operative intervention in obstetric2/Dr.Huda H.

Aljanabi

Operative intervention in obstetric

Caesarean section
A Caesarean section, is a surgical procedure in which incisions are
made through a mother’s abdomen (laparotomy) and uterus
(hysterotomy) to deliver one or more babies.
Indications
The four major indications accounting for greater than 70% of
operations are :
1.Previous Caesarean section
2.Dystocia
3.Malpresentation
4.Suspected acute fetal compromise
Other indications, such as multifetal pregnancy, abruptio placenta,
placenta praevia, active primary herpes at onset of labour.

Preparation for C/S

1. Full informed consent must always be obtained prior to operation.
2.The bladder should be emptied before the procedure.
3.A left lateral tilt minimizes compression of the maternal inferior
vena cava and reduces the incidence of hypotension.

Procedure of C/S
1.Skin incision :either
A.Pfannensteil incision :this commonly used ,which is incised using
a transverse supra-pubic incision,two fingerbreadths above the
symphysis pubis extending from and to points lateral to the lateral
margins of the abdominal rectus muscles.
Advantages :
1.Improved cosmetic results.
2.Decreased analgesic requirements .
3.Superior wound strength.

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B.The infra-umbilical incision((midline vertical incision))

is indicated in cases of extreme maternal obesity, suspicion of other
intra-abdominal pathology necessitating surgical intervention, or
where access to the uterine fundus may be required (classical
Caesarean section). The lower midline incision is made from the
lower border of the umbilicus to the symphysis pubis.
The advantages:The vertical incision provides greater ease of access to
the pelvic and intra-abdominal organs and may be enlarged more
easily.
The disadvantage:The incidence of wound dehiscence is increased.

2.Uterine incisions:
1.Transverse lower uterine segment incision is used in over 95per
cent of Caesarean deliveries due to ease of repair, reduced blood loss
and low incidence of dehiscence or rupture in subsequent pregnancies.
2.Vertical upper segment uterine incision (classical c/s)which is
rarely used because it is :
1.Difficult to repaired.
2.Associated with severe bleeding.
3.More incidence of rupture in subsequent pregnancies.

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Indications of classical c/s:

1.lower uterine segment containing fibroids or a lower segment
covered with dense adhesions, both may make entry difficult.
2.Placenta praevia.
3.Transverse lie with the back down.
4.Fetal abnormality (e.g. conjoined twins).
5.Caesarean section in the presence of a carcinoma of the cervix (to
avoid damage to the cervix and its vascular and lymphatic supply)
6.Postmortum C/S.

Other types of uterine incision are U shape , J shape ,or modified

classical incision ((lower segment vertical incision)).
 once the baby is delivered ,an oxytocic 5 unit syntocinon I.V is
given to aid uterine contraction &placental separation.
 The placenta is delivered by combined cord traction; manual
removal significantly increases the intraoperative blood loss and
postoperative infectious morbidity.
 Closure of the uterus should be performed in either single or
double layers with continuous or interrupted sutures.
 Abdominal closure is performed in the anatomical planes

Complications of C/S
Intraoperative complication
1.Anasthetic complications .
2.Urinary tract injury (bladder &ureter)
3.Bowel injury: may occur during a repeat procedure or if adhesions
are present from previous surgery.
4.Hemorrage: due to damage to the uterine vessels, or may be
incidental as a consequence of uterine atony or placenta praevia
There are many manoeuvres to manage haemorrhage; these range
from bimanual compression, oxytocin infusion, administration of

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prostaglandins, conservative surgical procedures, such as uterine

compression sutures to the more radical but life saving hysterectomy.
5.Caesarean hysterectomy : which is a life saving procedure .most
commonly done due to uncontrollable maternal haemorrhage.

Indications for c/s hysterectomy:

1.placenta accrete with uncontrollable haemorrhage.(most common
cause)
2.uterine atony.
3.uterine rupture.
4.Extension of a transverse uterine incision.
5. fibroids preventing uterine closure and haemostasis .

Post-operative complications
1.Increase incidence of postpartum hemorrhage .
2.Endometritis.
3.Urinary tract infection.
4.Wound infection.
5.Chest infection.
6.Pulmonary embolism & deep venous thrombosis.
7.Increase incidence of placenta praevia &placenta accreta in
subsequent pregnancy.
8.Increase psychological morbidity .

Acute haematomas
Most common causes
1.Epsiotomy (85-90%) of cases
2.Instrumental vaginal delivery.
3.Primiparity.
4.Hypertinsive disorder.

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Other causes vuval varicosities ,macreosomic baby, prolong second

stage &multiple pregnancy.

Infralevator haematoma
Most commonly associated with vaginal delivery ,limited superiorly
by the levator ani.
They usually arise from small vulvar or labial vessels,branches of
inferior rectal ,inferior vesical or vaginal branch of the uterine artery.

This include vulval &perineal haematomas as well as paravaginal

hematomas &those occurring at the ischiorectal fossa .

Signs and Symptoms

1.Vaginal swelling .
2.Continued vaginal bleeding .
3.Severe rectal or vaginal pain.
4.Urinary retention.

Supralevator haematomas
Have no fibrous boundaries ,they may be paravaginal or supravaginal
haematoma.
They arise from branches of uterine artery ,the inferior vesical &
pudendal artery.

Presenting signs and symptoms

1.Cardiovascular collapse .
2.Uterine displacement.
3.Abdominal or rectal pain.
4.Continued vaginal bleeding.

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a.supralevator hematoma b.infralevator hematoma

1.levator ani muscle ,2.vagina,3.urogenital diaphragm

Management of haematomas
 Small ,non expanding haematomas of less than 3cm can be
managed conservatively.
 Larger or expanding haematomas reqired surgical management
which include
1. An incision is made at the most distended point of the
hematoma.
2. Blood clot is evacuated .
3. The bleeding vessels are identified &ligated.
4. The incision is closed by layers.
5. We may need to put drain in the wound for 24 hours to
allow any oozing blood to flow out.
6. Broad spectrum antibiotics are given .
7. Keep the patient under closed observation.
8. Blood transfusion is given if necessary.

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Broad ligament haematoma:

This hematoma will cause upward &lateral displacement of the
uterus.it is rarely associated with vaginal delivery ,but can occur if
genital trauma extends to the fornices or if the cervical tear sustained.
It also occur in cases of the uterine rupture or scar dehiscence or
Extension during C/S.

Management of Broad lig. Haematoma:

Either conservative management with resuscitation OR surgical
exploration if it is not possible to maintain a stable haemodynamic
state.