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Operative obstetrics
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Operative Obstetrics

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this presentation shows how i use animations in my slides. that is why it is too much slides for a single topic --DrHanisahNotes

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Operative Obstetrics

  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 Sim’s speculum Allis forceps CuretteOvum forceps
  18. 18. TYPES ONE STAGE OPERATION Dilatation of cervix & evacuation of uterus done in the same sitting
  19. 19. Sim’s posterior vaginal speculum Allis forceps Curette
  20. 20. Preliminaries Steps: Sim’s 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 Sim’s 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 Sim’s 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:  Sim’s 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 (Karman’s) & 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 (Karman’s) & 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 (Karman’s) & 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 (Karman’s) & 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 (Karman’s) & 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 Karman’s 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 batholin’s 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 o’clock 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 patient’s 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…
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this presentation shows how i use animations in my slides. that is why it is too much slides for a single topic --DrHanisahNotes

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