OBSTETRIC OPERATIONS AND

PROCEDURES

INTRODUCTION

The best outcome of pregnancy is a healthy mother and

baby, ideally following a normal vaginal delivery with an
intact perineum. However, for many women and babies.
the hazards of child birth are a serious risk. Certain
operative interventions are employed to manage these
hazards.
EPISIOTOMY

This is the surgical incision of the perineum to increase

the diameter of the vulva outlet during childbirth.
Wide variations in rates exists through out the world. The
rate at Korle - Bu Teaching Hospital, Ghana is 15 –
17% and at Komfo Anokye Teaching Hospital.
An episiotomy must be performed at the correct time and
place and repaired properly within the shortest
possible time after delivery.
INDICATIONS

Routine use of episiotomy has been questioned. Notable indications

are the following:

1 When the perineum threatens to tear as in the following

situations.
a Persistent occipito – posterior position.
b Extensive scarring of the perineum.
2. Delay in second stage of labour due to soft tissue resistance.
3. Breech delivery.
4. Fetal distress and cord prolapse, to facilitate quick delivery.
5. Instrumental vaginal deliveries.
6. Preterm labour to minimise the stress on the fetal head.
7. Macrosomic babies to assist manuoeuvrability in the event of
shoulder dystocia.
TYPES OF EPISOTOMY

There are 3 types of episiotomy:

1. Midline: Common in U.S.A. Also known as central or median.
The episiotomy is cut in the centre of the perineum separating
the bulbo carvenosus and superficial transverse perineal
muscles, vertically down towards the anus.
2. Mediolateral: Standard type in the U.K. The cut is made at 45
degrees angle from the midline towards the ischial tuberosity
avoiding the anal sphincter.
3. The J – shaped incision: This type of incision has the advantage
of medial incision and provides better access than the
mediolateral. The incision is made tangential to the top of the
anus.
The first 2 types are widely used, with the mediolateral being the
commonest.
Advantages and disadvantages of the
midline
1. Less blood loss
2. Easier to repair
3. Wound heals quicker
4. Less pain in the postpartum period.
5. Reduced incidence of dyspareunia.
6. Anatomical result almost always excellent.
7. Extension through anal sphincter and rectum
common. (Third / Fouth degree tear)
 Advantages and Disadvantages of the
Mediolateral
1. More difficult to repair
2. More painful in the puerperium
3. Dyspareunia may occasionally follow
4. Greater blood loss.
5. Anatomical result not satisfactory in 10% of cases.
6. Extension to anal sphincter less common.
Technique of performing episiotomy

It is best performed with a large, sharp, straight scissors.

The best time to make the incision is when the presenting
part is distending the perineum with contraction
(crowning). The episiotomy must be made in one single
cut. Several small cuts gives rise to a zigzag incision line
which will be difficult to repair. The episiotomy should
begin in the midline of the forchette. Before performing the
episiotomy, adequate analgesia is obtained by local
infiltration with 10ml of 1% plain xylocaine (lidocaine).
Where regional or general anaesthesia has been instituted
already, there is no need for local anaesthesia. Incision
length varies form about 2cm to one extending the length
of the perineum.
Repair of Episiotomy.

