obstetricoperation&procedures ppt.pptx

info

1. Operative procedure in Obstetric SUNNY ALVA KHARSHANDI

2. Introduction Obstetric operation are surgical procedures Requires aseptic precautions and some protocols should be followed

3. Forceps delivery : Forceps delivery is a means of extracting the fetus with the aid of obstetric forceps when it is inadvisable or impossible for the mother to complete the delivery by her own efforts. Forceps are also used to assist the delivery of the after coming-head of the breech and on occasion to withdraw the head up and out the of the pelvis at caesarean section.

4. Forceps deliveries were classified by the level of the head at the time the forceps were applied, i.e. high-cavity, mid-cavity and low-cavity. Low-cavity forceps is the one frequently performed as caesarean section is usually preferred to the more traumatic high and mid-cavity operations. Low-cavity forceps can be divided into rotational and non-rotational. Rotational forceps delivery refers to a maneuver of the fetal head from a malposition into a more favourable position with the aid of specially design forceps usually Kielland's .

5. Basic Construction of the Forceps Obstetric forceps consist of two separate blades, each with a handle. Each blade is marked 'L' (left) or 'R' (right). They are inserted separately on either side of the fetal head and locked together by English or Smellie lock (rotational forceps have a sliding lock).

6. Types of Obstetric Forceps currently used Only three varieties are commonly used in present day obstetrics. They are:- 1. Long curved forceps with or without axis traction device. PARTS: Blade Shank Lock Handle Axis traction 2. Short curved forceps. 3. Kielland's forccps .

7. Classification according to the Level of the Fetal Head at which the Forceps are Applied 1. High Forceps Operation 2. Mid-Forceps Operation 3. Low Forceps Operation 4. Outlet Forceps

8. Indications for forceps delivery Relative indications (vacuum extraction or caesarean section may be an alternative option) Delay or maternal exhaustion in the second stage of labour . Dense epidural block with diminished urge to push Rotational instrumental delivery for mal-positioned fetus Suspected fetal distress

9. Specific indications (forceps delivery is usually superior to vacuum extraction or caesarean section in these to Circumstances) Delivery of the head at assisted breech delivery (Singleton or twin) Assisted delivery of preterm infant (< 34 weeks' gestation) Controlled delivery of head at caesarean section Assisted delivery with a face presentation Assisted delivery with suspected coagulopathy or thrombocytopenia in fetus lnstrumental delivery for maternal medical condition that proclude pushing lnstrumental delivery under general anaesthesia Cord prolapse in the second stage of labour.

10. Pre-requisites for Forceps Delivery There are certain conditions which must exist before forceps delivery can be performed. The cervix must be fully dilated and effaced. membranes must be ruptured. Presentation and positions must be suitable to apply the blades corrected to the sides of the head. The head must be engaged with no parts of the head palpable abdominally. No appreciable cephalopelvic disproportion. The bladder must be emptied. Presence of good uterine contraction as a safeguard to postpartum haemorrhage.  

11. Preparation of the woman Procedure of Low Forceps Operations Manual Rotation of the Fetal Head followed by Mid Forceps Operation

12. Appropriate method of application of forceps blade

13. Difficulties in Forceps Operation Difficulty in locking are caused by:-. Application on un-rotated head. Improper insertion of the blade (not for enough in). Failure to depress the handle against the perineum. Enlargement of the cord or fetal parts inside the blades.

14. Complications of Forceps Operation In the Mother Immediate Late complications Chronic low backache due to tension imposed on softened ligaments of lumbosacral or sacroiliac joints during lithotomy position. Genital prolapse or stress incontinence I n the infant Immediate

15. Prophylactic forceps (Elective) It refers to forceps delivery only to shortened the second stage of labour when maternal and or fetal applications are anticipated. The indications are: Eclampsia Heart disease Previous history of CS Postmaturity Low birth weight baby Patients under epidural anaesthesia To curtail the painful second stage.

