Obstetrical Procedures

Dr. Shamsa Al Awar

Chair Ob/Gyn
CMHS, UAEU
List of procedures

• Amniocentesis
• Chorionic Villus Sampling(CVS)
• Cervical Cerclage
• External Cephalic Version (ECV)
• Episiotomy
• Artificial rupture of membrane
(ARM)/ Amniotomy
• Assisted vaginal Delivery
• Cesarean Section
Amniocentesis
 Amniocentesis
Amniocentesis is a procedure wherein a sample of fluid is removed from the
amniotic sac for analysis &/or treatment.
Indications Contraindication
• Genetic diagnosis • Maternal skin site infection
• Lung maturity • Maternal bleeding disorders
• Uterine Infection • Patient refusal of procedure
• Rh incompatibility treatment and • Fetal distress
follow up • Severe oligohydramnios
• Fetal medical treatment • Labor, preterm contractions
• Decompression of polyhydramnios • Antepartum hemorrhage
• Maternal fever and possible sepsis
 Amniocentesis
Complications of amniocentesis:
• Maternal/fetal hemorrhaging.
• Leakage of amniotic fluid.
• Infection.
• Fetal injury.
• Miscarriage. is approximately 0.5%.
• The trauma of difficult family-planning
decisions. The threat posed to parental
and family mental health from the
trauma accompanying an abnormal test
result can not be underestimated
Chorionic
Villus
Sampling
(CVS)
 Chorionic Villus Sampling (CVS)

• CVS is a diagnostic procedure which involves

removing some chorionic villi cells from the placenta
at the point where it attaches to the uterine wall under
ultrasonic guidance for perinatal testing.
• There are two ways CVS samples are collected:
• Transcervical
• Transabdominal
• CVS is usually performed between 10 and 13 weeks
of gestation.
• Limitations of CVS:
• 1-2% of pregnancies have confined placental mosaicism
• Maternal Cell Contamination
 Chorionic villus sampling (CVS)
Indications Contraindication
• Abnormal first trimester screen results • Risk of miscarriage about 1-2%
• Increased nuchal translucency or other abnormal • Risk of infection and amniotic fluid leakage
ultrasound findings
• Mild risk of Limb Reduction Defects with early
• Family history of a chromosomal abnormality or CVS
other genetic disorder
• Retroplacental bleeding and abruptio
• Parents are known carriers for a genetic disorder
• Advanced maternal age (maternal age above 35)
 Amniocentesis vs CVS
Procedure Amniocentesis CVS
Tissue Amniotic fluid Chorionic villus
Timing 16- 38 weeks 10-37 weeks
Accuracy High High
Purpose Diagnostic & Therapeutic Diagnostic
Complications
1- Pregnancy loss 0.5-1% 1-3%
2- Fetal malformations Negative Fetal limb deformity
3- Placental mosaicism Negative Present
Cervical Cerclage
 Cervical Cerclage
• Cervical Cerclage is the procedure at which a cervical stitch inserted to the uterine
cervix as a treatment for cervical incompetence or insufficiency.
• Types of cerclage:
• Trans-vaginal (McDonald and Shirodkar)
• Trans-abdominal
• Insertion electively between 12-14 weeks of gestation
• Removal electively ≥ 37 weeks of gestation
• Preinsertion requirements:
• Viable pregnancy
• No contraindication for pregnancy continuation
• Intraamniotic infection
• Preterm premature rupture of the fetal membranes
• A cerclage is considered successful if labor and delivery is delayed to at least 37
weeks (full term). Success rate:
• 80-90% for elective cerclages
• 40-60% for emergency cerclages
 Commonest Cerclage

