Operative DELIVERIES SAEED MAHMOUD MRCOG MRCPI MIOG MBSCCP

Operative DELIVERIES SAEED MAHMOUD, MRCOG, MRCPI, MIOG, MBSCCP ASSISTANT PROFESSOR & CONSULTANT DEPARTMENT OF OBSTETRICS & GYNECOLOGY COLLEGE OF MEDICINE KING SAUD UNIVERSITY

Operative Deliveries 1. Instrumental deliveries A. Vacuum /Ventouse B. Forceps 2. Cesarean Section CS, C/S

VACUUM /VENTOUSE

INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress in the second stage

Conditions to be fulfilled : MNEMONIC A – Anesthesia adequate B – Bladder cathterization C – Cervix fully dilated / membranes ruptured D – Determine position, station, pelvic adequacy E – Equipment inspect vacuum cup, pump, tubing, check pressure

MNEMONIC F – Fontanelle position the cup over the posterior fontan low pressure 10 cm H 2 O initially & between cont sweep finger around cup to clear maternal tissue ↑ pressure to 60 cm H 2 O with the next contraction G – Gentle traction pull with contractions only traction in the axis of the birth canal ask the mother to push during cont

MNEMONIC H – Halt halt traction if no progress with three traction aided contractions vacuum pops off three times pulling for 30 min without significant progress I – Incision consider episiotomy if laceration imminent J – Jaw remove vacuum when jaw is reachable or delivery assured

Key points Vacuum –assisted delivery is less traumatic to the mother & fetus than forceps Ventouse should be the instrument of choice Should not be used for preterm, face presentation or breech

COMPLICATIONS Maternal Vaginal laceration due to entrapment of vaginal mucosa between suction cup & fetal head FETAL Scalp injuries abrasion & lacerations 12. 6% scalp necrosis 0. 25 -1. 8% Cephalohematoma 25% jaundice /anemia Intracranial hemorrhage 2. 5% Subgaleal hematoma

Fetal Complications

FETAL COMPLICATIONS Birth asphyxia 2. 6 -12% related to extraction force & time Some studies showed decrease birth asphyxia Retinal hemorrhage Forceps SVD Neonatal jaundice 50% 31% 19%

FETAL COMPLICATIONS Fetal mortality 15/1000 Lower in cases delivered by vacuum 1. 9%/ forceps 5. 2 % No long term effects on neurological psychomotor or intellectual development up to 4 years of age

FORCEPS

INDICATIONS MATERNAL Exhaustion Prolonged second stage Cardiac / pulmonary disease FETAL Failure of the fetal head to rotate Fetal distress Control of the fetal head in vaginal beech delivery

CLASSIFICATION OF FORCEPS DELIVERY Outlet forceps Scalp visible at the vulva without separating the labia Low forceps Vertex at +2 station

Midforceps Head is engaged but leading part above +2 station Sagittal suture not in the AP plane of the mother

CLASSIFICATION OF FORCEPS DELIVERY Outlet Wrigley’s Outlet & low forceps Simpson /Elliot Midforceps & outlet Tucker Mc lane Midforceps & rotation Kielland After coming head in breech Piper

Conditions to be fulfilled : MNEMONIC A – Anesthesia adequate /epidural or pudendal B – Bladder cathterization C – Cervix fully dilated / membranes ruptured D – Determine position, station, pelvic adequacy E – Equipment Know your forceps

MNEMONIC F – Forceps phantom application Lt blade , LT hand, maternal Lt side pencil grip & vertical insertion with Rt thumb directing blade Rt blade , RT hand, maternal Rt side pencil grip & vertical insertion with Lt thumb directing blade Lock blades

MNEMONIC Check application: Ø Post fontanelle 1 cm above the plane of the shanks Ø Sagittal suture lies in the midline of the shanks /perpindicular to the plane of the shanks Ø The operator can not place more than a fingertip between the fenestration of the blade & the fetal head on either side

MNEMONIC G – Gentle traction applied with contraction & maternal expulsive efforts H – Hand elevated traction in the axis of the birth canal I – Incision J – Jaw consider episiotomy if laceration imminent remove forceps when jaw is reachable or delivery assured

COMPLICATIONS Maternal trauma to soft tissue 3 rd/4 th degree double the risk compared to ventouse bleeding from lacerations trauma to urethra & bladder fistula Pain 17% ventouse 11%

COMPLICATIONS Fetal bruising & laceration to the face Injury to the fetal scalp cephalohematoma 9% Vent 25% retinal hemorrhage 30% Vent 50% skull fracture permanent nerve damage / Facial nerve The risk of shoulder dystocia is increased following instrumental deliveries

CESAREAN SECTION CS

TYPES OF CS Lower segment CS Classical CS

INDICATIONS FOR ELECTIVE CS Repeat CS Uterine surgery eg. Placenta previa Hystrotomy, myomectomy Severe IUGR Breech Multiple pregnancy Transverse lie Ca of the Cx/ TR obstructing the birth canal VV fistula repair HIV (poor controlled) Active herpes Fetal macrosomia > 4500 gm

Indications for classical CS Transverse lie back down (with SROM) Structural abnormality that makes lower segment approach difficult (Fibroids) Anterior Placenta Previa & abnormally vascular lower segment Poorly developed lower segment in Very preterm fetus in breech presentation Cervical cancer

TIMING OF ELECTIVE CS Usually at 38 -39 wks

COMPLICATIONS Bleeding & the need for bl transfusion Hysterectomy Complications of anaesthesia Damage to the bladder, ureter, colon , retained placental tissue Fetal injury Infection DVT/PE

MODE OF DELIVERY IN NEXT PREGNANCY CRITERIA FOR VBAC Pt must agree to the procedure A low transverse uterine incision Non recurrent cause of the previous CS No macrosomia, malposition, multiple gestation, breech

CONDUCT OF LABOUR Observe for Progress Fetal wellbeing Maternal well being Epidural HOSPITAL SHOULD PROVIDE BLOOD , OPERATING ROOM 24 HRS, NEONATAL RESUSCITATION, NURSING ANAESTHESIA &SURGICAL PERSONNEL CAN START CS WITHIN 30 MIN

Risk of SCAR RUPTURE O. 5% for LSCS 4 -9% for classical

SCAR RUPTURE Signs OF SCAR RUPTURE Fetal distress Ease of fetal palpation Cessation of contractions Elevation of presenting part Scar pain Bleeding / shock

Thank you Any Questions