16. Trial Forceps it is a tentative attempt of forceps delivery in a case of suspected mid pelvic contraction with a preamble declaration of abandoning it in favor of CS, if moderate traction fails to overcome the resistance. The procedure is conducted in an operating room keeping everything ready for CS. If moderate traction leads to progressive descend of the fetal head, the delivery is completed vaginally, if not, CS is done immediately.

17. Failed forceps When a deliberate attempt in vaginally delivery with forceps has failed to expedite the process, it is called failed forceps. It is predominantly due to lack of obstetric skill with poor clinical judgement. Failure in the operative delivery may be due to improper application or failure of descent of the head even with forcible contraction

18. Causes of Failed Forceps Incompletely dilated cervix Unrotated occipito -posterior position. Undiagnosed brow or hydrocephalus or fetal ascites. Constriction ring Large baby with the shoulders impacted at the brim.

19. Management Assess the effect on mother and fetus Start IV infusion with 5 percent dextrose if one is not already in place. Administer parenteral antibiotic Exclude rupture of uterus and plan for other modes of delivery. The woman should be shifted to an equipped hospital.

20. VENTOUSE DELIVERY/ VACCUM DELIVERY A ventouse is a small instrument used to help pull a baby out during the final moments of a vaginal birth. It consists of a soft plastic cup which is placed on the crown of the baby’s head, and a handle which is attached to a vaccum pump which gently sucks to aid the mother’s pushing. Meaning of Ventouse Delivery Ventouse is an instrument device designed to assist delivery by creating a vaccum between it and the fetal scalp.

21. When is ventouse delivery used Indications: Maternal Fetal Contraindications Conditions to be fulfilled There should not be any bony resistance below the level of head. The head of a single baby should be engaged. Cervix should be at least dilated.

22. Types : the main difference between vacuum extractors lies in the cup. Malmstrom cup: a metal cup to its centre attached a metal chain passed through the rubber tube. The other end of the chain is attached to a handle for traction. Bird’s cup : the suction rubber tube is attached to the periphery of the cup while the handle of traction is attached by a separate short metal chain to the centre of the cup. Soft cup : it is a bell-shaped 6.5 cm diameter soft cup which is made of a firm but supple silastic material.

23. Advantage : it produces symmetric, less cosmetically alarming caput succedaneum and less scalp abrasions. Disadvantage : it slips more than the metal cup but with less scalp injuries . Equipments

24. Procedure Applying the Malmstrom cup Complications Fetal Maternal

25. Advantages of Ventouse Over Forceps It can be used in un-rotated or mal-rotated occipito - posterior position of the head. It can be applied only through an incompletely dilated cervix. It is not a space occupying device like the forceps blades. Lesser traction force is needed (10kg) It can be used safely even when the head remains at a high level in second baby of twins. It is comfortable and injuries to the mother are less. Requires less technical skill for the operator.

26. Advantages: Forceps operation can quickly expedite the delivery in the case of fetal distress, where ventouse will be unsuitable as it takes longer time. Forceps is safe for a premature baby. The fetal head is remains inside the protective cage. It can be employed in anterior face or in after coming head of breech. Insuspected pelvic contraction, where moderate traction is required, ventouse will be effective.

27. CAESAREAN SECTION It is an operative procedure whereby the foetuses after the end of 28th week is delivered through an incision on the abdominal and uterine walls. The first operation performed on woman is referred to as a primary caesarean Section. when the operation is performed in subsequent pregnancies, it is called repeat caesarean section . lncidence

28. Indications for caesarean section Elective caesarean section : The term, elective, indicates that the decision to deliver the baby by caesarean section has been made during the pregnancy and before the onset of labor . While some indications are absolute, others will depend on a combination of factors. b. Absolute (definite) indications include:- Cepalopelvic disproportion Major degrees of placenta previa Multiple pregnancy with three or more fetuses Advanced carcinoma of cervix . Pelvic tumors such as cervical fibroid

29. Relative (possible) Indications Include Mal-presentation Pregnancy Induced Hypertension Medical-Gynaecological Conditions Emergency Caesarean Section - This is performed when adverse conditions develop during labour

30. Contraindications In the absence of maternal interest, the following are the contraindications for Cs. Dead fetus Baby, too premature to survive outside the uterus Presence of blood coagulation disorders.