Non-invasive Cerclage Surgical Cerclage

Cervical Cerclage

Complications:
• Risks associated with regional or general anesthesia
• Premature labor
• Premature rupture of membranes
• Infection of the cervix
• Infection of the amniotic sac (chorioamnionitis)
• Cervical rupture (may occur if the stitch is not removed before
onset of labor)
• Injury to the cervix or bladder
• Bleeding
• Cervical dystocia with failure to dilate requiring cesarean section
• Displacement of the cervix
External Cephalic Version
(ECV)
 External Cephalic Version (ECV)
• ECV refers to the manipulation of a fetus lying in a non cephalic or
breech presentation to cephalic presentation through the maternal
abdomen.
• It is effective in reducing caesarean section rate.
• The success of ECV depends largely on the experience of the
obstetrician, as well as on the selection of cases.
• Overall, a success rate :
• 40% for nulliparous
• 60% for multiparous women can be achieved.
 External Cephalic Version (ECV)
• ECV should be offered from:
• >36 weeks in nulliparous
• >37 weeks in multiparous
• ECV is associated with a very low rate of
complications.
• Complications of ECV:
• Placental abruption
• Uterine rupture
• Fetomaternal haemorrhage
• Emergency caesarean section following ECV at a rate of
0.5%
 ECV Case Selection
Absolute Contraindications
• Ruptured membranes
• Antepartum haemorrhage
• Placenta praevia
• Major uterine anomaly
• Multiple pregnancy
• Significant fetal abnormality
• Abnormal cardiotocography (CTG)
• Need for caesarean section for other
indications
Relative Contraindications
• Previous caesarean section or uterine
surgery
• Severe proteinuric hypertension/
preeclampsia
• Intrauterine growth restriction
• Rhesus isoimmunization
• HIV
• Obesity
• Oligohydramnios
 ECV
• Prior to Procedure
• Ultrasound to assess placental position, liquor
volume and fetal attitude
• Confirm normal and reassuring fetal heart rate
pattern
• Ensure you have the facility for an emergency
Caesarean section if a fetal complication develops
• Labour with a cephalic presentation following
ECV is associated with a higher rate of
obstetric intervention than when ECV has not
been required, and the labour should therefore
be managed at an institution where facilities
for caesarean section are available.
Episiotomy
Episiotomy
• Episiotomy is a surgical cut in the
muscular area between the vagina and the
anus (the perineum) made just before the
delivery of the fetal presenting part to
enlarge the vaginal opening.
• Types of episiotomy: There are 2 main
types of incision
• Medio-lateral
• Median
 Episiotomy
Contraindications:
• all contraindication to vaginal delivery
(Episiotomy should not be performed
unless vaginal delivery is considered
to be possible.
• Patient refusal (No consent by patient)
• Relative contraindications to the
procedure include inflammatory bowel
disease and severe perineal
malformations
Complications:
• Increased risk of anterior perineal
trauma & Extension to higher-order
lacerations.
• Increased risk of vertical transmission
of HIV.
• Excessive blood loss.
• Poor wound healing and infection.
• Dyspareunia and sexual problems.
Perineal Tears
Artificial rupture of membrane/
Amniotomy
 Artificial rupture of membrane/ Amniotomy
• Amniotomy (AROM) is the procedure by which the
amniotic sac is deliberately ruptured so as to cause the
release of amniotic fluid.
• Amniotomy is usually performed for the purpose of
inducing or expediting labor or in anticipation of the
placement of internal monitors (uterine pressure catheters or
fetal scalp electrodes).
• It is typically done at the bedside in the labor and delivery
ward.
• Indications:
• When internal fetal or uterine monitoring is needed
• For induction of labor, usually in conjunction with an oxytocin
infusion
• For augmentation of labor, in that amniotomy leads to an increase in
plasma prostaglandins.
 Artificial rupture of membrane/
Amniotomy
Contraindications: Complications:
• Known or suspected vasa previa/ placenta • Cord prolapse
previa • Trauma (maternal & fetal)
• Any contraindications to vaginal delivery • Rupture of a vasa previa
• Unengaged presenting part (although this • Chorioamnionitis
obstacle may be overcome with the use of a
controlled amniotomy or the application of
fundal or suprapubic pressure)
• Active vaginal serious infections such as
Herpes, Warts, HIV
Procedure: Amniotomy or
ARM

Instrument : Amnihook
Operative/Assisted Vaginal
Delivery
 Assisted Vaginal Delivery
• Forceps and ventouse delivery have become an integral part of obstetric practice.
• Both offer an effective means of expediting delivery in the second stage, and thereby
avoiding the morbidity associated with caesarean delivery.
• Both forceps and ventouse deliveries are associated with significant maternal and
infant morbidity.
• Optimal results with either instrument can be anticipated when careful attention is
given to the indications, prerequisites, and performance of the respective procedures.
 Assisted Vaginal Delivery
Indications
Maternal Fetal
I. Medical disorders that require shortening I. Fetal distress
of the second stage II. Prematurity
I. Cardiac disease
I. Forceps provides a protective frame and
II. Severe hypertensive conditions ensures good control over the delivery of
III. Respiratory disease the soft head
II. Maternal exhaustion III. Breech
III. Previous caesarean section (relative I. Delivery of the after coming head
indication) IV. Malposition
IV. Undue prolongation of the second stage I. Ventouse delivery may facilitate rotation
and delivery of malpositions such as
I. In cases of regional anaesthesia, an extra occipito posterior (OP), occipito
hour is allowed, provided both maternal and transverse (OT), and asynclitism
fetal condition is satisfactory
 Forceps Delivery
• No more rotational, high or mid pelvic forceps.
• Outlet/Low Forceps Delivery:
• Fetal head not palpable abdominally
• Sagittal suture in anterior-posterior diameter
• Fetal head is on the perineum

• There are over 600 variants in obstetric forceps. The most useful examples are :
• Wrigley Forceps
• Outlet or low forceps
• Caesarean section
• Piper Forceps
• After-coming head of breech
Prerequisites for Forceps Delivery
• Informed patient Forceps Mnemonic
• Experienced operator
• Adequate analgesia – local infiltration or regional FORCEPS:
• Empty bladder F-etus alive
• Episiotomy O-s dilated
• Membranes must be ruptured
R-uptured membrane
C-ervix taken up
• Cervix must be fully dilated
E-ngagement of head
• Adequate uterine contractions P-resentation suitable
• Head must be engaged – at or below spines S-agittal suture in AP
• No evidence of cephalo-pelvic disproportion (CPD) diameter of inlet
• Sagittal suture should be in the anterior –posterior diameter
Complications of Forceps Delivery
• Maternal • Fetal
• Trauma • Death
• Perineal, vaginal, cervical • Neurological injuries
laceration/haematoma
• Intracranial haemorrhage
• Bladder, urethral injury
• Facial nerve palsy/paralysis
• Rectal injury
• Brachial plexus injury
• Haemorrhage • Trauma
• Tears • Skull fracture
• Uterine atony • Damage to facial bones
• Infection • Lacerations and bruising
• Neurological injuries – drop-foot • Transmission of HIV
• Long term – pelvic floor prolapse,
incontinence, fistula formation
 Failed Forceps

