Symphysiotomy

1. Symphysiotomy • an incision of the fibro cartilage through the symphysis pubis • performed in labor to enlarge the transverse diameter of the pelvis. • A urinary catheter is inserted into the bladder to empty. • The fibro cartilage is incised over the centre of the symphysis pubis. • A vacuum extractor or forceps may be used to facilitate delivery. • Following the operation a bandage is applied around the pelvis to provide support. • The catheter may remain in situ for a few days

2. Caesarean section • an operative procedure, which is carried out under anaesthesia whereby the fetus, placenta and membranes are delivered through an incision in the abdominal wall and the uterus. • This is usually carried out after viability has been reached (i.e. 24 weeks' gestation onwards).

3. The operative procedure • -As pregnancy advances, the uterus grows up into the abdomen and peritoneum which cover uterus rises up with the uterus and comes into contact with the abdominal peritoneum. • • skin • • fat • • rectus sheath • • muscle (rectus abdominis) • • abdominal peritoneum • • pelvic peritoneum • • uterine muscle.

4. -incision carried out in the lower uterine segment caesarean section (LSCS). • -A Pfannenstiel or bikini line incision is usually performed. • - LS OF uterus is less muscular and heals better. • -The main reason for preferring the lower uterine segment technique is the reduced incidence of dehiscence of the uterine scar in subsequent pregnancy.

5. Indications to do A classical or vertical incision of the uterus: • 1- implantation of the placenta on the lower anterior uterine wall, • 2- presence of dense adhesions from previous surgery • 3- a large fetus with the shoulder impacted in the maternal pelvis. • The risk of this classical incision is that the uterine incision is more likely to rupture during a subsequent birth.

6. Description of operation : • -The abdomen& peritoneum is opened ,over the anterior aspect of the lower uterine segment and above the bladder . • - pushed down bladder away from the surgeon to visualize the fundus . • - The uterus is incised transversely. • -The surgeon directs the fetal head out while the assistant applies fundal pressure to help the delivery of the baby. • -Oxytocics may be given by the anaesthetist after delivery of the baby and clamping of the cord.

7. When the baby and placenta have been delivered, the uterus is sutured, done in two layers. • - The peritoneum sutured. • - The rectus sheath is closed • - the layer of fat and finally the skin is sutured with the surgeon.

8. Preparation • Preoperative preparation: • -an anaesthetic chart/preoperative assessment, weight and observations of blood pressure, pulse and temperature are undertaken. • - Gowning and removal of make-up and jewellery (or taping of rings) will be carried out. • -The woman is visited by the anaesthetist preoperatively, and assessed.

9. -Results of any blood tests that have been requested are obtained and a full blood count is carried out. • -Blood is grouped and saved. • - In the case of pre-eclampsia, urea and electrolyte levels will be examined and clotting factors assessed. • -The woman will have fasted and have taken the prescribed antacid therapy. • -Attitudes and practices vary regarding pubic shaving.

10. -The woman may prefer to be catheterized in the theatre under epidural, spinal or general anaesthetic, but it may be more private to do this in her room, before entering the operating theatre where others are present. • Positioning of the woman • - lie flat, a wedge or cushion is used, or the table is tilted, to direct the weight of the gravid uterus away from the inferior vena cava. Supine hypotensive syndrome is thus avoided.

11. Women's request for caesarean section • -previous bad experiences of normal delivery, expressed even as ‘nightmare’ by some women. • very few women actually request caesarean section in the absence of medical indications .

12. Psychological support and the role of the midwife • -assist woman in their decision,This will help women to decide what is best for them, in their circumstances. • -An informed, confident and competent practitioner will relieve the stress of the situation and help the woman make a decision, supporting her decision. • -The midwife has a pivotal role in giving women clear and unbiased information concerning the choices available . • - A continual, supportive presence in labour is important.

13. - an emergency C.S carried out after a few hours of labour when the CTG shows that there may be a degree of fetal compromise present, may be carried out urgently • Elective caesarean section • - the decision to carry out the procedure has been taken during the pregnancy, before labor has commenced.

