OBSTETRICS

ANESTHESIA

SPINAL

  • All obstetrical procedures can be performed in spinal anesthesia
  • Preferred method for C/S
    • Unless patient is in chock

KETAMINE

  • When spinal anesthesia fails
  • When spinal anesthesia is contraindicated
    • Shock due to
      • Sepsis
      • Hemorrhage
  • Combine with
    • atropine
    • valium
  • Recommended doses:
    • 1-5 mg/kg  IV  
    • 5-10 mg/kg IM
    • 1-2 mg/kg at rate of 0.5 mg/kg/min as infusion
      • solution of 1 mg/ml in Normal Saline or Glucose

PUDENDAL BLOCK / SACRAL ANESTHESIA

  • Forceps Delivery
  • Episiotomy

LOCAL INFILTRATION ANESTHESIA

  • Episiotomy
  • Symphysiotomy
  • C/S

GENERAL INTUBATION ANESTHESIA

  • Uterine Rupture
  • C/S in Eclampsia.

BLOOD TRANSFUSION

In lack of laboratory equipment for typing and crossmatching:

  • Take small samples of blood from recipient and donor
  • Centrifuge blood samples
  • Place a drop of serum from recipient on a white surface
  • Place a drop of red blood cells (the sediment) from donor beside
  • Mix the two drops
  • Read the result.
  • Does it clump together or not?

If blood transfusion set is not available:

  • Place recipient on floor
  • Place donor on a stretcher
  • Connect donor and recipient with an i.v. line
  • Enhance blood flow with venous stasis by a tourniquet on the donor’s arm
  • Stop transfusion when recipient and donor have same pink mucosal linings (equilibrium has been acchieved)

In lack of electric centrifuge:

Buy a handheld

Or make your own with a testtube and piece of string

Selfmade centrifuge

BREECH

Safer to deliver by C/S in primipara

C/S in Breech

SPONTANEOUS BREECH DELIVERY

Be prepared for a retained caput!

  • Catheterize the bladder.
  • Leave the catheter indwelling
  • Place the patient with legs in stirrups
  • Buttocks hanging free of the table
  • Infiltrate the pubic area with local anesthesia
  • Have the following items at hand:
    • Large vaginal speculum
    • Delivery Forceps  
    • Scalpel
    • Heavy scissors
  • Check fetal heart rate continuously
  • Do not intervene before the lower part of the body has been delivered unless the heartbeat slows down critically
  • As soon as the lower part of the body has been delivered palpate the umbilical cord for pulsations.
  • If feeble or absent proceed urgently with EXTRACTION OF BREECH
  • Let body be delivered spontaneously
  • Let arms be delivered spontaneously
  • Leave body hanging by the head for a short moment (Burn-Marshall maneuver)
  • Grasp both feet from the front with a forked finger grip
  • Lift the body vertically by both feet
  • Let the head be delivered spontanesously (Bratt’s procedure)

ASSISTED BREECH DELIVERY

Be prepared for a retained caput!

  • Catheterize the bladder.
  • Leave the catheter indwelling
  • Place the patient with legs in stirrups
  • Buttocks hanging free of the table
  • Infiltrate the pubic area with local anesthesia
  • Have the following items at hand:
    • Large vaginal speculum
    • Delivery Forceps  
    • Scalpel
    • Heavy scissors
  • Check fetal heart rate continuously
  • Do not intervene before the lower part of the body has been delivered
    • Unless fetal heartbeats slow down critically
  • As soon as the lower part of the body has been delivered palpate the umbilical cord for pulsations.
  • If feeble or absent proceed urgently with EXTRACTION OF BREECH
  • 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 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 same technique
  • In case the anteriorly positioned arm is difficult to release, rotate the truncus 180 ° bringing the arm to a posterior position and release /as described above
  • Leave the body hanging free for a short moment to facilitate the descent of the head in the birth canal. (Burn-Marshall maneuver)
Burn-Marshall maneuver
  • Deliver the head by Mauriceau-Levret’s maneuver:
    • Introduce index finger in the mouth
    • Flex the head with the index in the mouth
    • Apply traction with a forked finger grip posteriorly to the neck with the other hand
    • Apply fundal pressure by assistant
Assisted Breech Delivery

EXTRACTION OF BREECH

In case of fetal distress do a fast extraction:

  • Grasp one foot / both feets
  • Use forked finger grip with heel(s) in the palm of the hand
  • Grasp knee(s) with other hand
  • Apply strong traction
  • Combine with exaggerated pumping movements
  • Release arms
  • Perform Burn-Marshall’s procedure
  • Deliver head by Mauriceau-Levret’s maneuver
Extraction of Breech

RETAINED HEAD / FETUS ALIVE

Be prepared!    

