NGU5404 Session 23: Operative Procedures in Obstetrics

Session 23
Operative Procedures in Obstetrics
Introduction, p41
23.1 Repairing perineal tears, p41
23.2 Operative vaginal delivery, p44
23.3 Cesarean section, p52
23.4 Vaginal Birth after caesarean section, p56

Introduction

Pregnancy and childbirth is a physiological process. Most pregnant women

are expecting to have a normal childbirth without complications. However,
half of the childbearing women unable to complete normal vaginal delivery
and end up with some complications. To prevent or minimize those
complications some assistance is needed during the process of delivery. A
crucial assessment of the mother and fetus from the initiation of the labour
to the post-partum period is necessary to identify the time when the mother
and child need assistance to prevent those complications. Some of the
interventions which are assisting childbirth are operative procedures and
they need to attend on time carefully. This operative intervention will
minimize the maternal and neonatal mortality and morbidity. Repairing
perineal tears, performing episiotomy, assisted vaginal birth and caesarean
section are the common operative procedures in obstetrics. All of these
interventions should be performed by a well knowledgeable, competent and
skillful personnel in order to saving mother and child. The nurse who is
attending care for mothers and neonates also should have sound knowledge
and skills to attend and care for those mothers and babies.

23.1 Repairing Perineal tears

85% of the women who are undergoing normal vaginal delivery are having
some degree of perineal tear and majority needs suturing for repair the tear.
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NGU5404 Session 23: Operative Procedures in Obstetrics

It is necessary to examine the women for perineal tears immediately

following the placental delivery. The methods of repairing perineal tears are
different according to the degree of the laceration.

First degree tears are superficial and affect only the skin. They can occur
around labia, vestibule or around the vagina. These type of tears can heal
without any treatment.

Second degree tears affecting skin and the muscle layer. They require
stitches to repair which is usually carried out in the delivery room under
local anesthesia.

Third degree tears are involving injury to anal sphincter complex (Internal
sphincter alone, external sphincter alone or both at same time). Suturing of
the tear is essential for healing and to prevent fecal incontinence.

Fourth degree tears involve injury to perineal fascia, muscles, both internal
and external anal sphincters and the rectal mucosa. Usually repairing this
type of tears require anesthesia and surgical interventions.

After repairing the tears, it is needed to observe the site for infection and
hematoma formation as those are the identified major complications.
Further mother should be assessed for pain and adequate pain relief must be
given.

The following basic principles should be observed when performing

perineal repairs: (slcog. 2013)

• Perineal trauma should be repaired using aseptic techniques.

• Equipment should be checked and swabs and needles counted before

and after the procedure

• Good lighting is essential to see and identify the structures involved.

• Difficult injuries should be repaired by an experienced medical

officer in theatre under regional or general anaesthesia. An
indwelling catheter should be inserted for 24 hours to prevent
urinary retention.

• Good anatomical alignment of the wound should be achieved, and

consideration given to the cosmetic result.

• Rectal examination should be carried out after completing the repair

to ensure that suture material has not accidently been inserted
through the rectal mucosa.
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NGU5404 Session 23: Operative Procedures in Obstetrics

• Following completion of repair, an accurate detailed account should

be documented covering the extent of the trauma, the method of
repair and the materials used.

• Information should be given to the woman regarding the extent of

the trauma, pain relief, diet, hygiene and the importance of pelvic
floor exercises.

Perineal massage, warm compresses and a “hands on” guarding of the

perineum are recommended to reduce perineal trauma and it facilitate
spontaneous birth for women in the second stage of labour (WHO, 2015).

23.1.1 Episiotomy
An episiotomy is a surgical incision of the perineum performed during the
second stage of the labour to enlarge the vulval outlet and assist vaginal birth.
Episiotomy is performed selectively, in women in whom there is a clinical
need such as instrumental birth or suspected fetal compromise or a high
chance of perineal tears (SLCOG, 2013).

Before perform episiotomy, informed consent should be obtained from the

mother. It is performed when the fetal head is crowning at the second stage
of labour. Further, there should be adequate local anaesthesia around the
incision site.

There are two types of episiotomies

1. Midline episiotomy – performed in the midline of the perineum. It is

associated with relatively less bleeding and less pain and quick
healing as the midline is highly avascular area. However it has a
higher risk of damaging anal sphincter.

2. Medio-lateral episiotomy – This is performed by making incision at

45 – 60 angle from the midline. This is the recommended type of
episiotomy which is performed commonly.

