OBSTETRICAL OPERATIONS & PROCEDURES.pptx

obstetric operation

1. OBSTETRICAL OPERATIONS & PROCEDURES

2. INTRODUCTION Obstetric operations and procedures are surgical procedures requires aseptic precautions and some protocols should be followed.

3. induction of labor It is the deliberate initiation of labor by any method (medical , surgical or combined) before spontaneous onset after 28 weeks of pregnancy for the purpose of vaginal delivery. It is indicated when there is risk to the life of mother or fetus if the pregnancy continues.

4. Types of induction

5. Indications of iol Post-Term or prolonged pregnancy Previous history of IUFD Preclampsia or Eclampsia Maternal medical complications e.g ; diabetes, renal problem. Abruptio placentae or PROM Intrauterine growth retardation (IUD),congenital abnormality Hydramnios & Unstable lie

6. contraindications Cephalopelvic disproportion, contracted pelvis Malpresentation Previous history of cesarean section or hysteria Placenta previa , vasaprevia or unexplained vaginal bleeding,cord prolapse Active genital herpes infection High risk pregnancies Pelvic tumors,cervical carcinoma Elderly primigravidae with medical or obstetrical problems

7. complications maternal Psychological upset Prolonged labor Operative interference Increase need of analgesic during labor Increased morbidity fetal Iatrogenic prematurity Hypoxia

8. Prerequisites maternal Confirm indication & contraindication of IOL. Assess Bishop’s score. fetal Ensure fetal gestational age. Ensure fetal weight. Ensure fetal lung maturity. Ensure fetal presentation & lie. Confirm fetal wellbeing.

9. Methods of induction

10. MEDICAL METHOD OXYTOCIN MIFEPRISTONE

11. PROSTAGLANDINS

12. SURGICAL METHOD ARTIFICAL RUPTURE OF MEMBRANES STRIPPING THE MEMBRANES

13. COMBINED METHOD Both medical and surgical methods are used to increase the efficacy of induction by reducing the induction delivery interval. Oxytocin infusion is started either prior to or following rupture of membranes depending upon the state of cervix and head brim relation. In case of non- engaged head, Induce labor pain with prostaglandins or start oxytocin infusion followed by ARM.

14. Role of nurse in iol GENERAL ROLE ; Review patient’s history before IOL. Perform abdominal examination. Obtain informed consent. Maintain partograph . Use aseptic techniques.

15. Role of nurse in iol DURING PROSTAGLANDIN ADMINISTRATION; Instruct woman to pass urine before administration. Remain in lateral or supine position with hip tilt for 30-60 minutes after administration of gel, for 2 hours after insertion of vaginal tablets. Assess cervical dilation after 6 hours of insertion . If no cervical response or no adverse effects repeat the dose. Monitor the side effects of prostaglandin ,if any adverse reactions inform to physician.

16. Role of nurse in iol DURING OXYTOCIN INFUSION; Check respiration , BP , pulse, length, intensity, duration of contractions, FHR. Note the signs of water intoxication. Instruct the patient to report increase blood pressure, abdominal cramps , fever, foul smelling vaginal discharge.

17. Role of nurse in iol IF UTERINE HYPERSTIMULATION OR FETAL DISTRESS; Stop oxytocin infusion immediately. Provide left lateral position to woman. Increase primary intravenous rate up to 200 ml/ hr unless contraindicated. Provide oxygen therapy at the rate of 6L/min by face mask. Notify doctor if induction is failed. If membranes are ruptured prefer cesarean section , if intact discontinuous induction.

18. Role of nurse in iol AFTER ARM; The midwife should exclude the presence of cord prolapse. Note color, consistency, odor and quantity of amniotic fluid. Note presentation , position and station of fetal head. Check temperature every 2 hourly.

19. FORCEPS DELIVERY

20. DEFINITION Forceps delivery means using obstetric forceps(a pair of instruments designed to extract fetal head) for delivery when the mother is unable to deliver the baby by her own efforts.