  • Make a generous episiotomy. That might solve the problem by itself.
  • If needed to buy time:
    • Have an assistant lift the body vertically by the feet
    • Place large speculum posteriorly in the vagina.
    • Apply downward traction on the speculum
    • This will keep the airway free and accessible for suction.
  • Make a symphysiotomy:
    • Push the catheterized urethra to the side with two fingers in the vagina
    • Cut through the symphysis strictly in the midline with a scalpel
    • Cut until the pubic bones separate and you can feel the gap
  • Deliver the head with Mauriceau-Levret’s maneuver
Symfysiotomy in Breech

RETAINED HEAD DUE TO HYDROCEPHALUS

If not detected by previous palpation and/or ultrasound, the diagnosis will come into light when a myelomeningocele becomes visible as the lower part of the body is being delivered.

  • Puncture the hydrocephalic head suprapubically with a large bore needle
  • Drain the cerebrospinal fluid
  • Deliver the collapsed head by Mauriceau-Levret’s maneuver
  • Puncture and drainage of the head does not harm the child
Suprapubic Puncture and Drainage of Hydrocephalic Head

RETAINED HEAD / FETUS DEAD

Craniotomy

  • Apply firm traction on the neck
  • Perforate the back of the skull in the occipital area.
  • Be sure to perforate the skull. Not the upper part of the cervical spine.
  • Open the shanks of the perforating instrument
  • Destruct all intracranial septa.
  • Perform Mauriceau-Levret’s maneuver as follows:
    • Introduce index finger in the mouth
    • Flex the head with the index finger
    • Apply traction to the neck with a forked finger grip to the back of then neck
    • Extract the head by traction on the neck
  • Proceed slowly
  • Allow time for the head to collapse
Craniotomy in Breech

Occasionally attempts to extract the head by forceful traction to the neck have been attempted. The result may be a fractured spine with an elongated neck. When applying further traction to the neck the head will inevitably separate from the trunk.

Separation of head and trunk also occurs if you by mistake perforate the upper part of the spine instead of the skull. 

In case of such a scenario:

  • Remove the body
  • Extract the head from uterus with a finger in the mouth and the fractured spine in the palm of your hand
  • Apply fundal pressure with other hand
Retained Head in Breech. Separation from neck

CERVICAL PROLAPSE / UTERINE INVERSION

  • After prolonged and/or traumatic vaginal delivery an edematous cervix or an inverted uterus may prolapse through the introitus.
  • Uterine inversion is commonly the result of unsuccessfull attempt to deliver the placenta by harsh traction on the umbilical cord
  • Cervical prolapse and uterine inversion are treated the same
    • Remove placenta if still attached
    • Apply steady manual pressure to the prolapsed part
    • Continue untill prolapsed part is compeletely reduced
    • The prolapsed part will remain in place after reduction
    • No futher action needed

CESAREAN SECTIO (C/S)

Surgical technique

  • Low transverse incision through the skin
  • Small transverse incision strictly in the midline throuigh the subcutaneous tissue and fascia
  • Split the fascia by sliding a pair of slightly opened scissors transversely to the right and left.
  • That will spare the subcutaneous vessels avoiding unnecessary bleeding
  • Stretch the wound manually in a vertical direction
  • Open the peritoneum bluntly with your fingers
  • Stretch the wound further by manual traction in a transverse direction
  • Place a retractor distally in the wound
  • Apply downward traction to the retractor by assistant
  • Small transverse incision in the upper part of the lower segment of the uterus
  • Maintain a safe distance away from the bladder.
  • The more the lower segment is stretched, the higher the incision should be
  • 3 to 5 fingers above the bladder.
  • Do not incise the bladder peritoneum and push down the bladder to make the incision low in the lower segment as described in many textbooks. That’s a recipe for troublesome vaginal tears.
  • Stretch the uterine incision manually in a transverse direction
  • Apply fundal pressure by assistant
  • Lift out the presenting part with
    • One hand
    • Sellheim’s Obstetrical Lever
    • One blade of pair of ordinary obstetrical forceps  
  • Deliver the baby
  • Clamp and cut the umbilical cord
  • Lift out uterus from the abdominal cavity
  • Squeeze out placenta by fundal pressure
  • Or remove it by hand from the uterine cavity
  • Close the incision in the lower segment with a continuous inverting suture from one corner of the incision to the other.
  • Use resorbable suture such as Chromic Catgut or Polyglycolic Acid.
  • One layer is enough.
  • Remove blood from the abdominal cavity
  •  Return uterus into the abdomen
  • Close the fascia with a continuous suture
  • Close the skin
Cesarean Sectio

CHALLENGES WITH CESAREAN SECTIO

FULL BLADDER

Empty bladder by suprapubic puncture

Full Bladder in C/S

DEEPLY IMPACTED HEAD

There are two options:

  1. Have an assistant push the head from below with a hand in vagina
Pushing Impacted Head from Below

2) Perform internal version and extraction on a foot through the uterine incision

C/S with Internal Version

LATERAL TEARS OF THE UTERINE INCISION

  • Close the wound with two continuous sutures
  • Start suturing separately in each corner
  • Tie the sutures together in the midline

BLEEDING FROM UTERINE ARTERY

  • Clamp the artery above and below the bleeding point
  • Apply suture-ligation
Bleeding from Uterine Artery

