OPERATIVE

OBSTETRICS

Alan Mathew Skaria

Operative Obstetrics
Interventions intrapartum
I. Vaginal

A. Forceps Delivery
B. Breech Extraction
C. Vacuum Extraction
II. Abdominal

A. Cesarean Section
B. Postpartum Hysterectomy

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

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

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.

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.

Uses of forceps
1. Maternal or fetal indications
2. Prophylactic
3. Elective

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

Pre-requisites for application of Forceps Delivery

1.
2.
3.
4.
5.
6.

head engaged
presentation vertex or chin anterior
position known
cervix completely dilated
membranes ruptured
no disproportion between head & pelvis

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

Summary: Forceps Delivery

1. Forceps delivery, when performed inappropriately, can
result in maternal and fetal adverse effects.
2. Outlet & low-forceps operations of 45or less can be safely
performed if the basic guidelines are met.

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

FRANK
INCOMPLETE

COMPLETE

Methods of Breech Delivery

1. Spontaneous breech delivery
2. Partial Breech extraction, spontaneous up to umbilicus
3. Total Breech Extraction

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.

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

Maneuvers of Breech Delivery

C)Prague Maneuver
(back posterior)
2 fingers grasping
shoulders of the backdown fetus

Maneuvers of Breech Delivery

D)Pipers forceps
For the aftercoming
head

Maternal risks of Breech Delivery

Maternal infection
Uterine rupture
Cervical lacerations
Extensions of episiotomy
Deep perineal tears
Postpartum hemorrhage from uterine relaxants

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

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 vacuumassisted 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

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).

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.

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.

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.

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

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

Cesarean delivery rates: United States

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.

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

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

Thank You..!!