Operative Delivery Rahaf - PowerPoint Presentation

Slide1

Operative Delivery

Rahaf

Jereisat

Slide2

The most common form of operative intervention is suturing

of a

perineal

tear or episiotomy

.

operative intervention should only be performed when the benefits outweigh the potential risks and by clinicians who have competency in the procedure or under direct supervision of an experienced trainer.

Slide3

Perineal repair

Perineal

trauma involves any type of damage to the female genitalia during

labour

, which can occur spontaneously or

iatrogenically

(via episiotomy or instrumental delivery). 

Anterior

perineal

trauma can affect the anterior vaginal wall, urethra, clitoris and labia.

Posterior

perineal

trauma can affect the posterior vaginal wall,

perineal

muscle,

perineal

body,

Slide4

Of women who have a vaginal delivery, 85% will have some degree of

perineal

trauma and 60–70% will require suturing

Third-degree tears are reported more in

primigravidae

than

multiparae

.

In general terms, external anal sphincter incompetence causes faecal urgency, whereas internal anal sphincter incompetence causes faecal incontinence.

Slide5

Classification

Third- and fourth-degree tears are grouped together and termed obstetric anal sphincter injuries (OASI).

Most common type is first degree:

periurethral

tear

Buttonhole

tear:

 

a

type of

perineal

injury

which

involves the rectal mucosa and an intact anal sphincter.

This

is considered to be a

rare

type of injury not classified in the standard

perineal

 tear classification system.

Slide6

Surgical technique

First-degree tears or minor lacerations with minimal or no bleeding may not require surgical repair.

A systematic approach should be followed for second degree

perineal

repair

Slide7

2nd

degree repair

A gentle vaginal examination should be performed to check for any missed tears and to ensure that good apposition has been achieved.

A rectal examination should be performed to confirm that the sphincter feels intact and to ensure that no sutures have been inadvertently placed through the rectal mucosa. If sutures are felt in the rectum they must be removed and replaced.

The pad or tampon should be removed and a careful count of swabs, instruments and needles should be completed and documented in the records, alongside the operation note and postoperative instructions.

Analgesia should be prescribed.

Slide8

2nd

degree

perineal

repair

Slide9

OASI repair

3

rd

/4

th

degree

Repair of the rectal mucosa should be performed first. The torn external sphincter is then repaired. It is important to ensure that the muscle is correctly approximated with long-acting sutures so that the muscle is given adequate time to heal

Slide10

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OASI repair aftercare

Antibiotics: oral broad-spectrum antibiotic for 5–7 days.

Analgaesia

Laxatives or stool softeners

Positioning and movement

Pelvic floor exercises

Wound care

Follow up

by the obstetrician six to 12 weeks postpartum

Slide12

physiotherapy should include augmented biofeedback as this has been shown to improve continence

At 6–12 weeks, a full evaluation of the degree of symptoms should take place

Asymptomatic women should be advised that the risk of recurrence in a future pregnancy is 6–8% and that vaginal delivery is safely achievable.

Slide13

Episiotomy

An episiotomy is a surgical incision of the perineum performed during the second stage of

labour

to enlarge the

vulval

outlet and assist vaginal birth.

Slide14

Indications

Instrumental delivery

Fetal distress

History or risk for OASI

Big baby

Breech

Prolonged second stage

Slide15

Surgical technique

The question of informed consent needs to be addressed as part of antenatal care; when the fetal head is crowning, it is not possible to obtain true informed consent.

If there is not a good epidural, the perineum should be infiltrated with local

anaesthetic

.

Slide16

A

mediolateral

episiotomy at a 60° angle to the midline is usually recommended

Slide17

A

mediolateral

episiotomy at a 60° angle to the midline is usually recommended

A midline episiotomy is an incision in a comparatively

avascular

area and results in less bleeding, quicker healing and less pain; however, there is an increased risk of extension to involve the anal sphincter (OASI).

A

mediolateral episiotomy should start at the posterior part of the

fourchette

, move backwards and then turn medially well before the border of the anal sphincter, so that any extension will avoid the sphincter

The episiotomy should be repaired in the same way as a

second-degree tear unless there has been involvement of the anal sphincter complex requiring an OASI repair.

Slide18

Complications

Short-term complications of

perineal

trauma or episiotomy include pain, infection and

haemorrhage

.

Long-term effects include

dyspareunia, urinary/ fecal/ flatus incontinence.

Slide19

Operative vaginal delivery

Operative vaginal delivery (OVD) refers to a vaginal birth with the use of any type of forceps or vacuum extractor (

ventouse

).

The terms instrumental delivery, assisted vaginal delivery and OVD are used interchangeable

Slide20

most common fetal factor is suspected fetal

compromise

most

common maternal factor is a prolonged active second stage of

labour

.

