destructive operation and caesarian section
TRANSCRIPT
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DESTRUCTIVE OPERATION
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INTRODUCTION
The destructive operations are designed todiminish the bulk of the fetus so as to facilitateeasy delivery through the birth canal.
These procedures are difficult and may be
dangerous too unless the operator is sufficientlyskilled.
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Commonly performed operations are
Craniotomy
Evisceration
Decapitation
Cleidotomy
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1. CRANIOTOMY
It is an operation to make a perforation on thefetal head to evacuate the contents followed byextraction of the fetus.
INDICATIONS:
Cephalic presentation producing obstructedlabour with dead fetus
Hydrocephalus even in a living fetus
Interlocking head of twins.
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CONDITIONS TO BE FULFILLED
The cervix must be fully dilated Baby must be dead
CONTRAINDICATIONS
The operation should not be done when thepelvis is severely contracted
Rupture of the uterus where laprotomy isessential
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PROCEDURE
PRELIMINARIES Take consent
The patients is asked to empty her bladder.
She is to lie on her back with the shouldersslightly raised and the thighs slightly flexed.
Administer anaesthesia
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Step 2 : the Oldhams perforator with the blades
close, is introduced under the palmar aspect ofthe fingers protecting the anterior vaginal walland the adjacent bladder until the tip reachesthe proposed site of perforation
Step 3: by rotating movements the skull isperforated. During this step, an assistant isasked to steady the head per abdomen in amanner of first pelvic grip. After the skull isperforated, the instrument is thrust up to theshoulders and the handles are approximated soas to allow separation of the sharp blades forabout 2.5cm.
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The blades are again apposed by separating thehandles. The instrument is brought out keepingthe tip of the blades still inside the cranium. Theinstrument is rotated at right angle and thenagain thrust in up to the shoulders. The handles
are once more to be compressed so as toseparate the blades for about 2.5 cm. Theinstrument with the blades close is then thrust inbeyond the guard to churn the brain matter. The
instrument, with the blades closed is brought outunder the guidance of the two fingers still placedinside the vagina.
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Step 4: with the fingers brain matters is
evacuated. The idea is to make the skull collapseas much as possible
Step 5: when the skull is found sufficientlycompressed, the extraction of the fetus isachieved either by using a cranioblast or by twogiant volsella. Giant volsella are used to hold theincised skull and scalp margins.
Step 6: the traction is now exerted
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Step 7: after the delivery of the placenta, the
utero vaginal canal must be explored as aroutine for evidence of rupture of uterus or anytear.
Inj. Methergin 0.2 mg is to be given IM with the
delivery of the anterior shoulder. The rest of thedelivery is completed as in normal delivery.
Alternative to Oldhams perforator, similarprocedure could be performed using sharppointed Mayos scissor
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DECAPITATION
it is a destructive operation whereby the fetalhead is severed from the trunk and the deliveryis completed with the extraction of the trunk andthat of the decapitated head per vaginam.
INDICATION
Neglected shoulder presentation with dead fetus
where neck is easily accessible Interlocking head of twins
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PROCEDURES
Preliminaries : same as before.
ACTUAL STEPS
Step 1: if the fetal hand is not prolapsed, bringdown a hand. A roller gauze is tied on the fetalwrist and an assistant is asked to give tractiontowards the side away from the fetal head to
make the neck more accessible and fixed.
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Step 2 : two fingers of the left hand (middle andindex) are introduced with the palmar surface
downwards and the finger tips are to be placedon the superior surface of the neck theprolapsed site of decapitation.
Step 3: the decapitation hook with knife is to beintroduced flushed under the guidance of thefingers placed into the vagina, the knob pointingtowards the fetal head. The hook is pushed
above the neck and rotated to 900
so as to placethe knife firmly against the neck. The internalfingers,in the mean time, are placed on theunder surface of the neck to guard the tip of the
hook.
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Step 4: by upward and downward movements of
the hook with knife, the vertebral column issevered (evident by sudden loss of resistance).The rest of the soft tissue left behind may besevered by the same instrument or by
embryotomy scissors. While removing thedecapitation hook- it is to be pushed up; rotatedto 900and then to take out under the guidanceof internal fingers. The decapitated head is
pushed up and the trunk is delivered by tractionon the prolapsed arm.
