Operative Delivery

Alex Williams

Beth Bradley

Definition

• Operative delivery is defined as any procedure undertaken to facilitate delivery of an infant.

• Operative delivery should be undertaken for specific indications and those indications should be specifically noted in labour record.

Definition

Vaginal Operations

• Episiotomy

• Vacuum extraction

• Forceps Delivery

Abdominal Operations

• Caesarean Section

Vaginal Operations: Episiotomy

Rates vary. In 2001 the National Childbirth Trust produced figures for the UK of 15% in England 13% in Scotland 10% in Wales 22% in Northern Ireland Internationally 8% in Holland, 14% in England, 50% in the USA 99% in Eastern Europe

Episiotomy: Indications • Where a tear seems imminent and an episiotomy is deemed

preferable.

• Where there is delay due to a rigid perineum, and cutting it will expedite delivery and probably prevent a tear.

• Instrumental delivery

– forceps Tear – Kielland's forceps rotation and delivery the episiotomy needs to be

quite generous or a tear will accompany the cut.

• Premature delivery

• It estimates that 85% of women who have a vaginal delivery will have some degree of perineal trauma and that 60 to 70% will require suturing.

Episiotomy

Episiotomy

It estimates that 85% of women who have a vaginal delivery will have some degree of perineal trauma and that 60 to 70% will require suturing.

Vaginal Operations: Vacuum extraction (Ventouse)

Ventouse: Indications Maternal

– Exhaustion – Prolonged second stage (>1hr pushing) – Need to avoid expulsive effort (e.g.

Cerebrovascular disease)

Foetal – Failure of the foetal head to rotate – Foetal distress *Should not be used for preterm, face or breech presentation or in the case suspected foetal coagulation disorder

Ventouse: Delivery

Suction Cup applied to flexion point (2-3 cm anterior to posterior fontanelle) Traction applied in mother’s push.

Ventouse: Complications

• Vaginal laceration

• Scalp injuries

– Chignon

– Abrasion/laceration

• Cephalohematoma

• Intracranial haemorrhage

Vaginal operations: Forceps

Forceps: Indications

• Maternal

– Exhaustion

– Prolonged second stage

– Need to avoid expulsive effort

• Foetal

– Failure if the foetal head to rotate

– Foetal distress

– Control of head in breech delivery

Forceps: Choice

• Related to station of foetal head

Forceps: Choice

• Outlet forceps – Wrigley’s

• Low / Mid-cavity forceps – Neville Barnes

• Rotational Forceps – Kielland’s

Forceps: Requirements

F – Fully dilated cervix

O - no Obstruction (head <1/5 palpable per abdomen)

R – Review (lack of descent/rotation despite 3 tries)

E – Epidural or pudendal nerve block

P – Presentation (Cephalic)

S – Station (presenting part must be below ischial spines)

Forceps: Complications

• Foetus – Brachial plexus injury – Facial nerve damage – Fracture (skull) – Facial trauma – Shoulder dystocia

• Mother – Vaginal trauma – Haemorrhage – Infection

Abdominal Operations: Caesarean Section

1879

Caesarean Section: Definition Delivery of the foetus through an incision in the maternal abdomen and uterus.

Uterine Incision

• Lower Uterine Segment Incision

– Straight incision 3 cm above pubic Symphysis Pubis with blunt dissection to the uterus (reduces blood loss)

• Classic Caesarean section

– Vertical incision

– Very early foetus, anatomical difficulties

Caesarean Section: Indications

• Malpresentation, eg breech, transverse lie. • Multiple pregnancy. • Severe hypertensive disease in pregnancy. • Foetal conditions: distress, iso-immunisation, very low birth

weight. • Failed induction of labour. • Repeat Caesarean section: two sections nearly always means

subsequent births should also be by Caesarean section. • Large or obstructing Pelvic cyst or fibroid. • Maternal infection, eg herpes (if active), HIV (if viral load high) • Cephalopelvic disproportion

Caesarean Section

Caesarean Section

Caesarean Section Complications

• Maternal – Intra operative

• Haemorrhage • Caesarean Hysterectomy • Placenta Previa • Damage : Bowel ,Urinary Tract, Bladder

– Post Operative • Infection and endometritis • Scarring • PE • Psychological

Caesarean Section Complications

Foetal

• Respiratory problems

• Lacerations (rare)

• bonding

Instrumental and operative delivery: Summary

• The aim is to prevent foetal and maternal morbidity associated with a prolonged second stage of labour.

References

• www.patient.co.uk

• http://www.rcog.org.uk/

• Impey L, Child T. Obstetrics & Gynaecology (2012), 4th ed. Wiley & Blackwell

Images • http://www.theage.com.au/articles/2007/04/14/1175971419538.html • http://en.wikipedia.org/wiki/Caesarean_section • http://www.healthyhippie.net/more-twins-delivered-via-c-section/