8. PRELIMINARIES:
1. Anesthesia
2. Lithotomy Position
3. Full surgical asepsis
4. Empty the bladder
5. Vaginal examination
• General/Local
• May be performed with IV Diazepam sedation
10. PRELIMINARIES:
1. Anesthesia
2. Lithotomy Position
3. Full surgical asepsis
4. Empty the bladder
5. Vaginal examination
• Surgeon is to wear sterile mask, gown & gloves
• Vulva & vagina is to be swabbed
with antiseptic solution
• Cervix is cleaned with povidone
iodine solution
• Perineum is to be draped by
sterile towel &
the legs with leggings
11. PRELIMINARIES:
1. Anesthesia
2. Lithotomy Position
3. Full surgical asepsis
4. Empty the bladder
5. Vaginal examination
• If the patient is ambulant,
she is asked to empty the bladder
before she is placed on the table
• Otherwise, catheterization is to be done
12. PRELIMINARIES:
1. Anesthesia
2. Lithotomy Position
3. Full surgical asepsis
4. Empty the bladder
5. Vaginal examination • Size of uterus
• Position of uterus
• State of dilatation of cervix
17. ONE STAGE operation
1. Incomplete abortion
(commonest)
2. Inevitable abortion
3. Medical termination of
pregnancy (6-8 weeks)
4. Hydatidiform mole in the
process of expulsion
TWO STAGE operation
1. Induction of 1st
trimester abortion
(commonest)
2. Missed abortion
(uterus 8-10 weeks)
3. Hydatidiform mole
with unfavorable cervix
21. Preliminaries
Steps:
Sim’s posterior
vaginal speculum is
introduced
Anterior lips of
cervix is grasped by
an Allis forceps
Cervical canal is
gradually dilated up
Products are
removed by ovum
forceps
Inj. Methergin
0.2mg IV is
administered
Uterine cavity is
curetted gently
Speculum & Allis
forceps are removed
Uterus is massaged
bimanually
Sterile vulval pad is
placed
Patient is send back
to her bed
23. First phase (slow dilatation of cervix)
Consists of introduction of laminaria tents or
lamicel (MgSO4 sponge) into cervical canal
to effect its slow dilatation
May be effective by intravaginal insertion of
Misoprostol (PGE1), 400mcg 3 hrs before surgery (less side effect)
24.
25. Preliminaries
As previously mentioned
No anesthesia is required
Appropriate size &
number of the tent
required are selected
The threads attached to
one end are tied to
roller gauze
Sim’s posterior
vaginal speculum is
introduced and hold
Allis forceps is used
to grasp the anterior
lip of the cervix
Cervical canal may
have to be dilated
Tents are introduced
one after the other
for at least 4cm
(tips are placed
beyond external os)
Roller gauze is used
to pack the upper
vagina (to prevent
displacement)
Patient is send back
to her bed
Prophylactic
antibiotic
Doxycycline
100mg PO BID
for 3 days
+
Metronidazole
400mg PO BID
for 5 days)
Steps of Introduction of Tents
26. Second phase (rapid dilatation of cervix evacuation of uterus)
Procedures:
Patient is brought back to
operation theatre usually after 12
hours
Patient should empty her bladder
beforehand
Preliminaries:
As mentioned before
Operation may be conducted under
• IV Diazepam sedation
• Local paracervical block
• General Anesthesia
27. Removing the
roller gauze
The posterior
vaginal
speculum is
introduced
Tents are
removed with
the help of
sponge forceps
Preliminaries
Follow all the
steps as in one
stage operation
Sim’s posterior
vaginal speculum
is introduced
Anterior lips of
cervix is grasped
by an Allis
forceps
Cervical canal
dilatation
Removal of
products by
ovum forceps
Inj. Methergin
0.2mg IV
Uterine cavity is
curetted gently
Speculum & Allis
forceps removal
Uterus is
massaged
bimanually
a sterile vulval
pad is placed
Patient is send
back to her bed
Oxytocic agents
Inj. Methergin 0.2mg IM
OR
Oxytocin 20 units in
500mL of NS
intraoperatively and
continued after operation
for 30 mins
Prophylactic
antibiotic
Doxycycline
100mg PO BID
for 3 days
+
Metronidazole
400mg PO BID
for 5 days)
Steps of 2nd stage: (MTP-8 weeks)
29. Depends on the location,
size & nature of
the instrument
causing perforation
Procedure is stopped
30. CAUSES MANAGEMENT
Perforation by SMALLER size
dilator or sound
• Expectant treatment with
observation of pulse & BP
• Antibiotic
Perforation by BIGGER size
dilator,
or ovum, or ring forceps, or suction
cannula
• Dianostic laparoscopy
• Laparotomy
• Inspection of intestine &
omentum for evidence of injury
Lateral cervical tear with
broad ligament hematoma or
laceration of uterine artery
• Laparotomy followed by repair
• Hysterectomy
Perforation prior to
complete evacuation
• Stop evacuation. Evacuation can
be done
under laparoscopic visualization.
