2.

Postpartum: Retained placenta, atonicuterus, rupture Methods of Performing Dilatation and

uterus, coagulopathy, laceration. Evacuation

Treatment There are two methods of performing dilatation and

evacuation:
1. Good antenatal care (early recognition of anemia and 1. First method: Dilatation of the cervix and evacuation
malnutrition, etc.). of the uterus are done ín the same sitting.
2. Treatment of anemia and malnutrition. 2 Second method: There are twO phases in second
3. Provision of intrapartum care: method:
a Proper nourishment a. First phase includes slow dilatation of the cervix.
b. Treatment of dehydration and acidosis (if present) b. Second phase includes rapid dilatation of the
c. Sedative therapy cervix and evacuation.
4. Conduction of labor in an equipped hospital where
antishock measures are available. First Method
5. Proper postnatal care.
Indications
1. Incomplete abortion
OBSTETRICAL PROCEDURES 2. Inevitable abortion
[Link] 3. Medical termination of pregnancy
4. Hydatidiform mole in the process of expulsion
Obstetric operations are surgical procedures which are to be
carried withstrict asepsis and antisepticprecautions. Procedure
1. While doing any of the operative procedure, the 1. The patient is to be placed in lithotomy position.
following preliminaries are to be followed, these are: 2. Full surgical asepsis is to be taken.
a. The patient is given anesthesia: Either general or a. Surgeon is to wear sterile mask, gown and gloves.
local. b. Vulva and vaginaare to be swabbed with antiseptic
b. The patient is placed in 'Lithotomy Position! solution.
c. Full surgical asepsis is carried. c The perineum is to be draped by sterile towel and
d The bladder is emptied. the leg with leggings.
e. Vaginal examination is done. 3. Toempty the bladder: If the patient is ambulant, she is
2. Main operative obstetrics procedures: asked toempty the bladder before she is placed on the
a. Dilatation and evacuation (D + E) table. Otherwise, catheterization is to be done.
b. Suction evacuation/ vacuum aspiration 4. Vaginal examination is done.
c. Menstrual regulation/ endometrial extraction or 5. The patient is put under general anesthesia.
menstrual indication etomielle
e6, Internal examination is doFe to note the size of
d. Hysterotomy dilatation of the cerVix.
e. Episiotomy If the cervix is not sufficiently dilated to admit the
f. Forceps finger (usually it does), it should be dilated.
g Ventouse
Posterior vaginal speculumn is introduced and an
h. Version
assistant is asked to hold it. The anterior lip of the cervix
i. Cesarean section ee ea t)
/s grasped by an Allis forceps to steady the cervix.
j. Destructive operations: iterine sound is [Link] note the length of the
i. Craniotomy uterine cavity and the position of the uterus.
ii. Evisceration 9. The cervix is dilated upto the desired extent by
iii. Decapitation the
graduated metal dilators.
iv. Cleidotomy 10. The products are removed by ovum forceps. The
uterine cavity is finally curetted gently by a flushing
DILATATION AND EVACUATION curette. Injection methergin 0.2. mg is to be
Definition administered intravenously during the procedure.
11. The speculum and the Allis forceps are to be removed.
"The procedure dilatation and evacuation çonsists of dilatation The uterus is to be massaged bimanually with the help
of the cervix and evacuation of the products of conception of the external hand and the internal fingers placed
from the uterine cavity" inside the vagina.
 12. After being satisfied that the uterus is firm and the Procedure:
bleeding is minimal, the vagina and perineum are a. The patient is brought back to the operation theatre
toileted, a sterile vulval pad is placed and the patient is usually after 12 hrs. The patient should empty her
sent back tÝ her bed. bladder beforehand.
b. Prelininaries:The steps to be followed are those
Second Method previously mentioned. The operation may be
conducted under intravenous diazepam sedation,
Indications local paracervical block or under anesthesia.
1. Induction of 1s trimester abortion (commonest).
2. Missed abortion (uterus 8-10weeks). Dangers of D + EOperation
3. Hydatidiform mole with unfavorable cervix (long,
fim and closed). Immediate Dangers
1. Excessive hemorrhage mày be due to:
a. Incomplete evacuation
Procedure b. Atonic uterus
1. First phase: It consists of introduction of laminaria 2 njury:
tents (see figure. 8.34) or isabgol tents into the cervical a. Cervical lacerations of varying degree which may
canal to effect its slow dilatation. The same may be lead to the formation of a broad ligament
effective by intravaginal insertion of misoprostol hematoma.
(PGE), 400 ug 3 hrs. before surgery. b. Uterine perforation.
2. Second Phase: It consists of further dilatation of the 3. Shock may be due to:
cervix by graduated metal dilators following by a. Uterine perforation
eyacuation of the uterus. b. Bxcessive blood loss
. Anestheticcomplications
d Inreased morbidity
4. Late dangers:
A. Prior to introduction a. Pelvic Inflammation
b. Infertility
c. Cervical Incompeence
d Uterine synechiae
B. Marked swelling due to hygroscopic
action while kept in cervical canal SUCTION EVACUATION
It is a procedure in which the products of conception are
sucked out from the uterus with the help of acannulafitted
to a suction apparatus.

