Fig. 42.
4: SIMS' DOUBLE-BLADED POSTERIOR
VAGINAL SPECULUM
Description and identification: This double-bladed
speculum has a groove in the handle. This groove is in
continuity at either end with the concave inner surface of
the blade. The purpose of the groove is to allow drainage of
blood, urine (ina case of VVF), or to collect such samples
for tests.
The blades are of unequal breadth to facilitate introduc
available
tion into the vagina depending upon the space blade in
(narrow blade in nulliparous and the wider
parous women). It is used in obstetrics: (1) To inspect
the
(3) To inspect
cervix and vagina and to detect any injury following delivery. (2) To clean the vagina following delivery. During
preferred).(4) DandE
the cervix and vagina to exclude any local cause for bleeding in APH (Cusco's speculumn
operation. ato > 280F
Self-assessment: (i)Common sites of traumatic PPH (p. 393). (ii) Diagnosis of traumatic PPH (p.386). (i1) Indications of
D+E(p. 523). (iv) What are the local (extraplacerntal) causes of APH(p. 230).
(v) What is Sims' position and what is Sims'
triad? Béad more Dutta's Textbook of Gynecology (p. 85, 353).
Mg. 42.5: CUSCO'S BIVALVE SELF-RETAINING VAGINAL
SPECULUM
Description and ldentification: It has two blades jolned
by screws to allow the blades to open and close. The blades
are concave inside. The handles are designed to open and
close the blades witha separate rod and screw system. This
makes the blades self-retaining during examination. It
does not need an assistant to hold it.
Uses:
) To visualize the cervix and vaginal fornices for any local
cause (polyp, ectopy) of APH.
(i) To inspectthe cervix and to prepare cervical smear for
cytology screening,
(i) Todetect leakage of ligor from the cervical os
IsuspectedPROM.
Chapter 42: Practical Obstetrics 611
Fig. 426: MULTIFLE TOOTHED VULSELLUM
It sused to catch hold of the anterior lip of the cervix in
(a) D+E operation, (b) suction evacuation. As it produces
trauma to the soft and vascular cervix, Allis tissue forceps
may be used instead.
Fig. 42.7:ALLIS TISSUE FORCEPs
cervix in
Uses: (1) To catch hold of the anterior lip of the
D+E operation. (2) To hold the apex of the episiotomy
margins
wound during repair. (3) To catch hold of the
sheath, vaginal mucosa during
of the peritoneum, rectus
torn ends of the sphincter
repair. (4) To catch hold of the
perineal
ani externus prior to suture in repair of complete
tear. (5) Tocatch hold of the margins and angles of the
uterine flaps in LSCS after the delivery of the baby as an
alternative to Green-Armytage hemostatic clamp.
Self-assessment: (î)Episiotomy-p. 527. (ii) What are the obstetric causes of perineal tear?
(p. 398). (iüü) What are the
diferent degrees of perineal tear? (p. 398). (iv) When and how a recent perineal tear is repaired? (p. 398).
HEMOSTATIC FORCEPS
Fig. 42.9: KOCHER'S
This instrument has a
Description and identification:
a groove on the other so
tooth at the end of one blade and the catch.
handles have
as to have a firm grip. The
cord-for better grip and
Uses: (1) To clamp the umbilical
vessels. (2) In low
effective crushing effect to occlude the
induction of labor or
rupture of the membranes as surgical
augmentation of labor (Figs. 35.2, 35.3). (3) Can be used
as ahemostatic and pedicle clamp during hysterectomy.
Self-assessmen t: (1) Structures of umbilical
(iii) Indications of induction of labor
cord (p. 36), (ii) Significance of single umbilical artery (p. 208). Table 35.7), (v) Dangers of induction
P. 487). (iv) Indications of surgical induction of labor (p. 490,
labor (medical and surgical) (p. 487). (vi) What is the pre- induction cervical scoring system?
p. 487). (vi)What immediate attention we should pay following ARM? (p. 49l).
