Porodnické operace

Obrázky a doplňky

http://www.med.muni.cz/~mpesl/trafficjam/

17.5.2006

OPERATIVE OBSTETRICS

Forceps delivery

● Vacuum extraction (ventouse)

● Caesarean section

● Version

● Episiotomy

● Symphysiotomy

● Destructive operations

Forceps Delivery

Obstetric forceps is a double-bladed metal instrument used for extraction of the foetal head.

Lžíce/žebra + okénko/ Zámek Traktor držadlo

Forceps: Indikace

(I) Prolonged 2nd stage:It is prolongation for ,more than 1 hour in primigravidae or 30 minutes in multiparae.

1- Inertia and poor voluntary bearing down. 2- Large foetus. 3- Rigid perineum. 4- Malpositions: persistent occipito-posterior and deep transverse arrest. 5- Malpresentations: Face and brow presentations.

(II) Maternal indications: (1)Maternal distress: -Exhaustion-Pulse >100/min-Temperature >38oC-Signs of dehydration. (2) Maternal diseases as:-Heart disease. -Pulmonary T.B. -Pre-eclampsia and eclampsia.

(III) Foetal indications: 1- Foetal distress. 2- Prolapsed pulsating cord. 3- Preterm delivery. 4- After-coming head in breech delivery

(IV) During caesarean section: One (used as a lever ) or the two blades may be used to extract the head through the uterine incision

Forceps: Typy užití forcepsu

1. Traction : is the main action

2. Rotation: in deep transverse

arrest, persistent occipito- posterior and mento- posterior.

Forceps: Types of Forceps Application

1. Cephalic application: the forceps is applied on the sides of the foetal head in the mento-vertical diameter so injury of the foetal face, eyes and facial nerve is avoided .

2. Pelvic application: The forceps is applied along the maternal pelvic wall irrespective to the position of the head. It is easier for application but carries a great risk of foetal injuries.

3. Cephalo-pelvic application : It is the ideal application and possible when the occiput is directly anterior or posterior or in direct mento-anterior position.

Forceps: Trakce by měla být:

gentle by the force of the arm only,-intermittent with uterine contractions

only,-in correct direction i.e. downwards and

backwards till the occiput appears at the vulva, thendownwards and forwards.

-The 2 blades are unlocked between contractions to minimise the period of head compression

Forceps: Komplikace

(A) Maternal complications 1- Complications of anaesthesia.2- Lacerations: 3- Bone injuries:4-Pelvic nerve injuries.5-Postpartum haemorrhage:6-Puerperal infections.7-Remote effects: genital prolapse, stress incontinence, cervical incompetence and genito-urinary fistulas.

(B) Foetal complications:1- Fracture of the skull. 2- Cephalohaematoma. 3- Intracranial haemorrhage.4- Facial nerve palsy. 5- Trauma to the face, eyes or scalp.6- Asphyxia due to : intracranial haemorrhage or, cord compression between the head and the forceps

Extension of the episiotomy. Perineal tear. Vaginal tears.Cervical lacerations. Bladder injury. Ureteric injury Rupture uterus.3-

Vobrázky Forceps

Vacuum Extraction (Ventouse) V:

1.cup with a diameter of 3,4,5 or 6 cm. 2. A rubber tube attaching the cup to a

glass bottle with a screw in between to release the negative pressure.

3. Trakční systémy 4. Vývěva / Pumpa: negative pressure

that should not exceed - 0.8 kgm per cm2.

Ventouse: Typy Vakuumextraktorů

Mälmstrom cup:A metal cup to its centre attached a metal chain passed through the rubber tube. The other end of the chain is attached to a handle for traction. (II) Bird’s cup:The suction rubber tube is attached to the periphery of the cup while the handle of traction is attached by a separate short metal chain to the centre of the cup. (III) Soft cup:Advantage: It produces symmetric, less cosmetically alarming caput succadaneum and less scalp abrasions

Ventouse: Indikace a Kontra…

I 1. The same as forceps: but it is not recommended in preterm babies and not used for the after-coming head in breech delivery. vyčerpání, febrilie, ↓ námahy…2. During the 1st stage: The small cup 3 or 4 cm may be used in a soft, stretchable cervix of not less than 7 cm dilatation. 3. During caesarean section: It may be used to extract the foetal head through the uterine incision

KI1. Moderate or severe cephalopelvic disproportion.2. Other presentations than vertex. 3. Premature infants. 4. Intact membranes.

Ventouse: +/-

Výhody 1. Anaesthesia is not required so it is preferred in cardiac and pulmonary patient.

