lecture for medical students

1. OPERATIVE
DELIVERY
Dr.Tarig Mahmoud Ahmed
MD SUDAN
HAIL UNIVERSITY KSA

2. Operative vaginal delivery
Delivery of a baby vaginally using an
instrument for assistance.

3. Indications for assisted vaginal delivery
FETAL INDICATIONS:
◦ Malposition, (occipito-transverse and occipito-
posterior).
◦ Fetal distress

4. Maternal indications:
1. Maternal distress & exhaustion.
2. Prolonged second stage of labour:
• Nullipara: 3hours with and 2hours without regional
anaesthesia
• Multipara: 2 hours with and 1 hour without regional
anaesthesia
3. Medical conditions:
cardiac disease III/IV, hypertensive crises, aortic valve disease
with significant outflow obstruction, spinal cord injury,
proliferative retinopathy or myasthenia gravis.

5. Contraindications
◦ Forceps and vacuum extractor deliveries before full
dilatation of the cervix are contraindicated.
◦ Ventouse should not be used in:
1. gestations of less than 34 completed weeks
because of the risk of cephalohaematoma and
intracranial haemorrhage.
2. face or breech presentation.

6. Prerequisites for any instrumental delivery
◦ F: full dilatation
◦ O: OA, OP or occipito transverse
◦ R: ruptured membranes
◦ C: contractions are adequate, consent
◦ E: empty bladder, experienced staff
◦ P: pelvis of adequate size
◦ S: station (below ischial spines), less than 1/5
palpable per abdomin

7. Ventouse/vacuum extractors

8. ◦ The basic premise of such instruments is that a
suction cup, of a silastic or rigid construction, is
connected, via tubing, to a vacuum source.
◦ Recent developments have removed the need for
cumbersome external suction generators and have
incorporated the vacuum mechanism into ‘hand-
held’ pumps.

9. Technique
◦ soft cups: for straightforward deliveries with an
occipitoanterior position
◦ metal cups: suitable for occipitoposterior and
transverse.
◦ centre of the cup should be positioned directly
over flexion point . This is located at the vertex, on
the saggital suture 3 cm anterior to the posterior
fontanelle and thus 6 cm posterior to the anterior
fontanelle.

11. ◦ vacuum pressure (0.6 and 0.8 kg/cm2) is
built
◦ the traction plane is at 90º to the cup.
◦ no more than two episodes of breaking
suction in any vacuum delivery are safe.
◦ Maximum time from application to delivery
should ideally be less than 15 minutes.

12. Complications
Fetal:
◦ Scalp or cranial effects:
• Chignon
• Subgaleal bleed
• Cephalhematoma
◦ Intracranial injuries:
• Intracranial hemorrhage
• Retinal hemorrhage
• Cerebral irritation/asphyxia
◦ Neonatal jaundice

13. Maternal complications
◦ Trauma
◦ Hemorrhage
◦ Sepsis

14. Forceps

15. The basic forceps design
• two blades with shanks,
• joined together at a lock,
• handles to provide a point for traction.

16. Technique
◦ the left blade is inserted before the right
with the accoucheur’s hand protecting the
vaginal wall from direct trauma.
◦ The axis of traction changes during the
delivery and is guided along the ‘J’-shaped
curve of the pelvis.
◦ It has been recommended that an
episiotomy be cut whenever an
instrumental vaginal delivery is performed.

18. Fetal complications
◦ Simple skull fractures
◦ Compression distortion injuries
1. Tearing of tentorium
2. Rupture of bridging veins
◦ Cephalohaematoma
◦ Facial nerve palsy

19. Maternal complications
◦ Trauma
• Lower genital tract trauma
• Upper genital tract trauma
• Urinary tract trauma
◦ Hemorrhage
◦ sepsis

20. Comparison
The ventouse, when compared to the
forceps is significantly more likely to:
◦ fail to achieve a vaginal delivery.
◦ be associated with maternal worries about
the Baby.