21. Types of forceps

22. Parts of forceps

23. Function of forceps To provide traction force. For rotation of head with the help of kielland’s forceps. To provide protective cage to the head passes through the canal. If cesarean section one forceps should be used to delivery the head. When applied correctly the compression effect of forceps should be minimal.

24. Indications fetal Fetal distress After coming head in breech delivery Fetal compromise maternal Inadequate expulsive efforts Maternal exhaustion Prolonged 2 nd stage of labor Severe preclampsia Cardiac disease, hypertensive crisis, spinal cord injury, cerebrovascular disease.

25. prerequisites Fetal head must be engaged. Cervix must be fully dilated. Membranes must be ruptured. Pelvis is deemed adequate. Fetal position is exactly known. Bladder must be emptied. Adequate analgesia. Informed consent, experienced obstetrician or midwife. Aseptic techniques must be used.

26. Steps in forceps delivery STEP 1; APPLICATION OF BLADES: Identify the right and left blade. Insert first left blade between the perineum and fetal head under the guidance of vaginal fingers. The forefinger of the right hand are inserted along the leftlateral vaginal wall, palmer surface of finger rest against side of head. Introduction of right blade in the same manner of left one.

27. STEP 2; LOCKING OF BLADES: When correctly blade applied , head should be articulated with easily but if possible check once again FHR.

28. STEP 3; TRACTION: Encourage the mother to push and contract the uterus. Traction is released between contraction. Traction is continued in downward , backward traction until head comes to perineum.

29. STEP 4 ; REMOVAL OF BLADES: Remove of first right blade than left blade. Following birth of head provide 0.2 mg IV methergine to prevent bleeding.

30. Maternal complications immediate Injury Nerve injury Postpartum hemorrhage Anesthetic complications Puerperal sepsis Maternal morbidity remote Painful perineal scars dyspareunia Low back pain Genital prolapse Stress urinary incontinence Anal sphincter dysfunction

31. FETAL COMPLICATIONS IMMEDIATE Asphyxia Facial bruising Intracranial hemorrhage Cephalohematoma Hematoma Facial palsy Skull fracture and cervical spine injury REMOTE Cerebral or spasmatic palsy

32. Nursing interventions Before forceps delivery explain risks and benefits of forceps for mother & fetus. Inform the patient that forceps blades fit as tablespoons around egg. Check prerequisites of forceps applications. Assess FHR before forceps applications and during traction. After delivery examine any tears from forceps. Assess newborn for indication of injury. Check complications. Recording and reporting .

33. Ventouse delivery

34. definition Ventouse is an instrumental device designed to assist delivery by creating a vacuum between suction cup and fetal scalp. It is also known as vacuum ectraction .

35. equipments SUCTION CUP VACUUM PUMP

36. TRACTION ROD DEVICE

37. indications Deep transverse arrest with adequate pelvis Delay in descent of high head in case of second baby in twins Maternal exhaustion Inadequate expulsive efforts Prolonged second stage of labor Malposition

38. CONTRAINDICATIONS Fetal distress Face presentation Prematurity Fetal bleeding disorder

39. Advantages of ventouse Require less technical skills Applied through incomplete dilated cervix Lesser traction force is required Need of analgesia is quite less Comfortable Not a space occupying device like forceps

40. prerequisites No bony resistance below the head Head must be engaged Cervix at least 6 cm dilated

41. procedure Application of cup Applying traction

42. complications maternal Trauma is rare Injuries may occur due to inclusion of soft tissues such as cervix or vaginal wall inside the cup. fetal Sloughing of scalp Cephalohematoma Cerebral trauma Chignon

43. nursing interventions Review patient history, abdominal examination, check prerequisites. Take informed consent. Use aseptic techniques. Select ventouse cup as per size of fetal head. Check fetal heart rate before cup application and after ventouse application. After delivery check for any complications in mother or fetus. Recording or reporting.