31. Types of Operations Lower Segment Caesarean Section (LSCS ) Classical Caesarean Section Indications

32. Preparation of the Mother Psychological Preparation Physical Preparation Anaesthesia Position The anatomic layers incised are as follows Fat. Rectal Sheath Muscule (rectal abdominis ) Abdominal peritoneum Uterine Muscule

33. Delivery of the head The uterine cavity is then opened, the membranes are ruptured and the amniotic fluid is aspirated. The head is delivered by hooking the head with the fingers, which are carefully inserted between the lower uterine flap and the d head until the palm is placed below the head. As the head is drawn to the incision line, the assistant is to apply pressure on the fundus. Obstetric forceps (Wrigley's forceps) are often used to extract the head from the pelvis.

34. Removal of the Placenta and Membranes The placenta is extracted by traction on the cord with simultaneous pushing on the fundus towards the umbilicus (controlled cord contraction). The placenta and membranes are removed intact . Suturing of the Uterine Wound The margins of the wound are picked up by Allis tissue forceps or Green Armitage hemostatic clamps. The uterine muscule is sutured in two layers using continuos running sutures, the second of which tends to align the cut edges of the pelvic peritoneum. Repair of the rectus sheath brings the rectus abdominis into alignment. The Subcutaneous fat is sometimes sutured and finally the skin is closed with sutures or clips.

35. PROCEDURE OF LOWER SEGMENT CAESAREAN SECTION Narrow uterine incision Extension of the lower uterine segment incision may be done by "J" shaped or hockey-stick incision: i.e. extension of one end of the transverse semilunar incision upwards. "U"- shaped or trap-door incision: i.e. extension of both ends upwards. An inverted T incision: i.e. cutting upwards from the middle of the transverse incision. This is the worst choice because of its difficult repair and poor healing

36. Advantages of the lower segment over the upper segment operation

37. Caesarean Hysterectomy Hysterectomy is carried out after caesarean section in the same sitting for one of the following reasons: Uncontrollable postpartum haemorrhage. Unrepairable rupture uterus. Operable cancer cervix. Couvelaire uterus. Placenta accreta cannot be separated. Severe uterine infection particularly that caused by Cl. welchi . Multiple uterine myomas in a woman not desiring future pregnancy although it is preferred to do it 3 months later.

38. Caesarean Sterilisation Tubal sterilisation is usually advised during the fourth caesarean section   Postoperative Care Immediate care In the immediate recovery period, the blood pressure is recorded every l5 minutes. Temperature is recorded every every two hours. The wound must be inspected ever. half hour to detect any blood loss. The lochia are also inspected and drainage should be small initially. Following general anaesthesia, the woman is nursed in the left lateral or recovery position until she is fully conscious, since the risks of airway obstruction or regurgitation and silent aspiration of stomach contents are still present. Analgesia is given as prescribed

39. First 24 Hours IV fluid (5% dextrose or Ringer’s lactate) are continued. Blood transfusion is helpful in anemic mothers for speedy post operative recovery. Injection methargin 0.2mg may be repeated intramuscularly. Parental antibiotic is usually given for the first 48 hours. Analgesics in the form of pethidine 75-100mg are administered as required. Ambulation is encouraged on the day following surgery and baby is brought to her. After 24 hours The blood pressure, pulse and temperature are usually checked every four hours. Oral feeding is started with clear liquids and then advanced to light and regular diet IV fluids are continued for about 48 hours

