OBSTETRICAL PROCEDURES AND OPERATIONS.pptx

OBSTETRICAL PROCEDURES AND OPERATIONS

1. OBSTETRICAL PROCEDURES AND OPERATIONS Ms. Nirali Saravadiya B.Sc nursing tutor

2. CONTENT Dilatation and Evacuation Forcep Delivery Vacum Extraction ( Ventouse Delivery) Cesarean Section Destructive Operations

3. DILATATION AND EVACUATION

4. Dilatation and evacuation • Dilatation of the cervix and evacuation of the products of conception from uterine cavity One stage operation – Dilatation of cervix and evacuation of uterus done in the same sitting Two stage operation – First phase : slow method – Second phase : rapid method

5. One stage operation Steps ; • Dilate the cervix to desired extent • Products are removed by ovum forceps • IV methergine 0.2mg to be given • Uterus is massaged bimanually with both external and internal hand • Vagina and perineum is toileted, with sterile vulval pad Placed Indication Incomplete abortion Inevitable abortion MTP Hydatidiform mole

6. Two stage operation 1. First phase – Introduction of laminaria tent (MgSO4,sponge) 2. Second phase – Further dilatation of cervix with metal dilators followed by evacuation Patient is brought back to OT after 12 hours Conducted under IV diazepam/GA sedation Indication Induction of 1st trimester abortion Missed abortion Hydatidiform mole

7. Complication – Excessive hemorrhage : due to incomplete evacuation or atonic uterus – Injury : cervical laceration, uterine perforation – Shock – Sepsis – Hematometra – Continuation of pregnancy (failure)

8. FORCEPS DELIVERY

9. Definition:  Obstetric forceps is a double-bladed metal instrument used for extraction of foetal head.  This instrument is applied to foetal head and then the operative uses traction to extract the foetus, typically during a contraction while the mother is pushing.

10. Design of forcep : Basically it consist of two crossing branches. Each branch has four components: 1. Blade 2. Shank 3. Lock 4. Handle Each blades has two curves  Cephalic curve to shape of foetal head  Pelvic curve to pelvic curvature.

11. Obstetric Forceps

12. TYPES OF FORCEP APPLICATION  CEPHALIC APPLICATION:  The forceps is applied on the sides of the foetal head in the mentovertical diameter so, injury of the fetal face, eyes and facial nerve is avoided.  PELVIC APPLICATION:  The forceps is applied along the maternal pelvic wall irrespective to the position of the head. It is easier for application but carries a great risk of foetal injuries.  CEPHALO-PELVIC APPLICATION:  It is the ideal and possible application when the occiput is directly anterior or in mento -anterior diameter position.

13. INDICATIONS OF FORCEP DELIVERY  Prolonged 2nd stage  It is the prolongation for more than 1 hour in primigravida or 30 mins in multipara. This may be due to:  Poor voluntary bearing down  Large fetus  Rigid perineum  Malposition: persistent occipito -posterior and deep transverse arrest.

14. MATERNAL INDICATIONS  Maternal distress  Pulse greater than 100 beats per min  Temperature greater than 38 C  Sign of dehydration Maternal diseases as:  Heart disease  Pulmonary TB  Pre-eclampsia and eclampsia

15. FOETAL INDICATIONS  Fetal distress  Prolapse cord  Preterm delivery  breech delivery

16. PRE-REQUISITIES FOR FORCEPS APPLICATION  Anesthesia: general ,epidural, spinal, pudental block.  Adequate pelvic outlet.  Aseptic measures  Bladder and bowel evacuation  Contractions of the uterus should be present.  Dilatation of the cervix should be fully.  Engaged head.

17. MANAGEMENT:  Re-assessment: the forcep is removed and the patient is re-examined to detect the cause and correct it if possible.  Caesarean section: it is indicated in uncorrectable causes as CPD and contracted outlet.  Exploration of the birth canal : for any injuries.

18. CONTRAINDICATIONS  Fetal prematurity  Unengaged head  Unknown fetal position  Malpresentation

19. MATERNAL COMPLICATIONS  Complications of anesthesia  Lacerations: extentions of the episiotomy perineal tear vaginal tear cervical lacerations bladder injury rupture uterus pelvic nerve injuries puerperal infections

20. FETAL COMPLICATIONS  Fracture of the skull  Intracranial hemorrhage  Facial nerve palsy  Trauma to the eyes ,face, scalp.

