Operative Obstetrics:

I. Forceps DeliveryII. Vacuum Extraction III. Breech Delivery IV. Cesarean DeliverV. Postpartum Hysterectomy

Forceps Delivery

Indications

Indications for operative vaginal deliveries are identical for forceps and vacuum extractors.

No indication for operative vaginal delivery is absolute.

Forceps Delivery

The following indications apply when no contraindications exist:

Prolonged second stage: This includes nulliparous woman with failure to deliver after 2 hours without, and 3 hours with, conduction anesthesia.- It also includes multiparous woman with failure to deliver after 1 hour without, and 2 hours with, conduction anesthesia.

Suspicion of immediate or potential fetal compromise in the second stage of labor.

Shortening of the second stage for maternal benefits: Maternal indications include, but are not limited to, exhaustion, bleeding, cardiac or pulmonary disease, and history of spontaneous pneumothorax.

In expert hands, fetal malpositions, including the after-coming head in breech vaginal delivery, can be indications for forceps delivery.

Forceps Delivery

Forceps Delivery

Definition of prolonged second stage of labour redefined by A.C.O.G.(1988/1991):

Nullipara-

<3 hrs with regional anaesthesia <2 hrs without regional anaesthesia

Multipara-

<2 hrs with regional anaesthesia <1hr without regional anaesthesia

The head must be engaged.

The cervix must be fully dilated and retracted.

The position of the head must be known.

The type of pelvis should be known.

The membranes must be ruptured.

No disproportion should be suspected between the size of the head and the size of the pelvic inlet and mid pelvis.

The patient must have adequate anesthesia.

Adequate facilities and supportive elements should be available.

The operator should be fully competent in the use of the instruments and the recognition and management of potential complications. -The operator should also know when to stop so as not to force the issue.

Prerequisites for forceps delivery include the following:

Forceps Delivery

Vacuum Extraction

Fetal Indications

Prolonged second stage of labor

Shortening of the second stage of labor

Presumed fetal jeopardy/fetal distress

Maternal Indications

Need to avoid voluntary maternal expulsive efforts (e.g., the mother has cardiac or cerebrovascular disease)

Inadequate maternal expulsive efforts

Maternal exhaustion or lack of cooperation

Indications for Vacuum-Assisted Delivery

Vacuum Extraction

Fetal prematurity (<34 weeks of gestation)

Fetal scalp trauma

Unengaged head

Incomplete cervical dilatation

Active bleeding or suspected fetal coagulation defects

Suspected macrosomia

Nonvertex presentation or other malpresentation

Cephalopelvic disproportion

Delivery requiring rotation or excessive traction

Inadequate anesthesia

Relative Contraindications for Vacuum Extraction

Vacuum Extraction

Proper placement of the cup used in vacuum extraction.

The center of the cup should be over the sagittal suture and about 3 cm (1.2 in) in front of the posterior fontanelle.

The cup is generally placed as far posteriorly as possible.

Technique

Vacuum Extraction

Scalp lacerations and bruising

Subgaleal hematoma

Cephalohematomas

Intracranial hemorrhage

Neonatal jaundice

Subconjunctival hemorrahge

Clavicular fracture

Shoulder dystocia

Injury of CNs VI, VII

Erb palsy

Retinal hemorrhage

Fetal death

Fetal Complications

Vacuum Extraction

Cesarean Delivery

Cesarean Delivery

Indications for Cesarean Delivery

1) Prior cesareans

2) Labor dystocia

3) Fetal distress

4) Breech presentations

Intraoperative complications

1. Uterine lacerations: Uterine lacerations, especially of the lower uterine segment, are more common with a transverse uterine incision.

These lacerations can extend laterally or inferiorly.

They are repaired easily.

Take care to identify the uterine vessels when repairing lateral extensions, and, when repairing inferior extensions, the surgeon needs to think about the ureters.

If the laceration extends into the broad ligament, strongly consider opening the broad ligament and identifying the course of the ureters.

Cesarean Delivery

Intraoperative complications

2. Bladder injury: This is an infrequent complication. It is more common with transverse abdominal incisions and in repeat cesarean deliveries.

The bladder most commonly is injured when entering the peritoneal cavity or when separating the bladder from the lower uterine segment.

Bladder injury has been reported to occur in more than 10% of uterine ruptures and in approximately 4% of cesarean hysterectomies.

If a possibility exists that a cesarean hysterectomy may be performed, mobilize the bladder inferiorly as well as possible when dissecting it free of the lower uterine segment.

If the dome of the bladder is lacerated, it can be repaired simply with a 2-layer closure of 2-0 or 3-0 chromic sutures, with the Foley catheter left in place for a few extra days.

If the bladder is injured in the region of the trigone, consider ureteral catheterization with possible assistance from a urologist.

Cesarean Delivery

Intraoperative complications

3. Ureteral injury: Injury to the ureter occurs in up to 0.1% of all cesarean deliveries and up to 0.5% of cesarean hysterectomies.

It is most likely to occur when repairing extensive lacerations of the uterus.

Ureteral injury, most commonly occlusion or transection, usually is not recognized during the time of the operation.

Cesarean Delivery

Intraoperative complications

4. Bowel injury: Bowel injuries occur in less than 0.1% of all cesarean deliveries.

The most common risk factor for bowel injury at the time of cesarean delivery is adhesions from prior cesarean deliveries or prior bowel surgery.

If the bowel is adherent to the lower portion of the uterus, dissect it sharply.

Injuries to the serosa can be repaired with interrupted silk sutures.

If the injury is into the lumen, perform a 2-layer closure.

The mucosa can be closed with interrupted 3-0 absorbable sutures placed in a transverse fashion for a longitudinal injury.

For multiple injuries and injury to the large intestine, consider intraoperative consultation with a general surgeon or gynecologic oncologist.

Cesarean Delivery

Intraoperative complications

5. Uterine atony: Another intraoperative complication that can be encountered in a patient with a multiple gestation, polyhydramnios, or a failed attempt at a vaginal delivery in which the patient was on Pitocin augmentation for a prolonged period is uterine atony.

When the uterus is closed, attention must be paid to its overall tone.

Cesarean Delivery

Postpartum endomyometritis

Wound infection

Fascial dehiscence

Urinary tract infections

Bowel function

Thromboembolic complications

Pelvic thrombophlebitis

Postoperative complications

Wound dehiscence

Cesarean Delivery

Postpartum Hysterectomy