Operative Obstetrics Laceration of birth Canal Doc Stelmakh
Operative Obstetrics. Laceration of birth Canal Doc. Stelmakh O. E.
Cesarean Delivery Cesarean section means delivery of a viable fetus through an abdominal incision (i. e. , laparotomy) and a uterine incision (i. e. , hysterotomy). The terms cesarean and section used together are actually redun dant, because both words imply incision.
Labor Contraindicated Under certain conditions, forceful uterine contrac tions, as in normal labor, constitute a real or potential hazard to mother or fetus, or both. n Conditions in which the forces of labor increase the risk to the mother include central placenta previa, previous classic cesarean section, previous myomectomy tran secting the uterine wall, previous uterine reconstruc tion, and previous repair of a vaginal fistula. In such circumstances, normal labor and vaginal delivery may result in uterine rupture, hemorrhage, or serious lacerations of the birth canal, and may endanger the life or future health of the mother.
Conditions that have traditionally been cited as threatening the fetus and that may be worsened by labor include placenta previa, velamentous insertion of the cord or other forms of vasa previa, and cord presentation. n The majority of cesareans are performed for fetal indications; a few are solely for maternal reasons, and some benefit both fetus and mother. Repeat cesarean accounts for approximately 33% of cesarean births in the United States, dystocia is the indication for up to 30%, and fetal distress, breech, and all other conditions are responsible for the remaining cases. Unfortunately, there are few data to suggest that the liberalized in dications for cesarean section have reduced the in cidence of cerebral palsy and other long term disabilities
This is probably because most perinatal morbidity and mortality are caused by premature births, fetal anomalies, or antepartum events. Failed Induction n In conditions such as isoimmunization, diabetes mel litus, intrauterine growth retardation, and hyperten sive disorders, which constitute an ever increasing threat to the fetus, preterm delivery may be desirable. If attempts to induce labor are inappropriate or un successful, cesarean section is the alternative
Common Indications for Cesarean Delivery n n n n n Failed induction Cephalopelvic disproportion Failure to progress in labor Proven fetal distress Placental abruption Placenta previa Umbilical cord prolapse Obstructive benign and malignant tumors Active genital herpes infection Abdominal cerclage Conjoined twins Controversial (or Selective) Breech presentation Repeat cesarean Immune thrombocytopenia Severe Rh immunization Congenital fetal anomalies, major Cervical carcinoma Prior vaginal colporrhaphy Large vulvar condylomata
For example, fetal macrosomia occasionally causes CPD, but most cesarean births for abnormal labor involve a normal sized infant. Dystocia also occurs because of soft tis sue tumors and abnormal fetal presentations n n Fetal Distress Electronic fetal monitoring probably increases the chances of detecting fetal distress and has contributed to the increased number of cesarean sections in the United States. Vaginal breech deliveries have been abandoned by many clinicians and replaced by cesarean delivery. In this situation, cesarean birth avoids the potential risk of intrapartum asphyxia or delivery related trauma from head entrapment and umbilical cord prolapse
Classic incision in the upper segment of the uterus.
Incisions in lower uterine segment. (A) Low transverse incision. (B) Low vertical incision.
On the other hand, reckless surgical techniques for rapid delivery of the fetus should be condemned. An induction to delivery time of 5 to 15 minutes is reasonable if maternal oxygen ation, blood pressure, and displacement of the uterus . are monitored and maintained with care n Preparation of the abdomen includes shaving the skin of the abdomen and mons pubis when necessary, scrubbing the area with an antiseptic soap, and pre paring the skin with an antiseptic agent such as non organic iodide. The abdomen is draped so that the area between the umbilicus and the mons pubis is exposed.
The lower flap of peritoneum is elevated and the bladder is gently separated by blunt or sharp dissection from the underlying myometrium
The visceral peritoneum is grasped just above the bladder and incised in the midline.
A. The incision in a well developed (thin) lower uterine segment is extended laterally and cephalad with the fingers. B. The incision in a thicker lower uterine segment is extended laterally with bandage scissors.
The fetal occiput is lifted toward the incision. Care is taken not to use the lower uterine segment as a fulcrum in order to avoid lacerations.
The body is delivered after the mouth and nares have been suctioned thoroughly.
The placenta is delivered by shearing it manually from its uterine attachment.
The second layer of closure imbricates the first; ab sorbable suture is used in interrupted stitches in figures of eight, in Lembert stitches, or in a contin uous suture placed such that . the first layer of closure is completely covered n If, during the closure, any areas of bleeding are still apparent in the incision line, separate interrupted absorbable sutures in figures of eight should be placed in the bleeding area to secure hemostasis
A perplexing circumstance occurs in closing a trans verse lower uterine segment incision when the junc tion of the contractile and noncontractile portion of the posterior wall presents the appearance of the lower edge of the incision. n Suturing this to the upper cut edge would create a closure of the corpus, but the error is usually recognized when the lower cut edge presents when peritoneal closure is attempted. The confusion can be resolved by careful identifica tion of the upper and lower edges of the uterine in cisions at both angles.
When the uterus and visceral peritoneum have been reapproximated, the packs are removed from the abdominal cavity and any residual blood or amniotic fluid removed by suction. n If meconium soilage or exposure to infected amniotic fluid has occurred, the pelvic cavity should be lavaged with normal saline solution. Clinical studies have demonstrated in high risk patients a reduction in postoperative infection rates if the uterine cavity is lavaged by saline solution
Operative delivery 1)forceps operations 2)Vacuum extractor
Simpson forceps
2)Vacuum extractor
Laceration of birth canal
Laceration of birth canal
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