Jereisat 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 ID: 917341
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Slide1
Operative Delivery
Rahaf
Jereisat
Slide2The 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.
Slide3Perineal 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,
Slide4Of 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.
Slide5Classification
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.
Slide6Surgical 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
Slide72nd
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.
Slide82nd
degree
perineal
repair
Slide9OASI 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
Slide10Slide11OASI 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
Slide12physiotherapy 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.
Slide13Episiotomy
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.
Slide14Indications
Instrumental delivery
Fetal distress
History or risk for OASI
Big baby
Breech
Prolonged second stage
Slide15Surgical 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
.
Slide16A
mediolateral
episiotomy at a 60° angle to the midline is usually recommended
Slide17A
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.
Slide18Complications
Short-term complications of
perineal
trauma or episiotomy include pain, infection and
haemorrhage
.
Long-term effects include
dyspareunia, urinary/ fecal/ flatus incontinence.
Slide19Operative 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
Slide20most common fetal factor is suspected fetal
compromise
most
common maternal factor is a prolonged active second stage of
labour
.
Slide21Slide22Contraindications
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.
Slide23Slide24Choice 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.
Slide25Procedure
Evaluation
Analgesia
Positioning
Contingency planning
Instrument type
Technique
Slide26Evaluation
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.
Slide27Analgesia
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
.
Slide28Positioning
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.
Slide29Contingency 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.
Slide30Instrument 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™).
Slide31https://www.youtube.com/watch?v=AShsPCHs7og
Slide32Technique
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.
Slide33It 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.
Slide34Forceps
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.
Slide35https://www.youtube.com/watch?v=zgTLzpUTwck
https://www.youtube.com/watch?v=_InLgIcaNcA
Slide36The 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.
Slide37Special 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.
Slide38If 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.
Slide39Slide40Caesarean 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.
Slide41Incidence
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
Slide42Slide43History
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.
Slide44Slide45Slide46Classification
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
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.
Slide49Procedure
Consent
Preperation
Abdominal incision
Uterine incision
Closure
Complications
Post-op care
Slide50Informed 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.
Slide51Preparation
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.
Slide52Abdominal and Uterine incisions
https://www.youtube.com/watch?v=VkxwN8xQz80
Slide53Closure
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.
Slide54Post-op care
Slide55Complications
Intraoperative
complications
Haemorrhage
Caesarean hysterectomy
Placenta
praevia
Organ damage (bowel/bladder)
Postoperative complications
Infection
Venous
thromboembolism
Psychological
Fetal Complications:
TTN/respiratory distress syndrome
Slide56Caesarean 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
Slide57Subsequent 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.
Slide58From 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.
Slide59But 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.