Operative intervention in obstetrics

1. Operative intervention in obstetrics د هند عبد الخالق

2. Episiotomy An episiotomy is a surgical incision of the perineum performed during the second stage of labour to enlarge the vulval outlet and assist vaginal birth It is similar to a 2nd degree perineal tear.

3. Indications • prim gravida • Previous perineal reconstructive surgery. • previous pelvic floor surgery • Shoulder dystocia. • Rigid perineum. • Fetal distress. • An instrumental or breech delivery. Types: Midian(midline) Mediolateral

4. Technique : • The question of informed consent needs to be addressed during antenatal care; when the fetal head is crowning, it is not possible to obtain true informed consent. • An episiotomy is performed in the second stage ,usually when the perineum is being stretched. • If there is not a good epidural, the perineum should be infiltrated with local anesthetic drug. • The incision can be midline or at an angle from the posterior end of the vulva (a Medio lateral episiotomy). • A Medio lateral episiotomy should start at the posterior part of the fourchette, move backwards and then turn medially well before the border of the anal sphincter, so that any extension will miss the sphinctor . • A sharp scissors is used to make a single incision about 3–6 cm depending on the size of the perineum. • -The depth involves the superficial perineal muscles like a second degree tear. • -The episiotomy must be made in a single cut. If it is enlarged by several small cuts , a zigzag incision will be produced which will be difficult to repair.

6. Comparison between midline (median) and mediolateral episiotomy: Median mediolateral • •Muscle are not cut Muscle are cut • Blood loss is less Blood loss is more • Repair is easy Repair is difficult • Dyspareunia is rare dyspareunia is more • Extension if occurs may involve the rectum relative safety from rectal involvement

7. complications • Hemorrhage • pain • Infection • extension to the anal sphincter (third/fourth-degree tears) • dyspareunia • incontinence of urine • incontinence of flatus or feces.

8. Treatment of 1st and second degree tear • It is important to repair all perineal tears • immediately , to prevent any infection of the raw surface. • Local infiltration of the perineum with xylocain is • required for repair. • The vaginal epithelium is sutured from the apex of the • tear ( which must be clearly identified) down to the introitus • with a continuous or interrupted sutures of polygycol. • The perineal muscles are repaired with interrupted • sutures. • The skin edge are brought together without tension.

10. Operative vaginal delivery • Definition • Delivery of a baby vaginally using an instrument for assistance.

11. Indications for assisted vaginal delivery Fetal • The most common fetal indications are those concerning malpositions of the fetal head (occipito-transverse and occipito-posterior). Such positions occur more frequently with regional • anaesthesia as a consequence of alterations in the tone of the pelvic floor that impede spontaneous rotation to the optimal occipito-anterior position. • Fetal distress is a commonly indication for instrumental intervention. Maternal • The most common maternal indications for intervention are those of maternal distress,exhaustion • undue prolongation of the second stage of labour.if the second stage lasts 2 hours in aprimigravida(3 hours if an epidural is in situ), or 1 hour in a multipara (2 hours if an epidural is in situ). • Less common indications include medically significant conditions, such as aortic valve disease with significant out flow obstruction or myasthenia gravis to decrease the 2nd stage of labour.

12. Prerequisites for any instrumental delivery 1. Confirmed rupture of the membranes. 2. The cervix must be fully dilated (except second twin and rare other situations). 3. Vertex presentation with identification of the position. 4. No part of the fetal head should be palpable abdominally. Should be at 1 or more below the ischial spines. 5. •Adequate analgesia/anaesthesia. 6. Empty bladder 7. No obstruction below the fetal head (contracted pelvis/pelvic kidney/ovarian cyst, etc.). 8. •A knowledgeable and experienced operator with adequate preparation to proceed with an alternative approach if necessary. 9. Informed consent

13. Ventouse/vacuum extractors • The basic premise of such instruments is that a suction cup, of a silastic or rigid construction, is connected, via tubing, to a vacuum source. • Soft cups are significantly more likely to fail to achieve vaginal delivery than rigid cups, however, they are associated with less scalp injury. • There appears to be no difference in terms of maternal injury. • The soft cups are appropriate for straightforward deliveries with an occipitoanterior position; metal cups appear to be more suitable for ‘occipitoposterior’, transverse and difficult ‘occipitoanterior’ position deliveries ,where the infant is larger or there is a marked caput. •

14. The cup located at the vertex which, in an average term infant, is on the sagittal suture • 3cm anterior to the posterior fontanelle and thus 6 cm posterior to the anterior fontanelle. The center of the cup should be positioned directly over this, as failure to do so will lead to a progressive de flexion of the fetal head during traction, and an inability to deliver the baby. • • The operating vacuum pressure for nearly all ventouse is between 0.6 and 0.8 kg/cm2.to increase the suction to 0.2 kg/cm2 first and then to recheck that no maternal tissue is caught under the cup edge. When this is confirmed the suction can then be increased. • Traction must occur in the plane of least resistance • • along the axis of the pelvis – the traction plane • • the maximum time from application to delivery should ideally be less than 15 minutes. Rotation is achieved by the natural progression of the head through the pelvis.

16. Contraindications The ventouse should not be used: • in gestations of less than 34 completed weeks because of the risk of cephalohaematoma and intracranial haemorrhage. • face or breech presentation. • There is minimal risk of fetal haemorrhage if the vacuum extractor is employed following fetal blood sampling trials comparing deliveries performed with forceps or ventouse. Complications: Maternal • in ventouse maternal complications are less than with forceps • soft tissue injury • annular detachment of the cervix • traumaticPPH

17. Fetal • retinal hemorrhage • scalp injury • cephalhematoma • intracranial hemorrhage • subgaleal hemorrhage • asphyxia in difficult vacuum

18. Forceps • Classification of forceps delivery according to station and rotation • Type of procedure criteria forceps used • A high forceps vertex not engaged kielland forceps • Not longer used • B mid forceps head is engaged but station Simpson • Above +2 • C low forceps station is more than +2 but had • Not yet reached the pelvic floor • D out let forceps station more than +2 wrigley,s forceps Fetal head on the perineum Scalp is visible at the introitus Rotation <45 degree Sagittal suture is in direct AP diameter Or Rt,Lt OA or OP position

19. Complications of forceps delivery Maternal • Perineal tear ,Cervical tear ,Extention of episiotomy • Nerve injury • PPH • Anesthetic complications following local or general anesthesia • Puerperal sepsis • Dyspareunia • Genital prolapse • Fetal • • Facial brusing • • Facial pulsy • • Intracranial hemorrhage • • Skull fracture • • Asphyxia • • Cerebral pulsy

20. Fetal • Facial brusing • Facial pulsy • Intracranial hemorrhage • Skull fracture • Asphyxia • Cerebral pulsy