OBSTETRIC OPERATIONS,
OBSTETRIC ANALGESIA
AND ANAESTHESIA
DR. S. S. SAYIBU.
UDS – SMHS.
School of Medicine and Health Sciences,
1
University for Development Studies, Tamale.
OBSTETRIC OPERATIONS
• Some disease conditions may • And can take the form of:
call for the performance of 1) Elective, or
surgery in the pregnant woman.
2) Emergency.
• It can be done during the:-
1)Antenatal Period
2)Intrapartum
3) Postpartum
OBSTETRIC OPERATIONS
Cervical Cerclage
Episiotomy
Vacuum Delivery/Extraction
Forceps Delivery
Evacuation of The Uterus
Caesarean Section/Delivery
Caesarean Hysterectomy
Appendicectomy/Appendectomy
OBSTETRIC OPERATIONS
• CERVICAL CERCLAGE: A stitch placed around the cervix, usually to
prevent miscarriage.
Indication: Cervical Insufficiency (** X --˃ incompetence).
Causes of Insufficiency:
Forceful dilation
Delivery through partly dilated cervix
Conization/Trauma/
Idiopatehic.
Also NB Trachelectomy*** (Manchester-Fodergil procedure).
Multiple gestations.
OBSTETRIC OPERATIONS
• Cerclage:
Preferably inserted at/after 14wks.
May be emergency/rescue
Endocervical/Vaginal Cx for infection.
Types:
McDonald Tech: Purse string suture (non-absorbable – Merselene
Tape.
Shirodkar Tech.
Transabdominal
OBSTETRIC OPERATIONS
• CERCLAGE:
Post-operative care
Use of Antibiotics
Tocolytics
Bed Rest (24-48hr) prior to discharge; longer if indicated
Removal at term (#37wks or more), unless if there;
• APH
• PROM
• Preterm labor/IUFD.
OBSTETRIC OPERATIONS
• CERCLAGE:
Counselling: To report if there’s any of;
o Vaginal discharge
o Bleeding PV.
o Loss of liquor
o Labour
o Tears or Rupture.
OBSTETRIC OPERATIONS
• EPISIOTOMY (Perineotomy):
• Surgical incision made in made into the perineal body for the purpose
of aiding delivery or preventing tears (Telinde 10th Edit. 2008).
• Generally done by Obstetricians or Midwives to create a quick
enlargement of the introitus during second stage of labour.
OBSTETRIC OPERATIONS
• EPISIOTOMY
• Indications:
• 1 – Facilitate delivery
• 2 – Prevent pelvic floor damage*
• *Studies indicate that episiotomy does not appear to
prevent physical/anatomic or symptomatic changes
of pelvic floor relaxation.
OBSTETRIC OPERATIONS
• EPISIOTOMY:
First Degree Tear: Vaginal Third and fourth degrees to
Mucosa and Connective be repaired by a senior
tissue medical colleague
Second-degree: Vaginal
mucosa, connective tissue, • Types of episiotomy
and underlying muscles. • Medio-lateral
Third-degree: Second + • Midline
anal sphincter • Lateral
Fourth-degree: Third +
Rectal mucosa.
OBSTETRIC OPERATIONS
• EPISIOTOMY:
Midline Episiotomy: Directed downward in the midline.
Easier to perform and repair
Less post –operative pain
Less bleeding
Better anatomic approximation
(Preferred by the Americans)
NB increases risk of 3/4th degree tear.
Advantages and Disadvantages.
OBSTETRIC OPERATIONS
Mediolateral: Starts from the midline and is directed outward at an angle of
30-45ᵒ.
Fewer 3/4th degree tears.
Provides more room for delivery
More blood loss
More difficult to repair,
Poor anatomic re-approximation
Post-op pain very common
Greater risk of long-term dyspareunia.
OBSTETRIC OPERATIONS
• EPISIOTOMY:
Lateral: Rarely used; tendency to bleed.
OBSTETRIC OPERATIONS
• Performing an episiotomy
• Local anaesthesia
• 1% xylocaine solution
REPAIRING AN EPISIOTOMY
• Local anaesthesia
• 1% xylocaine solution
• Absorbable sutures
• Vicryl
• Chromic catgut
Episiotomy after-care
• Washing of incision site with tap water after
micturition or bowel motion
• Antibiotics
• Analgesia
OBSTETRIC OPERATIONS
• VACUUM DELIVERY:
Indication
Prolonged 2nd stage
Poor maternal effort
Maternal Exhaustion
To facilitate delivery in;
• Pre-eclampsia
• Eclampsia
• Heart disease
• SCD
• Fetal distress
• Retained 2nd twin***
OBSTETRIC OPERATIONS
• VACUUM (VENTUSE) DELIVERY:
Contra-indication:
In-experienced hands
Big baby (macrosomia)***
Cephalo-pelvic disproportion
Non-engaged head (3/5 descent or higher).
