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 tissues Fetal Distress Progress 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 Succedaneum Develops 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 cervix 3. 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 current labor. iv- Associated conditions as antepartum hemorrhage or malpresentations.

(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 labor Selective 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.