44. version

45. definition Version is a manipulative procedure designed to change the lie or to bring the comparatively favorable pole to the lower pole of the uterus.

46. types of version Spontanous External Internal Bipolar

47. indications external Breech presentation Transverse lie internal Transverse lie in second baby of twins

48. contraindications Antepartum hemorrhage Multiple pregnancy in external cephalic version PROM Congenital malformation of uterus Abnormal cardiotocography Contracted pelvis Previous cesarean section Rh incompatibility

49. prerequisites of version The cervix must be fully dilated. Liquor amnii must be adequate. Real time ultrasonography. Non stress test . Abdominal examination. Check FHR. Tocolytic drug ( terbutaline 0.25 mg SC)

50. PROCEDURE EXTERNAL VERSION( CEPHALIC) STEP 1 ; Mobilization of the buttocks using both hands to one iliac fossa toward which the back of the fetus. STEP 2 ; Rotation of the trunk holding the poles and maintain flexion of the trunk.

51. STEP 3; Change the hands to prevent crossing after the lie becomes transverse. STEP 4; The lie becomes longitudinal with the cephalic pole being brought to the lower pole of the uterus.

52. procedure INTERNAL VERSION; STEP 1; The hand is to be introduced in cone shaped manner . If the podalic pole of the fetus is on the left side of the mother , the right hand to be introduced and vice versa. STEP 2; The hand is to be pass up to the breech and then along the thigh until a foot is grasped. The identification of the foot is done by palpation of heel.

53. STEP 3; While the leg is brought down by steadily traction , the cephalic pole is pushed up using the external hand. STEP 4; After the delivery of one leg , deliver another leg and delivery is usually completed with breech extraction during uterine contractions. STEP 5; Explore the utero-vaginal canal to exclude rupture of uterus or any other injury.

54. Bipolar version It is lifesaving procedure especially in rural areas where it is not possible to transport the patient with placenta previa to an equipped hospital. The indications of this procedure is lesser degree of placenta previa when the fetus is dead , deformed or previable . Cervix must be at least two fingers dilated to facilitate manipulation of head to one iliac fossa and to grasp one leg at the ankle. Simultaneously manipulation by external hand facilitates the procedure. Bringing down of one leg facilitates compression over the placenta & stop bleeding.

55. complications maternal Premature onset of labor PROM Abruptio placenta or bleeding Increases chances of fetomaternal bleeding Amniotic fluid embolism fetal Asphyxia Cord prolapse Intracranial hemorrhage IUFD of fetus

56. Nursing responsibilities Advise the patient for follow up to check the corrected position. Report the physician if there is vaginal bleeding or escape of liquor or labor starts. Rh negative immunized women must be protected by intramuscular administration of 100mg anti D gamma globulin. Cardiotocography should be done after the procedure to reassure about FHR.

57. MANUAL REMOVAL OF PLACENTA

58. DEFINITION Failure of placental delivery within 30 minutes after delivery of the fetus is called retained placenta. When placenta is not expelled out spontaneously and retained inside the uterine cavity, manual removal of placenta is done. Manual removal of placenta is a procedure to remove a retained placenta from the uterus after childbirth.

59. steps STEP1; P rovide general anesthesia with 10 mg diazepam IV. Provide lithotomy position to patient. Catheterize the bladder. STEP 2; Separate labia by fingers and introduce other hand in uterine cavity in cone shape manner. STEP 3; Apply another hand on abdomen and counter pressure on uterine fundus .

60. STEP 4; As soon as placental margin is reached the fingers are insinuated between the placenta and uterine wall with back of hand in contact with uterine wall. The placenta is separated with sideways slicing movement of fingers. STEP 5; After complete separation of placenta apply traction on the cord by other hand and remove placenta . Put hand again to check any membranes of placenta in uterine cavity.

61. STEP 6; Administer methergine 0.2mg IV and remove the hand from uterus gradually by massaging the uterus with external hand’ STEP 7; After removal inspect the cervicovaginal canal for injury. STEP 8; Inspect placenta and membranes.

