2. Operative Obstetrics
• Interventions intrapartum
I. Vaginal
A. Forceps Delivery
B. Breech Extraction
C. Vacuum Extraction
II. Abdominal
A. Cesarean Section
B. Postpartum Hysterectomy
3. Vaginal Operations: Forceps Delivery
Forceps are a surgical instrument that resembles a pair of
tongs and can be used in surgery for grabbing, maneuvering,
or removing various things within or from the body. They can
be used to assist the delivery of a baby as an alternative to
the ventouse (vacuum extraction) method.
Classification: 1. Outlet forceps
2. Low forceps
3. Midforceps
4. High Forceps
4. Forceps Delivery
Outlet forceps
1. Scalp is visible at the introitus without separating the labia.
2. Fetal skull has reached the pelvic floor.
3. Sagittal suture is in the A-P diameter or ROA,ROP, LOA,
LOP
4. Fetal head is at or on perineum.
5. Rotation does not exceed 45 .
O=occiput
5. Forceps Delivery
• Low forceps delivery, when the baby's head is at +2
station or lower. There is no restriction on rotation for this
type of delivery.
• Midforceps delivery, when the baby's head is above +2
station. There must be head engagement before it can be
carried out.
• High forceps delivery is not performed in modern obstetrics
practice. It would be a forceps-assisted vaginal delivery
performed when the baby's head is not yet engaged.
6. Techniques of Forceps Delivery
The cervix must be fully dilated and retracted and the membranes ruptured.
The urinary bladder should be empty.The station of the head must be at
least +2 in the lower birth canal. The woman is placed on her back, usually
with the aid of stirrups or assistants to support her legs. A mild local or
general anesthetic is administered.
Ascertaining the precise position of the fetal was accomplished by feeling
the fetal skull suture lines and fontanelles, in the modern era, confirmation
with ultrasound is essentially mandatory. At this point, the two blades of
the forceps are individually inserted, the posterior blade first, then locked.
The position on the baby's head is checked. The fetal head is then rotated to
the occiput anterior position if it is not already in that position. An
episiotomy may be performed if necessary. The baby is then delivered with
gentle traction in the axis of the pelvis.
7. Uses of forceps
1. Maternal or fetal indications
2. Prophylactic
3. Elective
8. Indications for Forceps Delivery
Any condition threatening the mother or fetus that is likely to
be relieved by delivery.
Maternal Indications
1. Heart disease
2. Pulmonary compromise or Injury
3. Intrapartum infection
4. Certain neurological conditions
5. Exhaustion
6. Prolonged second stage
Fetal Indications
1. Prolapse of umbilical cord
2. Premature separation of the placenta
3. Non-reassuring fetal heart rate pattern
9. Pre-requisites for application of Forceps Delivery
1. head engaged
2. presentation vertex or chin anterior
3. position known
4. cervix completely dilated
5. membranes ruptured
6. no disproportion between head & pelvis
10. Complications of forceps delivery
A. Maternal
1. episiotomy,lacerations & Injuries to the bladder or urethra
2. uterine rupture
3. urinary and rectal incontinence
4. febrile morbidity
B. Fetal
1. trauma, Cuts and bruises
2. cephalo-hematoma
3. temporary facial nerve injury
4. clavicle fracture
11. Summary: Forceps Delivery
1. Forceps delivery, when performed inappropriately, can
result in maternal and fetal adverse effects.
2. Outlet & low-forceps operations of 45 or less can be safely
performed if the basic guidelines are met.
12. Vaginal Operations: Breech Delivery
A breech presentation is defined as the condition in
which the baby is in longitudinal lie and the podalic pole
presenting at the pelvic brim with the head occupying upper
pole of uterus.
Types of breech:
1. Frank –lower extremities flexed at the hips & extended at
knees
2. Complete – one or both KNEES are flexed
3. Incomplete – one or both HIPS are not flexed and one or
both feet or knees lie below the breech
14. Methods of Breech Delivery
1. Spontaneous breech delivery
2. Partial Breech extraction, spontaneous up to umbilicus
3. Total Breech Extraction
15. Maneuvers of Breech Delivery
A) Pinard Maneuver
in frank breech:
• used to deliver a foot into
the vagina
• Two fingers are carried up
along one extremity to the
knee to push it away from
the midline. Spontaneous
flexion follows.