14. - vaginal birth after caesarean (VBAC) may be attempted. • -Repeat caesarean section may be indicated in CPD ,previous 2 C.S • - truly ‘elective’ • - ‘scheduled’ caesarean sections ,no immediate compromise to mother or fetus.

15. Definite indications • • cephalopelvic disproportion • • major degree of placenta praevia • • high order multiple pregnancy.

16. Possible indications • breech presentation • • moderate to severe pre-eclampsia • • a medical condition that warrants the exclusion of maternal effort (high degree of abdominal hernia ) • • diabetes mellitus • • IUGR • • APHge • • certain fetal abnormalities (e.g. hydrocephalus).

17. Emergency caesarean section • when adverse conditions develop during pregnancy or labor. • (e.g. cord prolapse with fetal compromise). • • antepartum hemorrhage • • cord prolapse • • uterine rupture (dramatic/scar dehiscence) • • cephalopelvic disproportion diagnosed in labour • • fulminating pre-eclampsia • • eclampsia • • failure to progress in the first or second stage of labour • • fetal compromise

18. Vaginal birth after caesarean section(VBAC): • 80% of women with prior caesarean section have a trial of labour • Trial of labour • • adequate supervision, the presenting part is capable of flexing adequately to pass through the brim of the pelvis • • all the facilities for assisted birth are readily available • • progress of the labour is sufficient, observed both in the descent of the presenting part and by the dilatation of the cervix • • time limits as to the duration of the trial are set. • -previus C.S increased hospital stay, greater risk of placenta praevia and placenta accreta in future pregnancies. • -a VBAC attempt decreases the total number of hysterectomies performed.

19. General anaesthesia • - the increasing use of regional anaesthesia, general anaesthesia is sometimes required. • -Regional anaesthesia is incompatible with any maternal coagulation disorder. • -General anaesthesia can be more rapidly administered, and is of value when speed is important, such as when the fetus is in serious jeopardy • -Women are preoxygenated prior to induction of anaesthesia; that is, they are given oxygen-rich gas mixtures to breathe for several minutes.

20. -A muscle relaxant (suxamethonium) is given to allow safe or tracheal intubation • - a cuffed tube and cricoid pressure are essential to prevent aspiration of stomach contents. • - Induction agents include thiopental and propofol,Maternal unconsciousness ensues within seconds. • - There are minimal side-effects and relatively little negative fetal consequences . • - Regional anaesthesia, however, normally remains the safer option for caesarean birth. • -Anaesthesia is sustained by inhalational anaesthetic means using Fluothane or Ethrane.

21. Problems with anasthesia • serious complications related to giving anaesthetic • • delays with personnel • • delays in the provision of anaesthesia • -When the midwife recognizes an abnormality she must report it to the appropriate person.

22. Mendelson's syndrome • acid gastric contents are inhaled and result in a chemical pneumonitis. • This regurgitation may occur during the induction of a general anaesthetic and go unheeded. • The acidic gastric contents then damage the alveoli, impairing gaseous exchange. • It may become impossible to oxygenate the woman and death may result

23. The predisposing factors are: • 1- the pressure from the gravid uterus when the woman is lying down, • 2-the effect of the progesterone relaxing smooth muscle • 3- and the cardiac sphincter of the stomach being relaxed by the effect of the anaesthetic • 4- Analgesics such as pethidine cause significant delay in gastric emptying.

24. Prevention of Mendelson's syndrome • 1-Antacid therapy. • - Prophylactic treatment is given to all women in whom a caesarean is planned or anticipated. • -A usual regimen is for women having an elective operation to be given two doses of oral ranitidine 150 mg approximately 8 hrs apart, plus 30 mL sodium citrate immediately before transfer to theatre. • -Women in labour who are thought to have a high risk of caesarean section should have ranitidine 150 mg every 8 hrs. These drugs inhibit the secretion of hydrochloric acid in the stomach.