C. To hold the tent by tent introducing forceps Indications

FIGURE 8.34 Laminaria tent
oMedical termination of pregnancy during first
trimester.
2. Inevitable abortion.
3: Recent incomplete abortion.
AHydatidiform mole.
A. Ovum forceps
Procedure
Perliminaries
The steps to be followed are those mentioned in the starting
of the chapter. General anesthesia is usually not needed. If
B. Ring forceps the patient is apprehensive, intravenous diazepam 5-10 mg_
supplemented by paracervical block is quite effective. The
patient is put on the table after she empties her bladder.
O00

C. Flushing forceps
Steps
FIGURE 8.35 Special Instruments 1. Vaginal examination is done to note the size and
position of the uterus and to note the state of cervix.
 C. Reduction of uterine
B. Size of the uterine cavity following aspiration
A. Suction cannula attached to the
pump is introduced into the uterine cavity cavity prior to aspiration

FIGURE 8.36 Suction evacuation

blood loss. The suction is regulated by a finger placed
over a hole at the base of the cannula. The end pointof
suction is denoted by:
A a. No more materialis being suckedout.
b. Gripping of the cannula by the contracting small
sized uterus.
c. Grating sensation.
B d. Appearance of bubbles in the cannula or in the
transparent tubing.
FIGURE 8.37 A. 50 ml Karman's plastic syringe with cannula, 8. The vacuum should be broken before withdrawing the
B. Plastic cannut withdouble-whistle tip used [Link] cannula down through the cervical canal to prevent
evacuation. injury to the internal os.
9. It is better to curette the uterine cavity by a small
blushing curette at the end of suction and the cannula
2. Posterior vaginal speculum is introduced and an
is reintroduced to suck out any remnnants.
assistant is asked to hold it.
10. After being satisfied that the uterus is firm and there is
3. The anterior lip of the cervix is to be grasped by an Allis minimal vaginal bleeding, the patientis brought down
forceps. A uterine sound is to be introduced tonote the
from the table after placing a sterile vulval pad.
length ofthe uterine cavityand position of the uterus.
4. The cervix may have to be dilated with smaller size
graduated metal dilators up to one size less than that of Complications
the suction cannula (instead of dilatation by metal Similar complicationsas mentioned inD +Eoperation may
dilators specialyinprimigravida). It is advantageous to occur. Use of the plastic cannula can minimize uterine
introduce laminaria tent or intravaginal prostaglandin perforation. Blood loss and incomplete evacuation are less
E pessary 3-5 mg if available, at least 12 hrs. likely with pregnancy of 8 weeks or less.
beforehan.
5,8outinely administer 10 units of injection oxytocin,/ MENSTRUAL REGULATION
Mintramuscularly or an intravenous I/V infusion of
20 units oxytocin in 500 ml of saline or lactated "Menstrual regulation is the aspiration of endometrial cavny
Finger s solutionto prevent post partum hemorrhage within 14 days of the missed period in apreiously normal
cycle when the presence of an early pregnancy cun
in the third stage of labor. diagnosed accurately'"
6. The appropriate suction cannula is fitted to the uterus,
the lip is to be placed in the middle ofthe uterine cavity. The operation is done as an outdoor procedure. Strict aseptic
7. The pressure of thesuction is raised to 400-600 mmHg. precautions should be taken and in apprehensive palle
Thecannula is moved up and down and rotated within paracervical block anesthesia may be employed. Afteris
cervix
the uterine cavity with the pressure on. The suction introducing the posterior vaginal speculum, the
bottle is inspected for the products of conception and steadied with an Allis forceps introducing aa4-5 gflexible
mm
suction
