Operative Delivery

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Operative delivery

1- Instrumental delivery

Incidence: 6-12%

Indication:

1- Delay in 2

nd

stage of labor

2- Poor maternal effort
3- Fetal distress, cord prolapse in 2

nd

stage of labor.

4- Maternal indication: sever cardiac, respiratory, hypertension disease

or intracranial pathology that bearing down effort my lead to death.
Causes of prolonged second stage of labor:-

1- Inadequate uterine contraction
2- Poor expulsive effort by the mother.
3- Minor disproportion or malposition.

4- Uses  of  epidural  analgesia  à  inadequate  uterine  contraction

secondary  to  abolition  of  Ferguson's  reflex  (stretching  of  lower
vagina by presenting part à lead to release of oxytocin).

How to approach patient necessitate instrumental delivery?

1- Medical person should introduce himself to the patient.
2- Explain  the  indication,  complication  &  contraindication  of  the

procedure.

3- Verbal  or  written  consent  should  be  taken  from  the  mother  &

partner.

4- Prerequisite criteria need to be full filled.
5- General examination of the mother, pain relief & hydration.
6- Analgesia in form of pudendal block & local perineal infiltration with

20  ml  of  1%  lignocaine  &  sometime  spinal  anesthesia  is  used  in  (
midcavity forceps)

7- Fetal condition should be assessed either clinically or by CTG

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8- Abdominal  examination  is  important  for  assessment  of  the  size  of

the fetus & if > 4.5 kg, caution is required. , engagement of the head
& uterine contraction which should be efficient ( 3 contractions > 40
sec / min )

9- Empty bladder is necessary

10- Vaginal examination is done to know

a- Membrane rupture or not
b- Head engagement ( below ischial spine )
c- Fully dilated cervix
d- Assessment  for  caput  (  soft  tissue  swelling  of  the  scalp  )  or

molding ( overlapping of skull bone )

e- Position  of  the  head  &  descend  of  presenting  part  with  each

contraction

11- Position  of  the  mother  à  the  leg  is  flexed  &  abducted  or  in  left

lateral position but much easier in lithotomy position

12- Aseptic  technique  as  vulva  &  perineum  is  washed  with  antiseptic

solution.

Choice of the instruments, forceps or ventouse
The choice of the forceps or vacuum depend on

1- Operators Experience
2- Station & position of the head

1) Forceps: could be fenestrated or not & consist of two blades, shank,

handle & lock.
Types of forceps:

i.  Long forceps: midcavity forceps or Simpson's forceps

ii.  Short forceps : outlet forceps ( Wrigley's forceps )

iii.  Rotational  forceps  :  for  occipitolateral  or  occipitoposterior

position ( Keiland forceps )

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The  blade  has  cephalic  curve,  which  apply  on  the  fetal  maxilla  or
molar eminence while pelvic curve fit the maternal pelvis.
Keiland  forceps  has  no  pelvic  curve,  as  it  is  rotational  forceps  used
for malposition.
Prior  to  application  of  forceps,  the  blades  should  be  assessed  to
check whether they fit together as pair.
Left blade put on the left side of the vagina by the left hand while
right blade is held by right hand & applied between the left hand that
protect  vaginal  wall  &  then  locked  horizontally  &  when  apply
forceps:
a- The sagittal suture is in the midline
b- Occiput is 3-4 cm above the shank
c- Traction applied with the contraction & maternal bearing
d- Traction is applied upward as the head is delivered by extension
e- Episiotomy done when the head is crowning

Keiland forceps:
Is a rotational forceps used for occipitoposterior & occipitotransverse
position.
1- Determine the direction of fetal back
2- Apply the anterior blade over the face of the fetus, posterior blade

apply directly & then rotational movement by sliding the shank to
rotate  the  occiput  toward  the  fetal  back  to  occiput  anterior.  It
need experience one.

Complication of Forceps:
1- 3

rd

& 4

th

perineal tear

2- Transient facial & scalp abrasion.

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3- Rare  complication:  facial  nerve  injury  or  palsy,  cephalo-

haematoma, skull bone fracture of the fetus.

2) Ventouse delivery:

It is an alternative for forceps delivery for similar indication in second
stage of labor.
It is vary in size of the cup 4, 5, 6, cm.
The  cup  is  applied  at  flexion  point  which  3-4  cm  in  front  of  the
occiput on the midline indicated by sagittal suture
This  to  increase  flexion  of  the  head  to  permit  minimal  diameter  to
descend.
Once  the  cup  is  applied  correctly  ,  vacuum  is  created  start  by  0.2
kg/cm

2

negative pressure , then increase the pressure up to 0.7 -0.8

kg/cm

2

& then traction is applied , descend of the head with flexion

promote autorotation of the head to occipito-anterior.
It is less causing perineal trauma.

