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Operative Obstetrics: Richard G. Moutvic, MD, Facog

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OPERATIVE OBSTETRICS

RICHARD G. MOUTVIC, MD, FACOG


Objectives

 Episiotomy and Vaginal Lacerations


 Abortion---Spontaneous and Induced
 Ectopic Pregnancy
 Forceps
 Vacuum Extraction
 Cesarean Section
 VBAC
Episiotomy and Vaginal
Lacerations

 Midline Episiotomy

 Lateral Episiotomy

 Vaginal Lacerations

 First, Second, Third, Fourth Degree


Muscles of the Perineal Body

 Bulbocavernosus

 Transverse perineal

 Puborectalis

 External Anal Sphincter


Obstetric Laceration

FIGURE 2. Anal sphincter complex (cadaver dissection).


Abortion

 Spontaneous
 Induced
Treatment
Suction curettage
D and C
Medical Intervention
Spontaneous Abortion

 Spontaneous
 Threatened – bleeding in early gestation
 Inevitable – bleeding with contractions
and dilation
 Incomplete – products of conception
partially passed
 Missed – dead fetus retained without
expulsion
 Septic-Fever over 100.4F due to infection
(endo/parametritis-septicemia)
Spontaneous Abortion

 Etiology
 Developmental abnormality of zygote,
embryo,fetus, placenta
 >50% degenerated or absent embryo
(blighted ovum)
 60% abnormal chromosomes (>30% of 2nd
trimester Ab’s)
 Hemorrhage into decidua basalis causes
necrosis
 Ovum detaches, stimulates contractions
Spontaneous Abortion

 Treatment
 Observation

 Dilationand Curettage (D&C)


 Vacuum Extraction (suction
curettage)
Induced Abortion

 Rate: 238/1000 live births (60% in


first 8 weeks, 88% iw/in 12 weeks)
 Outpatient centers – up to 15 weeks

 Medical centers over 15 weeks


Induced Abortion
 Treatment Medical induction agents
RU487, Estrogen/Progesterone, Dilatories
 Menstrual aspiration
 Dilation and Curettage
 Dilation and Evacuation
 Cervical dilation substances
 Uterine stimulants
 Partial Birth Abortion
 Hysterotomy
 Hysterectomy
Female Pelvic Organs
D and C
Ectopic Pregnancy

 Diagnosis
o Abnormal uterine bleeding
o Pelvic Pain
o Positive Pregnancy Test
o Ultrasound
Ectopic Pregnancy
Ectopic Pregnancy

 Surgical Treatment
o Laparoscopy, Laparotomy

 Medical Treatment
o Methotrexate and others
Laparoscopic view
Female Pelvis
Pelvic Types

 Pelvic Types
Gynecoid, Android, Anthropoid, Platypoid
Gynecoid Pelvis
Android Pelvis
Pelvic Measurements

 Inlet

 Midplane

 Outlet
Mechanisms of Labor

 Flexion
 Descent
 Internal Rotation
 Extension
 External Rotation
 Explusion
STATION

 Plane across ischial spines


Station

 -3
 -2
 -1
 0 VTX @ Spines
 +1
 +2
 +3
 +4
Position of Fetal Head

 Descent---Head enters pelvic inlet in the


transverse
 Head Rotates to AP (Internal Rotation)
in the Mid Plan
 Head is born by Extension
25

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OP, LOP, ROP, ROT, LOT

Fetal Position
Forceps

 Position
 BOW must be ruptured
 Station
 High Forceps >0 station
 Mid Forceps> 0 - +2
 Low Forceps +3
 Outlet Forceps
Forceps

 Indications:
 Prolonged 2nd stage of labor
 Progress has stopped
 Inability to push due to anesthesia/analgesia
 Fatigue

 Immanent delivery is desirable (FHT’S


bleeding, etc. )
Go to Williams Obstetrics for forceps delivery
video
Forceps
 Law of Forceps:
 Complete cervical dilations
 BOW has ruptured
 Position is known
 Vertex is engaged at +2 station or below
Forceps
 Trial of Forceps/Failed Forceps:
o Anticipate difficult delivery with CS ready

o ACOG states: clinical assessment is highly


suggestive of successful outcome

 Emphasize proper training


FORCEPS
Vacuum Extraction

 Generally OK after 34 weeks gestation


 Indications same as forceps
Vacuum Extraction

 Contraindications

 Fetal Coagulopathy

 Can’t assess position

 High station

 Non vertex presentation

 Suspect cephalic disproportion


Vacuum Extraction

 Complications of vacuum extraction

 Cephalohematoma

 Scalp laceration

 Intercranial hemorrhage

 Neonatal jaundice

 6th and 7th intercranial nerve damage

 Skull fracture
Vacuum Extraction

 Same rules apply as forceps


 Used properly, no more incidence of fetal or
maternal complications than spontaneous
delivery
 Abandon procedure if no progress after 3rd
contraction or if cap dislodges > 3 times
Vacuum Extraction
 Contraindications

 Fetal coagulopathy

 Inability to assess position

 High station

 Non vertex presentation

 Suspect cephalo-pelvic disproportion

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Comparison of Forceps/Vacuum
 IQ tested at age 17- no difference between
spontaneous delivery, vacuum or forceps
 FDA showed 5% skull fracture in nulliparous woman
with over 3 pulls or “pop-offs”.
 Forceps causes more 3rd and 4th degree
lacerations
 Vacuum causes more retinal hemorrhages (no long
term effects)
 Vacuum causes less maternal damage, more fetal
trauma

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C-Sections

 Percentages of deliveries via C-Section


 31% (15-16% primigravidas)
 Indications for section
 Repeat C-Section
 Cephalo pelvic Disproportion (CPD)
 Failure to progress---due to fetal size, maternal soft tissues, power of uterine contractions (UC’s),
pelvic size
 Nonreassuring fetal heart tones
 Malpresentation
 Shoulder dystocia
 Pre eclampsia/Eclampsia
 Obesity
 Older age of parturiants
 Decrease in VBAC
 Legal
C-Sections (cont)

 Additional Indications for a C Section


o Medical problems—i.e. DM, Heart, Renal,
Vascular
o Decrease in VBAC (TOLAC=trial of labor
after CS)
o Cord prolapse
o Valuable Baby syndrome
o Elective
o Legal considerations
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Placenta Previa
Abruptio Placenta
Types of C-Sections

 Classical Incision

 Low Classical

 Low Transverse Incision


VBAC

 Vaginal Birth after C-Section (TOLAC)


 Success Rate:
o After CPD
o After Malpresentation
o After Bleeding Disorder

o Current Controversy (New Mexico 80% To 90% due to


restrictions requiring fully equipped OR for immediate
CS)
o ACOG and ASA

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