NUR HANISAH BINTI ZAINOREN

Dilatation and evacuation

Sucktion evacuation

Menstral regulation

Vacuum aspiration

Hysterotomy

Episiotomy

Operative vaginal delivery

Forceps

Ventouse

Version

Destructive operations

Cesarean section

Dilatation and evacuation

Sucktion evacuation

Menstral regulation

Vacuum aspiration

Hysterotomy

Episiotomy

Operative vaginal delivery

Forceps

Ventouse

Version

Destructive operations

Cesarean section

Dilatation and evacuation

Sucktion evacuation

Menstral regulation

Vacuum aspiration

Hysterotomy

Episiotomy

Operative vaginal delivery

Forceps

Ventouse

Version

Destructive operations

Cesarean section

Dilatation and evacuation

Sucktion evacuation

Menstral regulation

Vacuum aspiration

Hysterotomy

Episiotomy

Operative vaginal delivery

Forceps

Ventouse

Version

Destructive operations

Cesarean section

Dilatation and evacuation

Sucktion evacuation

Menstral regulation

Vacuum aspiration

Hysterotomy

Episiotomy

Operative vaginal delivery

Forceps

Ventouse

Version

Destructive operations

Cesarean section

PRELIMINARIES:

1. Anesthesia

2. Lithotomy Position

3. Full surgical asepsis

4. Empty the bladder

5. Vaginal examination

PRELIMINARIES:

1. Anesthesia

2. Lithotomy Position

3. Full surgical asepsis

4. Empty the bladder

5. Vaginal examination

• General/Local

• May be performed with IV Diazepam sedation

PRELIMINARIES:

1. Anesthesia

2. Lithotomy Position

3. Full surgical asepsis

4. Empty the bladder

5. Vaginal examination

PRELIMINARIES:

1. Anesthesia

2. Lithotomy Position

3. Full surgical asepsis

4. Empty the bladder

5. Vaginal examination

• Surgeon is to wear sterile mask, gown & gloves

• Vulva & vagina is to be swabbed

with antiseptic solution

• Cervix is cleaned with povidone

iodine solution

• Perineum is to be draped by

sterile towel &

the legs with leggings

PRELIMINARIES:

1. Anesthesia

2. Lithotomy Position

3. Full surgical asepsis

4. Empty the bladder

5. Vaginal examination

• If the patient is ambulant,

she is asked to empty the bladder

before she is placed on the table

• Otherwise, catheterization is to be done

PRELIMINARIES:

1. Anesthesia

2. Lithotomy Position

3. Full surgical asepsis

4. Empty the bladder

5. Vaginal examination • Size of uterus

• Position of uterus

• State of dilatation of cervix

DILATATION

of the cervix

EVACUATIONof the

product of

conception

FROM THE

UTERUS

TYPES

ONE STAGE

OPERATION

TWO STAGE

OPERATION

Dilatation of cervix &

evacuation of uterus

done in the same sitting

rapid dilatation

of cervix &

2nd phase: evacuation

slow dilatation

1st phase: of cervix

ONE STAGE operation

1. Incomplete abortion (commonest)

2. Inevitable abortion

3. Medical termination of pregnancy (6-8 weeks)

4. Hydatidiform mole in the process of expulsion

TWO STAGE operation

1. Induction of 1st

trimester abortion (commonest)

2. Missed abortion (uterus 8-10 weeks)

3. Hydatidiform molewith unfavorable cervix

Hawkin Ambler dilator Sim’s speculum Allis forceps Curette Ovum forceps

TYPES

ONE STAGE

OPERATION

Dilatation of cervix &

evacuation of uterus

done in the same sitting

Sim’s posterior vaginal speculum

Allis forceps

Curette

Preliminaries

Steps:

Sim’s posterior vaginal speculum is

introduced

Anterior lips of cervix is grasped by

an Allis forceps

Cervical canal is gradually dilated up

Products are removed by ovum

forceps

Inj. Methergin

0.2mg IV is

administered

Uterine cavity is

curetted gently

Speculum & Allis forceps are removed

Uterus is massaged bimanually

Sterile vulval pad is placed

Patient is send back to her bed

TYPES

TWO STAGE

OPERATIONrapid dilatation

of cervix &

2nd phase: evacuation

slow dilatation

1st phase: of cervix

First phase (slow dilatation of cervix)

Consists of introduction of laminaria tents or

lamicel (MgSO4 sponge) into cervical canal

to effect its slow dilatation

May be effective by intravaginal insertion of

Misoprostol (PGE1), 400mcg 3 hrs before surgery (less side effect)

Preliminaries

As previously mentioned

No anesthesia is required

Appropriate size &

number of the tent

required are selected

The threads attached to one end are tied to roller gauze

Sim’s posterior vaginal speculum is introduced and hold

Allis forceps is used to grasp the anterior

lip of the cervix

Cervical canal may have to be dilated

Tents are introduced one after the other

for at least 4cm

(tips are placed beyond external os)

Roller gauze is used to pack the upper vagina (to prevent

displacement)

Patient is send back to her bed

Prophylactic antibiotic

Doxycycline

100mg PO BID

for 3 days

+

Metronidazole

400mg PO BID

for 5 days)

Steps of Introduction of Tents

Second phase (rapid dilatation of cervix evacuation of uterus)

Procedures: Patient is brought back to

operation theatre usually after 12

hours

Patient should empty her bladder

beforehand

Preliminaries: As mentioned before

Operation may be conducted under

• IV Diazepam sedation• Local paracervical block• General Anesthesia

Removing the roller gauze

The posterior vaginal

speculum is introduced

Tents are removed with

the help of sponge forceps

Preliminaries

Follow all the steps as in one stage operation

Sim’s posterior vaginal speculum

is introduced

Anterior lips of cervix is grasped

by an Allis forceps

Cervical canal dilatation

Removal of products by

ovum forceps

Inj. Methergin0.2mg IV

Uterine cavity is curetted gently

Speculum & Allis forceps removal

Uterus is massaged

bimanually

a sterile vulvalpad is placed

Patient is send back to her bed

Oxytocic agents

Inj. Methergin 0.2mg IM

OR

Oxytocin 20 units in 500mL of NS

intraoperatively and continued after operation

for 30 mins

Prophylactic antibiotic

Doxycycline

100mg PO BID

for 3 days

+

Metronidazole

400mg PO BID

for 5 days)

Steps of 2nd stage: (MTP-8 weeks)

Immediate

1. Excessive hemorrhage

2. Injury

3. Shock

4. Perforation

5. Sepsis

6. Hematometra

7. Increased morbidity

8. Cont. of pregnancy (1%)

Late

Pelvic inflammation

Infertility

Cervical incompetence

Uterine synechiae

Depends on the location, size & nature of

the instrument

causing perforation

Procedure is stopped

CAUSES MANAGEMENT

Perforation by SMALLER size

dilator or sound

• Expectant treatment with

observation of pulse & BP

• Antibiotic

Perforation by BIGGER size

dilator,or ovum, or ring forceps, or suction

cannula

• Dianostic laparoscopy

• Laparotomy

• Inspection of intestine &

omentum for evidence of injury

Lateral cervical tear with

broad ligament hematoma or

laceration of uterine artery

• Laparotomy followed by repair

• Hysterectomy

Perforation prior to

complete evacuation

• Stop evacuation. Evacuation can

be done

under laparoscopic visualization.