plastic cannula into uterine cavity and lemployings
532 MIDWIFERY AND OBSTETRICS FOR BSC. NURSING STUDENTS
It may be
Procedure: It is an indoor procedure. theatre if
f. To place scalp electrode for electronic fetal conducted in the labor room or theoperation
monitoring the risk of cord prolapse is high.
prevent the risk of infection
Factors on which effectiveness of surgical induction a. Wash hands to
empty the bowel and
depends: It depends on: b. Instruct the mother to
a. State of the cervix. bladder.
lithotomy position
b. Station of the presenting part. c. Help the mother to lie down invisualization.
better
Note: The induction delivery interval is shorter when as this position ensures
amniotomy is combined with oxytocin. d. Follow strict aseptic techniques to decrease the
chances of in fection.
Advantages of Amniotomy: and gown.
e. Wear sterile gloves, mask techniques.
a. High success rate.
blood or f. Clean the perineum using aseptic
b. Chance to observe the amniotic fluid for g The physician introduces two
fingers of the Jeft
canal and
hand in the vagina upto the cervical
meconium.
blood
. Easy to carry out procedure like fetal scalp beyond the internal os. This helps to guide the
ARM
sampling, intrauterine pressure catheter and fetal
scalp electrode. forceps. membranes and
Limitation: It is not done in an unfavorable cervix
h. Now, the physician will assess the
place the palmar surface of the left hand upwards.
(Long, firm cervix with osclosed). For this procedure, This guiding hand will prevent injury to the cervix
the cervix should be at least one finger dilated.
Or vaginal tract.
forcep
i. The physician introduces a long Kocher's
Contraindications:
a. Intrauterine fetal death.
with blades closed up to the membranes along the
palmar aspectand ruptures the membranes.
b. Maternal AIDS.
c. Genital herpes infection. /. After the membranes have been ruptured,
Effects/Advantages of ARM: The immediate effects of immediately assess the following:
ARM are: i. The fetal heart rate
a. Lowers the blood pressure in pre-eclampsia and ii. Color of amniotic fluid
eclampsia. iii. Amount of amnniotic fluid
b. Controls bleeding in APH. iv. Status of the cervix
c. Reliefs tension in abruptio placentae and initiation v. Station of the head
oflabor.
vi. Presence or absence of cord prolapse.
d Relief of maternal distress in hydramnios. k The above written assessment helps to identify any
Hazards of ARM:
complication at the earliest.
a Intrauteine infection, particularly, iatrogenic from 1. Give the mother a sterile vulval pad and make her
digital or instrumental contamination.
comfortable.
b. Chance of umbilical cord prolapse. m. Administer prophylactic antibiotics as per the
c. Bleeding from the following sources: order of the docto.
i. Fetal vessels in the membranes in case of vasa
previa.
n. Record the date and time and the type of induction
ii. The friable vessels in the cervix done.
ii. Alow lying placental site.
d. Amniotic fluid embolism. Combined Methods
e. Once the procedure isstarted, there are nochances The combined medical and surgical methods are
ofretteating from the decision of termination. commonly used to increase the effiacy of induction by
Kow Rupture of Membranes (LRM):LRM has agreat reducing the induction delivery interval.
success rate now-a-days and is widely practiced.
Definition: In LRM, "the membranes below the presenting FORCEPS
part overlying the internal [Link] ruptured to drain some
amount of amniotic fluid". Introduction
Contraindication:It is contraindicated in: The obstetric forceps were invented in the l1h century by .
Chronic hydramnios: There is risk of sudden uterine Chamberlen.
decompression due to massive liquor drainage.
 UNIT-8 ABNORMAL
Definition LABOR-ASSESSMENT AND MANAGEMENT 533