• If laparotomy is decided, consider
to
preserve uterus or hysterectomy
Depends on the location,
size & nature of
the instrument
causing perforation
Procedure is stopped
31.
32. A procedure in which
the products of conception
are sucked out from the uterus
with the help of a cannula
fitted to a suction apparatus
34. PROCEDURES
Preliminaries:
As mentioned before
GA is usually not needed
If patient is apprehensive,
IV Diazepam 5-10 mg (conscious sedation)
supplemented by paracervical block is
quite effective
Patient is put on the table after bladder is emptied
35. PROCEDURES
Steps:
Sim’s posterior vaginal speculum is introduced
and hold by assistant
Anterior lips of cervix is grasped by an Allis
forceps
Cervical canal is gradually dilated by graduated
metal dilators up to one size less than the suction
cannula (characterized by feeling of “snap” around the dilator)
OR
Use of laminaria tent 12 hrs before or
Misoprostol 400mcg PV 3 hrs prior to surgery
37. PROCEDURES
Steps:
Introduced into the uterus, tip to
be placed in the middle of the
uterine cavity
Pressure of suction is raised to 400-
600 mmHg
Cannula is moved up & down and
rotated 360o
Suction bottle is inspected for the
products of conception & blood loss
38. The END POINT OF SUCTION is denoted by:
1) no more material is being sucked out
2) gripping of the cannula by the
contracting smaller size uterus
3) grating sensation
4) appearance of bubbles in the cannula
or in the transparent tubing
39. PROCEDURES
Steps:
Vacuum should be broken before
withdrawing the cannula
Better to curette the uterine cavity with
small flushing curette at the end of
suction
Cannula is reintroduced to suck out any
remnants
41. Similar complications as mentioned in D+E operation may
occur
Use of plastic cannula can minimize uterine perforation
Blood loss & incomplete evacuation are less likely with
pregnancy of 8 weeks or less
Use of USG during procedures shortens the operative time and
reduces complications
43. Aspiration of the endometrial cavity
within 14 days of missed period
in a woman with previous normal cycle
44.
45. PROCEDURE
Operation is done as an out patient
Aseptic precautions
Sedation or paracervical block anesthesia
may be employed
Introduction of posterior vaginal speculum &
Allis forceps
Gentle dilatation of cervix using 4-5mm size
dilators
Insertion of 5-6mm suction cannula
(Karman’s) & attached to 50mL syringe
Cannula is rotated, pushed in & out with
gentle strokes
46. PROCEDURE
Operation is done as an out patient
Aseptic precautions
Sedation or paracervical block anesthesia
may be employed
Introduction of posterior vaginal speculum &
Allis forceps
Gentle dilatation of cervix using 4-5mm size
dilators
Insertion of 5-6mm suction cannula
(Karman’s) & attached to 50mL syringe
Cannula is rotated, pushed in & out with
gentle strokes
47. PROCEDURE
Operation is done as an out patient
Aseptic precautions
Sedation or paracervical block anesthesia
may be employed
Introduction of posterior vaginal speculum &
Allis forceps
Gentle dilatation of cervix using 4-5mm size
dilators
Insertion of 5-6mm suction cannula
(Karman’s) & attached to 50mL syringe
Cannula is rotated, pushed in & out with
gentle strokes
48. PROCEDURE
Operation is done as an out patient
Aseptic precautions
Sedation or paracervical block anesthesia
may be employed
Introduction of posterior vaginal speculum &
Allis forceps
Gentle dilatation of cervix using 4-5mm size
dilators
Insertion of 5-6mm suction cannula
(Karman’s) & attached to 50mL syringe
Cannula is rotated, pushed in & out with
gentle strokes
49. PROCEDURE
Operation is done as an out patient
Aseptic precautions
Sedation or paracervical block anesthesia
may be employed
Introduction of posterior vaginal speculum &
Allis forceps
Gentle dilatation of cervix using 4-5mm size
dilators
Insertion of 5-6mm suction cannula
(Karman’s) & attached to 50mL syringe
Cannula is rotated, pushed in & out with
gentle strokes
50. Operator should examine the
aspirated tissues by floating it
in a clear plastic dish over a
light source
Placenta tissue appears fluffy
and feathery when floats in
normal saline
Help to detect failed abortion,
molar pregnancy or ectopic
pregnancy
51.
