Operative delivery

OPERATIVE DELIVERY

Dr.Tarig Mahmoud Ahmed

MD SUDAN

HAIL UNIVERSITY KSA

Operative vaginal delivery

Delivery of a baby vaginally using an instrument for assistance.

Indications for assisted vaginal delivery

FETAL INDICATIONS:

◦ Malposition, (occipito-transverse and occipito-posterior).

◦ Fetal distress

Maternal indications:1. Maternal distress & exhaustion.

2. Prolonged second stage of labour:

• Nullipara: 3hours with and 2hours without regional anaesthesia

• Multipara: 2 hours with and 1 hour without regional anaesthesia

3. Medical conditions:

cardiac disease III/IV, hypertensive crises, aortic valve disease with significant outflow obstruction, spinal cord injury, proliferative retinopathy or myasthenia gravis.

Contraindications

◦ Forceps and vacuum extractor deliveries before full dilatation of the cervix are contraindicated.

◦ Ventouse should not be used in:

1. gestations of less than 34 completed weeks because of the risk of cephalohaematoma and intracranial haemorrhage.

2. face or breech presentation.

Prerequisites for any instrumental delivery

◦ F: full dilatation

◦O: OA, OP or occipito transverse

◦R: ruptured membranes

◦C: contractions are adequate, consent

◦E: empty bladder, experienced staff

◦P: pelvis of adequate size

◦S: station (below ischial spines), less than 1/5 palpable per abdomin

Ventouse/vacuum extractors

◦The basic premise of such instruments is that asuction cup, of a silastic or rigid construction, isconnected, via tubing, to a vacuum source.

◦Recent developments have removed the need forcumbersome external suction generators and haveincorporated the vacuum mechanism into ‘hand-held’ pumps.

Technique

◦ soft cups: for straightforward deliveries with anoccipitoanterior position

◦metal cups: suitable for occipitoposterior andtransverse.

◦ centre of the cup should be positioned directlyover flexion point . This is located at the vertex, onthe saggital suture 3 cm anterior to the posteriorfontanelle and thus 6 cm posterior to the anteriorfontanelle.

◦ vacuum pressure (0.6 and 0.8 kg/cm2) isbuilt

◦ the traction plane is at 90º to the cup.

◦no more than two episodes of breakingsuction in any vacuum delivery are safe.

◦Maximum time from application to deliveryshould ideally be less than 15 minutes.

Complications

Fetal:◦ Scalp or cranial effects:

• Chignon

• Subgaleal bleed

• Cephalhematoma

◦ Intracranial injuries:

• Intracranial hemorrhage

• Retinal hemorrhage

• Cerebral irritation/asphyxia

◦ Neonatal jaundice

Maternal complications

◦Trauma

◦Hemorrhage

◦Sepsis

Forceps

The basic forceps design

• two blades with shanks,

• joined together at a lock,

• handles to provide a point for traction.

Technique◦ the left blade is inserted before the right with the accoucheur’s hand protecting the vaginal wall from direct trauma.

◦The axis of traction changes during the delivery and is guided along the ‘J’-shaped curve of the pelvis.

◦ It has been recommended that an episiotomy be cut whenever an instrumental vaginal delivery is performed.

Fetal complications

◦Simple skull fractures

◦Compression distortion injuries1. Tearing of tentorium

2. Rupture of bridging veins

◦Cephalohaematoma

◦ Facial nerve palsy

Maternal complications

◦Trauma• Lower genital tract trauma

• Upper genital tract trauma

• Urinary tract trauma

◦Hemorrhage

◦ sepsis

Comparison

The ventouse, when compared to the forceps is significantly more likely to:

◦ fail to achieve a vaginal delivery.

◦be associated with maternal worries about the Baby.

The ventouse, when compared to the forceps is significantly less likely to:

◦use of maternal regional/general anaesthesia.

◦ significant maternal perineal and vaginal

Trauma.

◦ severe perineal pain at 24 hours.

The ventouse, when compared to the forceps is equally likely to:

◦delivery by Caesarean section;

◦ low 5 minute Apgar scores.

factors contribute to delivery failure:

◦ inadequate initial case assessment – high head, misdiagnosis of the position and attitude of the head.

◦ failure due to traction in the wrong plane.

◦poor maternal effort with inadequate use of Syntocinon to aid expulsive efforts in the second stage.

◦ failure to select the correct ventouse cup type and/or incorrect cup position.

Strategies to lower the rates of assisted delivery

◦Provision of a caregiver during labour.

◦ Active management of the second stagewith syntocinon in women with epiduralanalgesia.

◦Delayed pushing(1-2hours) in women withepidural analgesia.

CAESAREAN SECTION

Definition

A Caesarean section, also known as C-section or Caesar, is a surgical procedure in which incisions are made through a mother’s abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies.

Prevalence

In the UK, more than 21 per cent of all babies are now delivered by Caesarean section.

Factors that increase in the rates of C- section:

◦ Inaccurate dating of the pregnancy.

◦ Fetal monitoring.

◦ Macrosomia.

◦ Maternal request.

Indications

There are many different reasons for performing a delivery by Caesarean section. The four major indications accounting for greater than 70 per cent of operations are:

1) previous Caesarean sections

2) dystocia

3) malpresentation

4) suspected acute fetal compromise.

Other indications, such as multifetal pregnancy, abruptio placenta, placenta praevia, fetal disease and maternal disease are less common.

No list can be truly comprehensive and whatever the indication, the overriding principle is that whenever the risk to the mother and/or the fetus from vaginal delivery exceeds that from operative intervention, a Caesarean section should be undertaken.

Morbidity and mortality

◦ case fatality rate for all Caesarean sections is five times that for vaginal delivery.

◦Some maternal deaths following Caesarean section are not attributable to the procedure itself, but to medical or obstetric disorders that lead to the decision to deliver using this approach.

Procedure

Informed consent:

◦ Full informed consent must always be obtained prior to operation.

◦ It is important to remember that no other adult may give consent for another, Where there is incapacity to consent the doctor is expected to act in the patient’s best interests.

◦Surgical basics

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 syndrome.

Skin incisions

1)The Pfannenstiel incision (low transverse) :

The skin and subcutaneous tissues are incised using a transverse incision two fingerbreadths 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):

from the lower border of the umbilicus to the symphysis pubis, and may be extended caudally toward the xiphisternum.

Uterine incisions

1)A lower uterine segment incision:

is used in over 95 per cent of Caesarean deliveries.

2)classical section (upper uterine segment):

Used when:

A) lower uterine segment containing fibroids or dense adhesions.

B) placenta praevia.

C) presence of a carcinoma of the cervix.

Complications of C/S

1) Haemorrhage2) Caesarean hysterectomy3) Bowel damage4) Urinary tract damage5) Infection and endometritis6) Thromboembolism and deep vein thrombosis7) prolonged recovery.

8) long-term bladder dysfunction.

9) increased risks of placenta praevia and scar rupture in subsequent pregnancies.

10) transient tachypnea of new born syndrome.