"Obstetric forceps is a pair of instruments Long Curved Obstetric Forceps

assist extraction of the head and specially designed to Long curved obstetric forceps is relatively
heavy and is about
delivery of the fetus". thereby accomplishing |37 cm long, In India, Das's variety
(named after Sir Kedar
Nath Das) is commonly used. It is
Varieties of Obstetric Forceps slightly shorter than its western comparatively
counterpart
lighter and
but isquite
suited for the comparatively small pelvis and small
Ever since either Peter 1 or Peter IIof Indian women. babies of
the Chamberlen family
invented the forceps around AD 1600. Many
invented or modified. But only designs were Measurements
three varieties Length is 37cm, distance in between the lips is 2.5 cm and
commonly used in present day obstetric
practice (see
are
widest diameter between the blades is 9 cm.
8.38) These are: figure
1. Long curved Blades
device.
forceps with or without axis traction There are two blades and are named right or left in
2. Short curved to maternal pelvis in which they lie when relation
forceps.
3. Kielland's forceps. applied. Each
blade consists of the following parts:
The basic construction of these Blade: The blade is fenestrated to facilitate a
of two halves (blades) forceps is the same. It consists of thefetal [Link] is usually a slot in the good grip
articulated by alock. of the fenestrum of the blades to allow the lower part
Mnemonic for F-O-R-C-E-P-S upper end of
F =Favorable head the axis traction rod to be fitted. The blades have two
position and
O= Open orifice (fully dilated), station, Curves.
R =Ruptured membranes, a. Pelvic curve: The curve on the edge is to
fit more or
C= Contractions present and less the curve on the axis of the birth canal. It forms
E = Engaged head, Empty bladder, consent, a part ofa circle whose radius is 17.5 cm. The front
P= Pelvimetry- no major CPD, ofthe forceps is the concave side of the pelvic curve.
S = Stirr ups, Lithotomy position. b. Cephaliccurve: It is the curve on the flat surface
which when articulated grasps the fetal head
without compression. The radius of the curve is
11.5 cm.
. Shank: It is the part between the blade and the lock and
usually measures 6.25 cm. It increases the length of the
instruments and thereby, facilitateslocking of the
blades outside the vulva. When the blades are
Keilland's articulated, the shank are not apposed together.
3: Lock:The common method of
articulation consists of
a socket system located on the shank at its junction
with the handle. Such type of lock requires
introduction of the left blade first.
4. Handle: The handles are opposed when the blades are
articulated. It measures 12.5 cm. There is a finger guard
on which a finger can be placed during traction.
Neville-Branes
Ascrew may be attached usually at the end of one blade
(commonly left). It helps to keep the blades in position.
Short Curved Obstetric Forceps (Wrigley)
The instrument is lighter, about athird of the weight of an
ordinary long curved forceps. The instrument is short which
Simpsons isdue to reduction in the length of the shanks and handles.
It has a marked cephaliccurve with a slight pelvic curve.