MYOMA

  • Make the uterine incision in a convenient place
  • Avoid the myoma(s) in the incision
  • Do not try to shell out or remove the myoma(s)
  • It may cause torrential and fatal bleeding.
Myoma in C/S

HIV POSITIVE PATIENT:

  • Use protection
  • Give prophylactic medication before surgery

ABDOMINAL PACK

  • Be sure to remove all abdominal packs before wound closure
  • Suspect retained pack in septic complications

CORD PROLAPSE

  • Palpate the prolapsed cord for pulsations

Pulsations present:

  • Place the patient in knee-chest position (“a la vache”)
  • Push the presenting part proximally with a hand in the vagina
  • Prepare for urgent C/S

Pulsations not present:

  • Proceed with vaginal delivery

Doubtful whether pulsations are present or not:

  • Check if fetal heart beats are present
  • Preferable with Doppler or ultrasound
  • Proceed accordingly

DESTRUCTIVE DELIVERY / INTRAUTERINE FETAL DEATH

  • In intrauterine fetal death (IUFD) do not perform C/S.
    • Severe maternal infection with fatal sepsis is a substantial risk.
  • Deliver vaginally
    • By destructive delivery if needed

INSTRUMENTS

From left to right: Basiotribe – Perforator – Heavy scissors – Delivery hook

CEPHALIC PRESENTATION

CRANIOTOMY

  • Perforate the skull with perforator or a pair of heavy scissors
  • In face presentations use an eye as entry point
  • Open the shanks of the perforator
  • Break all intracranial septa
  • Apply the basiotribe with the solid leg inside and fenestrated leg outside of the skull  
  • Be careful not to catch part of cervix or vagina in the grip
  • Tighten grip as much as possible
  • Extract the fetus.
  • Do this slowly
    • Allow time for the head to collapse.
  • In lack of a basiotribe use:
    • Ordinary delivery forceps
    • Several heavy toothed clamps
  • Remove the placenta manually
  • Check with a hand in the uterine cavity for rupture
Craniotomy I
Craniotomy II

RETAINED HEAD in BREECH

CRANIOTOMY

  • Apply firm traction on the neck
  • Perforate the back of the skull in occipital area
  • Be sure to perforate the skull
  • Do not the perforate upper part of the cervical spine
  • Open the shanks of the perforating instrument
  • Destruct all intracranial septa
  • Deliver head by Mauriceau-Levret’s maneuver
    • Introduce index finger into the mouth
    • Flex the head with index finger
    • Apply traction to the neck with a forked finger grip applied to the back of the neck
    • Extract the head by traction on the neck
  • Proceed slowly to allow time for the head to collapse
Craniotomy in Breech

SEPARATION OF HEAD FROM NECK

Attempts to extract the head by forcefull traction may result in a fractured spine with an elongated neck. Further traction will separate the head from the trunk.

Separation of head may also occur if you by mistake perforate the upper part of the spine

In case of such a scenario:

  • Remove the body
  • Extract the head from the uterus
    • With a finger in the mouth
    • The fractured spine in the palm of your hand
Retained Head Separated from the Neck

COMPOUND TRANSVERSE PRESENTATION (transverse presentation with prolapsed arm)

There are two scenarios:

I. YOUR FINGERS CAN REACH AROUND THE NECK

DECAPITATON

  • Apply the delivery hook around neck
  • Fracture the cervical spine forcefully with the hook
  • Apply traction to the prolapsed arm by assistant
  • Cut the neck with
    • Scalpel or
    • Heavy scissors
  • Deliver the body by traction to the arm
  • Extract the head from the uterus
    • With a finger in the mouth
    • Fractured spine in the palm of your hand
  • Remove placenta
  • Manually assess the uterine cavity for rupture
Decapitation in Compound Transverse Presentation

II. YOUR FINGERS CAN NOT REACHED AROUND THE NECK

EXVISCERATION

  • Apply traction to the prolapsed arm by assistant
  • Perforate abdomen / thorax
  • Insert a hand into the abdominal / thoracic cavity
  • Remove all internal organs from abdomen / thorax
  • Grasp one or both feet
    • Perform internal version and extraction
  • If unsuccessfull
    • Fracture the spine with the delivery hook
    • Cut the body in two parts
    • Deliver the body parts separately with traction on foot or arm

ECLAMPSIA

Eclampsia

Treatment:

  • Controle convulsions with Magnesium Sulfate and/or Valium
  • Treat hypertension  
  • Deliver as rapidly and least traumatically as possible
    • FETUS ALIVE
      • Gestational age > 36 weeks
        • Urgent C/S
      • Gestational age < 36 weeks
        • Vaginal delivery
        • Induction and/or augmentation
          • Oxytocin
    • FETUS DEAD
      • Vaginal delivery
      • Induction and/or augmentation
        • Misiprostol (Cytotec)
      • Destructive delivery if needed
  • Monitor vital signs closely
  • Continue antihypertensive treatment
  • Give regular doses of Magnesium Sulfate and/or Valium to prevent convulsions
  • Keep a syringe with 5-10 mg valium at bedside for immediate i.v. administration to control breakthrough convulsions
  • Watch out for signs of DIC (HELLP)