1. Operative Intervention in Obstetrics
Halim Dr. Raghad Abdul

2. Caesarean Section:
Caesarean section refers to an operation that is performed to deliver a baby via the trans- abdominal route.

3. Indications for caesarean section:
Past obstetric history:
Previous classical C/S.
Interval pelvic floor or anal sphincter repair.
Previous severe shoulder dystocia with significant neonatal injury.
Current pregnancy events:
Significant fetal disease likely to lead to poor tolerance of labour.
Mono-amniotic twins.
Placenta previa.
Obstructing pelvic mass.
Active primary herpes at onset of labour.
Intrapartum events:
Acute fetal compromise in the first stage.
Maternal disease for which delay in delivery may compromise the safety of the mother.
Absolute cephalo-pelvic disproportion (brow presentation, etc)
There are many other indications for C/S.

4. Preparations for ceasarean section:
Full informed consent must always be obtained prior to operation,
suprapubic shaving,
bladder should be emptied, foly's catheter is inserted and remains per operatively,
premedication with antacid is standard,
and all patients being transferred to theatre must be in the left lateral position with a wedge under the right buttock (to prevent supine hypotension and fetal distress).
The operating table must be kept in a left lateral tilt position until after the delivery.
Thromboprophylaxis should be considered for all patients
and prophylactic antibiotic should be given.

5. Operative Procedure: Skin incision either:
* suprapubic transverse incision (pfannenstiel incision commonly used): has the advantage of improved cosmetic results, decreased analgesic requirements and thus less postoperative pulmonary compromise and superior wound strength,
Or * midline vertical incision which provides greater ease of access to the pelvic and intra- abdominal organs and may be enlarged more easily, may be indicated in extreme maternal obesity, or suspected other intra-abdominal pathology.

6. Uterine incisions: either
* transverse lower segment uterine incision is used in more than 90% of C/S due to:
Ease to repair.
Reduced blood loss.
Lower incidence dehiscence or rupture in subsequent pregnancies
Or * vertical upper segment uterine incision which is indicated in certain situation because:
It is difficult to repair.
Associated with severe bleeding.
More incidence of rupture in subsequent pregnancies.

7. Indications of classical uterine incision:
Lower segment fibroid.
Lower segment dense adhesions.
Placenta previa with large vessels in the lower segment.
Transverse lie with back down and prolapsed arm.
PPROM associated with poor lower segment and transverse lie
Conjoined twins
C/S in the presence of cervical carcinoma.
Post-mortem C/S.

8. Other types of uterine incisions are U-shape, J-shape, or modified classical incision (lower segment vertical) incisions.
After delivering the baby, placenta and membranes should be delivered by continuous cord traction.
Uterine closure: either in single layer or in double layer, with good heamostasis. Closure with double layer is preferred as it is associated with less scar dehiscence in subsequent pregnancies.

9. Complications of ceasarean section:
Intraoperative:
Anesthetic complication (e.g. atelactasis).
Urinary tract damage (bladder and urertric injury).
Bowel injury.
Hemorrhage: due to vascular injury like uterine artery injury, or due to uterine atony or placenta previa. There are many maneuvers that may be employed to manage such cases rang from bimanual compression, infusion of oxytocin, applying compression sutures to the more radical but life saving hysterectomy.
Caesarean hysterectomy.

10. anatomy of female genital tract association between ureter and uterine artery

11. Postoperative complication:
Increased incidence of post partum hemorrhage.
Endometritis.
Chest infection.
Urinary tract infection.
Wound infection.
Mandelson's syndrome and aspiration pneumonia.
DVT and pulmonary embolism.
Increase incidence of placenta previa and placenta accrete in subsequent pregnancies.
Delayed contact with baby.

12. Caesarean hysterectomy:
This is usually undertaken as a life saving procedure and as a last resort, but should not be left too late in order to reduce maternal morbidity and mortality.
Indications:
Uncontrollable maternal heamorrhage usually occuring with placenta accreta.
Uncontrollable uterine atony.
Uterine rupture.
Extension of a low transverse incision.
Leiomyoma preventing uterine closure and heamostasis.