FIGURE 8.38 Types of forceps. Note the difference in cephalic

Kielland's Forceps
curve. The rotational forceps (Keilland's) have a long shaft and Itis along almost straight (very slight pelvic curve) obstetric
little pelvic curve forceps withoutany axis traction device. It has got asliding
534 MIDWIFERY AND OBSTETRICS FOR [Link]. NURSING STUDENTS
passed the
lock which facilitates correction of asynclitism of the head, a. High Mid: Biparietal diameter has of ischial
i.e. after the blades are applied, the head is rotated to an plane ofinlet but remains above the level
spines. Manual rotation followed by application of
occipito anterior position. Kielland's forceps is also used in theforceps isan example of such type of forceps
an unrotated vertex or face presentation. This is in limited
use because of its complexity in application and due to operation.
b. LowMid: Biparietal diameter has passed the plane
chances of injuries to vagina and perineum. of the inlet and lies at the level of ischial spines, So.
the lower pole lies belowthe level of ischial spine.
Types of Forceps Operation 3. Low Forceps Operation: Refers to the application of
Theoperations are classified according to the station of the the forceps and the fetal head where the biparietal
fetal head at which the forceps are applied. diameter has passed the level of ischial spines.
1. High Forceps Operation: Refers to the application of 4. Outlet Forceps: It is a variety of low forceps operation,
the forceps on the fetal bhead where the biparietal where the forceps are applied on the fetal head lying on
diameter has not yet pased the plane of the pelvic of the perineum and is visible at the introitus ín between
the intet (non-engaged head). contractons. The sagittal suture should lie in the
2. Mid Forceps Operation: Refers to the application of antero-posterior diameter of theoutlet. Thus, while all
the forceps wherethe biparietal diameter has passed outet forceps are lowforcepsbut not all low forceps are
the plane of the inlet but has not passed the level of Outlet forceps operations.
ischial spines. It may be described with two
sub-varieties:

A B

ErCuRE 839 A. Left blade being inserted. The fingers of the right hand quard the
Toction of the head is downwards until this point; when the head is loW, the vaginal tissue, B. Right blade being inserted,
direction of pull is outward, towards the operator,
D. As the head crowns it is lifted upwards
 UNIT-8 ABNORMAL
LABOR-ASSESSMENT AND MANAGEMENT 535
Functions
1. Traction is the most important 3Membranes must be ruptured.
function of the 4. The head must be engaged with no
primigravida, the pull required is estimated to beforceps.
about
In
18
parts of the head
palpable abdominally. In supermoulding of the head
kg and that in multiparae about 13 due to brim contraction, the lower pole of the
2. I's compression kg. head
effect on the cranium should be may be felt well below the level of the ischial
spines.
minimal when correctly applied over the biparietal a. There should not be undue
obstruction, bony or
plane and should not be more than otherwise at or below the station of the head.
the fetal head. However, it has got required to grasp b. Baby should be living.
on the well ossified base of the [Link] pressureeffect
c. Uterus should be preferably
3Rotation of the head can be achieved by Kielland's contracting and
relaxing as a safeguard to postpartum hemorrhage.
forceps. However, in the low forceps operation with d. The bladder must be emptied.
the sagittal suture placed obliquely with the
placed at 2 or 10 'O dlock position, occiput Succss ofthe Operation Depends on
application of the blades of ordinary forceps cephalic
traction cause rotation of the sagittal suture so asand to
1 Medculous observation onthe principles as laid down
bring it in anteroposterior diameter of the outlet. prior to forceps application.
4. To provide a protective cage for the head from the 12--Pre-application maternal and fetal health status.
pressure of birth canal as in premature baby or to [Link] of thesurgeon.
control the delivery of the after coming head to lessen L4. Amenities available.
the dangers of sudden decompression. Dangers of Forceps Operation
Indícations
1.
of Forceps Operation The hazards of the forceps operation are mostly related to
the faulty technique and to the indication for which the
Delay in the second stage: The forceps operation is
commonly indicated for delay in the second stage of forceps are applied rather than the instrument. The hazards
labor due to uterine inertia. Failuje of satisfactory are grouped into:
1. Maternal
advancement of the head for a period of an arbitrary
limit of 20-30 minutes while the head is on the 2. Fetal
perineum is an ideal time to apply forceps.
l2 Fetal indications: Maternal
a. Appearance of fetal distress in the second stage It is of two types:
1. Immediate
when prospect of vaginal delivery is safe.
b. Cord prolapse. 2. Remote