40. Complications of Caesarean Section Postpartum haemorrhage Shock related to blood loss, Anaesthetic hazards Sepsis Thrombosis Wound complications

41. DESTRUCTIVE OPERATIONS The destructive operations are designed to diminish the bulk of the fetus to facilitate easy delivery through the birth canal. It may occasional be necessary to destroy the fetus in the interest of saving the mother’s life. There are four types of operations:

42. CRANIOTOMY It is an operation to make a perforation on the fetal head to evacuate the contents followed by extraction of the fetus. Indications Cephalic presentation producing obstructed labour with a dead fetus. This is the commonest indication of craniotomy in the referral hospitals of the developing countries. Hydrocephalus even in a living fetus, this is applicable to the fore- coming and after coming head. Interlocking heads of twins.

43. Sites of Perforation Vertex- On the parietal bone, on either side of the sagittal suture. Face- Through the orbit or hard palate. Brow- Through the frontal bone. Cranioclast Forceps Cranioclast Forceps, 19th Century. Metal forceps with cupped and grained jaws to improve grip and have a blue tint (blued steel is the predecessor of plating). One handle is a scissor-like circle, the other doubles as a hook.

44. Oldham's Perforator Curved Oldham's Obstetric Perforator. Oldham was a surgeon of Guy's Hospital This instrument was used to facilitate removal of the foetus after an obstructed labour. The sharp point would pierce the foetal skull and closure of the handle would macerate the skull bones which when eventually removed would allow passage of the rest of the body. Marked by the maker's name Maw London

45. Craniotomy Forceps Simpson’s Improved Craniotomy Forceps

46. Procedure The obstetrician introduces two fingers (index and middle) into the vagina and the fingertips are placed on the proposed site of perforation. If the suture line cannot be defined because of a big caput, the perforation is done through the dependent part. An assistant fixes the head supra- pubically while the operator introduces the perforator with the blades closed, protecting the anterior vaginal wall and the bladder with the fingers in the vagina. When the tip reaches the site of perforation, the skull is perforated using rotating movements. After the skull is perforated, the instrument is advanced further and the handles are approximated so as to allow separation of the sharp blades which will extend the perforation.

47. DECAPITATION It is a destructive operation in which the fetal head is severed from the trunk and the delivery is completed with the extraction of the trunk and then of the decapitated head per vagina. Indications Neglected shoulder presentation with dead fetus where the neck is easily accessible. Interlocking head of twins.

48. Hook and Crochet Decapitating Hook Embryotomy scissors Decapitation Hook with Knife

49. Procedure:

50. EVISCERATION The operation consists of removal of thoracic and abdominal contents piecemeal through an opening on the thoracic or abdominal cavity at the most accessible site. The objective is to diminish the bulk of the fetus, which facilitates the extraction. Indications Gross fetal malformations such as fetal ascites or hugely distended bladder. Neglected shoulder presentation with dead fetus and neck is not easily accessible. The procedure is more feasible in a breech presentation. Embryotomy scissors are used for the procedure.

51. CLEIDOTOMY The operation consists of reduction of the width of the shoulder girdle by division of one or both the clavicles. ne operation is done only in dead fetus with shoulder dystocia. The clavicles are divided by the embryotomy Scissors or long straight scissors introduced under the guidance of two fingers of left hand placed inside the vagina.

52. Postoperative Care Following Destructive Operations A self-retaining ( Foly's ) catheter is inserted following craniotomy and maintained for 3-5 days or until bladder- tone is regained. Intravenous drip is to be continued until dehydration is corrected. Blood transfusion may be given if required. Antibiotics is given either parenterally or orally.

53. Complications of Destructive Operations Injury to utero-vaginal canal Postpartum haemorrhage-atonic or traumatic. Shock due to blood loss and dehydration. Puerperal sepsis. Subinvolution of the uterus. Injury to the adjacent viscera- vesico vaginal fistula or recto-vaginal fistula.