13. Heamatomas Vulval and paravaginal heamatomas: Definition:
Infralevator hematoma: those that lie below the levator muscle including vulval and perineal heamatomas, as well as paravaginal hematomas and those occurring at the ischiorectal fossa.
Supralevator hematoma: spread upwards and outwards beneath the broad ligament or partly downwards to bulge into walls of the upper vagina. These also can also track backwards into the retroperitoneal space.
Criteria used to define hematoma are hematomas>4cm in diameter, the incidence is 1:1000 deliveries.

14. (a)infralevator hematoma, (b) supralevator hematoma

15. Causes:
The injury is frequently related to episiotomy, but in about 20% of patients have intact perineum. Overall, half of the women who develop genital hematoma do so following spontaneous delivery.
Diagnosis: although vulval hematoma is usually obvious, a paravaginal hematoma may be missed, with no symptoms until shock develops.

16. Management of infralevator hematoma:
Management includes resuscitation and surgical evacuation.
If the hematoma<5cm and not expanding then observation with icepacks and pressure dressing to limit its expansion, and marking the edges of hematoma.
If hematoma>5cm or it is expanding, then surgical evacuation is required by incising through vagina to decrease scarring, ligation of bleeders is done. If no distinct bleeders then a surgical drain or pack can be used.

17. Sub peritoneal Heamatoma:
Sub peritoneal hematomas (broad ligament) are much less common than genital hematomas (1:20000) deliveries.
They follow spontaneous vaginal delivery, Caesarian section, or forceps operations.
More than 50 % of such hematomas are diagnosed immediately, whereas the other half only presents after 24 hrs. Symptoms and signs include lower abdominal pain, vaginal bleeding, deviation of uterus to one side, and hemodynamic instability.

18. Management of sub peritoneal hematoma:
a conservative approach is recommended, with expectant management and resuscitation.
If it is not possible to maintain a stable hemodynamic state, prompt surgical exploration is recommended and internal iliac artery or even hysterectomy may be indicate.

19. Injuries to the cervix:
After vaginal delivery most of will have lacerations and/or bruising of the cervix. Minor lacerations are extremely common and not requiring suturing unless associated with bleeding. So, bleeding that not appears to be arising from the vagina or perineum with contracted uterus is an indication for examining the cervix
Repair: for repairing a cervical tear, good visibility using right-angle retractors is essential.
Using two pairs of ring forceps applied to the cervix at any one time, it is possible to inspect the whole circumference accurately. Identification of the apex of the tear is essential prior to repair.
Deep lacerations and particularly those involving the vaginal vault may extend to bladder or laterally towards the uterine artery at the base of broad ligament. Such deep lacerations need to be managed and repaired in theatre under anesthesia.

20. Rarely performed but important operative interventions:
Symphysiotomy: it is associated with subsequent maternal morbidity such as pain in the symphysis pubis and groin.
Indication:
Cephalo-pelvic disproportion with a vertex presentation and a living fetus (especially in rural areas when no facilities to perform emergency C/S).
Trapped after-coming head of a breech vaginal delivery.
Last resort for shoulder dystocia.

21. Destructive operations:
These may be required where fetus is dead and where a vaginal delivery is the only delivery that can be managed in that particular situation or is the only route by which the mother wishes to be delivered.
These include; craniotomy, perforation of the after-coming head and decapitation.
Craniotomy: indicated for the delivery of a dead fetus with obstructed labour in a cephalic presentation.
After-coming head: when the fetus is dead this can be managed by craniotomy with perforation of the head through the occiput.
Where there is hydrocephalus CSF can be withdrawn by exposing the spinal canal and passing a catheter into the canal and decompress fetal head.
Decapitation: indicated in obstructed labour with shoulder presentation and a dead fetus.

22. Good Luck