52.
53. Procedure is SIMILAR to menstrual
regulation and is done as out patient basis Highly
effective
(98-100%)
Procedure may be:
Manual Vacuum Aspiration (MVA
Electric Vacuum Aspiration (EVA)
Termination is done
upto 12 weeks with
MINIMAL cervical
dilatation
54. A hand operated double valve plastic syringe (60mL)
is attached to Karman’s cannula (upto 12mm size)
Cannula is inserted transcervically into the uterus
and vacuum is activated
A negative pressure of 660 mmHg is created
Aspiration of the products of conception
*procedure takes less time (5-15 mins) and is less
traumatic
*complications are similar to other surgical method but
are less severe
59. INDICATI
LEGAL ABORT
MALAYSIA
Any medical condition that
can be worsened by
pregnancy.
A pregnancy with fetus that is
unlikely to survive like
anencephaly.
This is not applied to any
syndrome or congenital
malformation in which the baby
could survive like Down
syndrome.
A rape case in which the
pregnancy causing the
mental distress to the
patient.
60.
61. Operative procedure of…
extracting the product of conception out of the womb before
28th week by cutting through the anterior wall of the uterus
62. similar to a caesarean section,
but requiring a smaller incision
form of abortion in which
the uterus is opened
through an abdominal
incision and the fetus is
removed,
64. Fibroids in the lower uterine
segment (obstructing evacuation) Midtrimester MTP where
other methods are failed or
contraindicated
indications
Completely
low lying placenta
(placenta previa)
Cervical cancer with
pregnancy
Uterine
anomalies
Women with multiple
previous cesarean delivery
(due to risk of placenta
accrete)
67. A surgically planned incision on the perineum &
posterior vaginal wall during the 2nd stage of labor
68. To enlarge vaginal introitus facilitate easy
& safe delivery of the fetus
To minimize overstretching & rupture of
perineal muscles & fascia reduce stress &
strain on the fetal head
69. Recommended in selective cases than
in routine
A constant care during the 2nd stage
reduces the incidence of episiotomy &
perineal trauma
70. Elastic/rigid perineum
arrest/delay in descent of
the presenting part as in
elderly primigravidae
Operative delivery
forceps delivery
ventouse delivery
Anticipating perineal tear
big baby
face to pubis delivery
breech delivery
shoulder dystocia
Previous perineal surgery
pelvic floor repair
perineal reconstructive surgery
71. Requires judgment
EARLY blood loss is more
LATE fails to prevent invisible lacerations of
the perineal body fails to protect pelvic floor
IDEAL TIME
Bulging thinned perineum during contraction just
prior to crowning (3-4cm of head visible)
72. Maternal
A clear & controlled incision is easy to
REPAIR AND HEALS better than a
lacerated wound that may occur
otherwise
Reduction in the DURATION of 2nd
stage
Reduction of TRAUMA to pelvic floor
muscle reduces the incidence of prolapse &
urinary incontinence
Fetal
Minimize the intracranial injuries
specially in premature babies or after-
coming head of breech
73. Mediolateral
• Downwards &
outwards incision from
the center of the
fourchette (right/left)
• Directed diagonally in
a straight line which
runs about 2.5cm away
from the anus
Median/Midline
• Incision from the
center of the fourchette
• Extends posteriorly
along the midline for
about 2.5cm
Lateral
• Incision from about
1cm away from the
center of the fourchette
• Extends laterally
• Got many drawbacks
including chance of
injury to batholin’s
duct. TOTALLY
CONDEMNED.
‘J’ shaped
• Incision begins in the
center of the fourchette
• Directed posteriorly
along the midline for
about 1.5cm
• Then directed
downwards & outwards
along 5/7 o’clock
position to avoid anal
sphincter
• Apposition is not
perfect & the repaired
wound tends to be
puckered
75. MERITS DEMERITS
mediolateral episiotomy
The muscles are not cut
Less blood loss
Repair is easy
Postoperative comfort is maximum
Healing is superior
Wound disruption is rare
Dyspareunia is rare
median episiotomy
Extension if occurs, may involve the rectum
Not suitable for manipulative delivery or in
abnormal presentation or position.
Relative safety from rectal involvement
from extension
If necessary, the incision can be extended
Apposition of the tissues is not so good
Blood loss is little more
Postoperative discomfort is more
Relative increased incidence of wound
disruption
Dyspareunia is comparatively more
77. 1)Preliminaries
2)Incision
3)Repair
Perineum is thoroughly swabbed
with antiseptic (povidone-iodine)
lotion and draped properly
Local anesthesia
the perineum, in the line of proposed
incision is infiltrated with 10mL of 1%
solution of lignocaine
78.