Types of ventouse:
1- Metallic type
2- Silk type
3- selastic type

Anterior  cup à  for  O.A  position  &  its  tube  arise  from  the  anterior
surface of the cup.
Posterior cup à for O.P., O.T. & its tube arise from the lateral side of
the cup & usually it is metallic type.

Complication of vacuum:

1. Chignon:  soft  tissue  of  the  scalp  sucked  into  cup  &  usually

resolve within 2-3 days.

2. Scalp abrasion
3. Retinal haemorrhage.

4. Skull haematoma
5. Neonatal jaundice.

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6. Subgaleal  haemorrhage  which  is  associated  with  high  PNM  &

mortality.

Contraindication of vacuum:
1- Gestational age < 34 weeks (gestational age)
2- Fetal scalp haemorrhage
3- Face presentation.

2- Caesarean Section C/S:

It means delivery of the baby by an abdominal & uterine incision.

Incidence: 10-25%
Types:

1) Emergency: immediate threaten to the life & should be done within

30 min.

2) Urgent  C/S:  no  immediate  threaten  to  the  life  &  should  be  done

within 60-75 min.

3) Elective  C/S:  when  the  patient  is  prepared  &  done  at  39  weeks

gestational age.

Indication of C/S:

1. antepartum haemorrhage ( APH ) à abruption placenta & placenta

previa

2. Cord prolapse.
3. rupture scar
4. Fetal hypoxia, FHR bradycardia < 80 BPM.
5. Failure of progress of labor
6. IUGR with absent diastolic flow
7. Sever PET with unfavorable cervix
8. Malpresentation ( breech , brow )
9. History of hysterotomy or vertical incision.

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10. History of HIV infection
11. History of vesicovaginal fistula.

Placenta  accrete  is  more  common  complication  &  may  result  in
massive  haemorrhage  that  lead  to  hysterectomy  so  consent  &
preparation of the patient is necessary. (Placenta accrete occur when
the placenta is anterior, lower laying in women with history of scar)

Types of C/S:

1) lower uterine segment incision involve horizontal incision of the

lower segment after reflecting the vesical peritoneum , this is the
commonest  type  &  the  abdomen  opened  by  lower  midline  ,
paramedian  &  commonly  by  pfannensteil  incision  (  suprapubic
horizontal incision ) & the peritoneal cavity opened , the bladder
is reflected from the lower uterine segment & transverse incision
is  made  at  lower  uterine  segment  &  the  presenting  part  is
delivered through the lower segment ,
The  merits  of  single  versus  two  layers  closure  of  the  muscle  &
closure versus non-closure of the vesical peritoneum is currently
being investigated by many randomized controlled studies.

Advantages of lower segment incision:
1- easier to incise & suture as it is thin
2- Less blood loss & infection rate compared with upper uterine

segment.

Then  the  uterine  cavity  should  be  cleaned,  not  to  leave  any
retained piece & should be sure that cervical os is open to allow
drainage of the blood.
Closure  of  the  uterus  is  followed  by  peritoneal  toilet  through
removing of any blood or liquor in the abdominal cavity either by
suction or gauze swab.
Inspection of the ovary & tubes is done.
Prophylactic antibiotic is given routinely.

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If  the  mother  is  Rh  –ve  &  the  baby  is  Rh  +ve,  anti-D  should  be
given.

2) Classical C/S:

Could  be  done  at  upper  or  lower  uterine  segment,  commonly  it
start in the lower segment at as a small incision & extend upward

Disadvantage of it:
1- Difficulty to incise it
2- More blood loss
3- Inadequate apposition at closure
4- Increase risk of scar rupture that increase maternal mortality &
morbidity.

But it has certain indication:
1- When the lower segment approach is difficult because of fibroid
or anterior placenta previa.
2- Preterm breech with poorly formed lower segment
3- Impacted transverse lie with rupture membrane.
4- Impacted transverse lie with congenital anomaly.
5- Perimortem C/S

3) Other types: are inverted T & J – shape incision.

Complication of C/S:

Early complication :

Late complication:

1- primary haemorrhage

1- secondary hemorrhage

2- anesthetic related complication
like  lung  atelectasis,  Mendelson's

syndrome

2- wound infection

3-  Injury  to  the  bowel,  bladder,
ureter & to the fetus sometime.

3-  vesico-vaginal  ,  uretrovaginal
fistula are rare

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4- pulmonary embolism

4-  DVT,  so  prophylactic  dose  of
heparin is used & post operatively,

early  mobilization  &  chest
physiotherapy is advocated.

C/S may complicated by caesarean hysterectomy in :
1- Placenta previa, placenta accreta.
2- Uncontrollable postpartum haemorrhage.
3- Rupture uterus

4- CA- cervix

Maternal mortality is rare less than 0.3/1000 & is related to reason for
which C/S is done or to anesthesia or to haemorrhage complication.