OBSTETRIC PROCEDURES & OPERATIONS II

By

Kwabena Amo-Antwi, FWACS FCGS

25th Jan 2023

OBSTETRIC PROCEDURES & OPERATIONS II

Learning objectives

1. Define/Describe obstetric procedures or the operations

2. Identify women in whom the procedures or operations are needed

(Indications/contraindications)

3. Understand the recommended technique for the procedure. Describe the various
procedures along with their complications

4. To appreciate the effect of loss of traditional obstetric skills, such as external

cephalic version, internal podalic version and destructive vaginal procedures on
current the caesarean section rate
OBSTETRIC PROCEDURES & OPERATIONS II

Caesarean section (CS)

• Operative delivery of a baby of viable gestational age, through incisions in the anterior
abdominal wall and the uterus.

• In a pre-viable fetus, the equivalent procedure is called hysterotomy.

• CS is probably the most common performed obstetric procedure

• CS rate is rising worldwide (due to advancement in anaesthesia & techniques).

• KATH ~ 28-30% of all deliveries

Caesarean section - Classification

A. Type of incision on the uterus

• Lower segment CS
(including its modification :J-, U- or T-shaded incision )
• Classical CS
• Low vertical CS

B. Timing of the operation

• Emergency CS
• Elective CS

C. Previous history of CS
• Primary caesarean section
• Repeat caesarean section

D. Auxiliary procedure performed at the time of CS

• Caesarean myomectomy
• Caesarean hysterectomy
CAESAREAN SECTION- CLASSIFICATION (CONT.)

E. Degree of urgency (based on the indications or decision-to-delivery interval.)

Emergency CS: Immediate threat to life of woman or fetus

Urgent CS: Maternal or fetal compromise that is not immediately life-threatening

Scheduled CS: No maternal or fetal compromise but early delivery is desired

Elective CS): Delivery timed to suit woman or maternity team

FETAL/PLACENTAL INDICATIONS FOR CS

1. Fetal distress
6. Cord prolapse
2. Cephalo-pelvic disproportion
7. High order multiple pregnancy
3. Obstructed labour
8. Intrauterine growth restriction
4. Malpresentations
9. Severe oligohydramnios
5. Mal-positions
10. Congenital anomalies

11. Placenta previa

MATERNAL INDICATIONS FOR CS

1. Previous uterine surgery e.g. extensive 6. Previous VVF repair or pelvic floor repair
myomectomy, cornual resection,
metroplasty.
7. Pelvic fractures, pelvic deformity

2. Repaired Ruptured uterus

8. Maternal infections such as HIV, active
genital herpes
3. Classical caesarean scar

9. Simplex infection, massive vulvo-vaginal

4. 2 Previous lower uterine segment CS warts

5. One previous lower segment CS with 10. Maternal request

breech, face,
PERIPARTUM SCENARIOS AND INDICATED CS CATEGORY

Immediate threat to life of woman or fetus

Decision-to-caesarean delivery interval should be less than 30min

One of the “code red” situation in obstetrics.

Prompt communication between midwives, theatre staffs, obstetricians and
anaesthesiologists is key.

Prognosis for mother and fetus depends well-coordinated teamwork.

Periodic simulations enhance the ability to achieve the intervention within the stipulated
time.
PERIPARTUM SCENARIOS AND INDICATED CS CATEGORY

Immediate threat to life of woman or fetus

Conditions with Immediate threat to the life of woman or fetus where decision-to-
caesarean delivery interval should be within 5 minutes

Maternal Cardiopulmonary arrest caused by

• Severe intrapartum haemorrhage (following uterine rupture),
• Peripartum cardiomyopathy

Conditions with Immediate threat to the life of woman or fetus where decision-to-
caesarean delivery interval should be within 25 minutes

Persistent fetal bradycardia (Fetal distress)

Caused by
• placental abruptio or cord prolapse.
• Following failed vacuum delivery
PERIPARTUM SCENARIOS AND INDICATED CS CATEGORY

Maternal or fetal compromise but no immediate threat to the woman's or fetus's life.
• 3 previous CS with PROM

