7. PRELIMINARIES: 1. Anesthesia 2. Lithotomy Position 3. Full
surgical asepsis 4. Empty the bladder 5. Vaginal examination
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
9. PRELIMINARIES: 1. Anesthesia 2. Lithotomy Position 3. Full
surgical asepsis 4. Empty the bladder 5. Vaginal examination
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
13. DILATATION of the cervix
14. EVACUATION of the product of conception FROM THE
UTERUS
15. TYPES ONE STAGE OPERATION TWO STAGE OPERATION Dilatation of
cervix & evacuation of uterus done in the same sitting rapid
dilatation of cervix & 2nd phase: evacuation slow dilatation
1st phase: of cervix
16. 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
20. Preliminaries Steps: Sims 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
21. TYPES TWO STAGE OPERATION rapid dilatation of cervix &
2nd phase: evacuation slow dilatation 1st phase: of cervix
22. 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)
23. 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
Sims 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
24. 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
25. 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 Sims
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)
27. Depends on the location, size & nature of the
instrument causing perforation Procedure is stopped
28. 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
29. 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
31. 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
32. PROCEDURES Steps: Sims 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
33. PROCEDURES Steps: Injection Methergin 0.2mg IV Appropriate
suction cannula is fitted to the suction apparatus
34. 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
35. 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
36. 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
37. PROCEDURES Steps: After uterus is firmed & bleeding is
minimal, a sterile vulval pad is placed Patient is brought down
from the table
38. 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
39. Syn: induction, aspiration
40. Aspiration of the endometrial cavity within 14 days of
missed period in a woman with previous normal cycle
41. 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 (Karmans) & attached to 50mL
syringe Cannula is rotated, pushed in & out with gentle
strokes
42. 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 (Karmans) & attached to 50mL
syringe Cannula is rotated, pushed in & out with gentle
strokes
43. 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 (Karmans) & attached to 50mL
syringe Cannula is rotated, pushed in & out with gentle
strokes
44. 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 (Karmans) & attached to 50mL
syringe Cannula is rotated, pushed in & out with gentle
strokes
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 (Karmans) & attached to 50mL
syringe Cannula is rotated, pushed in & out with gentle
strokes
46. 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
47. 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
48. A hand operated double valve plastic syringe (60mL) is
attached to Karmans 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
49. Clear?
50. Clear?
51. Clear?
52. 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.
53. Operative procedure of extracting the product of conception
out of the womb before 28th week by cutting through the anterior
wall of the uterus
54. 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,
55. indications
56. 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)
57. PERINIOT OMY
58. A surgically planned incision on the perineum &
posterior vaginal wall during the 2nd stage of labor
59. 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
60. Recommended in selective cases than in routine A constant
care during the 2nd stage reduces the incidence of episiotomy &
perineal trauma
61. 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
62. 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)
63. 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
64. 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 batholins 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 oclock position to
avoid anal sphincter Apposition is not perfect & the repaired
wound tends to be puckered
65. mediolateral J shaped median lateral
66. 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
67. 1)Preliminaries 2)Incision 3)Repair
68. 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
69. 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
70. 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 patients prolonged apprehension of
stitches
71. 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
72. 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
73. 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)
74. 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
75. 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
76. 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
77. 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
78. immediate Extension of the incision Vulval hematoma Wound
dehiscence Incontinence remote Dyspareunia Chance of perineal
lacerations Scar endometriosis (rare)
79. Conclusion
80. 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