• If laparotomy is decided, consider

to

preserve uterus or hysterectomy

Depends on the location, size & nature of

the instrument

causing perforation

Procedure is stopped

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

• MTP during 1st trimester *

• Inevitable abortion

• Recent incomplete abortion

• Hydatidiform mole

PROCEDURES

Preliminaries:

As mentioned before

GA is usually not needed

If patient is apprehensive,

IV Diazepam 5-10 mg (conscious sedation)

supplemented by paracervical block is

quite effective

Patient is put on the table after bladder is emptied

PROCEDURES

Steps:

Sim’s posterior vaginal speculum is introduced and hold by assistant

Anterior lips of cervix is grasped by an Allis forceps

Cervical canal is gradually dilated by graduated metal dilators up to one size less than the suction cannula (characterized by feeling of “snap” around the dilator)

OR

Use of laminaria tent 12 hrs before or

Misoprostol 400mcg PV 3 hrs prior to surgery

PROCEDURES

Steps:

Injection Methergin 0.2mg IV

Appropriate suction cannula is

fitted to the suction apparatus

PROCEDURES

Steps:

Introduced into the uterus, tip to be placed in the middle of the uterine cavity

Pressure of suction is raised to 400-600 mmHg

Cannula is moved up & down and rotated 360o

Suction bottle is inspected for the products of conception & blood loss

The END POINT OF SUCTION is denoted by:

1) no more material is being sucked out

2) gripping of the cannula by the

contracting smaller size uterus

3) grating sensation

4) appearance of bubbles in the cannula

or in the transparent tubing

PROCEDURES

Steps:

Vacuum should be broken before withdrawing the cannula

Better to curette the uterine cavity with small flushing curette at the end of suction

Cannula is reintroduced to suck out any remnants

PROCEDURES

Steps:

After uterus is firmed & bleeding is minimal, a sterile vulval pad is placed

Patient is brought down from the table

Similar complications as mentioned in D+E operation may occur

Use of plastic cannula can minimize uterine perforation

Blood loss & incomplete evacuation are less likely with pregnancy of 8 weeks or less

Use of USG during procedures shortens the operative time and reduces complications

Syn: induction, aspiration

Aspiration of the endometrial cavity

within 14 days of missed period

in a woman with previous normal cycle

PROCEDURE

Operation is done as an out patient

Aseptic precautions

Sedation or paracervical block anesthesia may be employed

Introduction of posterior vaginal speculum & Allis forceps

Gentle dilatation of cervix using 4-5mm size dilators

Insertion of 5-6mm suction cannula (Karman’s) & attached to 50mL syringe

Cannula is rotated, pushed in & out with gentle strokes

PROCEDURE

Operation is done as an out patient

Aseptic precautions

Sedation or paracervical block anesthesia may be employed

Introduction of posterior vaginal speculum & Allis forceps

Gentle dilatation of cervix using 4-5mm size dilators

Insertion of 5-6mm suction cannula (Karman’s) & attached to 50mL syringe

Cannula is rotated, pushed in & out with gentle strokes

PROCEDURE

Operation is done as an out patient

Aseptic precautions

Sedation or paracervical block anesthesia may be employed

Introduction of posterior vaginal speculum & Allis forceps

Gentle dilatation of cervix using 4-5mm size dilators

Insertion of 5-6mm suction cannula (Karman’s) & attached to 50mL syringe

Cannula is rotated, pushed in & out with gentle strokes

PROCEDURE

Operation is done as an out patient

Aseptic precautions

Sedation or paracervical block anesthesia may be employed

Introduction of posterior vaginal speculum & Allis forceps

Gentle dilatation of cervix using 4-5mm size dilators

Insertion of 5-6mm suction cannula (Karman’s) & attached to 50mL syringe

Cannula is rotated, pushed in & out with gentle strokes

PROCEDURE

Operation is done as an out patient

Aseptic precautions

Sedation or paracervical block anesthesia may be employed

Introduction of posterior vaginal speculum & Allis forceps

Gentle dilatation of cervix using 4-5mm size dilators

Insertion of 5-6mm suction cannula (Karman’s) & attached to 50mL syringe

Cannula is rotated, pushed in & out with gentle strokes

Operator should examine the aspirated tissues by floating it in a clear plastic dish over a light source

Placenta tissue appears fluffy and feathery when floats in normal saline

Help to detect failed abortion, molar pregnancy or ectopic pregnancy

Procedure is SIMILAR to menstrual regulation and is done as out patient basis Highly

effective

(98-100%)

Procedure may be:

Manual Vacuum Aspiration (MVA)

Electric Vacuum Aspiration (EVA)

Termination is done upto 12 weeks with MINIMAL cervical dilatation

A hand operated double valve plastic syringe (60mL) is attached to Karman’s cannula (upto 12mm size)

Cannula is inserted transcervically into the uterus and vacuum is activated

A negative pressure of 660 mmHg is created

Aspiration of the products of conception

*procedure takes less time (5-15 mins) and is less traumatic

*complications are similar to other surgical method but are less severe

Clear?

