Transcript Caesarean section and instrumental delivery

Caesarean section
and instrumental
delivery
Dr. samira abudia
Caesarean section
• Definition :
it’s a surgical procedure that
permits delivery of the infant through
incision in the abdominal and uterine
wall after 28th weeks of pregnancy (a
similar procedure before that time is
referred to a hysterotomy).
Introduction:
Caesarean section to deliver the baby
of the mother who has died has
been documented in ancient Egypt ,
Asia and Europe.
The first caesarean carried out on alive
woman is though to be that of the
wife if jacob nufer, she was in
obstructed labour.
•The history of the operation
thereafter is fascinating with a wide
range of isolated cases being
documented with a various
techniques being investigated to
decrease the risk of death due to
hemorrhage and sepsis .
Incidence :
The incidence of the procedure was
stable (3-5%) for many years , yet
since 1960s the rate was rising
steadily reaching (20-25%) in late
1980s.
Causes increase C.S rate :
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Repeat C.S
Dystochia
Fetal distress
Breech presentation
Malpractice
Maternal request
Indication of C.S :
1) maternal indications :
• Ante-partum hemorrhage
• Contracted pelvis and cephalo-pelvic disproportion
• Pelvic tumor obstructing labour
• Pelvic fracture
• Pelvic successful vaginal operation for SI , fistula
• Previous uterine scar may cause rupture urgent
controlled delivery e.g. severe hypertension or
central aneurysm
• Maternal medical conditions require urgent
controlled delivery e.g. severe hypertension or
central aneurysm
2) Fetal indications :
• Fetal distress
• Certain cases of malpresentation
• Macrosomia and extreme prematurity
Contra-indications of caesarean
section :
• there are no absolute
contraindications , but C.S is better
to be avoided in cases of fetal
demise , major anomalies
incompatible with life , and in severe
incompatible with life , and in severe
maternal diseases as coagulopathy.
Timing of C.S :
• It may be elective (before the onset
of labour pain) , or selective (the
decision taken during labour) .
Types of C.S :
A) upper segment C.S (classical C.S) :
USCS done through a vertical incision in upper
uterine segment allows rapid entry , buy it
connects with complications as increase blood
loss and increase risk of uterine rupture in
subsequent pregnancy.
• Indications of USCS :
a) fibroids at lower uterine segment
b) Dense adhesions cover the lower ut. Segment.
B) lower segment C.S :
• It’s the most commonly performed
incision.
• Lower incidence of hemorrhage
because it’s thinner , less vascular and
away from the normal site of
placenta.
• Stronger uterine scar with lower
incidence of ut. Rupture in a subsequent
pregnancy 0.4% (USCS 4%) , because the
lower segment is relaxed during
puerperium and approximation of edges
during surgery as it’s relatively thin.
• Post operative adhesions , infection and
ileus are less likely to occur.
Preoperative preparation :
• Preoperative visit by anesthesiologist is
important to asses the patient’s
anesthesia status and the risk of
complications during and after surgery.
• Patient in elective procedure should be
kept fasting.
• A large intravenous line prior to anesthesia
and an infusion of crystalloid solution.
• A recent Hb and Hct should be checked.
• Blood group and cross matched blood.
• Urinary bladder catheterization.
• Preparation of abdominal and perineal
area.
• Anesthesia : G.A or regional anesthesia.
Complications of C.S :
• Maternal morbidity and mortality :
Improved surgical and anesthetic skills
, antibiotic , septic techniques and blood
products availability have decreased the
complication of C.S , despite significant
decrease the maternal morbidity still 8-12
times than vaginal birth.
• Anesthetic complications (mainly in G.A) as
aspiration pneumonia , intra-operative as
(hemorrhage and injury U.B , uterus or
bowel) , thromboembolic diseases and
postoperative febrile complications as
endometritis and UTI.
• Remote morbidity includes adhesive
intestinal obstructions , rupture uterine scar
, placenta previa at the site of previous scar
and incisional hernia.
Caesarean hysterectomy
• Definition : it’s a hysterectomy performed at
the time of C.S.
• Indications :
1-placenta accreta , ,increta and percreta 50%
2-uterine atony 20%
3-intractable hemorrhage 15%
4-uterine rupture 10%
Postmortem C.S :
• For a pregnant woman who has a cardiac
arrest and the fetus is available , postmortem
C.S should be carried out without delay.
Instrumental Delivery
The obstetric forceps
The vacuum extraction
The obstetric forceps
Definition :
It’s instrument designed to
extract the head of living baby.
• It’s used either to accelerate delivery or
to overcome certain abnormalities in the
cephalo-pelvic relationship the interfere
with advancement of the head in labour.
indications
• Fetal indications :
1. the most common indications are
malposition of fetal head (OP,OT) ,
breech presentation and epidural
analgesia which increases the fetal malposition
2. fetal distress during the 2nd stage of
labour
• Maternal indications :
The most common indications are
maternal distress , exhaustion and
prolonged 2nd stage of labour.
Maternal diseases as heart and chest
diseases.
Description of forceps parts
• It consists of two matched parts that articulate
and lock to each other (blades) , each blade of
made of the blade proper , shank , lock and
handle.
• The blades are usually fenestrated for
lightness to minimize the compression of fetal
head and obtain form grip.