79. 2 fingers are placed in the vagina
between the presenting part & the
posterior vaginal wall
Made by a curved/straight blunt
pointed sharp scissors
One blade is placed inside, in between
the fingers & the posterior vaginal
wall
The other is on the skin
Incision should be made at the
height of an uterine contraction
1)Preliminaries
2)Incision
3)Repair
80.
81. 1)Preliminaries
2)Incision
3)Repair
Timing
Done soon after expulsion of placenta
Oozing - controlled by pressure with a
sterile gauze swab
Bleeding – artery forceps
Early repair prevents sepsis &
eliminates the patient’s prolonged
apprehension of ‘stitches’
82. Preliminaries:
Lithotomy position
A good light source from behind is
needed
Perineum & wound area are cleansed
with antiseptic solution
Blood clots are removed from vagina &
wound area
Patient is draped properly repair
should be done under strict aseptic
precautions
If the repair is obscured by oozing of
blood from above, a vaginal pack may
be inserted & is placed high up
1)Preliminaries
2)Incision
3)Repair
83. 1)Preliminaries
2)Incision
3)Repair
Repair
Done in 3 layers
Principles to be followed are:
1) Perfect hemostasis
2) To obliterate the dead space
3) Suture without tension
Orders:
1) Vaginal mucosa & submucosal tissues
2) Perineal muscles
3) Skin & subcutaneous tissues
84.
85. POSTOPERATIVE CARE
Dressing
The wound is to be dressed each time
following urination & defecation
To keep area clean & dry
Swabbing with cotton swabs soaked in
antiseptic powder or ointment
(Furacin or Neosporin)
86. POSTOPERATIVE CARE
Comfort
To relieve pain in the area,
magnesium sulfate compress or
application of infrared heat may be
used
Ice packs reduces swelling & pain also
Analgesic drugs (Ibuprofen) may be
given when required
87. POSTOPERATIVE CARE
Ambulance
Patient is allowed to move out of the
bed after 24 hours
Prior to that, she is allowed to roll
over on to her side or even to sit but
only with thighs apposed
88. POSTOPERATIVE CARE
Removal of stitch
When wound is sutured by catgut or
Dexon which will be absorbed, the
sutures need not be removed
If non-absorbable material (silk/nylon)
is used, the stitches are to be cut on
6th day
89. POSTOPERATIVE CARE
Dressing
The wound is to be dressed each time
following urination & defecation
To keep area clean & dry
Swabbing with cotton swabs soaked in
antiseptic powder or ointment
(Furacin or Neosporin)
Ambulance
Patient is allowed to move out of the
bed after 24 hours
Prior to that, she is allowed to roll
over on to her side or even to sit but
only with thighs apposed
Comfort
To relieve pain in the area,
magnesium sulfate compress or
application of infrared heat may be
used
Ice packs reduces swelling & pain also
Analgesic drugs (Ibuprofen) may be
given when required
Removal of stitch
When wound is sutured by catgut or
Dexon which will be absorbed, the
sutures need not be removed
If non-absorbable material (silk/nylon)
is used, the stitches are to be cut on
6th day
90. immediate
Extension of the incision
Vulval hematoma
Wound dehiscence
Incontinence
remote
Dyspareunia
Chance of perineal
lacerations
Scar endometriosis (rare)
94. FOR MAIN POINTS:
DC Dutta ‘s Textbook of Obstetrics
FOR EXTRA POINTS:
http://medicowesome.blogspot.in/2014/10/what-is-difference-between-menstrual.html
http://www.glowm.com/section_view/heading/Surgical%20Techniques%20for%20First-
Trimester%20Abortion/item/439
http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03268.x/full
http://www.academia.edu/7691081/Legal_Issues_of_Abortion_in_Malaysia
FOR VIDEO:
https://www.youtube.com/watch?v=iHfRe7q7WEY
Injection Methergin 0.2mg IV
Appropriate suction cannula is fitted to the suction apparatus
The Silent Scream is a 1984 anti-abortion educational film directed by Jack Duane Dabner and narrated by Bernard Nathanson, an obstetrician, NARAL Pro-Choice America founder, and abortion provider turned pro-life activist, and produced in partnership with the National Right to Life Committee.[2] The film depicts the abortion process via ultrasound and shows an abortion taking place in the uterus. During the abortion process, the fetus is described as appearing to make outcries of pain and discomfort. The video has been a popular tool used by the pro-life campaign in arguing against abortion,[3] although it has been criticized as misleading by members of the medical community.[4]