• Late FHR decelerations on CTG

• APH with no fetal distress or maternal shock

• Failed instrumental delivery

• CPD, CS is planned within 1-2 hour

• IUGR with absent diastolic flow but normal CTG, CS is planned within 1-2 hour

• Severe pre-eclampsia, CS is planned within 1-2 hour

PERIPARTUM SCENARIOS AND INDICATED CS CATEGORY

Early delivery desired but have no associated maternal or fetal compromise

• Face presentation with mento-posterior position

• Big Breech in early stage of labour

• Cord presentation in early labour with normal CTG

• Preterm CS delivery after a course of steroid for lung maturity (Preterm CS

delivery in poorly controlled medical conditions in pregnancy after completion
of steroid
PERIPARTUM SCENARIOS AND INDICATED CS CATEGORY

The caesarean section is planned to suit the woman or the maternity team
• 2 previous CS

• Multiple pregnancy with first fetus non-cephalic at term

• 1 previous CS with any of the ff:

(Hypertensive disease in pregnancy, Multiple gestation and Macrosomia)

• HIV, massive vulvo-vaginal warts, HSV
CAESAREAN SECTION - PRE-OPERATIVE PREPARATION

1. Cross-check the identity of the patient,

2. Ensure that indication and the gestational age are correct

3. Counseling on Indication, Procedure, anaesthesia, reassurance.

4. Informed consent - signed

5. Laboratory. Tests - Hb, Sickling, group and X’match 2 pts of blood.

6. Inform Anaesthetist for assessment.

7. Inform Paediatrician / Resident / Baby Nurse

8. Inform theatre staff.

9. Clip pubic hair if required

10. Atropine, antacid if stomach is full

CAESAREAN SECTION – PROCEDURE

1. Skin preparation
• Scrub, gown, and prep. and drape before anaesthesia.

2. Skin incision and abdominal entry

• Skin - Pfannenstiel incision preferred but, sub-umbilical midline incision may be used.
• Fascia - Transverse incision
• Rectus muscle - Separated bluntly in the midline vertically.
• Peritoneum: Entered bluntly with fingers or incised with scissors

3. Correct dextro-rotation if present

4. Dissect vesico-uterine (bladder) peritoneum and reflect the bladder inferiorly.

CAESAREAN SECTION – PROCEDURE (CONT.)

5. Retract and keep the bladder away from the surgical field using Doyen bladder
retractor.

6. Uterine Incision:
• Lower segment transverse-Standard.
• Others :Low vertical, U-shaped, Inverted T and rarely classical incision

7. Delivery of products of conception :

• Baby delivered manually or with delivery forceps or by the breech.
• Placenta & membrane by Controlled cord traction. Manually explore the cavity

8. Uterine Closure :
• •Clamp incision corners and edges with green Armitage clamps/forceps.
• •Secure both uterine corners with sutures beyond the apex
• •Close the incision with vicryl – 1 in a continuous fashion in a single layer.
CAESAREAN SECTION – PROCEDURE (CONT.)

Others
• Ensure Haemostasis
• May close the uterus in-situ or exteriorised
• Leave bladder peritoneum unsutured.
• Clean peritoneal cavity of liquor and blood.
• Close abdominal incision after checking packs, gauze and instruments.

Immediate post-operative management

Provides : Analgesia, Antibiotics and IVFs
Vital parameter Q15 mins-first hour, Q30mins-4hours, and then Q 4hours-rest of the
24hour
CAESAREAN SECTION – PROCEDURE (CONT.)

Others
• Ensure Haemostasis
• May close the uterus in-situ or exteriorised
• Leave bladder peritoneum unsutured.
• Clean peritoneal cavity of liquor and blood.
• Close abdominal incision after checking packs, gauze and instruments.

Caesarean section-Complications
• The procedure of CS is continuously being improved. Attributable to safe anaesthesia,
suturing, techniques, antiseptics, asepsis, blood transfusion and antibiotics.