21. The ventouse, when compared to the forceps
is significantly less likely to:
◦ use of maternal regional/general anaesthesia.
◦ significant maternal perineal and vaginal
Trauma.
◦ severe perineal pain at 24 hours.

22. The ventouse, when compared to the forceps
is equally likely to:
◦ delivery by Caesarean section;
◦ low 5 minute Apgar scores.

23. factors contribute to delivery failure:
◦ inadequate initial case assessment – high head,
misdiagnosis of the position and attitude of the
head.
◦ failure due to traction in the wrong plane.
◦ poor maternal effort with inadequate use of
Syntocinon to aid expulsive efforts in the second
stage.
◦ failure to select the correct ventouse cup type
and/or incorrect cup position.

24. Strategies to lower the rates of assisted delivery
◦ Provision of a caregiver during labour.
◦ Active management of the second stage
with syntocinon in women with epidural
analgesia.
◦ Delayed pushing(1-2hours) in women with
epidural analgesia.

25. CAESAREAN
SECTION

26. Definition
A Caesarean section, also known as C-section
or Caesar, is a surgical procedure in which
incisions are made through a mother’s
abdomen (laparotomy) and uterus
(hysterotomy) to deliver one or more babies.

27. Prevalence
In the UK, more than 21 per cent of all babies are now
delivered by Caesarean section.
Factors that increase in the rates of C- section:
◦ Inaccurate dating of the pregnancy.
◦ Fetal monitoring.
◦ Macrosomia.
◦ Maternal request.

28. Indications
There are many different reasons for
performing a delivery by Caesarean section.
The four major indications accounting for
greater than 70 per cent of operations are:
1) previous Caesarean sections
2) dystocia
3) malpresentation
4) suspected acute fetal compromise.

29. Other indications, such as multifetal
pregnancy, abruptio placenta, placenta
praevia, fetal disease and maternal disease
are less common.
No list can be truly comprehensive and
whatever the indication, the overriding
principle is that whenever the risk to the
mother and/or the fetus from vaginal
delivery exceeds that from operative
intervention, a Caesarean section should be
undertaken.

30. Morbidity and mortality
◦ case fatality rate for all Caesarean sections is
five times that for vaginal delivery.
◦ Some maternal deaths following Caesarean
section are not attributable to the procedure
itself, but to medical or obstetric disorders
that lead to the decision to deliver using this
approach.

31. Procedure
Informed consent:
◦ Full informed consent must always be
obtained prior to operation.
◦ It is important to remember that no other
adult may give consent for another, Where
there is incapacity to consent the doctor is
expected to act in the patient’s best interests.

32. ◦ Surgical basics
The bladder should be emptied before the
procedure.
A left lateral tilt minimizes compression of the
maternal inferior vena cava and reduces the
incidence of hypotension syndrome.

33. Skin incisions
1)The Pfannenstiel incision (low transverse) :
The skin and subcutaneous tissues are incised
using a transverse incision two fingerbreadths
above the symphysis pubis extending from and
to points lateral to the lateral margins of the
abdominal rectus muscles.
2) The infra-umbilical incision(vertical):
from the lower border of the umbilicus to the
symphysis pubis, and may be extended caudally
toward the xiphisternum.

35. Uterine incisions
1)A lower uterine segment incision:
is used in over 95 per cent of Caesarean
deliveries.
2)classical section (upper uterine segment):
Used when:
A) lower uterine segment containing fibroids or
dense adhesions.
B) placenta praevia.
C) presence of a carcinoma of the cervix.

37. Complications of C/S
1) Haemorrhage
2) Caesarean hysterectomy
3) Bowel damage
4) Urinary tract damage
5) Infection and endometritis
6) Thromboembolism and deep vein thrombosis
7) prolonged recovery.
8) long-term bladder dysfunction.
9) increased risks of placenta praevia and scar
rupture in subsequent pregnancies.
10) transient tachypnea of new born syndrome.