Complications - operative obstetrics

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““PovertyPoverty is lot like is lot like childbirthchildbirth – you know it is – you know it is going to hurt before it happens, but you’ll never going to hurt before it happens, but you’ll never know how much until you know how much until you experienceexperience it” it”

Joanne Kathleen Joanne Kathleen Rowling Rowling

A day in a labour Room……A day in a labour Room……

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For successful vaginal For successful vaginal delivery….delivery….

Perineal massagePerineal massage  and regular   and regular pelvic pelvic floor exercises.floor exercises.

Perfect Perfect “P”s“P”s

Changes in maternal positioningChanges in maternal positioning

Reduction in neuraxial anesthesiaReduction in neuraxial anesthesia

Increased emotional support Increased emotional support

Laboring downLaboring down

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Operative DeliveryOperative Delivery

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TractionTraction

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Incidence (Birth 2002)

% 1980 1990 2000

Forceps 17.7 8.6 4.0

Vacuum 0.7 6.1 8.4

Caesarean 16.5 23.5 22.9

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Complications related to Complications related to Operative Obstetrics:Operative Obstetrics: Nursing Challenge Nursing Challenge

Problems arising from Problems arising from EpisiotomyEpisiotomy

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PainPain

EdemaEdema

BleedingBleeding

InfectionInfection

Defects in wound closureDefects in wound closure

Sexual discomfort /dysfunctionSexual discomfort /dysfunction

Complications of AVD - Maternal

Lacerations: Vaginal / perineal / cervicalLacerations: Vaginal / perineal / cervicalHematoma / HaemorrhageHematoma / HaemorrhageIncontinence / retention of urineIncontinence / retention of urineInfectionInfectionPainful perineal scarsPainful perineal scarsLow back painLow back painDyspareuniaDyspareuniaSUI SUI Nerve InjuryNerve Injury

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Neonatal MorbidityNeonatal Morbidity

Low Apgar scoresLow Apgar scores

Scalp traumaScalp trauma

Facial mark/injuryFacial mark/injury

CephalhematomaCephalhematoma

Subgaleal hematomaSubgaleal hematoma

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ChignonChignon

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CephalhematomaCephalhematoma

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CephalhematomaCephalhematoma

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Subgaleal HematomaSubgaleal Hematoma

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Subgaleal HematomaSubgaleal Hematoma

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Neonatal MorbidityNeonatal MorbidityIntracranial hemorrhageIntracranial hemorrhage

Retinal hemorrhageRetinal hemorrhage

Neonatal jaundice Neonatal jaundice

Erb palsyErb palsy

Fractured clavicleFractured clavicle

Nerve injuryNerve injury

Shoulder dystociaShoulder dystocia

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Birth Asphyxia & InjuriesBirth Asphyxia & Injuries

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Cesarean deliveryCesarean deliverycomplicationscomplications

BleedingBleeding

AtelectasisAtelectasis

Bladder injuryBladder injury

GIT injuryGIT injury

Ureter injuryUreter injury

Paralytic ileusParalytic ileus

Wound infectionWound infection

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Wound dehiscenceWound dehiscence

UTI

EndometritisEndometritis

ThrombophlebitisThrombophlebitis

DVTDVT

AdhesionsAdhesions

Intestinal ObstructionIntestinal Obstruction

Cesarean Section Cesarean Section ComplicationsComplications

University hospital, University hospital, GlostrupGlostrup– 7782 women7782 women– c/sec rate: 929 (11.9%)c/sec rate: 929 (11.9%)– Emergency c/sec rate : Emergency c/sec rate :

636(68.5%) 636(68.5%)

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Acta Obstet Gynecol Scand 2003 : 82: 251-256

Incidence of Intraoperative Incidence of Intraoperative ComplicationsComplications

Type of complication Total Emergency Elective

Cervical laceration 3.6%(33) 4.6%(29) 1.4%(4)

Corporal laceratoin 0.3%(3) 0.3%(2) 0.3%(1)

Vaginal laceration 1.2%(11) 1.7%(11) 0.0%(0)

Bladder laceration 0.5%(5) 0.8%(5) 0.0%(0)