Slide21

Slide22

Contraindications

When the safety criteria are not met, OVD is

contraindicated.

The

ventouse

should not be used in

gestations of less than 34 completed weeks because of the risk of

cephalhaematoma

and intracranial

haemorrhage

. It is relatively contraindicated at gestational ages 35–36 weeks.

Slide23

Slide24

Choice of instrument

The

ventouse

compared to forceps is significantly

more likely to be associated

with:

Failure to achieve a vaginal delivery.

Cephalohaematoma

(

subperiosteal

bleed).

Retinal

haemorrhage

.

Maternal worries about the baby.

The

ventouse

compared to forceps is significantly

less likely to be associated

with:

Use of maternal regional/general

anaesthesia

.

Significant maternal

perineal

and vaginal trauma.

Severe

perineal

pain at 24 hours.

The

ventouse

compared to forceps is

similar in terms of:

Delivery by caesarean section (where failed vacuum is completed by forceps).

Low 5 minute

Apgar

scores.

Slide25

Procedure

Evaluation

Analgesia

Positioning

Contingency planning

Instrument type

Technique

Slide26

Evaluation

A thorough abdominal and vaginal examination should take place to confirm the

fetal lie, presentation, engagement, station, position, attitude and degree of caput

or

moulding

. This will confirm whether or not the basic safety criteria for OVD

have been met.

A careful pelvic examination is essential to determine whether

there are any ‘mechanical’ contraindications to performing an OVD. Anthropoid (narrow), android (male/funnel-shaped) or platypelloid (elliptical) pelvises all make instrumental deliveries more difficult and may preclude the use of rotational forceps.

Slide27

Analgesia

Analgesic requirements are greater for forceps than for

ventouse

delivery.

Where

rotational forceps or

midpelvic direct traction forceps are needed, regional

analgesia is preferred.

For a rigid cup

ventouse

delivery, a pudendal block with perineal infiltration may be all that is needed and if a soft cup is used, analgesic requirements may be limited to perineal infiltration with local

anaesthetic

.

Slide28

Positioning

OVDs are traditionally performed with the patient in the

lithotomy

position. The

angle of traction needed requires that the bottom part of the bed be removed.

Slide29

Contingency planning

With any OVD there is the potential for failure with the chosen instrument and the

operator must have a back-up plan for such an event.

Slide30

Instrument types

Ventouse

/vacuum extractors

The basic premise of vacuum extraction is that a suction cup, of a

silastic

or rigid

construction, is connected, via tubing, to a vacuum

source.

Recent developments have removed the need for external

suction generators and have incorporated the vacuum mechanism into ‘hand-held’

pumps (e.g. OmniCup™).

Slide31

https://www.youtube.com/watch?v=AShsPCHs7og

Slide32

Technique

Soft vacuum cups are significantly more likely to fail to achieve vaginal delivery

than rigid cups; however, they are associated with less scalp injury.

The soft cups are appropriate for

uncomplicated deliveries with an

occipito

-anterior position (OA); metal cups

appear to be more suitable for

occipito

-posterior (OP), transverse and potentially difficult OA position deliveries where the infant is larger or there is marked caput.

Slide33

It is not acceptable to use a

ventouse

when:

The position of the fetal head is unknown.

There is a significant degree of caput that may either preclude correct placement of the cup or, more sinisterly, indicate a substantial degree of CPD.

The operator is inexperienced in the use of the instrument.

Slide34

Forceps

Non-rotational forceps are used when the head is OA with no more than 45º

deviation to the left or right (LOA, ROA).

If the head is positioned more than 45º from the vertical, rotation must be

accomplished before traction. Forceps designed for rotation, such as

Kielland

forceps, have minimal pelvic curve to allow rotation around a fixed axis.

Slide35

https://www.youtube.com/watch?v=zgTLzpUTwck

https://www.youtube.com/watch?v=_InLgIcaNcA

Slide36

The role of episiotomy at vacuum and forceps delivery is controversial with

conflicting studies reported. In practice, most obstetricians cut an episiotomy routinely for

forceps delivery, especially in

nulliparous

deliveries where anal sphincter

damage is more likely.

Slide37

Special considerations

Failure to complete delivery vaginally can occur when the choice of instrument is

wrong, when the application

of the instrument is wrong or when the position has been wrongly defined (most commonly OP–OA errors),

leading to inappropriately large diameters presenting to the pelvis. Failure is also

more common if the fetus is large or maternal effort is poor.

Slide38

If the reason

for failure was cup detachment of a vacuum and the fetal head is OA and on the

perineum, a low-pelvic or lift out forceps to complete delivery is

acceptable.

If the instrument

failed because the position was incorrectly defined, then the next option will

either be a rotational instrumental delivery or a caesarean section.

