6 ,jbkj operative delivery.pptx

operative delivery

1. OPERATIVE OBSTETRICS

2. Operative Obstetrics Interventions intrapartum I. Vaginal A. Forceps Delivery B. Breech Extraction C. Vacuum Extraction II. Abdominal A. Cesarean Section B. Postpartum Hysterectomy

3. 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

4. Forceps Delivery Outlet forceps 1. 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, LOP 4. Fetal head is at or on perineum. 5. Rotation does not exceed 45 °. O= occiput

5. 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 .

6. 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. .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.

7. Uses of forceps 1. Maternal or fetal indications 2. Prophylactic 3. Elective

8. Indications for Forceps Delivery Any condition threatening the mother or fetus that is likely to be relieved by delivery. Maternal Indications 1. Heart disease 2. Pulmonary compromise or Injury 3. Intrapartum infection 4. Certain neurological conditions 5. Exhaustion 6. Prolonged second stage Fetal Indications 1. Prolapse of umbilical cord 2. Premature separation of the placenta 3. Non-reassuring fetal heart rate pattern

9. Pre-requisites for application of Forceps Delivery head engaged presentation vertex or chin anterior position known cervix completely dilated membranes ruptured no disproportion between head & pelvis

10. 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.

11. 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: Frank –lower extremities flexed at the hips & extended at knees Complete – one or both KNEES are flexed Incomplete – one or both HIPS are not flexed and one or both feet or knees lie below the breech

12. FRANK COMPLETE INCOMPLETE

13. Methods of Breech Delivery 1. Spontaneous breech delivery 2. Partial Breech extraction, spontaneous up to umbilicus 3. Total Breech Extraction

14. 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.

15. 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

16. Maternal risks of Breech Delivery Maternal infection Uterine rupture Cervical lacerations Extensions of episiotomy Deep perineal tears Postpartum hemorrhage from uterine relaxants

17. Fetal risks of B reech 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

18. 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 scalp Indications & pre-requisites Same as in forceps delivery

19. Indications for use of vacuum There are several indications to use a ventouse to aid delivery : 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).

20. 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.

21. 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.

22. 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.

23. 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

24. 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

25. 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.

26. Techniques Total Hysterectomy more 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

27. 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