Bowel laceration 0.0%(0) 0.0%(0) 0.0%(0)

Lacerations in total 5.2%(48) 6.8%(43) 1.7%(5)

Blood transfusion 1.0%(9) 1.1%(7) 0.7%(2)

EBL ≥ 1000ml 9.2%(77) 9.0%(57) 6.8%(20)

Uterine rupture 0.3%(3) 0.5%(3) 0.0%(0)

Hysterectomy 0.2%(2) 0.2%(1) 0.3%(1)

Total 12.1%(112) 14.5%(92) 6.8%(20)

Effect of Delivery on Neonatal Effect of Delivery on Neonatal InjuryInjury

DeliveryDelivery DeathDeath ICHICH OtherOther

NSVDNSVD 1/5,0001/5,000 1/1,9001/1,900 1/2161/216

C/S in LaborC/S in Labor 1/1,2501/1,250 1/9521/952 1/711/71

C/S w/o LaborC/S w/o Labor 1/1,2501/1,250 1/2,0401/2,040 1/1051/105

VacuumVacuum 1/3,3331/3,333 1/8601/860 1/1221/122

ForcepsForceps 1/2,0001/2,000 1/6641/664 1/761/76

Vacuum & ForcepsVacuum & Forceps 1/1,6661/1,666 1/2801/280 1/581/582323

Postpartum maternal Postpartum maternal complicationscomplications

Postpartum hemorrhagePostpartum hemorrhage

Postpartum infectionsPostpartum infections

ThrombophelebitisThrombophelebitis

SubinvolutionSubinvolution

MastitisMastitis

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Prevention is betterPrevention is better

Experienced providerExperienced provider

Assessment of maternal pelvisAssessment of maternal pelvis

Selection of procedureSelection of procedure

Adequate anesthesiaAdequate anesthesia

Fulfillment of prerequisites Fulfillment of prerequisites

Willingness to abandon attemptWillingness to abandon attempt

Ability to perform c-sectionAbility to perform c-section

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Center of the cup Center of the cup over the sagittal over the sagittal suture, about 2 suture, about 2 cm in front of the cm in front of the posterior fontanel. posterior fontanel.

Some tips……

Soft cupSoft cupMetal cup2828

Release suction between Pushes 2 pop-offs, abandon procedure

Vacuum ProcedureVacuum Procedure

Check for vaginal or vulvar Check for vaginal or vulvar tissues trap between the tissues trap between the cup and fetal surface. cup and fetal surface.

Gradual Vs Rapid Gradual Vs Rapid Application of Vacuum Application of Vacuum PressurePressure

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Fear during labourFear during labour

Worries Worries

Review labour processReview labour process

Frequent progress reportFrequent progress report

Personal availability of nursePersonal availability of nurse

Promise postnatal debriefing Promise postnatal debriefing sessionssessions

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Nursing considerationsNursing considerations

AvailabilityAvailabilityOrganizationOrganizationCalmnessCalmnessCommunicationCommunicationDelegationDelegationConsentConsentPreparationPreparationTeamworkTeamworkTackling failureTackling failure

Be prepared, Be prepared, except the except the unexpectedunexpected

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As a midwife…….As a midwife…….Confidence & Competence Confidence & Competence

Open mind, accepting attitude, hands-on Open mind, accepting attitude, hands-on skills, and broad deep understandingskills, and broad deep understanding

Surveillance of fetus and motherSurveillance of fetus and mother

Data acquisition: interpret dataData acquisition: interpret data

Verbal and nonverbal cuesVerbal and nonverbal cues

Patient-centered care - Patient-centered care - “high tech”“high tech” and and “high “high touch” touch”

Conducive environment and low stressConducive environment and low stress

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THEY NEED YOU THEY NEED YOU

& YOUR& YOUR CARECARE

Speak tenderly to them. Let there be kindness in Speak tenderly to them. Let there be kindness in your face, in your eyes, in your smile, in the your face, in your eyes, in your smile, in the warmth of our greeting. Always have a cheerful warmth of our greeting. Always have a cheerful smile. Don't only give your care, but give your smile. Don't only give your care, but give your heart as well.heart as well. - - Mother TeresaMother Teresa

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