surgical evacuation1. Suction curettage

This method of dilation

of the cervix and vacuumaspiration of the

uterine content is used

for termination ofpregnancy at 12 weeks orless gestational age.


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a. Hygroscopic dilators such

as laminaria can be usedwhen necessary to facilitategentle dilation of the cervix.

b. Prophylactic antibioticsadministered just before or after

the procedure significantlyreduce the risk of infectionassociated with induced abortion.


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2. Dilation and extraction(D&E) This technique

is the preferred method oftermination at 13 or moreweeks of gestation.


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a. As the length of gestationincreases, wider

cervical dilation is necessary toaccomplish the proceduresuccessfully. Preoperative

cervical laminaria may be used.


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b. Vacuum aspirationofuterine contents is usually anadequate method of evacuation

between 13 and 16 week.

c. Prophylactic antibiotics

may be given.


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3. Other mechanicalmethods Theses

methodsinclude sharp curettage,

hystecrotomy, andhysterectomy.


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B. Induction of Labor.Medical means of inducing

abortion include extrauterineand intrauterineadministration of

abortifacients, such asprostaglandins, urea,hypertonic saline, and

oxytocin


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1. Prostaglandinsare mostcommonly administered asvaginal tablets of prostaglandin

E; 90% of abortions areaccomplished within 24 hours.Common side effects include

fever, nausea and vomiting,diarrhea, and uterinehyperstimulation.


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2. Hypertonic solutions ofsaline or ureaare injecteddirectly into the amnioticcavity. This procedure requires

amniocentesis and care toavoid intravascular injection.


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3. Complications rates are lowestwhen the uterus is

successfully evacuated within13 to 24 hours. Laminaria tofacilitate cervical dilation isuseful to shorten the length ofinduction.


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C. Progesterone antagonists1. Mifepristone(RU 486;Mifeprex), taken

orally, is highly effectivein pregnancies with up to49 days amenorrhea. Its

effectiveness can beincreased with theaddition of prostaglandin E.


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2. Side effectsare minimal,and complication rates,

including hemorrhage andretained tissue, are low


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AnesthesiaSedation with local

paracervical block is usuallyused for induced abortion.

General anesthesia can be usedbut is accompanied by a higherincidence of hemorrhage,

cervical injury, and perforationbecause it render the uterinemusculature more relaxed and,

thus, easier to penetrate.


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A. Immediate complicationsThese complications

develop during the

procedure or within 3 hoursafter completion.

1. HemorrhageThe incidence ofhemorrhage is most accurately

determined by the rate of


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2. Cervical Injury

The rates of cervical injuryassociated with suctioncurretage are within the range of

0.01 to 1.6%. Factors thatdecrease the risk of thiscomplication include the use of

local anesthetics instead ofgeneral anesthesia.; use oflaminaria; and an experienced

operator


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3. Uterine perforationThe incidence of thispotentially serious

complication ofsuction curettageabortions isapproximately 0.2%.


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a. RisksFactors that increase therate of uterine perforation

include multiparity, advancedgestational age, and operatorinexperience. The use oflaminaria to facilitate cervical

dilation decreases the rate.


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b. ComplicationsSerious consequences ofuterine perforation include

hemorrhage and damage tointra- abdominal organs.Because of the location of the

uterine vessels, lateralperforation may be associatedwith hemorrhage.


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c. TreatmentMany cases of uterine

perforation require onlyobservation. Surgical exploration

is indicated when there isevidence of hemorrhage, when

injury to abdominal organs issuspected, or whenperforation occurs with a

suction curette


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a. Risks Factors that increase the

risk of infection include thepresence of cervical gonococcalor chlamydial infection,advanced gestational age,

uterine instillation methods oftermination, and the use oflocal anesthesia instead of

general anesthesia


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2. Retained TissueThis conditions

complicates less than 1% ofsuction curettage abortions.


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Maternal mortalityThe case mortality

rate for induced abortion isless than 0.05 per100,000 procedures. The

risk varies with gestationalage and method of termination.


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b. The risk of death is lowest forsuction curettage procedures

and highest for instillationprocedures. Risk increaseswith advancing gestational age.


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Cesarean section is delivery ofa viable fetus through anabdominal incision and uterine

incision. The maternal mortalityrate was high up to the end ofthe nineteenth century, most

often because of hemorrhageand infection.


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a. As procedure-related morbidityand mortality rates decreasedwith advances in anesthetic andoperative techniques, the rateofprimary cesarean sections

increased.


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Dystocia or abnormalprogress of labor is usedmore freely as an indication

for cesarean section, with acorresponding decline inthe rate of forceps deliveries.


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Vaginal breech deliveries arenot recommended insingleton gestations.

Multiple gestation, anindication for cesarean section,

occurs more frequently.


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b. As the number of primarycesarean sections increased,previous cesarean section as an

indication for a repeatcesarean section increased.Thirty-three percent of

cesarean sections performed inthe United States are repeatcesarean sections.