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EVISCERATION
The operation consists in removal of thoracicand abdominal contents piecemeal through anopening on the thoracic or abdominal cavity at
the most accessible site. The object is todiminish the bulk of the fetus which facilitatesits extraction.
INDICATION
Neglected shoulder presentation with deadfetus; the neck is not easily accessible
Fetal malformation such as fetal ascites orhugely distended bladder or monsters
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CLEIDOTOMY
The operation consists of reduction in the bulkof the shoulder girdle by division of one or boththe clavicles.
The operation is done only in dead fetus(anencephaly exclude) with shoulder dystocia.The clavicles are divided by the embryotomyscissors or long straight scissors introduced
under the guidance of left two fingers placedinside the vagina.
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POST OPERATIVE CARE FOLLOWING
DESTRUCTIVE OPERATION
Exploration of the utero- vaginal canal must bedone to exclude rupture of the uterus or
lacerations on the vaginal or any genital injury.A self retaining (Foleys ) catheter is put inside
specially following craniotomy for a period of 3-5 days or until the bladder tone is regained.
Dextrose saline drip is to be continued tilldehydration is corrected. Blood transfusion maybe given, if required.
Ceftriaxone 1 gm IV is given twice daily.
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It is an operative procedure whereby the
foetuses after the end of 28thweek are deliveredthrough an incision of the abdominal anduterine walls.
The first operation performed on a patient isreferred to as a primary caesarean section.
When the operation is performed in subsequentpregnancies, it is called repeat caesarean section.
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FACTORS FOR INCREASING CS RATE
Identification of risk foetusesbefore term (IUGR)
Identification of risk mothers
Wider uses of repeat CS incases with previous Caesareandelivery
Rising rates of induction oflabour and failure of induction
Decline in operative vaginaland manipulative vaginaldelivery (rotational forceps
Decline in vaginal breechdelivery
Increased number of womenwith age > 30 and associatedmedical complication.
Adoption of small family normneither the obstetrician northe patients are ready toaccept any risk of abnormallabour.
Wider use of electronic fetalmonitoring and increaseddiagnosis of fetal distress
Caesarean delivery ondemand.
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INDICATIONSABSOLUTE RELATIVE
Vaginal delivery is not possible.Caesarean delivery is neededeven with a dead fetus.
Central placenta previa
Contracted pelvis or cephalopelvic disproportion.
Pelvic mass causingobstruction.
Advanced carcinoma cervix.
Vaginal obstruction
Vaginal delivery may be possiblebut risks to the mother and or tothe baby are high.
More often multiple factors maybe responsible.
Cephalo pelvic disproportion.
Previous caesarean delivery. Non reassuring FHR.
Dystocia
APH
Mal presentation
Failed surgical induction
Failure to progress in labour Bad obstetric history
Hypertensive disorders
Medical- gynaecologicaldisorders
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COMMON
PRIMIGRAVIDAE
Failed induction
Fetal distress
CPD
Dystocia Malposition and mal
presentation
MULTIGRAVIDAE
Previous LSCS
APH
Malpresentation
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TYPE OF OPERATON
ACCORDING TO TIME
ELECTIVE
EMERGENCY
ACCORDING TO THE SITE OF INCISION
LOWER SEGMENT CLASSICAL OR UPPER SEGMENT
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ELECTIVE CS
when the operation is done at prearranged timeduring pregnancy to ensure the best quality ofobstetrics, anaesthesia, neonatal resuscitationand nursing services.
Time Maturity is certain: the operation is done about
one week prior to the expected date ofconfinement.
Maturity is uncertain: Ultrasound assessment.Amniocentesis for L:S ratio is used t ensure fetalmaturity. Otherwise spontaneous onset of labouris awaited and then CS is done.
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EMERGENCY
when operation is performed due to unforeseenor acute obstetric emergencies.
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LOWER SEGMENT CAESAREAN SECTION
In this operation, the extraction of baby is donethrough an incision made in the lower segmentthrough a transperitoneal approach. It is the
only method practised in present day obstetrics In a LSCS, a transverse incision is made in the
lower segment; this heals faster and successfullythan an incision in the upper segment of theuterus. There is less muscle and more fibroustissue in he lower segment, which reduces therisk of rupture in the subsequent pregnancy
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It is commonly performed through a transverseincision on the abdomen, the pfannenstiel orbikini line incision.