Failure because there was little or no descent with the first pull of a correctly

applied instrument, then delivery must be by caesarean section as the likely diagnosis is CPD. If there is any uncertainty, senior help should be sought immediately and a full re-evaluation

should take place, ideally in an operating theatre.

In

many cases, delivery by

caesarean section will be the safer option for the fetus.

Slide39

Slide40

Caesarean section

A caesarean section is a surgical procedure in which incisions are made through a

woman’s abdomen (

laparotomy

) and uterus (

hysterotomy

) to deliver one or more

babies.

Slide41

Incidence

The overall rate of CS was 29.1% (13.2% as emergency CS and 15.9% as planned CS). (2017 Jordan)

WHO) that the rate of cesarean section (CS) should not exceed 10% to 15% in any country.

In recent years, the rate of caesarean deliveries increased dramatically worldwide and many countries had exceeded the WHO recommended rate 

Slide42

Slide43

History

There are three theories about it :

It is said to

derive from a Roman legal code called

Lex

Caesarea, which contained

a law prescribing that the baby be cut out of its mother’s womb in case she

dies before giving birth.

The derivation of the name is also attributed to an ancient

story, told in the 1st century AD by Pliny the Elder, who claimed that an ancestor of Caesar was delivered in this way. An alternative etymology suggests that the procedure’s name derives from the Latin verb caedere

, to cut.

Slide44

Slide45

Slide46

Classification

Traditionally, caesarean sections have been classified as elective or emergency.

e.g. uterine rupture, <30mins

e.g. cord

prolapse

, in 70mins

e.g. twins

e.g.

malpresentation

Slide47

Slide48

CESAREAN DELIVERY ON MATERNAL REQUEST (CDMR):

an elective cesarean in the absence of any medical or obstetric contraindication for attempting vaginal delivery.

There is also increasing recognition of a condition termed ‘

tocophobia

’, which describes an irrational fear of childbirth that can be very incapacitating for the woman.

Slide49

Procedure

Consent

Preperation

Abdominal incision

Uterine incision

Closure

Complications

Post-op care

Slide50

Informed consent

Informed consent must always be obtained prior to surgery and ideally the

possibility of caesarean section and the potential indications will have been

discussed in the antenatal period.

Where there is incapacity to consent (as may

occur with conditions such as

eclampsia

), the doctor is expected to act in the

woman’s best interests.

Slide51

Preparation

Most scheduled caesarean sections are performed under spinal

anaesthesia

with

the mother awake and the partner present.

If an epidural has been sited during

labour

, there is usually sufficient time to top-up the

anaesthesia

in preparation for

emergency caesarean section. The bladder should be emptied before the procedure commences and a urinary catheter is usually left in situ.

A left lateral tilt minimizes

aorto-caval

compression and reduces the

incidence of hypotension.

Prophylactic antibiotics should be administered intravenously prior to the

surgical incision.

Slide52

Abdominal and Uterine incisions

https://www.youtube.com/watch?v=VkxwN8xQz80

Slide53

Closure

Closure of the uterus should be performed in either single or double layers with

continuous or interrupted sutures.

A second layer is commonly used as a means to improve

haemostasis

and with the aim to improve the integrity of the scar.

Abdominal closure is performed in the

anatomical planes with high strength, low reactivity materials, such as

polyglycolic acid or polyglactin. The skin can be closed with either absorbable or non-absorbable suture material or with clips, again depending on operator

preference.

Slide54

Post-op care

Slide55

Complications

Intraoperative

complications

Haemorrhage

Caesarean hysterectomy

Placenta

praevia

Organ damage (bowel/bladder)

Postoperative complications

Infection

Venous

thromboembolism

Psychological

Fetal Complications:

TTN/respiratory distress syndrome

Slide56

Caesarean hysterectomy

The most common indication for caesarean hysterectomy is uncontrollable

maternal

haemorrhage

; life-threatening

haemorrhage

requiring immediate

treatment occurs in approximately 1 in 1,000 deliveries.

The most important risk

factor for emergency postpartum hysterectomy is a previous caesarean section – especially when the placenta overlies the old scar, increasing the risks of placenta accreta

Slide57

Subsequent birth following caesarean section

Elective repeat caesarean section

(ERCS)

vs

vaginal birth after caesarean section (VBAC).

Consideration of the risk of scar rupture is probably the most important

consideration when determining whether delivery should be by ERCS or by

attempted VBAC.

Slide58

From a fetal

perspective, ERCS reduces the risk of scar rupture.

From a maternal perspective, ERCS avoids labor with its risk of pelvic floor

trauma.

However, ERCS carries maternal and fetal risks.

Slide59

But providing the first operation was carried out for a non-recurrent indication, then it is appropriate to offer a trial of

labour

after caesarean

(TOLAC) to any woman with a previous uncomplicated lower segment caesarean

section and no other adverse obstetric feature.