Clear?

Clear?

INDICATION

LEGAL ABORTION MALAYSIA

Any medical condition that can be worsened by

pregnancy.

A pregnancy with fetus that is unlikely to survive like

anencephaly.

This is not applied to any syndrome or congenital

malformation in which the baby could survive like Down

syndrome.

A rape case in which the pregnancy causing the mental distress to the

patient.

Operative procedure of…

extracting the product of conception out of the womb before 28th week by cutting through the anterior wall of the uterus

similar to a caesarean section, but requiring a smaller incision

form of abortion in which the uterus is opened through an abdominal incision and the fetus is removed,

indications

Fibroids in the lower uterine segment (obstructing evacuation) Midtrimester MTP where

other methods are failed or contraindicated

indications

Completely low lying placenta (placenta previa)

Cervical cancer with pregnancy

Uterine

anomalies

Women with multiple previous cesarean delivery

(due to risk of placenta accrete)

PERINIOTOMY

A surgically planned incision on the perineum & posterior vaginal wall during the 2nd stage of labor

To enlarge vaginal introitus facilitate easy & safe delivery of the fetus

To minimize overstretching & rupture of perineal muscles & fascia reduce stress & strain on the fetal head

Recommended in selective cases than in routine

A constant care during the 2nd stage reduces the incidence of episiotomy & perineal trauma

Elastic/rigid perineum

arrest/delay in descent of

the presenting part as in

elderly primigravidae

Operative delivery

forceps delivery

ventouse delivery

Anticipating perineal tear

big baby

face to pubis delivery

breech delivery

shoulder dystocia

Previous perineal surgery

pelvic floor repair

perineal reconstructive surgery

Requires judgment

EARLY blood loss is more

LATE fails to prevent invisible lacerations of

the perineal body fails to protect pelvic floor

IDEAL TIME Bulging thinned perineum during contraction just

prior to crowning (3-4cm of head visible)

Maternal A clear & controlled incision is easy to

REPAIR AND HEALS better than a lacerated wound that may occur otherwise

Reduction in the DURATION of 2nd

stage

Reduction of TRAUMA to pelvic floor muscle reduces the incidence of prolapse & urinary incontinence

Fetal Minimize the intracranial injuries

specially in premature babies or after-coming head of breech

Mediolateral

• Downwards & outwards incision from the center of the fourchette (right/left)

• Directed diagonally in a straight line which runs about 2.5cm away from the anus

Median/Midline

• Incision from the center of the fourchette

• Extends posteriorly along the midline for about 2.5cm

Lateral

• Incision from about 1cm away from the center of the fourchette

• Extends laterally

• Got many drawbacks including chance of injury to batholin’sduct. TOTALLY CONDEMNED.

‘J’ shaped

• Incision begins in the center of the fourchette

• Directed posteriorly along the midline for about 1.5cm

• Then directed downwards & outwards along 5/7 o’clock position to avoid anal sphincter

• Apposition is not perfect & the repaired wound tends to be puckered

mediolateral

‘J’ shaped median

lateral

MERITS DEMERITS

mediolateral episiotomy

The muscles are not cut

Less blood loss

Repair is easy

Postoperative comfort is maximum

Healing is superior

Wound disruption is rare

Dyspareunia is rare

median episiotomy

Extension if occurs, may involve the rectum

Not suitable for manipulative delivery or in

abnormal presentation or position.