21. Vaccum extraction ( ventouse )

22. Introduction “Instrumental device designed to assist delivery by applying traction to a suction cup attached to the fetal scalp” • Any condition threatened to mother or foetus that is likely to be relieved by delivery • Fatus of at least 34 weeks

23. Instrumentation Components: • a suction cup with four sizes(30mm,40mm, 50mm, 60mm) – Metal cup – Soft cup – Silastic cup – Rigid plastic cup • vacuum pump, • traction tubing

24. Mityvac pump with tube and soft cup Application of vacuum cup Silastic vacuum cup

25.  Maternal indication 1. Maternal distress 2. Prolonged second stage of labor ( Nulliparous: >3hrs Parous: >2hrs ) 3. Maternal medical disorders such as heart disease, hypertensive disorders and moderate to severe anemia. 4. Previous caesarean section or genital prolapse repair. 5. Intra partum infection, certain neurological conditions.

26.  Fetal indication 1. Prolapse of umbilical cord 2. Premature separation of placenta 3. Fetal distress 4. Occipito -posterior position

27.  Contraindication • Operator inexperience • Inability to assess foetal position • Suspicion of cephalo-pelvic disproportion • Fetal coagulopathy • Preterm babies (<34 weeks) due to risk of foetal intraventricular hemorrhage • Macrosomia (≥4 kg) • Soft tissues obstruction in the pelvis • Breach presentation and face presentation

28. Technique • The woman's bladder should be empty (via voiding or catheterization). • The patient is placed in the lithotomy position. • Vaginal examination to check pelvic capacity, cervical dilatation, présentation, position, station and degree of flexion of head and that the membranes are ruptured • Determination of flexion point

29. Continue…. • Proper cup placement over flexion point • Exclude maternal soft tissue entrapment by palpation • Vacuum creation by increasing the suction in increments of 0.2 kg/cm2 every 2 mins until 0.8 kg/cm2 • A check is made using the fingers round the cup to ensure that no cervical or vaginal tissue is trapped inside the cup

30. • The pressure is gradually raised at the rate of 0.1kg/cm2 per minute until the effective vacuum of 0.8kg/cm2 is achieved in about 10 minutes time • The scalp is sucked into the cup and an artificial caput succedaneum is produced, which disappears within few hours. • Instrument handle is grasped, and initiation of traction

31. Continue…. • Traction is initiated by using a two-handed technique, i.e the fingers of one hand are placed against the suction cup, while the other hand grasps the handle of the instrument • Traction must be at right angle to the cup

32. • Traction should be synchronous with the uterine contractions; released in between the contractions. • Once head is extracted, vacuum pressure is relieved; cup is removed; vaginal delivery followed • The total time from the application until delivery should not exceed 20 minutes • If >20 minutes, the risk of fetal scalp trauma and intracranial damage increases

33. Fetal Complications • Scalp laceration and bruising • Subgalial hematoma, Cephalohematoma • Intracranial haemorrhage, intraventricular and cerebral hemorrhages • Retinal and sub- conjunctival hemorrhages • Neonatal jaundice • Clavicular fracture, Shoulder dystocia • Hypoxia, particularly when extraction has taken a long time and has been difficult • Fetal death

34. Maternal Complications • Soft tissues injuries such as cervical tears, vaginal tears, perineal lacerations and tears, extension of episiotomy, vaginal wall and perineal hematomas. • Traumatic postpartum hemorrhages • Infection • Genital prolapse

35. Management • To assess the effect on the mother and the fetus • To start a Ringer’s solution drip and to arrange for blood transfusion, if required • To exclude rupture of the uterus • To assess if procedure is to be abandoned and consider delivery by caesarean section • Laparotomy should be done in a case with rupture of uterus. • To administer parenteral antibiotic

36. CESAREAN SECTION

37. INTRODUCTION  An operative procedure that is carried out under anaesthesia whereby the foetus, placenta and membranes are delivered through an incision in abdominal wall and the uterus  Usually carried out after viability has been reached i.e. 24-48 weeks of gestation onwards.  The first operation performed on a women is referred to as a primary caesarean section.  When operation is performed in subsequent pregnancies, it is called repeat caesarean section.(C/S)

38. INCIDENCE:  The incidence of caesarean is steadily raising.  Factors responsible are increased safety of operation due to improved anaesthesia, availability of blood transfusion and antibiotics.  Increased awareness of foetal well being and identification of risk factors have caused reduction of difficult operation or manipulative vaginal deliveries.

39. Indication for Caesarean section . Absolute:  Advanced carcinoma of cervix  Cervical or broad of contracted pelvis.  Severe degree of contracted pelvis. . Relatives:  Cephalopelvic disproportion  Previous uterine scar  Fetal distress.  Malpresentations  Antepartum hemorrhage  Elderly primigravidae  Chronic hypertension  Diabetes  Pelvis atresia

40. .Fetal indication  Fetal distress  Umbilical cord prolapse  Macrosomia  Placental insufficiency  Multiple pregnancy

41. Contraindication  Dead fetus  Baby is too much premature  Presence of blood coagulation disorder

42. Time of operation: A. Elective caesarean section:  The term elective indicates that the decision to deliver the baby by caesarean has been made during the pregnancy and before the onset of labor.  It means pre-planning for doing caesarean section.  Indication: CPD Placenta previa Bad obstetric history

43. B. Emergency caesarean delivery  When the operation is performed due to unforeseen complication arising either during pregnancy or labour without wasting time following the decision.  Indication: Cord prolapse Uterine rupture Eclampsia Prolonged first stage of labour Abnormal uterine contraction Placenta previa diagnosed in labor.