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Figure 1: Types of Episiotomy

23.2 Operative vaginal delivery (OVD)

Operative vaginal delivery refers to a vaginal birth with the use of any type
of forceps or vacuum extractor (Ventouse). This is also known as
instrumental delivery or assisted vaginal delivery. OVD is used to shorten the
second stage of labour. It may be indicated for conditions of the fetus or of
the mother to reduce the maternal and fetal mortality during labour. However,
it is associated with maternal and neonatal complications.

23.2.1 Indications for OVD

OVD is performed when there is suspected fetal compromise, prolonged

active second stage of labour or if the mother’s medical condition limits the
ability for maternal effort (ex: cardiac disease).

Prolonged labour is diagnosed when there is lack of continuing progress

for 3 hours (total of active and passive second stage of labour) withregional
anaesthesia or 2 hours without regional anaesthesia for Nulliparous women.
For Multiparous women it is diagnosed when there is lack of continuing

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NGU5404 Session 23: Operative Procedures in Obstetrics

progress for 2 hours (total of active and passive second stage of labour)
with regional anaesthesia or 1hour without regional anaesthesia.

23.2.2 Before performing the procedure

When there is prolonged active second stage or fetal compromise, mother

should be examined carefully. Vaginal examination and an abdominal
examination can be performed to identify the station, position, fetal lie,
presentation, attitude, and cput or molding of head of the fetus. If there is
favorable criteria for OVD, obstetrician can recommend the appropriate
instrument for the delivery. Peron who is perform the procedure should be
confident, competent and knowledgeable regarding what he/she going to
perform.

23.2.2.1 prerequisite for OVD

Fetal head ≤ 1/5 palpable in the abdomen

Cervix is fully dialated

Membranes are ruptured

Station below the ischial spines

Prior to the procedure, mother should be counselled regarding procedure, risk

and benefits of the procedure and informed consent should be obtained.
Establishment of trustworthy relationship with mother is a positive point in
taking mother’s full support for the procedure. Mother should be positioned
in lithotomy position with supported legs. There should be a light source to
visualize the perineum. Adequate and appropriate analgesia should be given
prior to procedure (Usually regional block or pudendal block). Bladder should
be emptied and aseptic conditions should be used throughout the procedure.

A paediatrician should be there at the time of delivery for neonatal

resuscitation. Further, there should be a backup plan to perform the delivery

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in the case of failed instrumental delivery or presence shoulder dystocia.

Operating theater should be ready for cesarean section.

Figure 2: Lithotomy position

23.2.3 Forceps delivery

Forceps are used to assist the delivery of a baby as an alternative to the

ventouse method. Selecting the appropriate type of forcep is essential for the
success of the procedure.
The forcep is consisted with two blades with shanks which are joined together
at a lock to provide a point for retraction. The blades, length of the shanks,
the design of the lock and the fashioning of the handles are instrument
specific.

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NGU5404 Session 23: Operative Procedures in Obstetrics

Figure 3: Component of forcep

The main two types of forceps

1. Non rotational forceps – these are used when the head is OA with no more
than 450 deviation to LOA or ROA positions.
Eg: Neville Barnes forcep
Simpson’s forcep
2. Forceps designed for rotation – if the fetal head is positioned more than 450
from the vertical, rotation must be accomplished before the traction. These
types of forceps have minimal pelvic curve and allow rotation.
Eg: Kieland’s forcep.

Figure 4: Examples for rotational and non-rotational forceps

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23.2.3.1 Technique(non rotational)

Prior to the procedure, the practitioner should check the blades to ensure that
the both blades are matching and can lock with ease. Then two blades of the
forceps are individually inserted (first insert left blade and then insert right
with supporting to vaginal wall)) and then locked into position around the
baby's head. Then apply the traction intermittently with the uterine
contractions and maternal pushing. Traction change during delivery and is
guided along “J” shaped curve of the pelvis. Majority of the forceps deliveries
can complete with 3 pulls. An episiotomy is routinely performed and then the
baby is delivered.

Positive aspects
• Can be used to avoid caesarean delivery.
• Delivery of the infant can is more quicker than with emergency caesarean
surgery.