Relative safety from rectal involvement

from extension

If necessary, the incision can be extended

Apposition of the tissues is not so good

Blood loss is little more

Postoperative discomfort is more

Relative increased incidence of wound

disruption

Dyspareunia is comparatively more

1)Preliminaries

2)Incision

3)Repair

1)Preliminaries

2)Incision

3)Repair

Perineum is thoroughly swabbed with antiseptic (povidone-iodine) lotion and draped properly

Local anesthesia

the perineum, in the line of proposed incision is infiltrated with 10mL of 1% solution of lignocaine

2 fingers are placed in the vagina between the presenting part & the posterior vaginal wall

Made by a curved/straight blunt pointed sharp scissors One blade is placed inside, in between

the fingers & the posterior vaginal wall

The other is on the skin

Incision should be made at the height of an uterine contraction

1)Preliminaries

2)Incision

3)Repair

1)Preliminaries

2)Incision

3)Repair

Timing

Done soon after expulsion of placenta

Oozing - controlled by pressure with a sterile gauze swab

Bleeding – artery forceps

Early repair prevents sepsis & eliminates the patient’s prolonged apprehension of ‘stitches’

Preliminaries: Lithotomy position

A good light source from behind is needed

Perineum & wound area are cleansed with antiseptic solution

Blood clots are removed from vagina & wound area

Patient is draped properly repair should be done under strict aseptic precautions

If the repair is obscured by oozing of blood from above, a vaginal pack may be inserted & is placed high up

1)Preliminaries

2)Incision

3)Repair

1)Preliminaries

2)Incision

3)Repair

Repair

Done in 3 layers

Principles to be followed are:

1) Perfect hemostasis

2) To obliterate the dead space

3) Suture without tension

Orders:

1) Vaginal mucosa & submucosal tissues

2) Perineal muscles

3) Skin & subcutaneous tissues

POSTOPERATIVE CARE Dressing

The wound is to be dressed each time following urination & defecation

To keep area clean & dry

Swabbing with cotton swabs soaked in antiseptic powder or ointment (Furacin or Neosporin)

POSTOPERATIVE CARE

Comfort

To relieve pain in the area, magnesium sulfate compress or application of infrared heat may be used

Ice packs reduces swelling & pain also

Analgesic drugs (Ibuprofen) may be given when required

POSTOPERATIVE CARE Ambulance

Patient is allowed to move out of the bed after 24 hours

Prior to that, she is allowed to roll over on to her side or even to sit but only with thighs apposed

POSTOPERATIVE CARE

Removal of stitch When wound is sutured by catgut or

Dexon which will be absorbed, the sutures need not be removed

If non-absorbable material (silk/nylon) is used, the stitches are to be cut on 6th day

POSTOPERATIVE CARE Dressing

The wound is to be dressed each time following urination & defecation

To keep area clean & dry

Swabbing with cotton swabs soaked in antiseptic powder or ointment (Furacin or Neosporin)

Ambulance

Patient is allowed to move out of the bed after 24 hours

Prior to that, she is allowed to roll over on to her side or even to sit but only with thighs apposed

Comfort

To relieve pain in the area, magnesium sulfate compress or application of infrared heat may be used

Ice packs reduces swelling & pain also

Analgesic drugs (Ibuprofen) may be given when required

Removal of stitch When wound is sutured by catgut or

Dexon which will be absorbed, the sutures need not be removed

If non-absorbable material (silk/nylon) is used, the stitches are to be cut on 6th day

immediate

Extension of the incision

Vulval hematoma

Wound dehiscence

Incontinence

remote

Dyspareunia

Chance of perineal lacerations

Scar endometriosis (rare)

Conclusion…

FOR MAIN POINTS:

DC Dutta ‘s Textbook of Obstetrics

FOR EXTRA POINTS:

http://medicowesome.blogspot.in/2014/10/what-is-difference-between-menstrual.html

http://www.glowm.com/section_view/heading/Surgical%20Techniques%20for%20First-Trimester%20Abortion/item/439

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03268.x/full

http://www.academia.edu/7691081/Legal_Issues_of_Abortion_in_Malaysia

FOR VIDEO:

https://www.youtube.com/watch?v=iHfRe7q7WEY

Thank You…