Fig. 42.11:UTERINE SOUND
It is an olive pointed, graduated, malleable,
metallic
uterine sound. As it is malleable, its curvature could
be
changed to adapt the position of the uterus and for ease of
introduction.
Uses: (i) To know the position of the uterus and thelength
of the uterine cavity prior to dilatation of the cervix in
D+ E operation. (ii) Tosound the uterine cavity to detect any
cervical canal. foreign body (IUCD). (iii) It acts as a first dilator of the
Self-assessment: (i)What are the instruments required for D+E or
the important steps of S+ E or D + E? (p. 523, 524, suction evacuation? (p. 522, 524). (ii) What are
(p. 525).
525). (iii) What are the complications of S +E or D + E
operation?
Figs. 42.1 2A and B: CERVICAL DILATORS: HAWKIN
AMBLER (Fig. 42.12A) AND DAS ORHEGARS DILATORS
(Fig.42.12B)
Hawkin-Ambler: It is a single-ended metallic cervical A
dilator. It has got 16 sizes, the smallest one being 3/6
and the largest one being 18/21. The number is arbitrary
in the scale of Hawkin;Ambler. The smaller one denotes
measurement at the tip and the larger one measures the
maximum diameter at the base in mm. B
Das or Hegar's dilator is a double-ended one. The mini
mum size is 1/2 and the maximum size is 1l1/12. The number represents the diameter in mm, Both the sides are used with
thelower number first.
Use: It is used in dilatation of the cervical canal prior to evacuation operation.
Degree of dilatation required: (1) Incomplete abortion-sufficient to introduce the index finger
suction evacuation--one sizesmaller than the size of the suction cannula.(lm) In MTP by D+ (usually 16/19), () In
introduce ovum forceps (usually 9/12). Esufficient dilatation to
Self-assessment: (0) How to know the end point of
protocol when there is uterine perforation? (p. 525),suction procedure? (p. 526). () What is the management
(I0) What are the indications of laparotomy following
perforation?
Ans. Laparoscopy is helpful to assess the situation. (0) Lateral uterine wall
broad ligament hematoma. (01) Suspected injury to bowel and/or omentum. injury (il)
with intraperitoneal hemorrhage or
neriod of observation. (iv)Perloration prior to comnplete evacuation. Deterioration of vitalsigns during the
Fig. 42.14: DOYEN'S RETRACTOR
Description: It is a long metallic instrument with astout
handle at one end. The other end has a wide retracting
blade (fan-shaped and curved). It needs an assistant to
hold and to retract.
Uses: It is used to retract the abdominal wall as well as
the bladder for proper exposure of lower uterine segment
during LSCS. It is to be introduced after opening the
abdomen; to be temporarily taken off while the baby is
delivered, to be reintroduced after delivery of the baby and finally to be removed after toileting the peritoneal cavity.
Self-assessment: (1) Types of CS (p. 544). (ii) Common indications of LSCS (p. 543). (i) Principal steps of LSCS
(p. 545). (iv) Meritsand demerits of LSCS over classical (p. 548). (v) Complications of Cs (p. 549). (vi) Measures to
reduce cesarean delivery (p. 550).
reduce cesarean delivery (p. 550). 1Cal (p. 548). Complications of CS (p. 59). (vi) Measures to
Fig. 42.15:SPONGE-HOLDING FORCEPS
Description: It is a long metallic instrument (steel). It
has two ends. (A) One end is the handle with rachet and
catch. (B)The other end is ring-shaped with transverse
serrations inside for better grip.
Uses: (1) To clean the vulva, vagina and perineum prior
to and following delivery. (2) Antiseptic painting of the
abdominal wall prior to cesarean section. (3) To catch
hold of the membranes if it threatens to tear during
delivery of the placenta. (4) To catch hold of the cervix
(2 pairs are needed) for inspection in suspected cervical tear. (5) To catch hold of the cervix during encerclage operation.
