Caesarean section and instrumental

delivery

Dr. samira abudia

Caesarean section

• Definition :

it’s a surgical procedure that permits delivery of the infant through incision in the abdominal and uterine wall after 28th weeks of pregnancy (a similar procedure before that time is referred to a hysterotomy).

Introduction:Caesarean section to deliver the baby

of the mother who has died has been documented in ancient Egypt , Asia and Europe.

The first caesarean carried out on alive woman is though to be that of the wife if jacob nufer, she was in obstructed labour.

• The history of the operation thereafter is fascinating with a wide range of isolated cases being documented with a various techniques being investigated to decrease the risk of death due to

hemorrhage and sepsis.

Incidence :

The incidence of the procedure was stable (3-5%) for many years , yet since 1960s the rate was rising steadily reaching (20-25%) in late 1980s.

Causes increase C.S rate:

• Repeat C.S• Dystochia• Fetal distress• Breech presentation• Malpractice• Maternal request

Indication of C.S: 1) maternal indications :• Ante-partum hemorrhage• Contracted pelvis and cephalo-pelvic disproportion• Pelvic tumor obstructing labour• Pelvic fracture• Pelvic successful vaginal operation for SI , fistula• Previous uterine scar may cause rupture urgent

controlled delivery e.g. severe hypertension or central aneurysm

• Maternal medical conditions require urgent controlled delivery e.g. severe hypertension or central aneurysm

2) Fetal indications :• Fetal distress• Certain cases of malpresentation• Macrosomia and extreme prematurity

Contra-indications of caesarean section:

• there are no absolute contraindications , but C.S is better to be avoided in cases of fetal demise , major anomalies incompatible with life , and in severe incompatible with life , and in severe maternal diseases as coagulopathy.

Timing of C.S:

•It may be elective (before the onset of labour pain) , or selective (the

decision taken during labour) .

Types of C.S:

A) upper segment C.S (classical C.S) : USCS done through a vertical incision in upper

uterine segment allows rapid entry , buy it connects with complications as increase blood loss and increase risk of uterine rupture in subsequent pregnancy.

• Indications of USCS :a) fibroids at lower uterine segmentb) Dense adhesions cover the lower ut. Segment.

B) lower segment C.S:

•It’s the most commonly performed incision.

•Lower incidence of hemorrhage because it’s thinner , less vascular and away from the normal site of placenta.

•Stronger uterine scar with lower incidence of ut. Rupture in a subsequent pregnancy 0.4% (USCS 4%) , because the lower segment is relaxed during puerperium and approximation of edges during surgery as it’s relatively thin.

•Post operative adhesions , infection and ileus are less likely to occur.

Preoperative preparation:

•Preoperative visit by anesthesiologist is important to asses the patient’s anesthesia status and the risk of complications during and after surgery.

•Patient in elective procedure should be kept fasting.

•A large intravenous line prior to anesthesia and an infusion of crystalloid

solution .

•A recent Hb and Hct should be checked.

•Blood group and cross matched blood.

•Urinary bladder catheterization.

•Preparation of abdominal and perineal area.

•Anesthesia : G.A or regional anesthesia.

Complications of C.S:

• Maternal morbidity and mortality : Improved surgical and anesthetic

skills , antibiotic , septic techniques and blood products availability have decreased the complication of C.S , despite significant decrease the maternal morbidity still 8-12 times than vaginal birth.

•Anesthetic complications (mainly in G.A) as aspiration pneumonia , intra-operative as (hemorrhage and injury U.B , uterus or bowel) , thromboembolic diseases and postoperative febrile complications as endometritis and UTI.

•Remote morbidity includes adhesive intestinal obstructions , rupture uterine scar , placenta previa at the site of previous scar and incisional hernia.

Caesarean hysterectomy

• Definition : it’s a hysterectomy performed at the time of C.S.

• Indications :1-placenta accreta , ,increta and percreta 50%

2-uterine atony 20%3-intractable hemorrhage 15%

4-uterine rupture 10%

Postmortem C.S:

• For a pregnant woman who has a cardiac arrest and the fetus is available , postmortem C.S should be carried out without delay.

Instrumental Delivery

The obstetric forcepsThe vacuum extraction

The obstetric forcepsDefinition :

It’s instrument designed to extract the head of living baby.

•It’s used either to accelerate delivery or to overcome certain abnormalities in the cephalo-pelvic relationship the interfere with advancement of the head in labour.

indications

• Fetal indications :1.the most common indications are

malposition of fetal head (OP,OT) , breech presentation and epidural analgesia which increases the fetal mal-position

2.fetal distress during the 2nd stage of labour

• Maternal indications :The most common indications are maternal distress , exhaustion and prolonged 2nd stage of labour.

Maternal diseases as heart and chest diseases .

Description of forceps parts

•It consists of two matched parts that articulate and lock to each other (blades) , each blade of made of the blade proper , shank , lock and handle.

•The blades are usually fenestrated for lightness to minimize the compression of fetal head and obtain form grip.