But mortality and morbidity related to caesarean birth are still 3-4 times higher than
vagina birth, even higher in the developing countries
REVIEW OF CAESAREAN SECTION INDICATIONS

Short term risk of CS:

Mother
Anaesthetic complication, Severe haemorrhage/Peri-partum hysterectomy, thrombo-
embolism, Surgical site infection, Bowel/bladder/ureter injuries and amniotic fluid
embolism

Baby
Iatrogenic pre-term births and breathing difficulties
Neonatal adaptation is delayed in caesarean
Traumatic injuries/scalpel injuries

Medium/Long term risk of CS

Hypertrophic scar, Future uterine rupture and placenta praevia or accrete. Post-
caesarean subfertility.
Require management of subsequent pregnancies and delivery at a Tertiary Centre.
REVIEW OF CAESAREAN SECTION INDICATIONS

Absolute indication

The indication is absolute when the conditions directly threaten the mother's life, and
CS is the safest life-saving delivery option.
• Severe antepartum haemorrhage

• Mentoposterior position

• Obstructed labour with no possibility of instrumental delivery

Under these circumstances there is no question of choice other than CS

REVIEW OF CAESAREAN SECTION INDICATIONS

Relative indication
Under this circumstance, there are options for delivery (SVD or CS), but caesarean
section seems to give the best chance of safety for both mother and child.

• Information on alternatives to caesarean section should be discussed long with

their and possible complications

Let's re-visit the following as indication for caesarean section

• where there is no immediate threat to life, especially at advanced labour.
• Intrauterine fetal death, Breech presentation, transverse/oblique 2 nd twin
• Severe congenital anomalies, etc.
• Maternal request

Procedures to reduce increasing rate of caesarean section

• External cephalic version, Internal Podalic Version, Destructive procedures,
• Vaginal delivery after caesarean section and Induction of labour
EXTERNAL CEPHALIC VERSION

• It is a procedure for converting non-cephalic presentations to cephalic presentations

using manipulations on the anterior abdominal wall. The purpose is to achieve
vaginal delivery in a cephalic presentation.

• ECV should be offered from 36 weeks in Nulliparous and 37 weeks in Multiparous

women. There is no upper limit on the gestational age at which ECV can be
performed.

• Indication: Breech (usually), can also be done in transverse or oblique lie

Impact of external cephalic version: convert the majority of breech at term

Breech occurs in 3-4% of all deliveries at term,
(The rate of CS increased following the publication of the Multi-centre term Breech
trial)
EXTERNAL CEPHALIC VERSION

Absolute contraindications Relative contraindications

1. Ruptured membranes 1. Previous CS or myomectomy
2. Placenta praevia 2. Severe hypertensive disease in
3. Major uterine anomaly pregnancy
4. Multiple pregnancy 3. IUGR
5. Significant fetal abnormality 4. Rhesus isoimmunization
6. Abnormal cardiotocograph 5. HIV
7. Need for CS for other indications 6. Obesity
7. oligohydramnios
EXTERNAL CEPHALIC VERSION

Pre-procedure preparation
• Informed consent
• Setting: labour ward. Available theatre space
• Ultrasound: Confirm placental location, liquor volume and fetal attitude.
• Cardiotocograph: Confirm normal and reassuring fetal heart pattern
• Check maternal pulse rate and BP. Set an IV access and take blood for GXM. Ensure the
bladder is empty.
• Re-assure her and encourage her to report any usual discomfort or pain during the
procedure
• Position the patient in a semi-right lateral or Trendelenburg position

• Give tocolysis (Ritodrine 0.2mg/min IV for 20 mins).

• Apply talcum powder to the abdomen to enhance the smooth and free movement of the
hands
EXTERNAL CEPHALIC VERSION- PROCEDURE

Dis-impact the breech from the pelvis: Displace Breech from the pelvic
brim to the iliac fossa
 EXTERNAL CEPHALIC VERSION- PROCEDURE

Compress the baby into a ball, flex the fetal head and encourage a forward somersault. i.e.
• Right hand holds breech
•Left hand makes head and maintains flexion of the head and back throughout
 EXTERNAL CEPHALIC VERSION- PROCEDURE
The essence of the procedure revolves around manipulating the baby’s head down toward
the pelvis.
i.e
• Left hand brings head downwards
• Right hand pushes breech upwards
 EXTERNAL CEPHALIC VERSION- PROCEDURE

Once the baby is half turned, it usually kicks itself into a cephalic presentation.
EXTERNAL CEPHALIC VERSION-PROCEDURE

• If unsuccessful, try the opposite direction

• Uterine manipulation should be limited to < 10 minutes

• Confirm fetal well-being immediately after the procedure, whether successful or not

• Administer anti-D serum if rhesus negative

INTERNAL PODALIC VERSION (IPV)

• It is a procedure of converting non-breech to breech presentation followed by breech

extraction. It is formidable in reducing CS rate in twin gestation, cord and arm
prolapse

Indications
• 2nd twin in transverse or oblique lie/fetal distress
• Cord prolapse with adequate liquor,
• Arm prolapse with adequate liquor.