• A forceps delivery should be classified as failed if:

• There is no descent of the fetal head with each pull
• The fetus remains undelivered after either three pulls, or after
30 minutes

• In the event of a failed forceps delivery, a caesarean

section should be preformed.
 Ventouse/Vacuum Delivery

Prerequisites for Ventouse Delivery Contraindications to Ventouse

• Same criteria for forceps • Preterm fetus (< 36 weeks)
delivery, including: • Face and breech presentations
• Cooperative mother • Fetal head not engaged
• Uterine contractions must be
• Possible bleeding tendency of the
strong
fetus
• Episiotomy not always essential
• Fetal distress – relative
• Can be used for malpositions such
contraindication
as OP, OT, and asynclitism
Complications of Ventouse Delivery
• Maternal • Fetal
• Trauma to the birth canal • Scalp injury – bruising, abrasion,
• As with forceps delivery, but to a lesser laceration
extent • Cephalhaematoma, Subgalealhaematoma,
• Haemorrhage Intracranial haemorrhage
• Secondary to trauma • Retinal haemorrhage
• Uterine atony • Neonatal jaundice
• Transmission of HIV
Ventouse/Vacuum Delivery
Preparation
• Counsel and reassure the
patient
• Prepare the necessary
equipment – checking all the
connections on the vacuum
extractor and testing the
vacuum on a gloved hand
• Cover the cup of the vacuum
with aseptic cream/gel
Failed Vacuum
• A vacuum extraction should be classified as
failed if:
• There is no descent of the fetal head with
each pull
• The fetus remains undelivered after three
pulls or after 30 minutes
• The cup slips off the head twice with correct
application and maximum negative pressure
• In the event of a failed vacuum extraction, a
caesarean section must be performed.
Caesarean section
 Caesarean section
The indication for the caesarean section often dictates the type of uterine
incision, speed of procedure and method of delivery of the fetus.
General Rules: Types of Caesarean Section:
• Ensure that the fetal heart is still • Skin incision:
present • Transverse
• For elective cases, ensure that the • Vertical
indication for the CS is documented. • Uterine incisions:
• The gestational age, is correct. • Midline vertical on the upper segment
(classical)
• The Paediatrician should be informed • low transverse lower segment
whenever doubt exists about the • low vertical lower segment
condition of the baby post delivery.
Caesarean section
 Caesarean section
Maternal indications: Fetal indications:
• Repeat cesarean delivery • Situations in which neonatal morbidity and
• Obstructive lesions in the lower genital tract, mortality could be decreased by the
including malignancies, large vulvovaginal prevention of trauma
condylomas, obstructive vaginal septa, and • Malpresentation (e.g. preterm breech
leiomyomas of the lower uterine segment that presentations, non-frank breech term
interfere with engagement of the fetal head fetuses)
• Pelvic abnormalities that preclude engagement • Certain congenital malformations or
or interfere with descent of the fetal skeletal disorders
presentation in labor • Infection
• Certain cardiac conditions that preclude • Prolonged acidemia
normal valsalva done by patients during a
vaginal delivery

Indications for CS that benefit mother & fetus:

 Abnormal placentation (e.g. placenta previa, placenta accreta)
 Abnormal labor due to cephalopelvic disproportion
 Situations in which labor is contraindicated
 Caesarean section
Contraindications of CS:
There are few contraindications to performing
a cesarean delivery.
• When maternal status may be compromised
(e.g. mother has severe pulmonary disease).
• If the fetus has a known karyotypic
abnormality or known congenital anomaly
that may lead to death (anencephaly).
Complications of CS:
• Anesthesia related complications
• Intra-operative injury to bladder, bowel or
big vessels
• Infection: wound site infection,
endometritis and urinary tract infection
• Bleeding: intraoperative or postoperative
• Thromboembolic complications: deep
vein thrombosis and pulmonary embolism
 Caesarean section
Complications of CS:
• Approximately 2-fold increase in maternal mortality &
morbidity with cesarean delivery relative to a vaginal delivery
• Infection (e.g. postpartum endomyometritis, fascial dehiscence,
wound, urinary tract)
• Thromboembolic disease (e.g. deep venous thrombosis, septic
pelvic thrombophlebitis)
• Anesthetic complications
• Surgical injury (e.g. uterine lacerations; bladder, bowel, ureteral
injuries)
• Uterine atony
• Delayed return of bowel function
Thank You