54. SYMPHYSIOTOMY Definitions Symphysiotomy : It is the process of division of the symphysis pubis with a scalpel. Pubiotomy : Is division of the pubic ramus half an inch from the symphysis pubis with a Gigli saw to avoid injury to the urethra and bladder. It is out of modern obstetrics due to higher incidence of pubic pain and infection.

55. Indications It is particularly indicated in women living in distant areas where caesarean section cannot be done and even patient Will be left with a caesarean scar is in a high risk of rupture in the next labour. As symphysiotomy gives a permanent increase of the pelvic capacity, it can be an alternative to C.S. and indicated in the following conditions: Moderate cephalopelvic disproportion. Contracted outlet in funnel shaped pelvis. Retained aftercoming head in breech delivery failed to be delivered by other means. Shoulder dystocia with a living foetus cannot be delivered by other means.

56. Procedure

57. Postoperative Rest for 2 weeks. A tight binder of "Elastoplast" is strapped around the pelvic girdle and hips. Bladder drainage is continued for 3-4 days. A prophylactic antibiotic may be given. Complications Haemorrhage, compression for few minutes usually stop it. Injury to the urethra or bladder. Vesico -vaginal or urethro -vaginal fistula. Stress incontinence.

58. VERSION Definition It is manipulative procedure designed to change the lie or to bring the comparatively favourable pole to the lower pole of the uterus. Types of Version EXTERNAL CEPHALIC VERSION External cephalic version is a procedure used to turn a fetus from a breech position or side-lying (transverse) position into a head-down (vertex) position before labor begins. When successful, version makes it possible for you to try a vaginal birth. This version is done to bring the favourable cephalic pole in the lower pole of the uterus.

59. Version may be attempted when The mother is 36 to 42 weeks pregnant. Before 36 Weeks, a fetus is likely to turn back into a head-down position on its own. But version may be more Successful if it is done as early as possible after 36 Weeks because the fetus is smaller and is surrounded by more amniotic fluid and space to move in the uterus. The mother is pregnant with only one fetus. The fetus has not dropped into the pelvis (has not engaged). A fetus that has engaged is very difficult to move. There is enough amniotic fluid surrounding the fetus for turning the fetus. If the amount of amniotic fluid is below normal ( oligohydramnios ),. the fetus is more likely to be injured during a version attempt. The fetus is in the frank, complete breech, or footling breech position. No clinical evidence of contracted pelvic.

60. Version is usually not done when Patient preparation for External Cephalic Version Explain the procedure. The patient is asked to empty her urinary bladder. Maintain privacy. Keep her on back with the shoulder slightly raised and thigh slightly flexed. Abdomen is fully exposed

61. Procedures External cephalic version in breech presentation External version in Transverse lie the version is much easier than in breech. The association of placenta or congenital malformation or the uterus should be excluded. The external podalic version the external podalic version may be done in cases When the external cephalic version fails in transverse Iie in case of the second baby of twin.

62. INTERNAL CEPHALIC VERSION   Definition Maneuver performed by means of one hand within the uterus. Internal version is always a podalic version and is almost completed with the extractor of the fetus. Indications Internal version is hardly indicated in a singleton pregnancy n present day obstetric practice. Its only indication being transverse lie in case of the second baby of twins.  

63. Conditions to be fulfilled The cervix must be fully dilated Liquor amni must be adequate for intrauterine fetal manipulation Fetal must be living. Contraindications It must not be attempted in neglected obstructed labour even if the baby is living.  

64. Procedures

65. Hazards Placental abruption. Rupture of the uterus. Increased maternal morbidity and mortality. Fetal asphyxia. Intracranial haemorrhage.

66. BIPOLAR VERSION Bipolar version, a method for changing the position of a fetus in which one hand is placed on the abdomen of the mother and two fingers of the other hand are inserted into the uterus

67. DILATATION AND EVACUATION The procedure consists of dilatation of the cervix and evacuation of the procedures of conception from the uterine cavity. One- stage Operation Indications - Incomplete abortion (commonest) -Inevitable abortion -Medical termination of pregnancy (6-8weeks) - Hydatidiform mole in the process of expulsion.