Pre-procedure preparation
• Counseling and Consent
• General anaesthesia (or without if very urgent).
• Glove both hands, the vaginal (right) and abdominal (left) hand, in the elbow and
standard gloves, respectively.
• Apply a sterile lubricant on the dorsum of the vaginal hand to reduce friction
during entry
INTERNAL PODALIC VERSION (IPV)

Pre-procedure preparation (Cont)

• Secure the back of the fetus using the abdominal hand

• With the membrane intact ( or just a ruptured membrane), insert the vaginal
hand gently through the cervix and identify the fetal foot (NB fetal can be
distinguished from the hand by its heel).
• Between contractions, pull one or both feet into the vagina until the buttocks are
delivered.
• Rupture the membrane if not already ruptured

• Continue delivery with the maneouvres of breech delivery.

INTERNAL PODALIC VERSION (IPV)
FETAL DESTRUCTIVE OPERATIONS (FDOS)

• Operations aimed at reducing the size of the head, shoulder girdle, or trunk of the dead or
severely malformed fetus to allow its vaginal delivery.

• The art and its proficiency for has dwindled making CS an attractive delivery option to
clinicians. The incidence of fetal destructive operations varies between 0.2 and 1.6% of
deliveries from reports originating in Nigeria, Ghana and India

• Modern obstetrics (barely used/limited place):

Psychological effect
Litigation
Complications may be life threatening

• Can reduce CS rate

May be useful in countries with high rate of obstructed labour.
FETAL DESTRUCTIVE OPERATIONS (FDO)

Contraindications
• Living normal fetus
• Markedly contracted pelvis
• Cervix dilatation < 7cm
• Neoplasm obstructing the pelvis

Dangers/Complications
• Lacerations of vagina cervix, uterus and uterine atony
• Uterine Rupture
• PPH (lacerations and Uterine atony)
• Infections

Four Main Types Of FDOs

Craniotomy (most performed), Decapitation, Evisceration and Cleidotomy
CRANIOTOMY

Craniotomy is characterized by perforation of the fetal head and extraction of its content to
allow delivery of the dead fetus or severely malformed fetus.

• Cranioclasm: crushing of the cranium.

• Cephalotripsy: crushing of the whole head including the base of the skull.

Indications
• Neglected obstructed labour with dead fetus
(Impacted mento-posterior/occipitoposterior/brow positions)
• Hydrocephalus live or dead
• Interlocked of twins
CRANIOTOMY

Prerequisite for craniotomy

• Informed consent.

• Need a skilled operator and assistant

• Ensure/establish IV access,

• Take blood for grouping and cross-matching

• Catheterize the bladder

• Correct dehydration and treat ketoacidosis

• Prophylactic antibiotics

• Fetus is dead (hydrocephalus excluded)

CRANIOTOMY

Prerequisite for craniotomy (conti.)

• < 2/5 head palpable above the brim

• Head is impacted

• Cervix is at least 7cm dilated

• Uterus unruptured/Show no sign of imminent rupture

• True conjugate > 7.5cm

• Adequate pain control

• Episiotomy

• Full disclosure of fetal condition, procedure, and fetal state after the procedure.
CRANIOTOMY

Sites of Perforation

Vertex presentation
• The anterior fontanelle or in the parietal bone as near as to it. (Hydrocephalus)

After-coming head (Breech)

• The roof of the mouth.
• The foramen magnum.
• The occipital bone behind the mastoid .

Brow Presentation
• Frontal bone

Face presentation
• The orbit/palate
SIMPSON’S OF OLDHAM PERFORATOR
• Cranioclast
CRANIOTOMY-TECHNIQUE

PERFORATION OF FORE-COMING HEAD

• The first step is perforation carried out by the Oldham or Simpson perforator

• Feat head is secured and steadied from the above symphysis by an assistant
grasping it and pressing it against the pelvic brim.

