INDUCTION

ALIVE FETUS

  • Oxytocin 10 units in 500 cc Normal Saline solution
    • Start i.v. infusion with 10 ml per hour
    • increase by 20 ml every 20 minutes until contractions occur

DEAD FETUS (IUFD)

  • Misoprostol (Cytotec)

Gestational age < 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 2 cc orally every 6 hours
  • VAGINAL ADMINISTRATION
    • ½ tablet in vagina every 6 hours

Gestationalage > 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 1 cc orally every 4 hours
  • VAGINAL ADMINISTRATION
    • ¼ tablet in vagina every 4 hours
    • One tablet diluted in 10 cc
      • 1 cc in vagina every 4 hours

MANEUVERS

MAURICEAU-LEVRET

For delivering head at Breech Presentation

  • Lift body vertically by the feet
  • Introduce index finger in the mouth
  • Let the body ride on your arm
    • On the abdomen
    • Legs hanging down on each side of the arm
  • Flex the head with index finger in the mouth
  • Apply traction with a forked finger grip posteriorly to the neck with the other hand.
  • Apply fundal pressure by assistant

Mauriceau-Levret’s maneuver

INTERNAL VERSION AND EXTRACTION

For delivering breech and transverse presentations

  • Introduce one hand in uterus
  • Search for small parts of the fetus
  • Identify one or both feet
    • Foot has a heal
    • Hand has a thumb
  • Grasp one or both feet with forked fingergrip from behind
  • Apply strong traction on the foot/feet
  • Rotate the fetus by a combination of
    • Traction on the foot/feet
    • Upward pressure on caput with the other hand on mother’s abdomen
  • Continue strong traction on foot/feet
  • Combined with pumping movements
  • Grasp the knee anteriorly with the other hand
  • Extract lower part of the body by a combination of
    • Strong traction
    • Pumping movements
  • Grasp pelvis with both hands
  • Extract upper part of body by a combination of
    • Strong traction
    • Pumping movements
  • Release the arms
  • Deliver head by Mauriceau-Levret’s maneuver
Internal Version and Extraction

ARM RELEASE

In Assisted Breech Delivery

  • Release the posteriorly positioned arm first
  • Use left hand when the back is turned to the (mother’s) right
    • And vice versa
  • Place left thumb on the frontal aspect of the truncus
  • Left index and middle fingers on the back
  • Slide the hand inwards
  • Along the truncus
  • Until the thumb reaches the axilla
  • With a sweeping movement across the head
  • Bring the arm down with index and middle fingers
  • Change hands
  • Release the anteriorly positioned arm
    • Using the same technique

BURN-MARSHALL

  • In Breech presentation
  • Let the baby hang a short moment by the head
  • To facilitate it’s descendens in the birth canal
Burn-Marshall

LOEVSET

For delivering the shoulders

  • Grasp lateral border of the scapula with four ulnar fingers of your hand
  • Rotate truncus 180°
  • Use right hand when the back is turned to the (mother’s) left
    • And vice versa
  • The birth canal is shorter anteriorly
  • Bringing the posterior shoulder anteriorly will deliver it
Loevset’s Maneuver
Loevset’s Maneuver with Delivery Hook

PLACENTA PREVIA

Painless – sometimes massive – bleeding in the last trimester of the pregnancy strongly suggests previa.

Same treatment whether fetus is alive or dead:

  • Immediate resuscitation with fluids
  • Transfuse one or two units of fresh blood
  • Perform ultrasound examination
    • Total previa:
      • C/S
    • Marginal previa:  
      • Rupture the bulging membranes
        • Diminishes traction on the placenta
        • Reduces bleeding
      • Deliver vaginally

When ultrasound is not available

  • Bring patient directly to the operating theater
  • Prepare for urgent C/S
  • Perform gentle speculum examination
    • Total previa:
      • C/S
    • Marginal previa:
      • Rupture the bulging membranes
        • Diminishes traction on the placenta
        • Reduces bleeding
      • Deliver vaginally

Watch out for signs of DIC (HELLP Syndrome). Transfuse with fresh blood at the slightest suspicion

PREMATURE LABOUR

PREMATURE CONTRACTIONS

  • Bed rest in left lateral position
  • Salbutamol
    • Tablets 4 mg four times daily
  • Nifedipine
    • Initial dose of 20mg
    • Followed by three further doses of 20mg every 30 minutes
      • As long as contractions continue
    • Maintenance dose is 20-40mg orally every 4 hours for 48 hours
      • No more than 160mg/24 hours
  • Potent corticosteroids
    • Accelerates lung maturity of fetus
      • Betamethasone 1 ampule i.m. 2 doses 12 hours apart
      • Dexamethasone 6 mg i.m. 4 doses 12 hours apart

INSUFFICIENT CERVIX

  • Cerclage with heavy non-resorbable suture
  • Remove suture when contractions start
    • Or deliver by C/S

PREMATURE DELIVERY

  • Maintain body temperature
    • Incubator is questionable high tech
    • Kangaroo method is more appropriate technology
      • No significant difference in survival rate between the two methods
    • Cover head
  • Feed with breast milk
    • Cup
    • Spoon
    • Gastric tube

TWINS

  • Twins per se is not an indication for C/S
  • Typically twins are smaller with lower bodyweight
  • Vaginal delivery is usually possible

When presenting twin (twin A) is in breech and second twin (twin B) in a cephalic presentation there is a risk of “locked twins”. In this case deliver by C/S

VAGINAL DELIVERY – both twins in breech

RETAINED TWIN B

Cervix is fully dilated

  • Deliver by internal version and extraction using a foot or both feet.

Cervix is not fully dilated

  • Deliver by C/S

LOCKED TWINS

Head of second twin (twin B) in cephalic presentation locks head of presenting twin (twin A) in breech. Chin against chin.