Self-assessment: (i) What antiseptic solutions are commonly used to clean the vulva and vagina prior to and following
delivery? (p. 127) (iü) How the antiseptic painting of the abdominal wall is done before CS and what antiseptic
solution is commonly used? (p. 545) (i) What happens if bits of placental tissue or membranes are left behind?
(p. 393) (iv) How a cervical tear is repaired? (p. 400).
Fig. 42.16: OVUM FORCEPS
Description and identification: It is a long metallic (steel)
instrument with two ends and a shaft. The handle has no
catch and the blades are slightly bent and fenestrated.
Absence of catch minimizes uterine injury, if accidentally
Caught. It prevents crushing of the conceptus. It is to be
introduced with the blades closed, to open up inside the
uterine cavity, tograsp the products and to take out the
strument with a slight rotatory movement. The rotatory movements not only facilitate detachment of the products
Tom the uterine wall but also minimize the injury of the uterine wall, if accidentally grasped. It may be contused with
ponge-holding forceps but it has no catch moreover the blades of sponge forceps are serrated.
Self-assessment: (1) How to differentiate it from asponge- holding forceps?() How the absence of catch made it
vantageous? (ii) What are the indications of its use? (p. 524). Itis used to remove the products of conception in D&E
Operation and to remove the bitsof placenta and the membranes.
Fig42/8: UTERINE CURETTE
Destription and identification: It is a long metallic
instrument with a small fenestrated end at each side. The
shaft is there in the middle.
It may be sharp at both ends or sharp at one end and
blunt at the other. Its common use in obstetrics is in
[Link] of D+Cfor incomplete abortion. In D+E
operation, the curettage is done by blunt curette as the
uterine wall is very soft. It can also be used in D+ Copera
tion one week following evacuation ofhydatidiform mole.
Self-assessment: (1) Questions as in Figures 42,11, 42.12, 42.13, 42.15 and
evacuation of H. mole (p. 187). (iii) Drawbacks of vigorous Curettage. (iv) 42,16. (1) Place of curettage
What is the post-abortioncare? (p.524)following
Fig. 42.19: UTERINE DRESSING FORCEPS
Fi. 42.23: LONG-CURVED OBSTETRIC
fORCEPS (Ch. 37, p. 530)
It is commonly used in low forceps operation. Finger guard Screw
Self-assessment: (1) Different types of
obstetric forceps. (ii) Different parts
and the curvatures. (ii) Identification of
blades. (iv) Types of forceps application.
(v) Functions of the obstetric forceps. (vi)
Common indications of forceps delivery. (vii) Pelvic curve Shank Handle
Conditions to be fulfilled before application
of forceps. (viii) Steps of forceps application.
(ix) Direction of pull during delivery,
7.14). (x) Complications of forceps delivery. (xi) Indications of elective (prophylactic) forceps delivery.(xi) Trial
of forceps. (xiii) What is a failed forceps?
616 Chapter 42: Practical Obstetrics
Fig/42.24: SHORT-CURVED OBSTETRIC
FORCEPS (WRIGLEY'S FORCEPS) (Ch. 37, p.
It can only be used as 531) Handle
extraction of the head.
outlet forceps for
Self-assessment: (i)Difference with long-curved
forceps. (ii) Define outlet forceps. (iii) What is Cephalic curve
the direction of pull?
Shank
Fig. 42.26: FORCEPS' AXISs
TRACTION DEVICES
It includes axis traction rods
and handle. The rods are (right and left)
assembled in the
blades of long-curved obstetric forceps prior
introduction and lastly the handle is attached toto
the rods. The devices are required where much
forces are necessary for traction as in mid-forceps
operation. These are less commonly used now.
Self-assessment: (1) Identification of traction
rods. (i) Indications of use.
Fig. 47.27: EPISIOTOMY SCISSORS
(Cb7, p. 527)
It is bent on edge. The blade with blunt tip goes
inside the vagina.
Self-assessmen t: Comnon indications of
episiotomy (p. 527). (ii) Should episiotomy
be made in allcases? (p. 527). (ii) Types of
episiotomy (p. 527). (v) Complications of
episiotomy (p. 529).