25. -Cricoid pressure. This is the most important measure in preventing pulmonary aspiration • -The esophagus is occluded by the use of cricoid pressure. Cricoid pressure is a technique whereby the pressure exerted on the one whole ring of tracheal cartilage, the cricoid cartilage, thus occludes the esophagus and prevents reflux. • - Cricoid pressure is maintained by an assistant until the tracheal tube is positioned by the anaesthetist, and the seal of the cuff is verified

26. Difficult or failed intubation • - with those who have pregnancy-induced hypertension. • - having Laryngeal edema ,A well-lubricated stylet or bougee may be used to aid endotracheal intubation. • - Management of failed intubation is: continued cricoid pressure • - ventilation by face mask until the effects of suxamethonium and thiopental have worn off (and the woman has regained consciousness and her cough reflex).

28. Complications of c.s • 1-rise in maternal mortality • -2-Infection • -antibiotic prophylaxis markedly reduces the risk of serious postoperative infection such as pelvic abscess, septic shock and septic pelvic vein thrombophlebitis, endometritis. • Predisposing factors for wound infection : • -PPROM • - obesity. • - stay in hospital prior to operation. • -Delaying shaving of the operation site until immediately before operating • -, sterilization of all instruments • - sterile and surgical technique

29. *Urinary tract infection, intrauterine infection • 3-Thromboembolic disorders -direct cause of maternal death. • -Pregnancy and surgery carry increased risks of thromboembolus and according to body weight • - thromboembolic prophylaxis are crucial.

30. Postoperative care • Immediate care • Observations • -vital sign should be recorded every 15 min in the immediate recovery period. • - The temperature should be recorded every 2 hrs. • - The wound must be inspected every 30 min to detect any blood loss. • - The lochia should also be inspected

31. -Following general anesthesia ,put her in left lateral or ‘recovery’ position until she is fully conscious, since the risks of airway obstruction or regurgitation and silent aspiration of stomach contents. • Analgesia • -as prescribed. • -If the mother intends to breastfeed, the baby should be put to the breast as soon as possible. • • an epidural opioid • • rectal analgesia, such as diclofenac

32. (this is contraindicated if there is • 1-continuing bleeding • 2- poor urine output • 3- a history of sensitivity to NSAIDs, or peptic ulcer) • • intramuscular analgesia (though this is never given in conjunction with epidural opioids because of the risk of cumulative effects) • • oral drugs (e.g. dihydrocodeine(percodan , paracetamol). • Antiemetics (e.g. cyclizine; prochlorperazine) are usually

33. Care following regional block • Following epidural or spinal anaesthesia, record her blood pressure • Fluids are introduced gradually, followed by a light diet. The intravenous infusion remains in progress for about 12 hrs. • Care must be taken to avoid any damage to the legs, which will gradually regain sensation and movement. • - an opiate administered via the epidural route may cause some respiratory depression, the woman's respiratory rate must be recorded.

34. - Women are usually able to become mobile very quickly, which reduces the risk of deep venous thrombosis. • - the baby should remain with his mother and they should be transferred to the postnatal ward together once the recovery team says it is safe to do so

35. Care in the postnatal ward • -V\S checked every 4 hrs. • -The intravenous infusion will continue • - the urinary catheter may remain in the bladder until the woman is able to get up to the toilet. • - The wound and lochia must initially be observed at least hourly. • - the mother has adequate rest. • - The mother is encouraged to move her legs and to perform leg and breathing exercises.

36. The physiotherapist will usually teach these and may give chest physiotherapy. • -Prophylactic low dose heparin and antiembolism stockings are often prescribed. • -The woman is helped to get out of bed as soon as possible

37. Urinary output must be monitored carefully both before and after removal of the urinary catheter; women may have some difficulty with micturition initially and the bladder may be incompletely emptied. • -Any haematuria must be reported to the doctor. • - may feel very tired and drowsy for some hours. • -The mother must be encouraged to rest as much as possible

39. Intervention to reduce caesarean section include: • external cephalic version (ECV) at 36 weeks • • continuous support in labour • • induction of labour for pregnancies beyond 41 weeks • • use of a partogram with a 4 hrs action line in labour • • fetal blood sampling before caesarean section for abnormal cardiotocograph in labour • • support for women who choose vaginal birth after caesarean section.

40. Thank you