Episiotomy and version

episiotomy, normal labour, vaginal delivery, external cephalic version, internal podalic version, destructive operation, operative obdtetrics, perineal tear, malpresentation, breech, transverse lie, delivery of 2nd twins.

1. By Magdy Abdelrahman Mohamed 2017 EPISIOTOMY, VERSION AND DESTRUCTIVE OPERATIONS

2. EPISIOTOMY

3. It is an incision of the perineum during labour. Definition.

4. It is a pyramidal shaped area between the lower vagina and the anal canal and the lower end of the rectum. Anatomy of the perineal body.

5. Avoid irregular tears. Avoid fetal intracranial hemorrhage. Aim

6. Absolute: Preterm labour. Breech presentation. During forceps application. INDICATION

7. Relative: Primipara . Scarred perineum Rigid perineum. Narrow subpubic angle. Shoulder dystocia. Malposition. INDICATION

8. Median ( midline) episiotomy: Mediolateral episiotomy: J shaped episiotomy: TYPES

9. Timing. Local anesthesia. Repair. Technique

10. Hematoma. Abscess formation. Infection and gapped wound. COMPLICATIONS

11. VERSION

12. It is replacement the presenting part by another one. If the aim is to make the head the presenting part it is called cephalic version and if the breech will be the presenting part it is podalic version. DEFINITION

13. External cephalic version. Internal podalic version. TYPES

14. Indications * Breech presentation. * Transverse or oblique lie. EXTERNAL CEPHALIC VERSION

15. Timing: Preferred after 36w till onset of labour. EXTERNAL CEPHALIC VERSION

16. Prerequisites : 1. Facilities for monitoring. US : FHR visualisation CTG : before & after procedure 2. Facilities for immediate delivery . 3. Anti-D immunoglobulin to rhesus-negative. 4. Informed consent. EXTERNAL CEPHALIC VERSION

17. Contraindications: CS is indicated. Antepartum haemorrhage within the last 7 days. A bnormal CTG. M ajor uterine anomaly. Ruptured membranes. Multiple pregnancy. EXTERNAL CEPHALIC VERSION

18. Technique: No anaesthesia as the pain is a safe guard against rough manipulations. The patient evacuates her bladder. She lies in a Trendelenburg position with exposed vulva to detect any vaginal bleeding. The fetal position is determined and FHS is auscultated. EXTERNAL CEPHALIC VERSION

19. Technique: One hand is applied externally to the fetal head and the other on its buttock. The two poles are approximated to flex the fetus and rotation is done by the two hands simultaneously to bring the head lower down. EXTERNAL CEPHALIC VERSION

20. If neither vaginal bleeding nor fetal distress results, an abdominal binder is applied to fix the new position and re-examined twice weekly. If the original presentation returned again, the procedure of version can be repeated . Some doctors prefer to induce labour immediately after successful version. EXTERNAL CEPHALIC VERSION

21. Complications: Placental separation. Rupture of membrane. Fetal distress. EXTERNAL CEPHALIC VERSION

22. Indications: Retained second twin in a transverse lie. INTERNAL PODALIC VERSION

23. P re-requisites: General anaesthesia . Evacuation of the bladder. Complete aseptic conditions. Cervix is fully dilated . No previous uterine scar. Adequate amniotic fluid. INTERNAL PODALIC VERSION

24. Complications: Neurogenic shock Rupture uterus. Puerperal sepsis. INTERNAL PODALIC VERSION

25. HISTORICAL Destructive operations

26. Craniotomy. Decapitation. Evisceration. Cleidotomy : division one or both calvicle DESTRUCTIVE OPERATIONS