Each blade has two parts the flat one to fit the fetal head (the cephalic curve) and the curved one in the edge to fit the concavity of the sacrum (the pelvic curve)

• The shank : each blade is joined to the handle by the shank (variable lengths)

• Lock : the two blades are fitted together by lock (English , French and sliding lock)

• Handles : they have different lengths according to the type of forceps.

Type of forceps

• Short-shanked forceps : used in low forceps operations ( when the head is low ) or to deliver the head in cases of C.S , e.g. wrigle forceps

• Long shanked forceps : e.g. Simpson type forceps .

• Special types forceps: e.g. Kielland’s forceps , for rotation of the vertex 90 degree or more .

Classification of forceps delivery

• American college of obstetric and gynecology classifications of forceps deliveries according to the station and rotation .

Type of procedureclassification

Outlet forceps•The scalp is or has been visible at introitus without separating the labia .•The skull has reached the pelvic floor .•The sagittal suture is in the antero-posterior diameter or has a rotation of 45 degree or less .

Low forceps•The station is +2 cm or greater .•Rotation of 45 degree or less .•Rotation of greater than 45 degree .

Mid-forceps•The station is less than +2 cm .•Head engaged .

Prerequisites criteria for forceps application:

The use of forceps is permissible only when all the following condition prevail , regardless of the urgent need for delivery :

• The cervix must be fully dilated• The membrane must be ruptured • The head must be engaged• Suitable presentation and position• No cephalo-pelvic disproportion• The bladder should be empty• Lithotomy position• Sterilization• Episiotomy• Anesthesia

Complication of forcepsProperly performed outlet forceps operation should have

morbidity rate similar to spontaneous vaginal delivery .• Maternal complication :1) Uterine , cervical or vaginal lacerations2) Extension of episiotomy3) U.B or urethral injury4) Hematoma• Fetal complications :1) Cephalo-hematoma , bruising and laceration .2) Facial nerve and brachial plexus palsies .3) Skull fracture and intracranial haemorrhage .

(The vacuum extraction (ventouse

Introduction and history

• Modern obstetric vacuum extraction (VE) originated in cupping ,a therapeutic technique that predates Hippocrates .

• In cupping , a metal or glass cup was heated over an open flame and placed over a lesion or skin puncture , as the cup cooled . A vacuum developed , extracting blood or other fluids.

• Cupping was also successfully used for certain surgical procedures , such as raising depressed skull fractures .

• 1849- James young Simpson , introduced his (structured tractor) and attempted to popularize vacuum operated delivery device as an alternation to forceps for cephalic and breech presentation .

• Vacuum-based delivery instrument did not become popular duo to technical problems with applying traction and maintaining vacuum .

• 1950-Malmstrom, inverted his rigid cup design namely , traction , an a metal cup designed suction creates an artificial caput or chignon , within the cup holds firmly and allows adequate traction .

• Birds modifications , in which vacuum tube is attached to a lateral portion part independence of the traction chain has proven the most popular and useful.

Design of the vacuum extractor

1) Suction cup :• Rigid cup designs include :-the classic malmstrom stainless steel vacuum

cup .-rigid plastic cup extractors (mimic malmstrom)• Soft cup extractors include :-disposable polyethylene cup designs .-combined polyethylene-silastic cup designs .

2) Tube :connecting cup with vacuum source .3) Vacuum source : -suction bottle-vacuum release valve -manometer3) Chain : for traction connecting to the cup 4) The traction handles .

indications

Basically these are the same as for forceps deliveries , but:

1 )it must not be used for face deliveries

2 )it can not be used for after coming head of breech presentation.

3 )should not be used in case of prematurity and with large caput or much moulding.

Common indications:

1 )delayed 2nd stage of labour

2 )fetal and maternal distress in 2nd stage of labour

Prerequisites for vacuum extraction

• Informed consent. •Prepared physician : physician should have

knowledge of the instrument chosen. •Prepared patient:

-engaged membrane-Ruptured membrane-No suspicion of CPD

-Fetal position and station-Acceptable analgesia

Complications of vacuum extraction

•Maternal complications:

-cervix or vaginal wall may be included in the cup and lacerations may occur.

-applications before full dilatation of the cervix and traction may cause annular detachment of the cervix and may predispose to utero-vaginal prolapse.

Fetal complications

-scalp : abrasions and necrosis

-skull fractures or cephalic hematoma

-brain : neurological signs , meningeal tear , retinal hemorrhage or intracranial hemorrhage.

Points in favor of vacuum extraction :

•Use of instrument is easy to learn •Risks of maternal injuries are less than with

forceps •Less general anesthesia is needed

•Spontaneous rotation of the fetal head •Less force (traction) can be exerted on the fetal

head •The vacuum cup doesn’t take up any room in the

pelvis

Contraindication to vacuum extractions

Operator in experience

•inability to achieve a correct application •Uncertainty concerning fetal position and

station

•Suspicion of cephalo-pelvic disproportion •Fetal mal-position e.g. breech , face and brow.

•Known or suspected fetal coagulation defects •Dead baby