2 P i t l t lit


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2. Perinatal mortality

There is a littledocumentation for an association

between the increase in rates

of cesarean delivery and adecline in perinatal mortalityand morbidity. The major

causes of perinatal morbidityand mortality continue to be lowbirth weight and congenital

anomalies


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1. Contraindications to labora. Placenta previab. Vasa previa

c. Previous classic cesareansection

d. Previous myomectomy with

entrance into the uterinecavity


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e. Previous uterinereconstructionf. Malpresentation of the

fetusg. Active genital herpesinfection

h. Previous cesarean sectionand patient declinestrial of labor


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2. Dystocia and failedinduction of labor

a. Cephalopelvicdisproportion, failure todescend, or arrest of

descent or dilation


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b. Failure to progress in normal-size infant, usually because offetal malposition or posture.

c. Failed forceps or vacuumextractor deliveryd. Certain fetal malformations

that may obstruct labor.


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3. Emergent conditions thatwarrant immediate

delivery

a. Abruptio placentae withantepartum hemorrhage

b. Umbilical cords prolapse


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c. Nonreassuring antepartumor intrapartum fetal testing d. Intrapartum fetal acidemia,

with intrapartum scalp of pHless than 7.20 e. Uterine rupture

f. Impending maternal death


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Types of cesereanoperations

Ceserean operations are

classified according to theorientation (transverse orvertical) and the site of

placement (lower segment orupper segment) of the uterineincision.


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The incision is made in thenoncontractile

portion of the uterus,minimizing chances ofrupture or separation in

subsequent pregnancies.


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The incision requirescreation of the bladder

flap and lies behindthe peritoneal bladderreflexion, allowing

reperitonealization.


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Uterine closure isaccomplished more easilybecause of the thin

muscle wall of the lowersegment, and the potentialfor blood loss is lowestwith this type

of incision.


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This incision may involvepotential extension

into the uterine vesselslaterally and into thecervix and vagina

inferiorly.

2 Low vertical


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2. Low vertical

(Sellheim or Kronig)The vertical incision beginsin the noncontractile lower

segment but usually extends into

the contractile uppersegment.

Thi i i i i d h


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This incision is used when a

transverse incision isnot feasible. 1. The lower uterine segment

may not be developed iflabor has not occurred; thetransverse incision may not

provide enough room fordelivery of the infant


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Sometimes it is The uterinewound

necessary to extract is closed with 2the head with forceps. layers of catgut

and theperitoneum

-


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Ergometrine or synthetic oxytocin isgiven and the placenta andmembranes removed.


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2. Malpresentations of theterm or premature

infant may necessitatea vertical incision toallow more room for

delivery of the infant.


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3. This incision issometimes used when

an anterior placentaprevia is noted tofacilitate delivery without

cutting through the bodyof the placenta.


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This incision also requires

creation of the bladderflap and allowsreperitonealization.

The risk of uterine rupture insubsequent pregnancies

is increased when theupper segment of the

uterus is entered


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Uterine closure is moredifficult, and blood loss

is greater if theupper segment

is involved.


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3. Classic incision (Sanger)The classic incision is

a longitudinal incision inthe anterior fundus.


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Indication for this incision


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Indication for this incision

includes invasivecarcinoma of the cervix,presence of lesions in the

lower segment of theuterus (myomas) that prohibit

adequate uterine closure,

and transverse lie with theback down. It is thesimplest and quickest


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This incision does not requirebladder dissection, and

reperitonealization is not

performed; the potentialfor intraperitonealadhesion formation is

greater.


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Uterine closure is moredifficult because of the

thick muscular uppersegment, and the potentialfor blood loss is greater.

PROCEDURE


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PROCEDURE

1. Patient preparationa. The patient should be well

hydrated.

b. The preoperativehematocrit should be

known, and blood should bereadily available asindicated


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c. The bladder should beempty. Placement of a FoleyCatheter is typical.

d. Prophylactic antibiotics areusually given after

clamping the umbilical cord.


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e. Antacids are also given toreduce acidity of the

stomach contents in

the event that the patientaspirates material into thelungs.

f. Informed consent shouldalways be obtained.

2. Anesthesia


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Most often, anesthesia isregional (spinal or epidural), but itcan be inhalational (general) asdictated by the individual

situation. General anesthesia mayresult depression of the infant

immediately after delivery, the

degree of which increases with thelength of time from incision to

delivery.

3 Surgical techniques


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3. Surgical techniques

Abdominal incision.1. The abdominal incision may

be midline, paramedian, or

Pfannenstiel. Midline- The infraumbilicalvertical midline incision is

less bloody and allows morerapid entry into theabdominal cavity.


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Paramedian- A verticalincision lateral to theumbilicus.

Pfannenstiel This allowstransverse incision near the

symphysis pubis provides themost desired cosmetic effectand is used most often.

2 The incision is made with the


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2. The incision is made with the

patient on the operating tablein a left lateral tilt to prevent

maternal hypotension and

uteroplacental insufficiency,which may results fromcompression of the inferior

vena cava by the uterus whenthe patient is supine.