Whatever method is used for the closure, effective

haemostasis and anatomical reconstruction without
excessive suturing are essential for success. Repair
should be done as soon as possible because delay will
result in the following:
 Unnecessary blood loss
 Discomfort to the patient
 Increased risk of infection
 Tissues oedema making repair more difficult.
The preferred suture material is chromic catgut 0 or 2/0
on a round bodied needle. However, the use of
absorbable synthetic material polyglycolic acid for the
repair is associated with less perineal pain, analgesic
use, dehiscence and re – suturing compared to catgut
suture material. A pack with a tail is inserted in the
upper vagina to facilitate identification of the apex of
the incision and to prevent blood from the uterine
cavity flooding the operating field.
The vaginal mucosa and submucosa are closed with
continuous suture starting from the apex. Large bites
should be taken but care should be taken not to invert
the vaginal epithelium. The muscle layers are
interposed with interrupted sutures. The perineal skin
is closed with subcuticular catgut without tension.
Then the vaginal pack is removed.
After care:
 Adequate pain relief.
 Perineal toileting after defaecation.
 Patients should not sit in warm or hot water.
 Antibiotics may be given.
 In the event of persistent pain, examine the
perineum to exclude a large vulval, paravaginal or
ischiorectal haematoma or abscess.
Complications of Episiotomy
Maternal
 Early
- Haematoma
- Dehiscence
- Infection
 Late
- Dyspareunia
- Psychosexual problems
- Rarely endometriosis at episiotomy site,
squamous cell tumour of the vulva at the episiotomy
site, scar as metastatic site for cancer of cervix.
Forceps
This was invented in the seventeenth century by the
chamberlains. The forceps are a paired instrument
made up of a left and right halves which articulate by
crossing of their shanks.
Parts of the Forceps
A.The blades
B. The shanks
C. The lock
D. The handles
Operative Classification of Forceps

Classification is done according to the station of the presenting part

when the instrument is being applied
1. Mid Forceps: This term is used when the forceps is applied on
an engaged head above station plus 2 (+2).
The usual forceps is the Kiellands.
2. Low Forceps: Here the fetal head is at station plus 2
or below but the fetal scalp is usually not visible at the vulva.
3. Outlet Forceps: The fetal head is on the perineum (Station +3)
with the fetal scalp visible without separating the labia. The
sagital suture is in the A-P diameter of the pelvis.
Indications For Forceps Delivery
Maternal:
1. Conditions where the second stage must be shortened to
reduce stress on the mother’s cardio pulmonary system.
- Cardiac disease
- Pulmonary disease
- Severe anemia
- Severe hypertension / Pre – eclampsia.
- Thyroid disease.
Cont.
2. Emergency situations
- Maternal distress or exhaustion
- Intrapartum bleeding in second stage e.g. abruptio
placenta.
- Eclampsia.
- SCD patient in imminent crisis.
- Delayed second stage of labour.
Fetal Indications
- Fetal distress in second stage of labour
- Cord prolapse at full cervical dilatation
- Abruptio placentae in the second stage.
- The after coming head in breech presentation.
- Premature baby.
Contradications to Forceps Delivery.
- Head not fully engaged
- Cervix not fully dilated.
- Cephalopelvic disproportion.
Conditions that must be fulfilled before
embarking on forceps delivery.
- The presentation must be suitable. Usually vertex, but occasionally
face (mento anterior) and after coming head of breech.
- The head must be engaged.
- There should be no cephalopelvic disproportion.
- The cervix must be fully dilated.
- The membranes must be ruptured.
- The bladder must be empty.
- The estimated fetal weight must be less than 4kg.
- Adequate analgesia.
- Episiotomy must be performed.
- The experience and skills of the operator is most crucial.
- There must be adequate facilities for neonatal resuscitation.
Technique of Application
1. Ensure that all the above conditions are fulfilled i.e.
Head is fully engaged, catheterization done, episiotomy
is given and position of the head carefully noted.
2. The operator should check the forceps pair that he has
been given.
3. The left-handed blade is applied first. This held in the
operators left hand (like a pen), inserted downwards
and inwards, guided by the right hand. The same
procedure is followed for the other blade.
4. At the end of the application, the blades must lock
easily. They should not be forced to close.
Complications of Forceps Delivery

Maternal
- Anaesthetic complications.
- Extension of episiotomy and perineal tears.
- Vaginal lacerations.
- Cervical lacerations
- Bladder damage leading to VVF.
- Sepsis due to prolonged labour and genital tract
trauma during delivery.
- Spinal sprain and nerve root damage.
Fetal Complications
- Asphyxia.
- Skull lacerations
- Supratentorial haemorrhage.
- Subdural and sub arachnoid haemorrhage.
- Cephalhaematoma.
- Facial abrasion.
- Facial nerve damage leading to facial palsy.
Vacuum Extraction

