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OPERATIVE DELIVERY
Dr Jacqueline WoodmanConsultant Obstetrician & Gynaecologist
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Caesarean Section
• A Caesarean section is a surgical procedure in which an incisions is made in the uterus to deliver one or more babies
• The first modern Caesarean section was performed by German gynaecologist Ferdinand Adolf Kehrer in 1881.
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Indications for Caesarean Section
1. Placenta praevia2. Transverse lie3. Previous classical Caesarean section4. Obstructed labour
e.g. cephalo-pelvic disproportion, failure to progress
5. Breech presentation6. Abruptio placenta7. Previous repeated Caesarean section8. Fetal indications:
Congenital abnormality e.g. severe hydrocehalus Multiple pregnancy e.g. first twin breech, triplets Cord prolapse Severe preterm IUGR
9. Maternal request e.g. tokophobia
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Planned Caesarean section will increase the following risks:
• Maternal: – Longer hospital stay– Bleeding that requires a hysterectomy– Heart attack
• Neonatal:– ICU admission
http://www.nice.org.uk/nicemedia/live/13620/57166/57166.pdf
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Risks of Caesarean section
• Maternal: – Haemorrhage: 5 per 1000
• Hysterectomy: 8 per 1000– Infection: 6 per 100– Thrombosis: 4-16 per 10 000– Visceral and / or vascular injury
• Bladder injury: 1 per 1000– Anaesthetic risks– Death: 1 per 12 000– Future pregnancy:
• antepartum stillbirth: 1-4 per 1 000• Uterine rupture: 2-7 per 1000• Placenta accreta: 4-8 per 1000
• Neonatal:– Tansient tachypnoea of the newborn (TTN)– Injury to baby: 1-2 per 100
http://www.rcog.org.uk/guidelines
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Caesarean section: the procedure
• Skin incision and entry?– Joel Cohen vs Phannelstiel: a 65% reduction in reported
postoperative morbidity with the Joel-Cohen incision.• Incision of uterus:
– transverse lower segment vs Classical• Closure of the uterus:
– 1 vs 2 layer• Closure of the abdomen:
– peritoneum, sheath, subcutaneous, skin
http://apps.who.int/rhl/reviews/CD004453.pdf
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Classification of urgency of Caesarean section
Maternal or fetal compromise:1. Immediate threat to life2. No immediate threat to moterh or baby 3. Requires early delivery
No maternal or fetal compromise4. At a time convenient to all
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Operative Vaginal Delivery
• Ventouse• Forceps
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Indications for ventouse / forceps
• Failure to progress in second stage• Fetal distress in second stage• Maternal exhaustion• Maternal conditions e.g. Heart conditions
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Conditions for a ventouse / forceps
• Fully dilated• Maternal consent• Station and position of fetal head known• Bladder empty• Lithotomy• Analgesia
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Thank you
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References
• NICE• CEMACH• RCOG