62. difficulties Hourglass contraction leading to difficulty in introduction the hand. Morbid adherent placenta may cause difficulty on getting to the plane of cleavage of separation.

63. complications Hemorrhage due to incomplete removal Injury to uterus Infection Inversion Subinvolution Thrombophlebitis Embolism

64. Cesarean section

65. definition Cesarean section is an operative procedure whereby the fetus after the end of 8 th week is delivered through incision on abdominal and uterine walls.

66. Time of operation

67. INDICATIONS Cephalopelvic disproportion Major degree of placenta previa Multiple pregnancies Cancer of cervix, pelvic tumors, cervical fibroids Malpresentation Pregnancy induced hypertension Medical / gynecological disorders such as; diabetes mellitus, APH Previous history of cesarean section

68. Emergency indications Cord prolapse Uterine rupture or scar dehiscence Cephalopelvic disproportion diagnose in labor Fulminating PIH Eclampsia Failure to progress in the 1 st or 2 nd stage of labor Fetal distress Abnormal uterine contractions

69. contraindications Dead fetus Premature baby , not able to servive in womb Presence of blood coagulating disorder

70. Types of operation

71. MATERNAL COMPLICATIONS IMMEDIATE PPH Shock Anesthetic hazards Infection Intestinal obstruction Thromboembolic disorder Wound complications Burst abdomen REMOTE Menstrual irregularties Chronic pelvic pain Backache Incisional hernia Intestinal obstruction Scar rupture

72. Fetal complications Iatrogenic prematurity Respiratory distress syndrome

73. Nursing management

74. Dilation & evacuation

75. DEFINITION It is a procedure in which cervix is dilated and the product of conception are taken out from uterine cavity.

76. stages

77. INDICATIONS ONE STAGE OPERATION Inevitable abortion MTP AT 6-8 WEEKS Hydatidiform mole Incomplete abortion SECOND STAGE OPERATION Missed abortion Hydatidiform mole in unfavourable cervix First trimester abortion

78. dangers of d & e immediate Excessive hemorrhage Cervical/ uterine injuries Shock Perforation Sepsis Hematometra Increased morbidity remote Pelvic inflammation Infertility Cervical incompetence Uterine synechiae Preterm labor Ectopic pregnancy

79. Suction evacuation

80. definition It is 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.

81. indications Incomplete abortion Hydatidiform mole Medical termination of pregnancy Inevitable abortion

82. complications immediate Excessive hemorrhage Shock Cervical/ uterine injuries Perforation of bowel & bladder Sepsis Hematometra remote Pelvic incompetence Infertility Cervical incompetence Pretem labor Ectopic pregnancy

83. Manual vacuum aspiration

84. Destructive operations

85. definition The destructive operations are designed to diminish the bulk of the fetus so as to facilitate the delivery of the fetus. The aim is to destroy the fetus in the womb or to save the life of the woman.

86. Types of operations

87. preliminaries Give anesthesia. Provide lithotomy position. Use aseptic techniques. Empty bladder. Perform vaginal examination.

88. CRANIOTOMY It is an operation to make perforation on the head to evacuate the contents followed by extraction of fetus. SITES OF PERFORATION; Vertex , face , brow

89. craniotomy indications Cephalic presentation producing obstruction of labor with dead fetus. Hydrocephalus even with live fetus. Interlocking heads of twins. contraindications Severely contracted pelvis . Rupture of uterus.

90. decapitation It is a destructive operation where fetal head is separate from the trunk & that of decapitated head per vaginam .

91. evisceration It is a destructive operation in which removal of thoracic and abdominal contents through an opening on the thoracic or abdominal cavity at the most accessible site. Indications; Fetal ascites , neglected shoulder presentation

92. cleidotomy There is the division of one or both clavicles in order to reduced bulk of fetus in the operation . This is done only on dead fetus with shoulder dystocia.

93. assignment Nursing care plan on destructive operations.