• The operator holds the perforator in his right hand. Under the protection of the fore
and middle fingers of the left hand, placed in the vagina, the tip of the instrument is
directed up against the skull

• The tip is pushed through a selected part of the fetal head. About half of the length of
the blades is advanced into the selected part of the fetal skull.

• Pressing the handles together produces a linear incision in the skull bones. The
instrument should be turned around and a similar tear made at right angles
CRANIOTOMY-TECHNIQUE

PERFORATION OF FORE-COMING HEAD (cont.)

• This allows the drainage of the CSF and brain matter. The perforator is closed and
withdrawn under protection of the left hand
e.g. Hydrocephalus : Perforation can be made using any suitable sharp instrument,
provided the cervix is sufficiently dilated to allow two fingers to be introduced.

EXTRACTION
• Spontaneous delivery can occur after reduction of the size . Two volsella or Willet’s
scalp forceps may be applied for traction to assist delivery.

• Forceps can be applied if there is no disproportion.

• •The cranioclast (2 blades) or the combined cranioclast and cephalotribe (3 blades) are
used for crushing and extracting the head if there is disproportion.

Complications : Injuries to uterus, cervix, vagina, bladder, urethra, rectum and Haemorrhage
DECAPITATION
DECAPITATION
It is severing of the fetal head from the trunk.
Neck of the fetus should be accessible per vaginaam

Indication
• Neglected shoulder presentation with hand prolapse.
• Locked twins.
• Double-headed monsters.

Technique: Severing of fetal head

• The fetal neck is severed using a thimble and a wire or with decapitation hooks
• The prolapsed arm is grasped to bring the neck within easier access.
• The decapitation hook, protected by the palm of the left hand, is passed up over the fetal
shoulder and turned over the neck.
o If the hook is sharp, the neck is severed by sawing movement
o if it is blunt, rotate it to cause fracture dislocation of the cervical spines then the
soft tissue is cut by embryotomy scissors with a blunt tip.
DECAPITATION

Technique (cont.)

Removal of the severed head

• manually by a finger hooked into the month and pulling on the jaw, or with forceps, unless
the pelvis is deformed

• In the severely contracted pelvis, the head is steadied by suprapubic pressure, perforated,
and the removed with then cranioclast, crotchet, etc

• After the head is completely severed, the trunk is removed by traction on the arm
CLEIDOTOMY

It is division of one or both clavicles with an embryotomy scissors to reduce the bisacromial
diameter in shoulder dystocia with a dead fetus
Reduces the bulk of the shoulder girdle (particularly done in the shoulder dystocia in dead
fetus

Two fingers of the left hand are passed along the ventral aspect of the child, and under the
protection of them the long straight scissors is introduced and the clavicle divided

Considerable power is required to snip the hard bone

The only danger is injuring the soft tissue of the mother

Care must be taken to identify the position of the clavicles

Evisceration

It is the placement of an incision on the abdomen or thorax to evacuate its viscera,

reducing its size and allowing its vaginal delivery.

Indications
• Neglected shoulder presentation with dead fetus; neck not easily accessible
• Thoracic or abdominal tumours.
• Fetal malformations such as fetal ascites or monsters

Techniques
• A large incision is made on the fetal thorax or abdomen with embryotomy scissors
then the viscera are evacuated manually. The abdominal viscera can be
approached through the diaphragm.
Fetal Destructive Operations (FDOs)

Others

Morcellations
Severing the fetus into pieces may be necessary on some rare occasions before vaginal
delivery can be accomplished

Spondylectomy is the transection of the spine of the delivered thorax.

• In breech presentation, it may allow drainage of CSF. It is done when the back is
anterior, and the head and neck are out of reach

• In cases of hydrocephalus, the fluid may be drained through the forebrain this way,
thus obviating the need for craniotomy
Fetal Destructive Operations (FDOs)

Post delivery care

1. Active management of the third stage
2. Oxytocin infusion is to be continued for 6-8hours as the risk of atonic PPH following
prolonged obstructed labour is high
3. Careful inspection of the genital tract for signs of trauma, including uterine exploration,
to rule out uterine rupture
4. Bladder should be catheterized for 5-7days in cases where bladder distension was
prolonged
5. Broad spectrum antibiotics
6. Thrombo-prohylaxis
7. Psychotherapy: mother/husband/family members should be taken care of