OPERATIVE INTERVENTION

IN

OBSTETRICS

Operative Obstetrics

Operative Vaginal

deliveries

Episiotomy Cesarean Section

Operative vaginal

delivery

Delivery of baby vaginally using

an instrument.

INDICATIONS FOR OVD

No indication is absolute

• Prolonged 2nd

stage of labor

• Fetal compromise

• Maternal benefit to shortened 2nd

stage

Contraindications

• Gestation of less than 35 week

• Breech presentation

TYPES

A. Forceps Delivery

B. Vacuum Extraction

PREREQUISITES FOR OVD

Informed consent

Vertex

Engaged

≥34 weeks (vacuum delivery)

Fully dilated

Membranes ruptured

Adequate maternal pelvis

Adequate anesthesia

Maternal empty bladder

Backup plan

Ongoing fetal and maternal assessment

PREREQUISITES FOR OVD

Informed consent

Vertex

Engaged

≥34 weeks (vacuum delivery)

Fully dilated

Membranes ruptured

Adequate maternal pelvis

Adequate anesthesia

Maternal empty bladder

Backup plan

Ongoing fetal and maternal assessment

INDICATIONS OF

FORCEPS DELIVERY

• 1. Heart disease

• 2. Pulmonary compromise or injury

• 3. Intrapartum infection

• 4. certain neurological conditions

• 5. Exhaustion

• 6. Prolonged second stage

Maternal Indications

FORCEPS DELIVERY

• 1. prolapse of umbilical cord

• 2. premature separation of the placenta

• 3. non-reassuring fetal heart rate pattern

Fetal indications

B.VACUUM EXTRACTION

Principle

Creation of an artificial caput by attaching a

traction device by suction to the fetal scalp

VACUUM EXTRACTION

Technique

Center of the cup

should be over the

sagittal suture about 3

cm. in front of the

posterior fontanelle

Complication of forceps delivery

• Maternal

• Lacerations to the vagina , cervix, perineum, and uterus.

• Fetal-neonatal:

• Soft tissue compression or cranial injury.

Complication of vacuum extractor:

• Maternal:

• Vaginal lacerations

• Neonatal:

• Cephalohematoma

• Scalp laceration

• Intra cranial hemorrhages

CESAREAN DELIVERY

Birth of a fetus through incisions in

the abdominal wall (laparotomy) and

the uterine wall (hysterectomy).

THE FIVE MOST COMMON CAUSES OF

CESAREAN SECTION

CS on Request

Routine repeat cesareans .

Dystocia (non-progressive labor) .

Abnormal fetal presentation eg breech , transeverse , cord presentation .

Fetal distress .

CESAREAN DELIVERY

Criteria for timing of repeat cesarean:

1. FHT have been documented for 20 weeks by

fetoscope or 30 weeks by doppler.

2. 36 wks. Since a +serum or urine HcG

3. US with CRL at 6-11 wks compatible with 39 wks.

4. US at 12-20 wks compatible with 39 weeks

determined by clinical Hx & PE

Elective caesarian section

(Planned operation)Advantages are:-

Patient with empty stomach and surgeon

usually with full breakfast

Best anesthetist available at that time

Best assistant and nursing staff.

Disadvantages are :-

If wrong judgment, premature child may be

born.

Cervix may not be dilated and hence poor

drainage of lochia

Lower segment is not formed and hence

uterine incision in lower part of upper

segment.

Emergency caesarian

section (Unplanned)Working under adverse circumstances:-

Patient may be with full stomach and

surgeon may be with empty belly

Odd working hours either of day or

night

Anesthetist, assistant and nursing staff

may not be of your choice

Advantage is :-

Mature child as patient is in labor

Cervix is open, better drainage of

lochia.

Lower segment is well formed

CESAREAN DELIVERY

Abdominal Incisions

1. Vertical Incision

quickest to make

greater chance of dehiscence

2. Pfannenstiel Incision

cosmetically better, stronger

less chance of dehiscence

exposure not as good

CESAREAN DELIVERY

Types of uterine incisions

1. Classical

vertical incision into the body of uterus

Indications:

a. Lower segment cannot be exposed

b. transverse lie

c. placenta previa, anteriorly located

d. Lower segment not formed

ABDOMINAL OPERATIONS: CESAREAN

DELIVERY

2. Low Segment Transverse

easier to repair

located at a site least likely to rupture in a

subsequent pregnancy

Does not promote adherence of bowel or omentum

to the incisional line

CESAREAN DELIVERY

COMPLICATIONS

• Bowel damage

• U T damage

• Placenta previa

• hemorrhage

Intra operative

COMPLICATIONS(CONTINUED..)

• 1.infection

• 2.endometriosis

• 3. embolism

• 4.psychological

Post oprative

PURPOSE OF EPISIOTOMY:

“A surgical incision of the perineum usually performed to enlarge the vaginal opening and assist in childbirth.”

EPISIOTOMY:

The purpose is to increase the diameter of the soft

tissue pelvic outlet, thereby preventing perineal

lacerations, facilitating delivery, and reducing the time

for expulsion of the infant.

POSSIBLE INDICATION FOR EPISIOTOMY:

Shoulder dystocia

Vaginal breech delivery

Non-assuring monitoring tracing

Forceps or vacuum extractor vaginal delivery

Narrow birth canal.

COMPLICATION:

Perineal* trauma

Infection

Dehiscence

HematomaRecto

vaginal fistula

Recto vaginal fistula

Perineal abscess

PREVENTION

Avoid assisted delivery

Vacuum if needed

Restrictive use of episiotomy

Support perineum during delivery

Allow time for perineal thinning

THANK YOU

By

Muhammad Bilal

Roll no 08-111