C After-coming head of breech. Tmmediate: The immediate complications are:

dLow birth weight baby. a. Injury:
e. Postmaturity. i. Extension of episiotomy externally even to
3. Maternal indications: involve the rectum or its upward extension
a. Maternal distress g
upto the vault of vagina.
b. Pre-eclampsia ii Vaginal lacerations.
c. Post-cesarearn pregnancy
iii. Cervical tear specially when applied through
d. Heart disease.
incompletely dilated cervix.
B Postpartum hemorrhage: Due to:
Conditions to be Fulfilled Prior to Forceps i, Traumna
Operation ii. Atonic uterus due to prolonged labor or effect
of anesthesia.
The following criteria are to be fulfilled prior to forceps
C. Shock: Due to:
applications:
i. Blood Loss
: Presentation and position must be suitable so as to
apply the blades correctly to the sides of the head, vertex,
ii Prolonged labor and dehydration
anterior face and coming head. d Sepsis: Due to improper asepsis and devitalization
The cervixr must be fully dilated and effaced: Temptation
of the local tissues.
e. Anesthetic hazards.
to apply forceps through the cervical rim is to be
checked.
536 MIDWIFERY AND OBSTETRICS EOR RSC NURSING STUDENTS
The fetal risk intermssofmortality iss also brought
down
2. Reprote: significantlyto about 2%. It is mostly related to the health
a. Chronic low backache: Due to tension imposed headliin relation to
statusand the station of the the perineum
on the softened ligaments guarding the at the time of forceps application. Fetal deaths are due to
lumbo-sacral or sacro iliac joints during lithotomy asphyxia and intracranial hemorrhage.
position.
b Genital prolapse or stress incontinence: This
Prophylactic Forceps (Elective)
may occur specially when the head is dragged
down through incompletely dilated cervix or in Thistype of forceps operation was named after Dr. Iee le
unrotated position or due to faulty repair of perineal refers to forcepsdelivery only toshorten the second sta
lacerations. of labor when maternal and/or fetal complications are
Fetal
anticipated. The indications are:
It is of two types: 1. Eclampsia
2. Heart disease
1. Immediate
2. Remote 3. Previous history of cesarean section
4. Postmaturity
1. Immediate 5. Low birth weight baby
a. Asphyxia due to intracranial stress out of prolonged 6. To curtail the painful second stage
Compression. 7. Patient under epidural analgesia.
bAntracranial hemorrhage due to malapplication of
blades (occipito-frontal plane) leading to It prevents possible fetal cerebral injury due to pressure on
Overcompression. the perineum and spares the mother from the strain of even
e Cephalohematoma. afew bearing down efforts. Prophylactically, forceps should
d Facial palsy. not be applied until the criteria of low forceps is fulflled.
e Abrasions on the soft tissues of the face and
forehead by the forceps blades.
2. Remote: Cerebral and spastic palsy due to residual Trial Forceps
cerebral injury. It is a tentative attempt of forceps delivery in a case of
suspected mild pelvic contraction with a preamble
Prognosis declaration of abandoning it in favor of cesarean section, if
As the difficult forceps delivery has been almost replaced moderate traction fails to overcome the resistance. The
by cesarean section, the maternal risk is practically procedure should be conducted in an operation theatre
brought down to nil. There is however, increased keeping everything ready for cesarean section. The conduct
morbidity compared to the spontaneous vaginal delivery. of trial forceps requires a great deal of skill and judgement. If
Occasional deaths are related to anesthesia, postpartum moderate traction leads to progressive descent of the fetal
hemorhage, shock or pulmonary embolism. head, the delivery is completed vaginally, if not, cesarean
section is done immediately. Many unnecessary cesarean
sections or difficult vaginal deliveries can thus be avoided.
 UNIT-8 ABNORMAL
Failed Forceps LABOR-ASSESSMENT AND MANAGEMENT 537

MANAGEMENT PROTOCOL OF FAILED FORCEPS

" To start
" To
Ringer's solution To assess the effect on
exclude rupture uterus To exclude
the mother and fetus
rupture uterus
Fetal condition-good Fetus dead or
Malformed Rupture uterus
Safe vaginal
delivery not possitble Safe vaginal
delivery possible
Cesarean section
Immediate Further wait
Constriction ring
Manual rotation
and Forceps or Ventouse Cesarean section