Prematurity (less than 36wks).
Malposition
Malpresentation (face and breech).
Possible fetal bleeding tendency.
OBSTETRIC OPERATIONS
• VACUUM DELIVERY:
Pre-requisites:
Cephalic presentation
No sign of CPD
Head 3/5 or lower
Fully dilated cervix**
(Analgesia)
Counselling (couple):
o Explain the need, procedure, outcome, complications.
o Chignon may persist for 24-48hrs; Hyperemic ring for few days.
OBSTETRIC OPERATIONS
• Procedure:
• Position of patient: Lithotomy position; buttocks at the edge of the bed,
• Clean the external genitalia and inner thighs with antiseptic solution
(Savlon).
• Empty urinary bladder ( use Catheter).
• Drape the patient.
• Assess the head of fetus and cervical dilatation, (the position of the
sutures and fontanelle should be known).
• Selection of cup- Selastic/Metal cup.
- Size: 5-6 cm
Test vacuum with open palm. Check for leakage in the system.
Episiotomy (medicolateral) under local anaesthesia.
Vacuum cup in midline (for synclitism), close to posterior fontanelle.
OBSTETRIC OPERATIONS
• Procedure:
• Edge of cup to be at least 3cm from
posterior edge of ant. font.; for good
flexion.
• Create vacuum slowly to 0.2kg/cm2 ,
keeping cup in place.
• Feel around cup to free any entrapped
tissues.
• Slowly build up pressure to 0.8kg/cm².
• Traction during contractions, along axis of
birth canal.
• Abandon procedure after 3 pulls.
• Cup not to stay for 30mins or more.
• Remove cup after delivery of head. Deliver,
complete 3rd stage and inspect tears.
OBSTETRIC OPERATIONS
• Complications of Vacuum Delivery:
c) Hemorrhage
Maternal:
d) Thrombo-embolic disease
a) Tears: Cervical, vaginal, urethral,
Fetal
urinary bladder.
a) Scalp laceration
b) Utero-vaginal prolapse when
b) Intra-cranial hemorrhage
excessive traction is applied.
c) Subgaleal hematoma
OBSTETRIC OPERATIONS
• FORCEPS DELIVERY: Fetal Indications
Maternal Indications Fetal Distress
Medical Conditions Prematurity
needing expedition of Breech (After coming
2nd stage head)
• Cardiac Disease
Malposition **(rather
• Sever hypertension
better with ventuse)
• Respiratory Disease
Maternal Exhaustion
Previous C/S (Relative)
Prolonged 2nd stage
OBSTETRIC OPERATIONS
• FORCEPS DELIVERY: Types of Forceps
Over 600 variants
Classes of Forceps Wriggley: Outlet/Low
o Outlet/ Low forceps forceps; C/S.
Fetal Head not palpable abd Neville Barnes: Midpelvic
Sagittsl suture in AP position and Outlet’
Fetal Head on Perineum
Pijper: After coming head
o Midpelvic Firceps
of Breech
Fetal head is 1/5 in descent
Kielland: Rotational
Position of head may vary
forceps.
Station 0 to +2
o High Forceps
Head not engaged
C/S preferred.
OBSTETRIC OPERATIONS
Prerequisites for Forceps • Prerequisites for
Delivery Forceps Delivery.
1. Informed Patient (Consent)
9. Head engaged (below
2. Experienced Operator spines)
3. Adequate Analgesia (LA, or
Reg) 10. No CPD
4. Empty bladder 11. Suture in AP position
5. Episiotomy Preparation:
6. Membranes must be ruptured a. Counsel about procedure
7. Cervix must be fully dilated
b. Prep your equipment
8. Adequate contractions and consumbles
OBSTETRIC OPERATIONS
OBSTETRIC OPERATIONS
OBSTETRIC OPERATIONS
• Now Remove forceps
and deliver the rest of
the body.
OBSTETRIC OPERATIONS
• Failed Forceps: • Fetal Complications
1. No descent of head with eac pull 1. Death
2. Failed delivery after 3 pulls or after 30mins 2. Injurie: ICH, Facil nerve/Brachail plexus
injuries.