The principle is based on the use of a cap/cup

attached by a tube to a pump that creates
negative pressure (vacuum) of 0.8kg/cm3.
Indications for Vacuum Extraction
 Maternal:
Elective
- Cardiac Disease
- Pulmonary Disease
- Severe hypertension/Pre-eclampsia
- Severe Anaemia
- Thyroid Disease
Cont.
 Emergency
-Maternal distress /exhaustion
-Intrapartum haemorrhage in 2nd stage of labour eg.
Abruptio placenta
-Delayed second stage of labour
-Eclampsia
-SCD patient in imminent crisis
Cont.
 Fetal Indications
- Fetal distress in the second stage of labour
- Cord prolapse when cervix is 8cm or more dilated
- Abruptio placenta in second stage labour
- Second twin with vertex presentation
Conditions that must be fulfilled before
embarking in Vacuum extraction

Conditions are almost the same as for forceps with the

following modifications
- The cervix must be at least 8cm dilated
- An anesthesia and/or episiotomy are not always
required.
Contra indications
1. Use of the vacuum is contraindicated if any of the
above conditions are not met.
2. Gestational age less than 32 weeks
Complications of Vacuum Extraction
 Maternal
- Periurethral and perineal Lacerations
- Vaginal laceration and/or haematoma
- Cervical Lacerations
Fetal
- Scalp Trauma
- Cephalhaematoma
- Neonatal Asphyxia
- Neonatal Jaundice
Advantages of Vacuum over Forceps

-Technique is easily learnt

-The vacuum cap does not occupy space in the maternal
pelvis
-Anaesthesia is not a prerequisite
-Natural forces come into play.
-There is an in-built safety mechanism
-Failed vacuum extraction is associated with fewer
complications to the mother and the baby.
-The vacuum can be used in the first stage of Labour
-Maternal and fetal/neonatal complications are lower
compared to the forceps.
Advantages of Forceps over Vacuum

-In experienced and skilled hands it effects faster

delivery.
-It can be safely used to deliver the premature infant with
birth weight less than 1.5kg.
-It can be used to deliver the after coming head in breech
delivery.
-Very handy and does not easily develop faults.
 1. Internal Podalic Version :
Procedure of converting presentation to breech followed by
extraction
a. Indications
 2nd twin in transverse lie or oblique lie.
 2nd twin cephalic, high head where rapid delivery is
required eg. fetal distress,
cord prolapse with adequate liquor,
Arm prolapse with adequate liquor.
b. Procedure :
Counselling and Consent
Elbow glove
Intact membrane ( or just ruptured membrane)
General Anaesthesia (or without if very urgent).
Grasp one foot through the membranes by the ankle and foot.
Use left hand to stabilize uterus abdominally
Draw the grasped foot gently into vagina.
The other foot usually follows spontaneously.
Grasp the other foot and draw it down.
Grasp both feet and draw them out, till the buttocks are
delivered.
Rupture the membrane if not already ruptured
Continue delivery with the manoeuvres of breech delivery.
 2. External Cephalic Version
Definition:
Procedure for Converting non cephalic presentations to
cephalic presentations to achieve vaginal delivery.
b. Indications
Breech (usually)
Transverse / Oblique lie
c. Timing
36 – 37 weeks – ante natal
2nd twin in abnormal lie – 2nd stage of twin delivery
d. Conditions:
- Informed consent
- Mother awake
- Uterus relaxed ( with / without tocolytics)
- CTG before and after procedure
- ultrasound before, during, and after procedure.
- Facility for emergency C/S
- No Contra indications
e. Contra – Indications
Uterine scar
APH
Multiple pregnancy
 Uterine abnormalities
Hypertensive disorders
Polyhydraminios
Oligohydraminios
PROM
Lack of experience
f. Factors for success
Multiparity
Adequate liquor
Breech above the pelvic brim
g. Give Anti- D immunoglobulin for Rh negative mothers.
Abandon after 3 attempts or if fetal distress.
 If ECV successful continue ANC and allow spont.
Labour. Stabilizing induction for unstable lie.
h. ECV Complications
- Cord accidents
- Abruptio placentae
- Preterm labour
- PROM
- Uterine rupture
- Feto – maternal bleed Rh ISO immunization
 3. Caesarean section
a. Definition: Operative delivery of a baby of viable
gestational age, through incisions in the
interior abdominal wall and the uterus.
b. History: Started as postmortem OP to safe
live babies.
On live mothers in the 16th century.
Initially classical incision used.
Lower uterine segment incision by
Munro – Kerr in the 1920’s.
c. Indications: Maternal
Fetal
Both
 d. Pre-Operative Preparation
Counselling - Reason, Procedure, anaesthesia, reassurance.
Informed consent - signed
Urgent lab. Tests - Hb, Sickling, group and X’match 2 pts of
blood.
Patient in left lateral position
Inform Anaesthetist for assessment.
Inform Paediatrician / Resident / Baby Nurse
Inform theatre staff.
Clip pubic hair if required
Atropine, antacid if stomach is full
e. Operative Procedure
* Scrub, gown, and prep. and drape before anaesthesia.
* Skin - Pfannenstiel incision preferred but
sudumbilical midline incision may be used.
* Fascia - Transverse incision
* Rectus muscle - Separated bluntly in the midline
vertically.
* Peritoneum: Entered bluntly with fingers or incised
with scissors
* Correct dextro rotation if necessary
Bladder (Utero – vesical) peritoneum incised in middle and
bladder reflected down and retracted with Doyen bladder
retractor.
 Uterine Incision:
Lower segment transverse-Standard.
Low vertical.
U – shaped
Inverted T ( )

