OPERATIVE OBSTETRICS

Alan Mathew Skaria

Operative Obstetrics

• Interventions intrapartum

I. Vaginal A. Forceps DeliveryB. Breech ExtractionC. Vacuum Extraction

II. AbdominalA. Cesarean SectionB. Postpartum Hysterectomy

Vaginal Operations: Forceps Delivery

Forceps are a surgical instrument that resembles a pair of tongs and can be used in surgery for grabbing, maneuvering, or removing various things within or from the body. They can be used to assist the delivery of a baby as an alternative to the ventouse (vacuum extraction) method.

Classification: 1. Outlet forceps

2. Low forceps 3. Midforceps 4. High Forceps

Forceps Delivery

Outlet forceps1. 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, LOP4. Fetal head is at or on perineum.5. Rotation does not exceed 45°.

O=occiput

Forceps Delivery

• Low forceps delivery, when the baby's head is at +2 station or lower. There is no restriction on rotation for this type of delivery.

• Midforceps delivery, when the baby's 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 baby's head is not yet engaged.

Techniques of Forceps Delivery

The cervix must be fully dilated and retracted and the membranes ruptured. The urinary bladder should be empty.The station of the head must be at least +2 in the lower birth canal. The woman is placed on her back, usually with the aid of stirrups or assistants to support her legs. A mild local or general anesthetic is administered.

Ascertaining the precise position of the fetal was accomplished by feeling the fetal skull suture lines and fontanelles, in the modern era, confirmation with ultrasound is essentially mandatory. At this point, the two blades of the forceps are individually inserted, the posterior blade first, then locked. The position on the baby's head is checked. The fetal head is then rotated to the occiput anterior position if it is not already in that position. An episiotomy may be performed if necessary. The baby is then delivered with gentle traction in the axis of the pelvis.

Uses of forceps1. Maternal or fetal indications2. Prophylactic3. Elective

Indications for Forceps Delivery

Any condition threatening the mother or fetus that is likely to be relieved by delivery.

Maternal Indications1. Heart disease2. Pulmonary compromise or Injury 3. Intrapartum infection4. Certain neurological conditions5. Exhaustion6. Prolonged second stage

Fetal Indications1. Prolapse of umbilical cord2. Premature separation of the placenta3. Non-reassuring fetal heart rate pattern

Pre-requisites for application of Forceps Delivery

1. head engaged2. presentation vertex or chin anterior3. position known4. cervix completely dilated5. membranes ruptured6. no disproportion between head & pelvis

Complications of forceps delivery

A. Maternal1. episiotomy,lacerations & Injuries to the bladder or urethra

2. uterine rupture 3. urinary and rectal incontinence4. febrile morbidity

B. Fetal 1. trauma, Cuts and bruises

2. cephalo-hematoma 3. temporary facial nerve injury 4. clavicle fracture

Summary: Forceps Delivery

1. Forceps delivery, when performed inappropriately, can result in maternal and fetal adverse effects.

2. Outlet & low-forceps operations of 45°or less can be safely performed 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

FRANK COMPLETE INCOMPLETE

Methods of Breech Delivery

1. 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 Delivery

B)Mauriceau Maneuver (back anterior)

• Delivery of the after coming head

• index & middle finger applied over the maxillae to flex the head

Maneuvers of Breech Delivery

C)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 vacuum

There 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 Extraction

The woman is placed in lithotomy position and assists throughout the process by pushing.

A suction cup is placed onto the head of the baby and the suction draws the skin from the scalp into the cup.

Correct placement of the cup directly over the flexion point, about 3 cm anterior from the occipital (posterior) fontanelle, is critical to the success of a VE.  Ventouse devices have handles to allow for traction. When the baby's head is delivered, the device is detached, allowing the accoucheur and the mother to complete the delivery of the baby.

Summary : Vaccum Extraction

Positive 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 mother's abdomen

 (laparotomy) and uterus (hysterotomy) to deliver one or

more babies.

Abdominal Incisions

1.Vertical Incision• Vertical incisions are very rare.• quickest to make• greater chance of dehiscence

2. 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

Cesarean delivery rates: United States

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.

Techniques

1. Total Hysterectomymore extensive mobilization of the bladder medially and laterally is necessary

2. 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

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