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Transverse incision
Advantages Disadvantages
Post operative comfort is more
Fundus of the uterus can bebetter palpated during
immediate post operativeperiod
Less chance of wounddehiscence
Cosmetic value
Less chance of incisionalhernia
Takes little longer time and assuch unsuitable in acuteemergency operation
Blood loss is little more
Requires competency duringrepeat section
Unsuitable for classicaloperation
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PREOPERATIVE PREPARATION
Informed written permission for the procedure, anaesthesia
and blood transfusion is obtained. Abdomen is scrubbed with soap and nonorganic iodide lotion.
Hair may be clipped. Premediactive sedative must not be given Non-particulated antacid(0.3molar sodium citrate, 30ml) is
given orally before transferring the patient to theatre. Ranitidine (H2 blocker) 150mg is given orally night before(
elective procedure) and it is repeated one hour before surgery Metaclopromide(10mg IV) is given The stomach should be emptied The bladder should be emptied by a foley catheter
FSH should be checked ones more at this stage Neonatologist should be made available. Cross match blood when above average blood loss is
anticipated.
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Incision on the abdomen: the surgeon may
choose either a vertical or a transverse skinincision. Vertical incision may be infraumbilicalmidline or paramidline. Transverse incision,modified Pfannenstiel made 3cm above the
symphisis pubis The anatomical layers incised are:
Fat
Rectal sheathMuscle (rectus abdominis)
Abdominal peritoneum
Uterine muscle
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REMOVAL OF THE PLACENTA AND
MEMBRANES
The placenta is extracted by traction on the cordwith simultaneous pushing of the uterus towardsthe umbilicus per abdomen using the left hand
The membranes are to be carefully removedpreferably intact and even a small piece, ifattached to the deciduas should be removed
using a dry gauze.
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SUTURE OF THE UTERINE WOUND
The margins of the wound are picked up by Allistissue forceps or Green Armitage Hemostaticclamp.
SUTURE OF THE UTERINE INCISION
A continuous suture A second layer of interrupted suture
The third layer of continuous suture
Repair of rectal sheath brings the rectusabdominis in to alignment. The subcutaneous fatis sometimes sutured and finally the skin isclosed with sutures or clips
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POST OPERATIVE CARE
First 24 hours (day 0) Observation- pulse, BP, amount of bleeding,
behaviour of uterus
Fluid-2-2.5L of NR or RL.
Prophylactic antibiotic
Analgesics- inj pethadine hydrochloride 75-100mg.
Ambulation- can sit, can get out for bladderempting.
Baby- feeding.
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Day 1: oral fluid in the form of plain orelectrolyte water or raw tea may be given. Activebowel sounds are observed by the end of the day.
Day 2:light solid diet of the patients choice isgiven. Bowel care: 3-4 teaspoons of lactulose is
given at bed time, if the bowels do not movespontaneously.
Day 5 -6: the abdominal skin stitches are to beremoved on the D5 or D6
Discharge: the patient is discharged on the dayfollowing the removal of the stitches
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Lower segment ClassicalTechnique Technically slight difficult
Blood loss is lessThe wall is thin and as such apposition is perfectPerfect peritonisation is possible
Technical difficulty in placenta praevia or
transverse lie
Technically easyBlood loss is moreThe wall is thick and apposition of the margins is
not perfect
Not possibleComparatively safer in such circumstances.
Post operative Haemorrhage and shock lessPeritonitis is less even in infected uterus because
of perfect peritonisation and if occurs, localised to
pelvisPeritonel adhesion and intestinal obstruction are
lessConvalescence is betterMorbidity and mortality are much lower
MoreChance of peritonitis is more in presence of
uterine sepsisMore because of imperfect peritonisationRelatively poorMorbidity and mortality are high.
Wound healing The scar is better healed The scar is weakDuring future
pregnancyScar rupture is less More risk of scar rupture
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INTRA OPERATIVE COMPLICATION
Extension of uterine incision
Uterine lacerations
Bladder injury
Urethral injury
GI tract injury Haemorrhage
Morbid adherent placenta
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