1. Operative Obstetrics: I.Forceps Delivery II.Vacuum Extraction III.Breech Delivery IV.Cesarean Deliver V.Postpartum Hysterectomy

2. Forceps Delivery

3. Indications  Indications for operative vaginal deliveries are identical for forceps and vacuum extractors.  No indication for operative vaginal delivery is absolute. Forceps Delivery

4. The following indications apply when no contraindications exist:  Prolonged second stage: This includes nulliparous woman with failure to deliver after 2 hours without, and 3 hours with, conduction anesthesia. - It also includes multiparous woman with failure to deliver after 1 hour without, and 2 hours with, conduction anesthesia.  Suspicion of immediate or potential fetal compromise in the second stage of labor.  Shortening of the second stage for maternal benefits: Maternal indications include, but are not limited to, exhaustion, bleeding, cardiac or pulmonary disease, and history of spontaneous pneumothorax.  In expert hands, fetal malpositions, including the after-coming head in breech vaginal delivery, can be indications for forceps delivery. Forceps Delivery

5. Definition of prolonged second stage of labour redefined by A.C.O.G.(1988/1991): Nullipara- <3 hrs with regional anaesthesia <2 hrs without regional anaesthesia Multipara- <2 hrs with regional anaesthesia <1hr without regional anaesthesia

6.  The head must be engaged.  The cervix must be fully dilated and retracted.  The position of the head must be known.  The type of pelvis should be known.  The membranes must be ruptured.  No disproportion should be suspected between the size of the head and the size of the pelvic inlet and mid pelvis.  The patient must have adequate anesthesia.  Adequate facilities and supportive elements should be available.  The operator should be fully competent in the use of the instruments and the recognition and management of potential complications. -The operator should also know when to stop so as not to force the issue. Prerequisites for forceps delivery include the following: Forceps Delivery

7. Vacuum Extraction

8. Fetal Indications  Prolonged second stage of labor  Shortening of the second stage of labor  Presumed fetal jeopardy/fetal distress Maternal Indications  Need to avoid voluntary maternal expulsive efforts (e.g., the mother has cardiac or cerebrovascular disease)  Inadequate maternal expulsive efforts  Maternal exhaustion or lack of cooperation Indications for Vacuum-Assisted Delivery Vacuum Extraction

9.  Fetal prematurity (<34 weeks of gestation)  Fetal scalp trauma  Unengaged head  Incomplete cervical dilatation  Active bleeding or suspected fetal coagulation defects  Suspected macrosomia  Nonvertex presentation or other malpresentation  Cephalopelvic disproportion  Delivery requiring rotation or excessive traction  Inadequate anesthesia Relative Contraindications for Vacuum Extraction Vacuum Extraction

10.  Proper placement of the cup used in vacuum extraction.  The center of the cup should be over the sagittal suture and about 3 cm (1.2 in) in front of the posterior fontanelle.  The cup is generally placed as far posteriorly as possible. Technique Vacuum Extraction

11.  Scalp lacerations and bruising  Subgaleal hematoma  Cephalohematomas  Intracranial hemorrhage  Neonatal jaundice  Subconjunctival hemorrahge  Clavicular fracture  Shoulder dystocia  Injury of CNs VI, VII  Erb palsy  Retinal hemorrhage  Fetal death Fetal Complications Vacuum Extraction

12. Cesarean Delivery

13. Indications for Cesarean Delivery 1)Prior cesareans 2)Labor dystocia 3)Fetal distress 4)Breech presentations

15. Intraoperative complications 1. Uterine lacerations: Uterine lacerations, especially of the lower uterine segment, are more common with a transverse uterine incision.  These lacerations can extend laterally or inferiorly.  They are repaired easily.  Take care to identify the uterine vessels when repairing lateral extensions, and, when repairing inferior extensions, the surgeon needs to think about the ureters.  If the laceration extends into the broad ligament, strongly consider opening the broad ligament and identifying the course of the ureters. Cesarean Delivery

16. Intraoperative complications 2. Bladder injury: This is an infrequent complication. It is more common with transverse abdominal incisions and in repeat cesarean deliveries.  The bladder most commonly is injured when entering the peritoneal cavity or when separating the bladder from the lower uterine segment.  Bladder injury has been reported to occur in more than 10% of uterine ruptures and in approximately 4% of cesarean hysterectomies.  If a possibility exists that a cesarean hysterectomy may be performed, mobilize the bladder inferiorly as well as possible when dissecting it free of the lower uterine segment.  If the dome of the bladder is lacerated, it can be repaired simply with a 2- layer closure of 2-0 or 3-0 chromic sutures, with the Foley catheter left in place for a few extra days.  If the bladder is injured in the region of the trigone, consider ureteral catheterization with possible assistance from a urologist. Cesarean Delivery

17. Intraoperative complications 3. Ureteral injury: Injury to the ureter occurs in up to 0.1% of all cesarean deliveries and up to 0.5% of cesarean hysterectomies.  It is most likely to occur when repairing extensive lacerations of the uterus.  Ureteral injury, most commonly occlusion or transection, usually is not recognized during the time of the operation. Cesarean Delivery

18. Intraoperative complications 4. Bowel injury: Bowel injuries occur in less than 0.1% of all cesarean deliveries.  The most common risk factor for bowel injury at the time of cesarean delivery is adhesions from prior cesarean deliveries or prior bowel surgery.  If the bowel is adherent to the lower portion of the uterus, dissect it sharply.  Injuries to the serosa can be repaired with interrupted silk sutures.  If the injury is into the lumen, perform a 2-layer closure.  The mucosa can be closed with interrupted 3-0 absorbable sutures placed in a transverse fashion for a longitudinal injury.  For multiple injuries and injury to the large intestine, consider intraoperative consultation with a general surgeon or gynecologic oncologist. Cesarean Delivery

19. Intraoperative complications 5. Uterine atony: Another intraoperative complication that can be encountered in a patient with a multiple gestation, polyhydramnios, or a failed attempt at a vaginal delivery in which the patient was on Pitocin augmentation for a prolonged period is uterine atony.  When the uterus is closed, attention must be paid to its overall tone. Cesarean Delivery

20.  Postpartum endomyometritis  Wound infection  Fascial dehiscence  Urinary tract infections  Bowel function  Thromboembolic complications  Pelvic thrombophlebitis Postoperative complications Wound dehiscence Cesarean Delivery

21. Postpartum Hysterectomy