3. The approach of the uterus


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pp

in reference to the peritonealcavity can be made in one oftwo ways:

a. The transperitonealapproach is used almost

exclusively today. The parietalperitoneum is opened to

expose the abdominal

contents and uterus

b Th i l h


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b. The extraperitoneal approach

is mentioned for historicalpurposes; it has been virtuallyabandoned since the advent ofeffective antibiotics. Thisapproach was devised for casesof amnionitis to avoid seedingthe abdominal cavity in attemptsto decrease the risk of peritonitis.


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(1) A Bladder Flap is


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( ) A adde ap is

created to approach thelower uterine segment. Thereflection of bladder

peritoneum is incised anddissected free from theanterior uterine wall, exposing

the myometrium.(2) Incision of the

myometrium is


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Wound Closure (1) The uterus is often

exteriorized to

massage the fundus, inspectthe adnexa, and facilitatevisualization of the wound

for repair.


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Complicationsi


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Common postoperativecomplications include thefollowing conditions:

1. EndomyometritisPostoperative infection is

the most commoncomplication after cesareansection

a. The average incidence of


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a. The average incidence of

endomyometritis is 34 to40 %, with a range of 5 to 85%.

b. Risk factors include lowersocioeconomic status, prolonged

labor, prolonged duration of

ruptured membranes and thenumber of vaginal

examinations


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c. Infection is polymicrobial andincludes the following

organisms: aerobicstreptoccoci, anaerobic gram-positive cocci, and aerobic

and anaerobic gram-negative bacilli.

d Use of prophylactic antibiotics


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d. Use of prophylactic antibiotics

at the time of the proceduredecreases incidence. With theuse of modern, broad-spectrum

antibiotics, the incidence ofserious complications,

including sepsis, pelvic abscess,and septic thrombophlebitis,is less than 2%.


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b. Practices that decrease riskinclude preparing the patient

properly and minimizingduration of catheter.

3. Wound Infection


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a. The incidence ofpostcesarean wound infectionrates ranges from 2.5 to

16%.b.Risk factors includesprolonged labor,

ruptured membranes,amnionitis, meconiumstaining morbid obesity,

anemia and diabetes


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c. Common isolates includesStaphylococcus aureus,

Escherichia coli, Proteus

mirabilis, Bacteroides sp., andGroup B streptococci


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4. ThromboembolicDisorders

a. The incidence is 0.24% of

deliveries, and deepvein thromboses arethree to five times more

common after cesareandelivery.


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b. Diagnosis andtreatment

are the same as for

nonpregnant women. Promptdiagnosis and treatmentdecrease the risk of

complicating pulmonaryembolus to 4.5% and that of

death to 0.7%


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5. Cesarean Hysterectomya. Hysterectomy after

cesarean delivery is an

emergencyprocedure that occurs in less

than 1% of cesarean

sections.


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b. Indications include uterineatony (43%), placenta accreta(30%), uterine rupture (13%),

extension of a low transverseincision (10%), leiomyoma

preventing uterine closure, and

cervical cancer.

6. Uterine Rupture in Future


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p

Pregnanciesa. The risk of rupture of

previous cesarean scar

varies with the location ofthe incision.

(1) Low transverse scar

(2) Low vertical scar(3) Classical scar

b. Separation of the uterine scar


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b. Separation of the uterine scar

can be categorized asdehiscence or rupture

(1) a dehiscence is a

frequently asymptomaticseparation and is foundincidentally at the time of

repeat cesarean or onpalpation after a vaginal

birth.


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1. ConsiderationsThe risk of a vaginal birth


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The risk of a vaginal birthafter cesarean section, whenperformed in the proper setting,are less than the risks of arepeat cesarean section.

a. There are 60 to 80% rate

of successful vaginaldelivery after previouscesarean section.


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3. Contraindicationsa. previous classic uterine

incision

b. Maternal or fetalcontraindications to

labor.

c. Trial to labor declined bymother


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It is made at the end ofthe second stage of labor

just before delivery,when indicated.


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b. DisadvantageMore difficult to

repair, more blood loss,more discomfort duringhealing.


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Damage to the BrachialPlexus

This is caused by

excessivelateral flexion of the neck duringvertex or breech delivery.


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Klumpkes ParalysisC8. T1 is rare. The hand is


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C8. T1 is rare. The hand is

paralysed with wristdrop and absenceof grasp reflex.

Most degrees of injury may be leftuntreated but gentle physiotherapy is

essential to prevent stiffness anddelayed recovery. Severe injuryshould be renewed by an orthopaedicspecialist.


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The fetal brain is protected againstdamage in labor by:


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Softness and moulding ofmembranous bones

Ability of fontanelles to giveslightly on pressure.

Cushioning effect of cerebrospinalfluid.

Anatomical arrangement of dural

septa with their free edges. Plasticity of brain tissue.


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7343376 Ob Operative Obstetrics

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