Both twins alive

  • Deliver the second twin (twin B) by C/S
  • Cover the incision with sterile towels
  • Position the patient’s legs in stirrups
  • Deliver the head of first twin (twin A) by Mauriceau-Levret’s maneuver
  • Change gown and glows
  • Return to the abdominal incision
  • Proceed as usual

First twin (twin A) is dead / Second twin (twin B) is alive

  • Give appropriate anesthesia
    • Spinal
    • Ketamine
    • General intubation
  • Place patient’s legs in stirrups
  • Decapitate the first twin (twin A)
    • Heavy scissors
    • Scalpel
  • Remove the body
  • Push the decapitated head up inside the uterus
  • Grasp a foot or both feet of the second twin (twin B)
  • Perform internal version
  • Deliver twin B by extraction on the foot/the feet
  • Continue as usual for a breech delivery
  • Introduce one hand into the uterus
  • Extract the decapitated head
    • One finger in the mouth
    • The severed neck in the palm of the hand
    • To protect vagina from injuries
  • Apply fundal pressure with the other hand
  • Remove placenta
  • Check for uterine rupture

Both twins dead

Same procedure as with “First twin dead / Second twin alive”

UTERINE RUPTURE

Ultimate result of unrelieved obstructive labor

Symptoms and signs

  • Shock
  • Abdominal pain
  • Contractions absent
  • Fetal heartbeats absent
  • Small parts of fetus are visible and/or palpable directly under the skin

Diagnosis

  • Usually straight forward
  • Occassionally challenging
    • Particularly with posterior ruptures
  • Abdominal aspiration:
    • Blood at aspiration confirms the diagnosis
    • No blood at aspiration is inconclusive

If diagnosis is still in doubt, there are two options:

I. Do a laparotomy

Rupture is present:

  • Proceed with repair

No rupture is present:

  • Close the abdominal incision
  • Perform destructive delivery

II. Deliver the dead fetus by destructive procedure

Check uterine cavity manually for rupture

  • Rupture is present
    • Proceed with laparotomy & repair

In selected cases, when:

  • Peritoneum is intact
  • The palpating hand does not come into direct contact with the bowels
  • Patient is critical
  • Surgeon unexperienced
    • Relay on firm gauze packing
    • Remove pack in OR after 24 hours

TYPES of RUPTURES:

  • Anterior  –   transverse or longitudinal  –  with or without bladder rupture
  • Lateral     –   always longitudinal              –  with or without bladder rupture
  • Posterior –   transverse or longitudinal –  always without bladder rupture

The far most common type is the anterior transverse.

Use the same principles as in trauma surgery:

  • Minimal Surgery
  • Make a fast and simple repair of the rupture
  • Do not traumatize the patient further by performing hysterectomy.   
  • The only indications for hysterectomy are:
    • Gangrene of the uterus
    • When technically easier and faster to do than a repair

REPAIR OF RUPTURED UTERUS

  • Main objectives of the repair are to:
    • Stop bleeding
    • Separate the abdominal cavity from vagina

SURGICAL TECHNIQUE

  • Resuscitate with i.v. fluids
  • Give i.v. antibiotics (ampicillin/gentamycin/metronidazole)
  • Transfuse one or two units of fresh blood if available
  • Ketamine i.v. works well
  • General anesthesia is even better when a skilled anesthetist is present
  • Repair the rupture with a continuous inverting suture
  • Use heavy resorbable suture (Chromic Catgut or Polyglycolic Acid)
  • Cover the repair with a second layer of peritoneum
  • In critical situations suturing the torn peritoneum may be sufficient and lifesaving.
  • Reaching the most distal part of a rupture may be challenging.
  • Do not struggle
  • Leaving the most distal part of the rupture open for drainage is in fact an advantage.
  • In case the patient has no – or only one – living child
    • The relatives promise solemnly to take her to hospital for C/S at the next delivery
    • Offer that option.
    • Otherwise perform bilateral tubal ligation (BTL).
  • Clean the abdominal cavity
    • Remove all contaminated, infected blood
    • Irrigate with plenty of saline before closure.

REPAIR OF ANTERIOR TRANSVERSE UTERINE RUPTURE

Repaire of Anterior Transverse Uterine Rupture

REPAIR OF LATERAL UTERINE RUPTURE

  • Close rupture with a continuous suture
  • Leave the most distal part of the rupture open for drainage
  • Cover the repair with a second layer of peritoneum

REPAIR OF POSTERIOR LONGITUDINAL

  • Same technique as for lateral rupture
  • A second layer is usually not possible

REPAIR OF POSTERIOR TRANSVERSE RUPTURE

  • Somewhat challenging as the lower segment is short and inaccessible.
  • Repair with interrupted inverting sutures in a row
  • Tie suture when all are in place

REPAIR OF RUPTURED BLADDER

Bloody urine raises the suspicion of bladder involvement

SURGICAL TECHNIQUE

  • Repair bladder with one or two layers of continuous inverting resorbable suture
  • Watch out for the ureters
  • Repair the ruptured uterus
  • In critical situations the bladder can be left unrepaired with an indwellingath catheter
  • The resulting VVF (vesicovaginal fistula) can be repaired later

Using these principles resulted in the present maternal mortality of less than 3 % in Aira Hospital as seen in the presentation below. One of the two deceased patients in the material expired before reaching the operating theater. The maternal survival rate after surgery is thus 98.6 % and mortality with surgical treatment 1,4 %

Ruptured uterus follow upp 2009

An improvement from 5% mortality previous 10 years

Retrospective analysis of uterine ruptures 2000 – 2009

An improvement from the 5 % mortality rate during the preceding 10 years.