68. Preparation for the operation Local preparation, perineal care and catherization are done once the decision is made for evacuation the woman and her spouse are given adequate explanation and psychological support.

69. Procedure

70. Two Stage Operation Indications First trimester abortion. Missed abortion (8-10 weeks uterus). Hydatidiform mole with unfavourable cervix (l0 firm and closed os ).

71. Procedure

72. Dangers of Dilatation and Evacuation Operation Immediate Dangers Haemorrhage due incomplete evacuation or atonic uterus. Injury such as cervical laceration or uterine perforation. Shock due to excessive blood loss, uterine perforation or anaesthetic complications. Increased morbidity.

73. Late Complications Pelvic inflammation Infertility Cervical incompetence Uterine adhesions.

74. SUCTION EVACUATION If 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. Indications Medical termination of pregnancy during first trimester (commonest). Inevitable abortion. Recent incomplete abortion. Hydatidiform mole.

75. Procedures

76. Complications Immediate Dangers Haemorrhage due incomplete evacuation or atonic uterus. Injury such as cervical laceration or uterine perforation. Shock due to excessive blood loss, uterine perforation or anaesthetic complications. Increased morbidity.

77. Late Complications Pelvic inflammation Infertility Cervical incompetence Uterine adhesions

78. MANNUAL VACCUUM ASPIRATION Manual vaccuum procedure is the aspiration of the endometrial cavity within 7 menstrual weeks of missed period in a woman with previous normal cycle Clinical uses Vacuum aspiration may be used as a method of induced abortion, as a therapeutic procedure after miscarriage, to aid in menstrual regulation, and to obtain a sample for endometrial biopsy. It 1s also used to terminate molar pregnancy

79. Procedure

80. Advantages Complications When used for uterine evacuation, vacuum aspiration is 98% effective in removing all uterine contents. Retained products of conception require a second aspiration procedure. This is more common when the procedure is performed very early in pregnancy, before 6 weeks gestational age. Other complications occur at a rate of less than I per 100 procedures and include excessive blood loss, infection, injury to the cervix or uterus, and uterine adhesions.

81. EPISIOTOMY An episiotomy is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The incision can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic ( pudendal anesthesia ), and is sutured closed after delivery. Purposes To enlarge the vaginal orifice to facilitate easy and safe delivery of the fetus. To minimize overstretching and rupture of the perineal muscles and fascia. To minimize stress and strain on the fetal head. To shorten the second stage of labour.

82. Indications

83. Types of episiotomies . Median Episiotomy : This is midline incision which follows the natural line of insertion of the perineal muscles. This incision reduces blood loss and but higher incidence of damage to the anal sphincter. The incision made about 2.5cm long. Advantages of median episiotomy Muscules are not cut. Blood loss is least. Easy to repair. Post incisional comfort is maximum. Wound healing is superior and disruption is rare. Dysparenuia is rare.

84. Disadvantages of median episiotomy Extension of episiotomy is limited due to chance of rectal involvement. This episiotomy is not suitable for manipulative delivery e.g. abnormal presentation and position and assisted delivery.

85. Lateral Episiotomy :This incision is made about 1cm away from the center of fourchette and extends lateraly . There is more chance of injury to the Bartholin's duct. This incision is not used and totally condemned. J- shaped Episiotomy: This incision begins in the center of the fourchette and is directed posterily along the midline for about 1.5cm and then directed downwards and outwards along 5 or 7 o'clock position to avoid the anal sphincter

86. Medio - Lateral Episiotomy : A mediolateral episiotomy involves cutting into more muscle tissue and does not follow the natural way a woman would tear. This can mean they are harder to repair, have increased bleeding, the cut may not heal as well, it may produce more scarring, and possibly more pain in the weeks following the birth.

