Operative Delivery Dr. Tamara M. Darwish - PowerPoint Presentation

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Operative Delivery

Dr. Tamara M. Darwish

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Cesarean Section

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Overview

A fetal delivery through an open abdominal incision (laparotomy) and an incision in the uterus (

hysterotomy

). 

The cesarean delivery rate rose from 5% in 1970 to 31.9% in 2016

Safe CS rate as defined by WHO is 15%

There has been an emphasis decreasing the number of first-time cesareans, as many women who have one cesarean delivery will ultimately have the remainder of their children via cesarean. 

Maternal mortality 4 times that of vaginal delivery

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Reason

Operative delivery has been abandoned in favor of CS due to medical litigation

Increased CS delivery due to breech presentation

Advanced maternal age

Increased repeated CS due to primary CS

Increased CS due to maternal request

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Indications

Maternal

Prior cesarean delivery

Maternal request

Pelvic deformity or

cephalopelvic

disproportion

Previous

perineal

trauma

Prior pelvic or anal/rectal reconstructive surgery

Herpes simplex or HIV infection

Cardiac or pulmonary disease

Cerebral aneurysm or

arteriovenous

malformation

Pathology requiring concurrent

intraabdominal

surgery

Perimortem

cesarean

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Uterine/Anatomic Indications

Abnormal placentation (such as placenta

previa

, placenta

accreta

)

Placental abruption

Prior classical

hysterotomy

Prior full-thickness myomectomy

History of uterine incision dehiscence

Invasive cervical cancer

Prior

trachelectomy

Genital tract obstructive mass

Permanent

cerclage

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Fetal

Nonreassuring

fetal status (such as abnormal umbilical cord Doppler study) or abnormal fetal heart tracing

Umbilical cord prolapse

Failed operative vaginal delivery

Malpresentation

Macrosomia

Congenital anomaly

Thrombocytopenia

Prior neonatal birth trauma

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Types

According to site:

Lower segment cesarean section:

Transverse incision over the lower segment of the uterus

2.Upper segment/Classical:

Vertical incision over the body or fundus of the uterus

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Indications for a classical CS:

1.Lower segment is abnormally vascular/ cannot be identified due to adhesions

2.Postmortum delivery

3.Hysterectomy is to follow the procedure

4.Rapid delivery is needed

5.Transverse fetal lie that cannot be corrected

6.Cervical cancer

7.Anterior placenta

previa

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According to timing:

Elective CS

Urgent CS

**Elective delivery should be conducted after 39+0 weeks of gestation.

**If elective CS is conducted before 39 weeks, dexamethasone for fetal lung maturity should be administered at least 24 hours ahead.

**All women undergoing urgent CS should receive

thromboprophylaxis

.

**Antibiotics should be administered before making the skin incision in women undergoing both types of CS.

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According to urgency:

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Complications

Intraoperative:

Anasthesia

complications

Hemorrhage

Bladder/bowel injury

Fetal injury

Fetal respiratory distress

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Postoperatively:

**Early:

VTE

Paralytic ileus

Wound infection/puerperal sepsis

Chest infection

**Late:

Hernia

Rupture of uterine scar

Abnormal Placentation

Infertility

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How to decrease the rate?

Educate women about Cesarean section

Encourage operative vaginal delivery

Encourage vaginal birth after CS (VBAC)

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VBAC

Candidate:

A singleton pregnancy

Cephalic presentation

Term baby: at 37+0 weeks or beyond

Have had a single previous lower segment caesarean delivery

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Contraindications:

Previous uterine rupture

Classical caesarean scar

Women who have other absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. major placenta

praevia

).

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Women should be informed that planned VBAC is associated with an approximately 1 in 200 (0.5%) risk of uterine rupture.

Women should be informed that the success rate of planned VBAC is 72–75%

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Signs of uterine dehiscence/Rupture

Nonreassuring

/pathological CTG (Most common/early)

Vaginal bleeding

Pain between contractions

Pain at the site of previous scar

Loss of station of the presenting part

Maternal collapse

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Factors that increase the likelihood of success

Women with one or more previous vaginal births

**Particularly previous VBAC, is the single best predictor of successful VBAC

**Associated with a planned VBAC success rate of 85–90%.

** Previous vaginal delivery is also independently associated with a reduced risk of uterine rupture.

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Instrumental delivery

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Overview

Operative vaginal delivery rates have remained stable at around 10%

Continuous support during can reduce the need for operative vaginal delivery.

