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Obstetric procedures (Cesarean section (indications (in maternal diseases…
Obstetric procedures
Cesarean section
indications
- Absolute and relative
- Preventive without fetal distress (history, functional disturbancies)
- Preventive with onset of fetal distress (chronic, acute, subacute)
- Prompt (severe fetal distress diagnosed in CTG and pH-metry)
-
electice indications
- Abnormal fetal lie – transverse and oblique, breech in primipara, EFW above 3500 in breech presentation.
- Fetal macrosomy – EFW above 4500, or 4250 in diabetic patients
- Multiple pregnancy with 3 or more fetuses, twins with breech presentation of first fetus, tranverse lie of the second twin or EFW difference above 20% with smaller first twin
- Patients after two or more cesarean sections
Immediate indications
- Prolonged second stage of labor:
head-to-pelvis diproportion
abnormal contractility of the uterus, originally or secondarily weak, not causing labor progress
deflexed fetal head presentations
uterine cervix dystocia – original or secodary problem with cervical dilation
Emergency indications
bleeding during labor (placenta previa, preterm placental abruptio, vasa previa)
uterine rupture
eclampsia
threatening fetal distress
failed forceps or vacuum
failed internal version of the second twin
-
surgical techniques
Transperitoneal suprapubic transverse (sectio caesarea transperitonealis suprapubica transversa)
Classic
Extraperitoneal
Transvaginal
Incision of the uterine muscle in lower segment
Extraction of the fetus
Extraction of the placenta
Reconstruction of layers
-
-
complications
Early
Anesthetic: headache, aspiration syndrome
Surgical: not rare, bleeding from uterine vessels cut during surgery, slower uterine involution
Damage of urinary tract (urinary bladder and ureters)
Wound infections
Uterine bladder infection
Pneumonia
Abscessuss in pelvis
Septic shock
Thrombo-embolic complications
Long-term
Endometriosis in the scar (0.03-0.07%)
Utero-vesical fistula
Uterine rupturę in the next pregnancy (0.5% after first cesarean section, 5% after classic cesarean section)
Abnormal placental implantation in the next pregnancy
Abnormal gestation implantation in the uterine scar
Remember
- Vaginal delivery i s the best for mother and child
- Cesarean section is useful tool saving lives and health of mothers and children
- Elective cesarean section should be performer after 39 weeks (except multiple pregnancies) or preferable after labor onset
- Cesarean section is not beneficial for the babies below 800g (SGA, IUGR)
Forceps
indications
- Maternal: diseases requiring shortening of the second stage of labor, weak uterine contractions, epidural anesthesia, eclampsia, placental abruptio
- Fetal: distress
conditions
- Full cervical dilation
- Head below pelvic inlet
- Normal anatomy of the pelvis, no head-to pelvis disproportion
- Alive fetus
- Ruptured membranes
application
Emptying of the urinary bladder
Forceps presentation
Application of the forceps (left blade with the lock as the first)
Locking forceps
Trial traction
Real traction
Episiotomy
Delivery of the head and removing forceps
Shoulders extraction
episiotomy
Aims
Prevents rupture of perineum, which may damage anal sphincter
Protects fetal head from injury caused by pelvic floor resistance
Shortens the 2nd stage of labor in cases of fetal heart rate abnormalities
technique
- At the top of the contraction, after local anesthesia
Lateral episiotomy –in the direction of the ischial tuberosis
Median episiotomy
-
Curettage
-
technique
Visualization of vaginal part of the cervix in wide speculum
Catching vaginal part with the window-like forceps and moving it down
Introducing large Bumm curette into uterine cavity
Vacuum extractor
- Indications – like for forceps
- Conditions similar, cervix does not have to be fully dilated
- Procedures performed in labor or pregnancy to deliver healthy baby
- Experienced obstetrician should decide to perform obstetric procedure
- Cesarean section
- Versions (external and internal)
- Maneouvres in breech delivery
- Forceps, Vacuum
- Episiotomy and stiching
- Manual revision of uterine cavity
- Manual separation of placenta
- Curettage