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Operative DELIVERIES

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.

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Operative DELIVERIES

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  1. Operative DELIVERIES Saeed Mahmoud,MRCOG,MRCPI,MIOG,MBSCCP Assistant Professor & Consultant Department of Obstetrics & Gynecology College of Medicine King Saud University

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

  3. VACUUM /VENTOUSE

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

  5. 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

  6. MNEMONIC • F – Fontanelle  position the cup over the posterior fontan  low pressure 10 cm H2O initially & between cont  sweep finger around cup to clear maternal tissue  ↑ pressure to 60 cm H2O 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

  7. 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

  8. 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

  9. 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

  10. Fetal Complications

  11. FETAL COMPLICATIONS • Birth asphyxia  2.6-12%  related to extraction force & time Some studies showed decrease birth asphyxia • Retinal hemorrhage 50% Forceps 31% SVD 19% • Neonatal jaundice

  12. 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

  13. FORCEPS

  14. 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

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

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

  17. 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

  18. 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

  19. 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

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

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

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

  23. 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

  24. CESAREAN SECTION CS

  25. TYPES OF CS • Lower segment CS • Classical CS

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

  27. 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

  28. TIMING OF ELECTIVE CS • Usually at 38-39 wks

  29. 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

  30. 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

  31. 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

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

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

  34. Thank you Any Questions

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