87. Advantages It is less likely to extend to a 3rd or 4th degree tear. Rectal involvement from episiotomy extension is less. Incision can be extended if necessary. Disadvantages Apposition of the tissues is not so good. Blood loss is little more. Postoperative discomfort is more. Wound disruption is higher. Dysparenuia is more

88. Procedure

89. Complications Immediate: Extension of the incision to invole the return, likely in median episiotomy. Vulval haematoma. Infection Wound dehiscence. Remote Dyspareunia due to narrow introitus , painful perineal Scar. Chance of perineal lacerations in subsequent labour, if not managed properly. Scar endometriosis.

90. Care of the episiotomy repair

91. Products of conception are sucked out from uterus with the help of cannula fitted to a suction GA is usually not needed Indication MTP during 1 st trimester Inevitable abortion Incomplete abortion Hydatidiform mole Suction evacuation

92. Similar to menstrual aspiration, Highly effective (98- 100%) It may be manual vacuum aspiration or electric vacuum aspiration Vacuum aspiration

93. Extraamniotic instillation of 0.1% ethacridine lactate Done through Foley’s catheter Removed after 4 hours Intrauterine instillation of hypertonic solution

94. Intra- amniotic instillation of hypertonic saline Instilled through abdominal route Preliminary amniocentesis is done Amount of saline instilled = no. of weeks gestation X 10mL Infused slowly at the rate of 10mL/min Induction-abortion interval : 32 hours

95. Extracting the products of conception out of the womb before viability (28th week) Performed through abdominal route Indication Failed MTP Cases where D&E are conraindicated – fibroid,uterine anomalies H y s t e r o t o m y

96. Destructive operation Operation to diminish the bulk of fetus to facilitate easy delivery through the birth canal Types : craniotomy, evisceration, decapitation, cleidotomy

97. Indications Cephalic presentation producing √√ obstructed labor with dead fetus Hydrocephalus even in living fetus Interlocking head of twin Operation to make a perforation on the fetal head, evacuated the contents followed by extraction of the uterus Condition to be fulfilled C r anio t o m y √ cervix fully dilated √ baby must be dead C/I Severly contracted pelvis Rupture of uterus

98. S t e p s

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

100. Vaginal Episiotomy Planned incision on the perineum and posterior vaginal wall during the second stage of labor Indication Threatened perineal injury Rigid perineum Forceps, breech, OP or face presentation Objective To enlarge the vaginal introitus To minimize overstretch and muscle rupture

101. T ypes Mediolateral : downward & outward diagonally from midpoint of fourchette Median : center of fourchette  2.5cm posteriorly Lateral : condemned J shaped : not done widely

102. Steps Step 1 – preliminaries Thorough swabbed with antiseptic and draped. Perineum is infiltrated with 10mL of 1%lignocaine Step 2 – incision Structures cut are : Posterior vaginal wall Sup. And deep transverse perineal muscle Fascia covering muscle Branch of pudendal vessels and nerve Sc tissue and skin

103. Step 3 – repair Timing of repair – soon after expulsion of placenta Preliminaries – lithotomy position, good lighting, wound area cleansed with solution, blood clots removed, vaginal packs to prevent blood oozes Order of repair – Vaginal mucosa and submucosal tissue Perineal muscle Skin and subcutaneous tissue

104. Postoperative care Dressing : Swabbing with cotton swab soaked in antiseptic solution Comfort : MgSO4, compression, ice packs, analgesics Ambulance : allow to move out of bed Removal of stitches : on 6 th day

105. Compli c a tions Remote Dyspareunia Chance of perineal laceration Scar endometriosis (rare) Immediate Extension of incision Vulval hematoma Infection Wound dehiscence

106. Summa r y

107. REFERENCES Williams Obstetrics, 24 th Edition DC Dutta’s Textbook of Obstetrics, 8 th Edition Internet