operative deliveries
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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SAEED MAHMOUD,MRCOG,MRCPI,MIOG,MBSCCP
ASSISTANT PROFESSOR & CONSULTANTDEPARTMENT OF OBSTETRICS & GYNECOLOGYCOLLEGE OF MEDICINEKING SAUD UNIVERSITY
Operative DELIVERIES
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Operative Deliveries
1.Instrumental deliveries
A. Vacuum /Ventouse B.Forceps
2. Cesarean Section CS, C/S
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VACUUM /VENTOUSE
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INDICATIONS
MATERNALExhaustion Prolonged second stageCardiac / pulmonary disease
FETALFailure of the fetal head to rotateFetal distress in the second stage
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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
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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
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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
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Key points
Vacuum –assisted delivery is less traumatic to the mother & fetus than forceps
Ventouse should be the instrument of choiceShould not be used for preterm, face
presentation or breech
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COMPLICATIONS
Maternal Vaginal laceration due to entrapment of vaginal mucosa between suction cup & fetal
headFETAL Scalp injuries abrasion & lacerations 12.6% scalp necrosis 0.25-1.8% Cephalohematoma 25% jaundice /anemia
Intracranial hemorrhage 2.5%
Subgaleal hematoma
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Fetal Complications
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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
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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
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FORCEPS
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INDICATIONS
MATERNALExhaustion Prolonged second stageCardiac / pulmonary disease
FETALFailure of the fetal head to rotateFetal distressControl of the fetal head in vaginal beech
delivery
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CLASSIFICATION OF FORCEPS DELIVERY
Outlet forceps Scalp visible at the vulva without
separating the labia
Low forceps Vertex at +2 station
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Midforceps Head is engaged but leading part
above +2 station Sagittal suture not in the
AP plane of the mother
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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
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Conditions to be fulfilled :
MNEMONICA – 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
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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
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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
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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
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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%
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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
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CESAREAN SECTION CS
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TYPES OF CS
Lower segment CSClassical CS
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INDICATIONS FOR ELECTIVE CS
Repeat CSPlacenta previaVV fistula repairHIV (poor controlled)Active herpesFetal macrosomia >
4500 gm
Uterine surgery eg. Hystrotomy, myomectomy
Severe IUGRBreech Multiple pregnancyTransverse lieCa of the Cx/ TR
obstructing the birth canal
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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 segmentPoorly developed lower segment in Very
preterm fetus in breech presentationCervical cancer
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TIMING OF ELECTIVE CS
Usually at 38-39 wks
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COMPLICATIONS
Bleeding & the need for bl transfusionHysterectomyComplications of anaesthesiaDamage to the bladder, ureter, colon ,
retained placental tissueFetal injuryInfectionDVT/PE
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MODE OF DELIVERY IN NEXT PREGNANCY
CRITERIA FOR VBACPt must agree to the procedureA low transverse uterine incisionNon recurrent cause of the previous CSNo macrosomia, malposition, multiple
gestation, breech
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CONDUCT OF LABOUR
Observe forProgressFetal wellbeingMaternal well beingEpidural HOSPITAL SHOULD PROVIDE BLOOD ,
OPERATING ROOM 24 HRS, NEONATAL RESUSCITATION, NURSING ANAESTHESIA &SURGICAL PERSONNEL CAN START CS WITHIN 30 MIN
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Risk of SCAR RUPTURE
O.5% for LSCS4-9% for classical
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SCAR RUPTURE
Signs OF SCAR RUPTUREFetal distressEase of fetal palpationCessation of contractionsElevation of presenting partScar painBleeding / shock
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Thank you Any Questions