Use of upright or lateral positions can reduce the need for operative vaginal delivery.

Delayed pushing in

primiparous

women with an epidural can reduce the need for operative vaginal delivery.

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Indications

Maternal:

Maternal fatigue/exhaustion

To shorten and reduce the effects of the second stage of labor on medical conditions :

A.Cardiac

disease Class III or IV

B.Hypertensive

crises

C.Myasthenia

gravis

D.Proliferative

retinopathy

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Fetal:

1.Presumed fetal compromise

2.Proven

fetal compromise

Inadequate progress:

Nulliparous women – lack of continuing progress for 3 hours (total of active and passive second-stage

labour

)with regional

anaesthesia

, or 2 hours without regional

anaesthesia

Multiparous women – lack of continuing progress for 2 hours with regional

anaesthesia

, or 1 hour without regional

anaesthesia

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Preparation of mother :

Clear explanation should be given.

Informed consent to be obtained.

Appropriate analgesia is in place for mid-cavity rotational deliveries.

Maternal bladder must been empty

In-dwelling catheter should be removed or balloon deflated

Aseptic technique

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Prerequisites

Full abdominal and vaginal exam:

Head is ≤1/5th palpable per abdomen

Vaginal examination Vertex presentation

Cervix is fully dilated

The membranes are ruptured

Exact position of the head can be determined so proper placement of the instrument can be achieved.

Pelvis is deemed adequate.

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Preparation of staff

Operator must have the knowledge, experience and skill necessary.

Adequate facilities are available (appropriate equipment, bed, lighting).

CS to be performed within 30 minutes in case of failure to deliver.

Personnel present that are trained in neonatal resuscitation

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High risk of failure

Maternal body mass index over 30

Estimated fetal weight over 4000 g or clinically big baby

Occipito

-posterior position

Mid-cavity delivery or when 1/5th of the head palpable per abdomen.

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Vacuum

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Technique

Determine the position of the head

Insert the cup into the vagina

Ensure that no maternal tissues are trapped by the cup

Apply the cup to the flexion point 3 cm in front of the posterior fontanel, centering the sagittal suture

Pull during a contraction with a steady motion, keeping the device at right angles to the plane of the cup

.

Remove the cup when the fetal jaw is reachable

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Complications

Scalp lacerations

Cephalohematoma

: limited to suture line



Subgleal

hematoma: crosses suture line



Intracranial/retinal hemorrhage

Hyperbilirubinemia

/jaundice

Higher incidence of

cephalohematoma

/retinal hemorrhage/jaundice compared to forceps

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Failure

Head does not descend with each pull

Head is not delivered after 3 pulls

Head is not delivered after 20 minutes

The cup slips off the head with maximum pressure

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Forceps

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Classification

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Technique

Identify & apply blades

1.Place instrument in front of pelvis with tip pointing up & pelvic curve forward

2.Apply left blade, guided by right hand, then right blade with left hand

Lock blades

Should articulate with ease

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Check for correct application

1.Sagittal suture in midline of shanks

2.Cannot place more than one fingertip between blade and fetal head

Apply traction

1.Steady and intermittent

2.Downward and then upward

3.Remove blades as fetus crowns

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Complications

1. Maternal Risks

Perineal Injury (extension of episiotomy)

Vaginal and Cervical lacerations

Postpartum hemorrhage

2. Fetal Risks

Intracranial hemorrhage

Cephalic hematoma

Facial / Brachial palsy

Injury to the soft tissues of face & forehead

Skull fracture

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Failure

When a deliberate attempt in vaginal delivery has failed to expedite delivery

Fetal head does not advance with each pull

Fetus is not delivered after 3 pulls

Fetus is not delivered after 30 minutes

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Sequential use

Highest risk for injury is for combined forceps/vacuum extraction or cesarean delivery after failed operative delivery

The weight of available evidence is against multiple efforts with different instruments