• C/S is the next option
3. Trauma to fetal head
• Materna Complications
1. Trauma 4. Transmission of viral infection,
2. Hemorrhage
3. Infection
4. Neurological complications e.g. foot
drop
5. Long term: prolapse, incontinence,
fistula
OBSTETRIC OPERATIONS
• EVACUATION OF THE UTERUS:
Manual Removal of Placenta
Require general anesthesia.
OBSTETRIC OPERATIONS
• CAESAREAN 6. Previous C/S with other
SECTION/DELIVERY/OPERATION complications of pregnancy
(ABDOMINAL DELIVERY):
• INDICATIONS -Breech Presentation
• Maternal -Severe PIH
1. Cephalo pelvic disproportion -Diabetes mellitus
2. Ante-partum haemorrhage -Multiple pregnancy
-placenta praevia 7. Previous Vaginal Surgery
- Abruptio placentae -Colporrhaphy
3. Previous Caesarean Deliveries (2 or -Repaired vesico-vaginal fistula
more)
4. Failed Vacuum Extraction or Forceps
Delivery
5. Obstructive Labour
OBSTETRIC OPERATIONS
• C/S INDICATIONS CONTD: • COMPLICATIONS CONTD
• FETAL • c) Bowel injury
1. Fetal Distress d) Cardiac arrest
2. Fetal macrosomia
2)Post-Operative
3. Fetal malpresentation/ malposition
a)Infection-endomyometritis
-(Transverse, Shoulder, Brow)
presentations - Salpingitis
-Face presentation with - Wound Sepsis
mentoposterior position b) Wound disruption
4. Cord prolapse with viable fetus c) Postpartum haemorrhage
• COMPLICATIONS OF C/S d) Aspiration pnemonitis
• 1)Intra-operative
e) Urinary tract infection
a) Haemorrhage
f) Deep vein thrombosis
b) Urinary Track Infection
g)Pulmonary embolism
OBSTETRIC OPERATIONS
• C/S COMPLICATIONS b) Wound disruption
CONTD:
• 1)Intra-operative
c) Postpartum
hemorrhage
a) Haemorrhage
b) Urinary Track Infection d) Aspiration
c) Bowel injury pneumonitis
d) Cardiac arrest e) Urinary tract infection
f) Deep vein thrombosis
2)Post-Operative g)Pulmonary embolism
a)Infection-endomyometritis
- Salpingitis
- Wound Sepsis
CAESAREAN HYSTERECTOMY
INDICATIONS
Ruptured uterus
Placenta accreta, increta or percreta
Post-partum hemorrhage (E.g. uterine atony).
OBSTETRICS ANALGESIA &
ANESTHESIA
• LOCAL ANESTHESIA
Local Infiltration: Mostly 1% Xylocaine.
Pudendal Block.
OBSTETRICS ANALGESIA &
ANESTHESIA
• LOCAL ANESTHESIA
• Local Infiltration: • Maximum Dose Lidocaine without
Mostly 1% Xylocaine/Lidocaine. Epinephrine – 3-5 mg/kg
Max infiltration dose as follows: • Maximum Dose Lidocaine with
Epinephrine – 5-7 mg/kg
• 1% Lidocaine = 10 mg • 0.25% Bupivacaine = 2.5 mg Lidocaine per
Lidocaine per mL mL
• 2% Lidocaine = 20 mg • Maximum Dose Bupivacaine without
Lidocaine per mL Epinephrine – 2 mg/kg
• Maximum Dose Lidocaine with
Epinephrine – 3 mg/kg
OBSTETRICS ANALGESIA &
ANESTHESIA
Agent Maximum Dose ( for 70kg Maximum Dose in ml
adukt =154lbs) in mg
1% Lidocaine w/o Epinephrine 300 30
1% Lidocaine w Epinephrine 500 50
2% Lidocaine w/o Epinephrine 300 15
2% Lidocaine w Epinephrine 500 25
0.25% Bupivacaine w/o 140 56
Epineph
0.25% Bupivacaine w Epineph 210 84
OBSTETRICS ANALGESIA &
ANESTHESIA
• REGIONAL
ANESTHESIA:
• Epidural
Anesthesia:
• Saddle Block:
• Spinal Anesthesia:
OBSTETRICS ANALGESIA &
ANESTHESIA
• Regional Anesthesia
OBSTETRICS ANALGESIA &
ANESTHESIA
• GENERAL ANESTHESIA:
• Induction
• Maintenance