23.2.3.2 Negative aspects

• An episiotomy is usually required which itself involves anesthesia
• The internal tissues, particularly the pelvic floor muscles, are
bruised
• Maternal injuries are commoner than vacuum deliveries.
• Facial bruising or temporary marks on the baby
• Nerve damage - which may be temporary or permanent
• Skull fractures

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NGU5404 Session 23: Operative Procedures in Obstetrics

Figure 5: forceps delivery

Activity 1

List the prerequisites for forceps delivery

23.2.4 Ventouse /Vacuum delivery

Ventouse is a vacuum device used to assist the delivery of a baby when labour
has not progressed adequately. It is an alternative to a forceps delivery and
caesarean section. Before selecting the ventouse delivery, followings also
should be considered other than the above mentioned prerequisites.
Ventouse delivery is not recommended before 36 weeks completed gestation
age as there is an increased risk of cephalhematoma and intracranial
haemorrhage. It should not be used for breech or face presentations. Further
it is not recommended if the position of the fetal head is unknown of if there
is a significant degree of caput formation.

Technique
Ventouse is consisted with suction cup and is connected to vaccum source
via a tube. Traction can be applied to the presenting part along with the
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maternal pushing efforts. Operating vaccum pressure for all types of devices
usually between 0.6 – 0.8kg/cm2 . First apply 0.2cm2 pressure to ensure that
the maternal tissues are not caught under the suction cup. Then pressure can
be increased. A suction cup is placed onto the head of the baby and the
suction draws the skin from the scalp into the cup. Proper placement is
critical to keep the head flexed, thus the cup is placed on the flexion point,
about 3 cm anterior from the occipital (posterior) fontanelle. Ventouse
devices have handles to allow for traction. When the head is born the device
is detached, allowing the woman to complete the delivery of her child.

Figure 6: Vacuum extractor

If the ventouse attempt fails it may be necessary to deliver the infant by

caesarean section.
Indications
• There are three generally accepted indications to use a ventouse to
aid delivery:
• Prolonged pushing in the second stage of labour or maternal
exhaustion
• Fetal emergency in the second stage of labour, generally indicated by
changes in the fetal heart rate
• Maternal illness where "bearing down" or pushing efforts would be
risky (e.g. cardiac conditions, blood pressure)
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NGU5404 Session 23: Operative Procedures in Obstetrics

Positive aspects
• An episiotomy is not usually required and there is little internal
bruising.
• The mother still takes an active role in the birth.
• No special anesthesia required.
• The force applied to the baby can be less than that of a forceps
delivery, leaving no marking on the face.
• Less potential for maternal trauma compared to forceps and cesarean
section.
Negative aspects
• The baby is left with a temporary lump on its head, known as a
chignon.
• A possible cephalhematoma formation.
• The baby may become distressed due to strong suction to its head

Figure 7: vaccume delivery

Activity 2

List the prerequisites for vacuum delivery

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NGU5404 Session 23: Operative Procedures in Obstetrics

23.3 Caesarean Section

Caesarean section is a surgical procedure in which incisions are made through
a mother's abdomen and uterus to deliver one or more babies after 28th week
of pregnancy. It is usually performed when a vaginal delivery would put the
baby's or mother's life or health at risk, although in recent times it has been
also performed upon request for childbirths that could otherwise have been
natural.
According to the classification, there are two types of caesarian section. One
is elective and other one is emergency. Elective caesarian sections are planned
days or weeks before the surgery and usually performed at day time. All other
caesarian sections are emergency CS. It is also categorize in to four (4)
categories considering the urgency (category 1- 4).

23.3.1 Types

There are several types of Caesarean section (CS). The differences between
them lie primarily on the incision made over the uterus.
1. The classical Caesarean section involves a midline
longitudinal incision over the upper segment of the uterus. It
is rarely performed today as it is more prone to complications.
2. The lower uterine segment section is the procedure most
commonly used today; it involves a transverse incision over
the lower segment of the uterus (just above the edge of the
bladder) and results in less blood loss and easy to repair.

23.3.2 Indications

• Malpresentation of the fetus

• Prolonged labor or a failure to progress (dystocia)
• Obstertrics emergencies such as cord prolapse and fetal
distress.
• Placental problems (placenta praevia, placental abruption or
placenta accreta)

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NGU5404 Session 23: Operative Procedures in Obstetrics

• Failed induction of labour

• Failed instrumental delivery
• Fetal macrosomia
• Fetal or maternal disease Preparation

23.3.3 Preparation for the procedure

23.3.3.1 Elective CS

Before the preparation, written informed consent should be taken

from the mother. Blood investigations including grouping and
Rh and hemoglobin should be done before the surgery day.
Blood should be cross matched and preserved. Mother should be
instructed to wash the skin before sending to the theater and skin
should be prepared with shaving of pubic hair according to the
institutional guidelines. Mother should be prepared with suitable
attire without any jewelry. Mother should be kept fasting for 6
hours and premedication should be administered according to the
medical prescription. Vital signs of the mother should be
measured and recorded. At the same time fetal wellbeing should
be monitored. Identification tag should be with the mother before
sending to the theater.