16. Maneuvers of Breech Delivery
B)Mauriceau Maneuver
(back anterior)
• Delivery of the after
coming head
• index & middle finger
applied over the maxillae
to flex the head
17. Maneuvers of Breech Delivery
C)Prague Maneuver
(back posterior)
• 2 fingers grasping
shoulders of the back-
down fetus
19. Maternal risks of Breech Delivery
• Maternal infection
• Uterine rupture
• Cervical lacerations
• Extensions of episiotomy
• Deep perineal tears
• Postpartum hemorrhage from uterine relaxants
20. Fetal risks of Breech Delivery
• Trauma
• Cord prolapse
• Fracture of humerus or clavicle
• Separation of the epiphysis of the scapula, humerus or
femur
• Paralysis of the arm
• Spoon depressions or skull fracture
• Broken fetal neck
• Testicular injury
21. Vaginal Operations: Vacuum Extraction
Ventouse is a vacuum device used to assist the delivery of
a baby when the second stage of labour has not progressed
adequately.
It is an alternative to a forceps delivery and caesarean section.
It cannot be used when the baby is in the breech position or
for premature births. This technique is also called vacuum-
assisted vaginal delivery or vacuum extraction (VE).
Principle
• Creation of an artificial caput by attaching a traction device by
suction to the fetal scalp
Indications & pre-requisites
• Same as in forceps delivery
22. Indications for use of vacuum
There are several indications to use a ventouse to aid delivery:
• Maternal exhaustion
• Prolonged second stage of labor
• Foetal distress in the second stage of labor, generally
indicated by changes in the fetal heart-rate
• Maternal illness where prolonged "bearing down" or
pushing efforts would be risky (e.g. cardiac conditions, blood
pressure, aneurysm, glaucoma).
23. Techniques of Vaccum Extraction
The woman is placed in lithotomy
position and assists throughout the
process by pushing.
A suction cup is placed onto the
head of the baby and the suction
draws the skin from the scalp into
the cup.
Correct placement of the cup directly over the flexion point, about
3 cm anterior from the occipital (posterior) fontanelle, is critical to the
success of a VE. Ventouse devices have handles to allow for traction.
When the baby's head is delivered, the device is detached, allowing the
accoucheur and the mother to complete the delivery of the baby.
24. Summary : Vaccum Extraction
Positive aspects
• An episiotomy may not be required.
• The mother still takes an active role in the birth.
• No special anesthesia is required.
• The force applied to the baby can be less than that of a
forceps delivery, and leaves no marks on the face.
• There is less potential for maternal trauma compared to
forceps and caesarean section.
Negative aspects
• The baby will be left with a temporary lump on its head,
known as a chignon.
• There is a possibility of cephalohematoma formation, or
subgaleal hemorrhage.
25. Abdominal Operations: Cesarean Delivery
A Caesarean section is a surgical procedure in which one
or more incisions are made through a mother's abdomen
(laparotomy) and uterus (hysterotomy) to deliver one or
more babies.
26. Abdominal Incisions
1.Vertical Incision
• Vertical incisions are very rare.
• quickest to make
• greater chance of dehiscence
2. The horizontal or Pfannenstiel Incision
• It it placed at the top of to pubic hair or just over the hair
line as the c-section is started.
• cosmetically better & stronger
• less chance of dehiscence
• exposure not as good
27. Indications for Cesarean Delivery
• Prolonged labour
• Dystocia or failure to progress in labor
• Breech presentation
• Those performed out of concern for fetal well-being
• Failed labour induction
• failed instrumental delivery (by forceps or ventouse)
• Uterine rupture
• Multiple births
• Previous transverse Caesarean section
29. Abdominal Operations: Postpartum Hysterectomy
A hysterectomy is the surgical removal of the uterus , usually
performed by a gynecologist.
Hysterectomy may be:
• Total
• Partial
It is the most commonly performed gynecological surgical
procedure.
30. Techniques
1. Total Hysterectomy
more extensive mobilization of the bladder medially
and laterally is necessary
2. Supracervical Hysterectomy
amputate the body of the uterus above the level of the
cervix
31. Indications for Postpartum Hysterectomy
• Intrauterine infection
• Grossly defective scar
• Markedly hypotonic uterus
• Laceration of major vessels
• Large myomas
• Severe cervical dysplasia
• Carcinoma in situ
• Placenta previa, accreta
