1. 1. NUR HANISAH BINTI ZAINOREN
2. 2. Dilatation and evacuation Sucktion evacuation Menstral regulation Vacuum aspiration Hysterotomy Episiotomy Operative vaginal delivery Forceps Ventouse Version Destructive operations Cesarean section
3. 3. Dilatation and evacuation Sucktion evacuation Menstral regulation Vacuum aspiration Hysterotomy Episiotomy Operative vaginal delivery Forceps Ventouse Version Destructive operations Cesarean section
4. 4. Dilatation and evacuation Sucktion evacuation Menstral regulation Vacuum aspiration Hysterotomy Episiotomy Operative vaginal delivery Forceps Ventouse Version Destructive operations Cesarean section
5. 5. Dilatation and evacuation Sucktion evacuation Menstral regulation Vacuum aspiration Hysterotomy Episiotomy Operative vaginal delivery Forceps Ventouse Version Destructive operations Cesarean section
6. 6. Dilatation and evacuation Sucktion evacuation Menstral regulation Vacuum aspiration Hysterotomy Episiotomy Operative vaginal delivery Forceps Ventouse Version Destructive operations Cesarean section
7. 7. PRELIMINARIES: 1. Anesthesia 2. Lithotomy Position 3. Full surgical asepsis 4. Empty the bladder 5. Vaginal examination
8. 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. 9. PRELIMINARIES: 1. Anesthesia 2. Lithotomy Position 3. Full surgical asepsis 4. Empty the bladder 5. Vaginal examination
10. 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. 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. 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. 13. DILATATION of the cervix
14. 14. EVACUATION of the product of conception FROM THE UTERUS
15. 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. 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
17. 17. Hawkin Ambler dilator Sims speculum Allis forceps CuretteOvum forceps
18. 18. TYPES ONE STAGE OPERATION Dilatation of cervix & evacuation of uterus done in the same sitting
19. 19. Sims posterior vaginal speculum Allis forceps Curette
20. 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. 21. TYPES TWO STAGE OPERATION rapid dilatation of cervix & 2nd phase: evacuation slow dilatation 1st phase: of cervix
22. 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. 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. 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. 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)
26. 26. Immediate 1. Excessive hemorrhage 2. Injury 3. Shock 4. Perforation 5. Sepsis 6. Hematometra 7. Increased morbidity 8. Cont. of pregnancy (1%) Late Pelvic inflammation Infertility Cervical incompetence Uterine synechiae
27. 27. Depends on the location, size & nature of the instrument causing perforation Procedure is stopped
28. 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. 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
30. 30. MTP during 1st trimester * Inevitable abortion Recent incomplete abortion Hydatidiform mole
31. 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. 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. 33. PROCEDURES Steps: Injection Methergin 0.2mg IV Appropriate suction cannula is fitted to the suction apparatus
34. 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. 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. 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. 37. PROCEDURES Steps: After uterus is firmed & bleeding is minimal, a sterile vulval pad is placed Patient is brought down from the table
38. 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. 39. Syn: induction, aspiration
40. 40. Aspiration of the endometrial cavity within 14 days of missed period in a woman with previous normal cycle
41. 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. 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. 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. 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. 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. 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. 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. 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. 49. Clear?
50. 50. Clear?
51. 51. Clear?
52. 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. 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. 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. 55. indications
56. 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. 57. PERINIOT OMY
58. 58. A surgically planned incision on the perineum & posterior vaginal wall during the 2nd stage of labor
59. 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. 60. Recommended in selective cases than in routine A constant care during the 2nd stage reduces the incidence of episiotomy & perineal trauma
61. 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. 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. 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. 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. 65. mediolateral J shaped median lateral
66. 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. 67. 1)Preliminaries 2)Incision 3)Repair
68. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 78. immediate Extension of the incision Vulval hematoma Wound dehiscence Incontinence remote Dyspareunia Chance of perineal lacerations Scar endometriosis (rare)
79. 79. Conclusion
80. 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
81. 81. Thank You