The mother is educated on post-operative complications and preventive

methods of complications such as maintaining hygiene, post op exercises,
early ambulation.

23.3.3.2 Emergency CS

Preparing a mother for emergency CS is different from elective CS. Here,

the mother is not physically or mentally prepared for facing CS. A strong
psychological support is needed for reduce the fear and anxiety. Informed
consent should be obtained from the mother. If she cannot provide the
consent, it can be taken from the partner. A 30ml of Sodium citrate is
administered to the mother orally to reduce the gastric acidity.

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NGU5404 Session 23: Operative Procedures in Obstetrics

23.3.4 Intraoperative care

Intraoperative phase is starts when the mother enters to the operating

theater. Here, establishment of rapport between the nurse and mother will
reduce the fear and anxiety of the mother. Mother is identified with the
identification tag and BHT in the operating theater. Then regional (spinal)
anaesthesia will be given to the mother. For that mother should be
positioned in sitting position while he back remaining in “C” shape curve.
After giving regional anaesthesia mother will be kept in supine position and
will drape with sterile GS towels. An indwelling urinary catheter should be
inserted. A nurse should be there to support the mother throughout the
procedure.

Mother’s vital signs should be monitored throughout the procedure. A

pediatrician should be there at the operating theater at the time of the
delivery.

23.3.5 Post-Operative care

Breast feeding should be initiated as soon as possible if the baby is in good

condition. Continuous assessment of the vital signs of the mother,
measuring urine output and observing mother for bleeding is necessary for
early detection of post-partum complications. IV fluid is given as ordered in
the post-operative management. The mother is instructed to not to get down
from the bed until regional anaesthesia is worn off. Adequate pain relief
medications are administered as needed. Once the mother is able to get
down from the bed, she can attend the new born care with support. The
mother’s vital signs, newborn care, bleeding, and psychological wellbeing
are monitored and her personal care is looked afer by the nurse.

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NGU5404 Session 23: Operative Procedures in Obstetrics

23.3.6 complications

Risks for the mother

Caesarian section is a relatively safe procedure. As with all types of

abdominal surgery, a Caesarean section is associated with several
complications including,
• Infections – women who is undergoing CS has a higher risk of having
infections than women with vaginal delivery. Endometritis, Urinary
tract infections, Wound site infections and bacteremia are the
commonest type of infections after CS.
• Hemorrhage – post-partum haemorrhage is a known complication due
to damage to the blood vesseles or as a consequence of placenta previa
or uterine atony.
• Venous thromboembolism – deep vein thrombosis and pulmonary
embolism are direct causes of maternal death after CS.
• Psychological distress
• Atelectasis
• Haematoma formation
• Post-operative adhesions
• Incisional hernias (which may require surgical correction)
• Adjacent organ damage

Risks for the child

For the baby, tachypnea of the newborn is an identified complication. Further,

complications such as neonatal depression due to anesthesia and fetal injury
due to the uterine incision and extraction also be found.

Risks for both mother and child

Due to extended hospital stays, both the mother and child are at risk for developing
a hospital-borne infection.

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NGU5404 Session 23: Operative Procedures in Obstetrics

23.4 Vaginal Birth After Caesarean Section (VBAC)

Vaginal birth after a caesarean section is not contraindicated. It can perform
with close observation and attention. However VBAC is contraindicated if
there is previous classical inverted “T” shape incision, Trans fundal surgery,
history of uterine rupture, contracted pelvis or medical or obstetrics
contraindications for vaginal delivery.

Activity 3

What is the procedure for patient preparation in an elective caesarian

section?
What is the procedure for patient preparation in an emergency caesarian
section?

Objectives

1. Identify the types of operative procedures in obstetrics.

2. Discuss the methods of repairing perineal tears with its degree of
tear.
3. Describe the care of mothers undergoing different type of operative
vaginal deliveries.
4. Identify the prerequisites for the forceps and vacuum delivery.
5. Discuss the indications and preparations of the mother for caesarean
section.

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