2. The ventouse is not occupying a space beside the head as forceps. 3. Less compression force (0.77 kg/cm2) compared to forceps (1.3 kg/cm2) so injuries to the head is less common. Less genital tract lacerations.4. Can be applied before full cervical dilatation. 5. It can be applied on non-engaged head.

Komplikace

Foetal : 1- Cephalohaematoma.

2- Scalp lacerations. 3- Rarely, intracranial haemorrhage.

(II) Maternal: 1. Vaginal and cervical lacerations. 2. Annular detachment of the cervix, cervical incompetence and may be future

prolapse if used with incompletely dilated cervix.

Caesarean Section (C.S.:)

There are several elements which contribute to a linguistic explanation of the word caesarean.

The term may be simply derived from the Latin verb caedere (supine stem caesum), 'to cut'. The term caesarean section then would be a tautology.

The caesarean is possibly named after the Roman dictator Julius Caesar who allegedly was so delivered. Historically, this is impossible as his mother was alive after he reached adulthood, but the legend is at least as old as the 2nd century AD.

Roman law prescribed that the procedure was to be performed at

the end of a pregnancy on a dying woman in order to save the life of the baby. This was called the lex caesarea. Thus the Roman law may be the origin of the term.

C.S.:) Indikace mateřské

Indications: (A) Maternal indications: 1. Contracted pelvis and cephalopelvic disproportion (see before). 2. Pelvic tumours especially if impacted in the pelvis or cancer cervix. 3. Antepartum haemorrhage (see before). 4. Hypertensive disorders with pregnancy ( see before). 5. Abnormal uterine action (see before). 6. Previous uterine scar as hysterotomy or metroplasty. 7. Previous successful repair of vesico-vaginal fistula. 8. Previous caesarean section if,

i- the cause of the previous section is permanent e.g.contracted pelvis.ii- previous section was upper segment.iii- suspected weak scar as evidenced by:

-History of puerperal infection after the previoussection. -Hysterosalpingography or hysteroscopy doneafter the previous

section reveals a defect in the scar. -Vaginal bleeding during current labour.-Marked tenderness over the scar during currentlabour.

iv- Associated conditions as antepartum haemorrhage or malpresentations

C.S.:) Indikace fetální

Foetal indications: 1. Malpresentations and malposition ( see before). 2. Prolapsed pulsating cord or foetal distress before full

cervical dilatation. 3. Diabetes mellitus (see before). 4. Bad obstetric history as recurrent intrauterine foetal death

in last weeks of pregnancy or repeated intranatal foetal death. 5. Post-mortem C.S. done within 10-20 minutes of maternal

death to save a living baby.

1- Dead foetus: except in; -Extreme degree of pelvic contraction. -Neglected shoulder. -Severe accidental haemorrhage.2- Disseminated intravascular coagulation: to

minimise blood loss. 3- Extensive scar or pyogenic infection in the abdominal wall e.g. in

burns.

C.S.:) Druhy sekce

Types of Caesarean Section:

(A) According to timing:Elective CS: completed 39 weeks. Selective CS:done after onset of labour.

(B) According to the site of uterine incision:Upper segment CS classical vertical Lower segment CS (LSCS) : trans/vert

(C) According to number of the operation:Primary cs: for the first time. Secondary: Repeated cs

D) According to opening the peritoneal cavity:Transperitoneal / Extraperitoneal:

C.S.:) Průběh CS

C.S.:) Komplikace

Complications of Caesarean Section: (I) Operative: 1- Primary maternal mortality is 4 times that of vaginal delivery which may be due to:

i- shock . ii- Anaesthetic complications particularly Mendelson’s syndrome iii- Haemorrhage usually due to extension of the uterine incision to the uterine vessels, atony of the

uterus or DIC. 2- Injuries to the bladder or ureter. 3- Foetal injuries.

(II) Post-operative:

(A) Early: 1. Thrombosis and pulmonary embolism. 2. Acute dilatation of the stomach and paralytic ileus. 3. Wound infection, puerperal sepsis and burst abdomen. 4. Chest infection. (B) Late : 1. Rupture of the uterine scar. 2. Incisional hernia.

Version – obraty plodu O:

It is changing the transverse lie to a longitudinal one or replacement the presenting pole by the other. If the aim is to make the head the presenting part it is called cephalic version and if the breech will be the presenting part it is podalic version

Types: 1. External version, usually cephalic.

2. Internal podalic version. 3. Bipolar podalic version. Obsolentní??

Obrat zevními hmaty

Indications: 1-Breech presentation.2- Transverse or oblique lie.