Each blade has two parts the flat one to fit the
fetal head (the cephalic curve) and the curved
one in the edge to fit the concavity of the
sacrum (the pelvic curve)
• The shank : each blade is joined to the
handle by the shank (variable lengths)
• Lock : the two blades are fitted together
by lock (English , French and sliding lock)
• Handles : they have different lengths
according to the type of forceps.
Type of forceps
• Short-shanked forceps : used in low forceps
operations ( when the head is low ) or to deliver
the head in cases of C.S , e.g. wrigle forceps
• Long shanked forceps : e.g. Simpson type
forceps .
• Special types forceps: e.g. Kielland’s forceps ,
for rotation of the vertex 90 degree or more .
Classification of forceps delivery
• American college of obstetric and
gynecology classifications of forceps
deliveries according to the station and
rotation .
Type of procedure
classification
Outlet forceps
•The scalp is or has been visible at introitus without
separating the labia .
•The skull has reached the pelvic floor .
•The sagittal suture is in the antero-posterior diameter or
has a rotation of 45 degree or less .
Low forceps
•The station is +2 cm or greater .
•Rotation of 45 degree or less .
•Rotation of greater than 45 degree .
Mid-forceps
•The station is less than +2 cm .
•Head engaged .
Prerequisites criteria for forceps
application :
The use of forceps is permissible only when all the following
condition prevail , regardless of the urgent need for
delivery :
• The cervix must be fully dilated
• The membrane must be ruptured
• The head must be engaged
• Suitable presentation and position
• No cephalo-pelvic disproportion
• The bladder should be empty
• Lithotomy position
• Sterilization
• Episiotomy
• Anesthesia
Complication of forceps
 Properly performed outlet forceps operation should have
morbidity rate similar to spontaneous vaginal delivery .
• Maternal complication :
1) Uterine , cervical or vaginal lacerations
2) Extension of episiotomy
3) U.B or urethral injury
4) Hematoma
• Fetal complications :
1) Cephalo-hematoma , bruising and laceration .
2) Facial nerve and brachial plexus palsies .
3) Skull fracture and intracranial haemorrhage .
The vacuum extraction (ventouse(
Introduction and history
• Modern obstetric vacuum extraction (VE)
originated in cupping ,a therapeutic technique
that predates Hippocrates .
• In cupping , a metal or glass cup was heated over
an open flame and placed over a lesion or skin
puncture , as the cup cooled . A vacuum
developed , extracting blood or other fluids.
• Cupping was also successfully used for certain
surgical procedures , such as raising depressed
skull fractures .
• 1849- James young Simpson , introduced his
(structured tractor) and attempted to
popularize vacuum operated delivery device
as an alternation to forceps for cephalic and
breech presentation .
• Vacuum-based delivery instrument did not
become popular duo to technical problems
with applying traction and maintaining
vacuum .
• 1950-Malmstrom, inverted his rigid cup design
namely , traction , an a metal cup designed
suction creates an artificial caput or chignon ,
within the cup holds firmly and allows
adequate traction .
• Birds modifications , in which vacuum tube is
attached to a lateral portion part
independence of the traction chain has
proven the most popular and useful.
Design of the vacuum extractor
1) Suction cup :
• Rigid cup designs include :
-the classic malmstrom stainless steel vacuum
cup .
-rigid plastic cup extractors (mimic malmstrom)
• Soft cup extractors include :
-disposable polyethylene cup designs .
-combined polyethylene-silastic cup designs .
2) Tube :connecting cup with vacuum source .
3) Vacuum source :
-suction bottle
-vacuum release valve
-manometer
3) Chain : for traction connecting to the cup
4) The traction handles .
indications
Basically these are the same as for forceps
deliveries , but :
1) it must not be used for face deliveries
2) it can not be used for after coming head of
breech presentation.
3) should not be used in case of prematurity and
with large caput or much moulding.
Common indications :
1) delayed 2nd stage of labour
2) fetal and maternal distress in 2nd stage of
labour
Prerequisites for vacuum extraction
• Informed consent.
• Prepared physician : physician should have
knowledge of the instrument chosen.
• Prepared patient :
-engaged membrane
-Ruptured membrane
-No suspicion of CPD
-Fetal position and station
-Acceptable analgesia
Complications of vacuum extraction
• Maternal complications :
-cervix or vaginal wall may be included in the
cup and lacerations may occur.
-applications before full dilatation of the cervix
and traction may cause annular detachment
of the cervix and may predispose to uterovaginal prolapse.
Fetal complications
-scalp : abrasions and necrosis
-skull fractures or cephalic hematoma
-brain : neurological signs , meningeal tear
, retinal hemorrhage or intracranial
hemorrhage.
Points in favor of vacuum extraction :
• Use of instrument is easy to learn
• Risks of maternal injuries are less than with
forceps
• Less general anesthesia is needed
• Spontaneous rotation of the fetal head
• Less force (traction) can be exerted on the fetal
head
• The vacuum cup doesn’t take up any room in the
pelvis
Contraindication to vacuum
extractions
Operator in experience
• inability to achieve a correct application
• Uncertainty concerning fetal position and
station
• Suspicion of cephalo-pelvic disproportion
• Fetal mal-position e.g. breech , face and brow.
• Known or suspected fetal coagulation defects
• Dead baby
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