44. Types of operation: 1. Lower segment caesarean section:  Is lesser muscular than the upper segment of the uterus.  Transverse incision is made in the lower segment this heals faster and sucessfully than an incision in the upper segment of the uterus.  There is less muscle and more fibrous tissue in lower segment which reduces the risk of rupture in a subsequent pregnancy.

45. 2. Classical caesarean section:  In this baby is extracted through an incision made in upper segment of uterus.  Is rarely performed.  Operation is done only under forced circumstances, such as: carcinoma of cervix Big fibroid on lower segment lower segment is difficult or risky example: placenta previa

46. Nursing Management A. Pre-operative management: Patient should be physically prepared i.e. abdomen, back ,private parts and upper part or thigh are shaved and cleaned. Prepare mother psychologically by providing assurance and explaining the indication, procedure and need of caesarean section. Administration of IV infusion of 50% dextrose to avoid hypotension following spinal anaesthesia, the infusion line is maintained patent by an intra venous cannula. Blood grouped and cross matched for emergency requirement.

47. Bladder should be empty by inserting foleys catheter. This may be done before and after induction of anesthesia. Mother should be in NPO for about 8 hours. Patient should be in clean gown, valuable ornament should be taken off and all make up should be removed. If elective caesarean section then Ranitidine 150mg should be given orally in the night before and repeated one hour before surgery to prevent

48. B. Post operative care : 1. Immediate care (4-6 hours): • In the immediate recovery period,the blood pressure is recorded in every 2 hourly. • The wound must be inspected half hourly to detect any blood loss. • The lochia are inspected and drainage should be small initially Following general anaesthesia, the women is nursed in left lateral or recovery position until she is full conscious. • Analgesic is given as prescribed.

49. 2. First 24 hours:  IV fluids are continued, blood transfusion is helpful in anemia mothers.  Parental antibiotic is usually given for 1st 48 hour, analgesics is the form of pethidine 75-100mg are given as needed.  Ambulation is encouraged following day of surgery and baby is given to mother. After 24 hours:  TPR are usually checked every 4 hourly  Orally feeding is started with clear liquid and then advanced to normal diet and IV fluid are continued for about 48 hours.  Catheter may be removed on following day when the women is able to get up to the toilet. She should be helped to get out of bed.  The mother must be encouraged to take rest and provide care to the baby and should breast feed the baby.

50. Complication  Mother: partum hemorrhage related to uterine atony and rarely blood coagulation disorders. Shocks related to blood loss. Anesthesia hazards Sepsis, secondary PPH. Thrombosis Lung infection post.

51.  Late complication: Menstrual irregularity Chronic pelvic pain Backache  Fetus: Respiratory distress syndrome. Injury to baby due to surgical knife. Birth asphyxia due to anaesthesia.

52. DESTRUCTIVE SURGERY CRANIOTOMY DECAPITATION EVICERATION CLEIDOTOMY

53. Craniotomy • Operation to make a perforation on the fetal head, evacuated the contents followed by extraction of the uterus • Indications – Cephalic presentation producing obstructed labor with dead fetus – Hydrocephalus even in living fetus – Interlocking head of twin Condition to be fulfilled √cervix fully dilated √ baby must be dead C/I Severely contracted pelvis Rupture of uterus

54. Decapitation • Head is severed from the trunk, delivery is completed with extraction of trunk and that decapitated head per vagina Indication Neglected shoulder presentation with dead fetus where neck is easy accesible Interlocking head of twins

55. Evisceration • Removal of thoracic and abdominal contents piecemeal through an opening at the most accessible site • Together with spondylectomy Indication Neglected shoulder presentation (dead fetus) Fetal malformations

56. eviceration

57. Cleidotomy • Reduction in the bulk of the shoulder girdle by division of one or both the clavicles • Clavicle are divided by embryotomy scissor/long straight scissor Indication Only in dead fetus with shoulder dystocia

58. Complication • Injury to utero-vaginal canal • Postpartum hemorrhage • Shock – blood loss/dehydration • Subinvolution

59. Postoperative care for destructive operation • Exploration of utero-vaginal canal • Self retaining Foley’s catheter to be put inside following craniotomy • Dextrose saline drip – to be continued • Ceftriaxone IV 1g infusion

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