Procedure:

● No anaesthesia as the pain is a safe guard against rough manipulations. ● The patient evacuates her bladder. ● She lies in a trendelenburg position with exposed vulva to detect any vaginal

bleeding. ● The foetal position is determined and FHS is auscultated. ● One hand is applied externally to the foetal head and the other on its buttock,

the two poles are approximated to flex the foetus and rotation is done by the two hands simultaneously to bring the head lower down.

● The FHS is auscultated again, if there is foetal distress lasting for more than 5 minutes, the foetus is returned back to its previous position as the cord might be coiled or entangled around the neck.

● If neither vaginal bleeding nor foetal distress results, an abdominal binder is applied to fix the new position and re-examined twice weekly. If the original presentation returned again, the procedure of version can be repeated.

Obrat vnitřní hmaty

Indications: 1.Retained second twin in a transverse lie.2. Some cases of shoulder presentation.

Prerequisites: 1. General anaesthesia to guard against pain and give uterine and pelvic relaxation. 2. Evacuation of the bladder. 3. Complete aseptic conditions. 4. Cervix is fully dilated. 5. Uterus is not tonically contracted. 6. No previous uterine scar. 7. Adequate liquor amnii ( intact or recently ruptured membranes). 8. No obstruction to vaginal delivery whether maternal as contracted pelvis or foetal as hydrocephalus

Procedure: ● Lithotomy position. ● Episiotomy in primigravida. ● The hand is introduced through the cervix into the uterus and grasp the lower foot if the

back is anterior and the upper foot if the back is posterior ,so that the back is kept anterior during delivery.

● The other hand is pushing the head upwards while the foot is brought downwards. ● The other foot is brought down and breech extraction is done. ● The birth canal is explored after delivery for possible injuries.

Obraty: Komplikace

(A) Maternal :1- Shock ( in light anaesthesia) .2- Premature separation of the placenta.3- Rupture uterus. 4- Cervical lacerations.5- Postpartum haemorrhage. 6- Puerperal sepsis.

(B) Foetal:

1. Asphyxia due to premature separation of the placenta or entangling of the cord. 2. Complications of breech delivery.

Episiotomy – nástřihy E:

It is an intrapartum incision of the perineum to widen the introitus

Benefits: 1. Prevention of perineal lacerations by anatomical

incision and repair of the episiotomy. 2. Prevention of prolonged and overstretch of the

perineum which predisposes to prolapse and stress incontinence.

3. Minimising compression and decompression of the head which causes intracranial haemorrhage.

Episiotomy: Indikace

(A) Maternal: 1. Nearly in all primiparas. 2. Old perineal scar about to rupture. 3. Prolonged second stage due to rigid perineum. 4. Prior to most instrumental vaginal delivery as forceps and

vacuum. 5. Vulval oedema.

(B) Foetal 1- Large sized baby. 2- Preterm baby. 3- Direct occipito-posterior. 4- Breech delivery.

Episiotomy: Druhy a postup

(1) Median episiotomy: A midline incision down to, but not, including the external anal sphincter. Advantages: 1. It is the easiest to perform and to repair. 2. Associated with less blood loss. 3. Less pain and

discomfort in the puerperium. 4. Less dyspareunia later on. 5. Better end-result cosmetic appearance.

(2) Mediolateral episiotomy: The incision extends from the midline of the forchette mediolaterally at 5 or 7 o’clock towards the

direction of the ischial tuberosity. Advantages: Extension to the anal sphincter is less common so it is more suitable for

instrumental delivery and in short perineum.

Procedure: ● Anaesthesia: Local infiltration, pudendal nerve block, epidural, spinal or general ● Timing: when the introitus is distended by the presenting part or the cup of the

ventouse with a visible diameter not less t han 3-4 cm, and done at the maximum of a uterine contraction. If forceps will be used episiotomy is done just before its application.

● Incision: The index and middle fingers of one hand is introduced between the presenting part and the proposed site of perineal incision to protect the presenting part and support the tissues that will be incised. The incision is usually 3-5 cm length. including the posterior vaginal wall, forchette, perineal muscles and perineal skin.

● Repair: Cut gut O, Dexon or vicryl 2/0 may be used to close the posterior vaginal wall by continuous sutures where the first stitch should be above the apex of the vaginal incision, then the muscles with interrupted sutures and lastly the skin with interrupted or subcuticular sutures.

Destructive Operations(Embryotomy)

Zmenšovací operace-mrtvý,VVV=překážka hydrocefal reducing the size of the head , shoulder girdle or trunk

of the dead foetus to allow its vaginal delivery. It has been abandoned from the modern obstetrics in favour of caesarean section which is safer to the mother.

Procedures: 1- Craniotomy. 2- Decapitation. 3- Cleidotomy. 4- Evisceration 5- Spondylotomy