Operative intervention in obstetrics Episiotomy An episiotomy is

Operative intervention in obstetrics ﺩ ﻫﻨﺪ ﻋﺒﺪ ﺍﻟﺨﺎﻟﻖ

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 2 nd degree perineal tear.

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

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.

• 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 • •

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

• • • Treatment of 1 st 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.

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

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 2 nd stage of labour.

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

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. •

• The cup located at the vertex which, in an average term infant, is on the sagittal suture • 3 cm 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/cm 2. to increase the suction to 0. 2 kg/cm 2 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.

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 • traumatic. PPH

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

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

Wrigley forceps or short shank forceps

Simpson or long shank forceps

Kielland forceps with a sliding lock

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

Cervical injury • Bleeding which does not appear to be arising from the vagina or perineum and which continues despite a well contracted uterus, is an indication for examining the cervix to exclude cervical injury. • Minor cervical lacerations are extremely common but does not cause symptoms. • Deep lacerations and particularly those that involve the vaginal vault cause excessive bleeding and need to be managed in theatre under anesthesia

Causes of deep cervical tear: • • 1. Precipitate labour. • 2. Application of forceps with the cervix • incompletely dilated. • 3. Rapid delivery of the head in breech • presentation. • 4. A scar in the cervix may also tear.

Management: • 1. Prompt recognition of the injury and action to control the bleeding is essential. • 2. Good light for proper visualization of the tear is essential so the patient should be taken to theatre and examined under general anesthesia. • 3. By using two pairs of sponge forceps applied to the cervix at any one time, it is possible to inspect the whole circumference accurately. • 4. Identification of the apex of the tear is essential before commencing repair. • 5. Interrupted dexon sutures can be inserted through the whole thickness of its wall.

Caesarean section • is a surgical procedure in which incisions are made through a mother’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. usually performed when a vaginal delivery is a risk for mother or baby • INDICATIONS • There are many different reasons for performing a delivery by caesarean section. • The four major indications accounting for greater than 70% of operations are: • Previous caesarean section. • Malpresentation (mainly breech). • Failure to progress in labour. • Suspected fetal compromise in labour. • Other indications, such as multiple pregnancy, placental abruption, placenta • praevia, fetal disease and maternal disease, are less common.

Types of Caesarean Section According to timing • Elective caesarean section: The operation is done at a pre-selected time before onset of labour, usually at completed 39 weeks. • emergency caesarean section: The operation is done after onset of labour.

Repeat Caesarean section • up to 70 per cent of women with a previous Caesarean section can achieve a vaginal delivery. • Patient choice cannot and should not be ignored in decisions regarding management, and it is important to discuss the risks and benefits of elective Caesarean section as compared to trial of vaginal delivery. • elective Caesarean section avoids labour with its risk of perineal trauma(urinary and fetal problems), the need to undergo emergency Caesarean section, and scar dehiscence/rupture with subsequent morbidity and mortality. • However, elective Caesarean section carries maternal risks: increased bleeding, thromboembolism, febrile morbidity, prolonged recovery, long-term bladder and increased risks of placenta praevia • Providing the first operation was carried out for nonrecurrent cause, and providing the obstetric situation close to term in the succeeding pregnancy is favourable, then it is appropriate to offer a trial of labour to any woman with a previous uncomplicated lower uterine segment

Procedure • Informed consent: Full informed consent must always be obtained prior to operation. • The bladder should be emptied before the procedure. • A left lateral tilt minimizes compression of the maternal inferior vena cava and reduces the incidence of hypotension (with its consequent reductions in placental perfusion).

Skin incision either , 1. The Pfannenstiel incision The skin and subcutaneous tissues are incised using a transverse curvilinear incision two finger breadths above the symphysis pubis extending from and to points lateral to the lateral margins of the abdominal rectus muscles. 2. The infra-umbilical incision vertical skin incision is indicated in cases of extreme maternal obesity, suspicion of other intra-abdominal pathology necessitating surgical intervention, or where access to the uterine fundus may be required (classical Caesarean section). The lower midline incision is made from the lower border of the umbilicus to the symphysis pubis. *Pfannenstiel incision has a better cosmetic appearance, better healing and less incidence of incisional hernia but it is more time consuming associated with more blood loss and gives less exposure

Uterine incision either: 1. A lower uterine segment incision is used in over 95 per cent of Caesarean deliveries due to ease of repair, reduced blood loss and low incidence of dehiscence or rupture in subsequent pregnancies 2. There are relatively few absolute indications for classical section (which incorporates the upper uterine segment. These include � a lower uterine segment containing fibroids � a lower segment covered with dense adhesions, both of which may make entry difficult. � placenta praevia, � transverse lie with the back down, � fetal abnormality (e. g. conjoined twins), � Caesarean section in the presence of a carcinoma of the cervix (so as to avoid damage to the cervix and its vascular and lymphatic supply).

clouser • Closure of the uterus should be performed in either single or double layers withcontinuous or interrupted sutures. The initial suture should be placed just lateral tothe incision angle, • A second layer is commonly used as a means to improve haemostasis and with the aim to improve the integrity of the scar. • additional ‘figure-of-eight’ sutures can be employed to control any bleeding points. • Peritoneal closure is not routine and depends on the operator’s preference. • Abdominal closure is performed in theanatomical planes with high strength, low reactivity materials, such as polyglycolic acid or polyglactin • The skin can be closed with either absorbable or non-absorbable suture material

Complications of classical incision include: • A - increased blood loss. B - risk of uterine rupture prior to or during labor in a subsequent pregnancy. • Complications • Caesarean section is a major abdominal surgical procedure and carries significant risks.

Post operative note and orders The patient should be discharged to the ward with comprehensive orders for the following: • �Vital signs • �Pain control • �Rate and type of intravenous fluid • �Urine and gastrointestinal fluid output • �Laboratory investigations The patient’s progress should be monitored and should include at least: • �A comment on medical and nursing observations • �A specific comment on the wound or operation site • �Any complications • �Any changes made in treatment

Prevention of complications • Encourage early mobilization: o Deep breathing and coughing o Active daily exercise o Joint range of motion o Muscular strengthening • Ensure adequate nutrition • Prevent skin breakdown and pressure sores: o Turn the patient frequently o Keep urine and faeces off skin • Provide adequate pain control

Intraoperative complications • 1. Bowel damage may occur during a repeat procedure or if adhesions are present from previous surgery. • 2. Caesarean hysterectomy The most common indication for Caesarean hysterectomy is uncontrollable maternal haemorrhage; The most important risk factor for emergency postpartum hysterectomy is a previous Caesarean section – especially when the placent overlies the old scar, increasing the risks of placenta accrete • 3. Haemorrhage may be a consequence of damage to the uterine vessels, or may be incidental as a consequence of uterine atony or placenta praevia • 4. Placenta praevia The proportion of patients with a placenta praevia increases almost linearly after each previous Caesarean section • 5. Urinary tract damage The risk of bladder injury is increased after prolonged labours where the bladder is displaced caudally, after previous Caesarean section where scarring obliterates the vesicouterine space • 6. anesthetic complications

Post-operative complications • 1 -Infection and endometritis Women undergoing Caesarean section have a 5– 20 -fold greater risk of an infectious complication when compared with a vaginal delivery. Complications include fever, wound infection, endometritis, bacteraemia and urinary tract infection • 2 -Pulmonary emboli and deep vein thrombosis Deaths from pulmonary embolism remain the leading direct cause of maternal death, and Caesarean section is a major risk factor • 3 -Psychological complications All difficult deliveries carry increased maternal psychological and physical morbidity. -