Fourth session: Skill lab

Outline

Demonstrate the indications, prerequisites, application and complications of forceps/ventouse

Discuss the indications, technique and complications of cesarean section

Forceps/ventouse

Indications

Maternal • Distress • Disease• Rigid soft tissuesFetal • DistressProgress• Arrest in the second stage with full cervical

dilatation

Prerequisites • Mother: Generally cooperative (ventouse) cervix, uterus, pelvis, bladder, rectum, analgesia/anesthesia• Baby: presentation, >34 weeks (ventouse), viable (ventouse), station, size

Application: Forceps

Vacuum extraction

Complications: forceps/vacuum

• Short term

Maternal

Fetal

Long term

Maternal

Fetal

Complications vacuum

(I) Foetal :1- Cephalohaematoma.2- Scalp lacerations.3- Rarely, intracranial haemorrhage.(II) Maternal:1. Vaginal and cervical lacerations.2- Annular detachment of the cervix, cervical

incompetence 3-prolapse if used with incompletely dilated cervix.

Cephalhematoma Caput

Cephalhaematoma Caput SuccedaneumDevelops hours or days after birth. Present at birth .

limited by sutures at its edges. overlies more than one bone .

Well-defined edges Ill-defined edges.Elastic does not pit on pressure. Soft , pits on pressure.

Disappears within few weeks. Disappears within 1-2 days.

Complications: forceps(A) Maternal complications:1- Complications of anesthesia.2- Lacerations:- Extension of the episiotomy.- Perineal tear.- Vaginal tears.- Cervical lacerations.- Bladder injury.- Rupture uterus.3- Bone injuries: to pelvic joints, coccyx or symphysis pubis.4- Pelvic nerve injuries.5- Postpartum haemorrhage: due to lacerations or atony.6- Puerperal infections.7- Remote effects: genital prolapse, stress incontinence, cervical incompetence

and genito-urinary fistulas.

(B) Fetal complications:

1- Fracture of the skull.

2- Intracranial hemorrhage.

3- Facial nerve palsy.

4- Trauma to the face, eyes or scalp.

Facial nerve palsy

• Due to pressure by forceps on the nerve at its exit from the stylomastoid foramen in the parotid region.

• Good prognosis as it heals spontaneously and does not interfere with suckling.

Cesarean section

Indications

(A) Maternal indications:1. Contracted pelvis and cephalopelvic disproportion (see

before).2. Pelvic tumors especially if impacted in the pelvis or

cancer cervix3. Antepartum hemorrhage (see before).4. Hypertensive disorders with pregnancy ( see before).5. Abnormal uterine action (see before).6. Previous uterine scar as hysterotomy or metroplasty.7. Previous successful repair of vesico-vaginal fistula.

8. Previous caesarean section if,i- the cause of the previous section is permanent e.g.contracted pelvis.ii- previous section was upper segment.iii- suspected weak scar as evidenced by:- Vaginal bleeding during current labor.- Marked tenderness over the scar during currentlabor.iv- Associated conditions as antepartum hemorrhage ormalpresentations.

(B) Fetal indications:

1. Malpresentations and malposition.

2. Prolapsed pulsating cord or fetal distress before full cervical dilatation.

3. macrosomia

4. Bad obstetric history

5. Conjoined twins

6. Post-mortem C.S. done within 10 minutes of maternal death to save a living baby.

Types of Caesarean Section:(A) According to timing:Elective caesarean section: at a pre-selected time before

onset of laborSelective caesarean section: The operation is done after

onset of labor. (B) According to the site of uterine incision:Upper segment caesarean section (classical C.S.): The

incision is done in the upper uterine segment (vertical).Lower segment caesarean section (LSCS) : It is the

commoner type. Usually transverse Vertical in the following conditions:-i- Presence of lateral varicosities.ii- Constriction ring to cut through it.