Rarely classical incision

Delivery : Baby delivered manually or with short
shank delivery forceps or by the breech.
Placenta : controlled cord traction after oxytocic
contracts the uterus. Manually explore the cavity
Uterine Closure :Clamp incision corners and edges with green
armitage clamps / forceps.
Secure both corners with sutures beyond the apex
Close the incision with vicryl – 1 or chromic – 1 in continues
fashion in dingle layer.
NB. Ensure haemostasis
May close the uterus in-situ or exteriorised
Leave bladder peritoneum unsutured.
Clean peritoneal cavity of liquor and blood.
Close abdominal incision after checking packs, gauze and
instruments.
f. Complications
Early : Anaesthetic, haemorrhage, infection,
thromboembolism, organ injury, wound dehiscence.
Late - Uterine rupture
- infertility, etc. if infected.
g. Management of subsequent pregnancies and delivery -
Tertiary Centre.
 4. Destructive Operations
a. “Destroying” the fetus to achieve vaginal delivery
Done for cases of obstructed labour where the fetus is dead or
has lethal congenital anomaly and one wants to avoid C/S.
Infrequently done these days.
b. Pre-requisites / Conditions to be fulfilled
* Full disclosure of fetal condition, the procedure, and fetal
state after the procedure.
* Informed consent – signed.
* Operators skill and competence not in doubt.
* cervix fully dilated, membranes ruptured.
* uterine rupture or pending rupture ruled-out
 * General / Regional anaesthesia
* Episiotomy
* Empty Bladder
c. Types
1. Craniotomy
Cephalic presentation with head fixed in pelvis.
Dead fetus
lethal hydrocephalus
breech obstructed after – coming head, fetus dead.
i. Sites to perforate:
Fontannels
Foramen magnum
 ii. Instruments :
Simpson’s perforator or
long robust straight pointed scissors.
4 pairs of volsella
iii. Steps :
Perforation, and collapse of skull bones

Holding of skull bones and traction

Full delivery

Examination of genital tract.

 2. Decapitation
Dead first twin breech in locked twin
Impacted transverse lie with / without prolapsed arm.
Instruments
Blond – Heidler saw or Jardine’s decapitating hook
or robust embryotomy scissors.
3. Cleidotomy
Shoulder dystocia – dead fetus
Shoulder dystocia – anencephaly
Rarely Shoulder dystocia – live fetus
4. Embryotomy
Fetal Ascitis
Abdominal tumour
In all cases examine genital tract after the procedure.