Progress satisfactory Progress unsatisfactory

Cesarean section
Vaginal delivery Forceps
FLOWCHART 8.10

VENTOUSE
Ventouse is an
Instrumnents
instrumental device designed to assist
delivery by creatinga vacuum Ever since Malmstrom in 1956
between it and the scalp".
The pulling forceps, is dragging the Craniumfetal popularized its use, various modificationsreintroduced and
of the instruments
forceps, the pulling force is directly transmitted towhile in are now available. Each,however, consists of the following
of the skull.
the base basic components:
1. Suction cups with 4 sizes (30, 40,
50, 60 mm) made of
metal

Valve Manometer
(kglcm²) Tube

Hand pump

Pump Metal cup

Vacuum
bottle

Cup
A
B

FIGURE 8.40 The ventouse or vacuum extractor A. Malmstrom device B.

Mityvac pump with tube and soft cup
538 MIDWIFERY AND OBSTETRICS FOR [Link]. NURSING STUDENTS

2. A vacuum pump with a manometer attached to it Conditions

(modern vaccum extractors consist of an electrical 1. The head of asingleton baby should be engaged.
least Gcm.
pump). 2. Cervical dilatation should be at below the
3. Traction rod device. 3. There should not be any bony resistance
4. Rubber tubing with a chain in the centre. head.

Contraindications
Indications
needed.
1. Deep transverse arrest with adequate pelvis. 1. Fetal distress-where urgent delivery is
2. Delay in descent of the high head in case of second 2. Face presentation
baby of twins. 3. Premature chance of scalp avulsion or sub-aponeurotic
hemorrhage is more.
3. As an alternative to forceps operation except
a. Face presentation and after cominghead ofbreech., 4. Fetal bleeding disorder.
b. Fetal distress or prematurity.
C. Delay in late first stage due to uterine inertia or Procedure
primary cervical dystocia. Follow all the pre-requisites as for forcep delivery.
d As an adjunct to symphysiotomy. 2. It should be done by an expert.
e. Prolonged second stage of labor. 3. Position the woman as in forcep delivery.
f In rotation of caput from posterior to anterior
position.

Silicon cup Suction cup (metal) Chignon

C
D

FIGURE 8.41 Application of vacuum extractor; A, B, Cand Dindicating the directions of traction at different stations of the fetal head
 UNIT-8 ABNORMAL LABOR-ASSESSMENT AND MANAGEMENT 539

4 Position of fetal head is determined and a well fitting VERSION

cup is chosen.
5 Pudendal block or perineal infiltration is done with Definition
1% lignocaine. It is a manipulative procedure designed to change the lie or
6. Vacuum is testedprior to its application. bring the comparatively favorable pole to the lower pole of
7. The cup is placed against the fetal head nearer to the the uterus.
occiput with the "knob" of the cup pointing towards
the occiput (It will help in flexion of the head). Types
8. A vacuum of 0.2 kg/cm (kilograms per square
centimeters) is induced by hand pump slowly taking According to the methodsemployed,the following are the
atleast two minutes. Check around the cup with the types:
fingers that there is no cervical or vaginal tissue being 1. External
trapped in the cup. 2. Internal
9. The pressure is gradually raised at the rate of 0.1 kg/cm² 3. Bipolar
per minute until the effective vacuum of 0.8 kg/cm² is
1. External: The maneuver is done solely by external
attained in about 1 minute. manipulation.
10. The scalp is sucked into the cup and an artificial caput
2. Internal: The conversion is done principally by one
succedaneum chignon) is produced. This chignon hand introducing into the uterus and the other hand on
usually disappears within few hours. the abdomen.
11. Traction is exerted using one hand in direction of curve 3. Bipolar: The conversion is done by introducing one or
of carus.
two fingers through the cervix and the other hand on
12. Traction must be at right angles to the cup and along the abdomen.
with uterine contractions, while applying traction,
fingers of the hand are to be placed against the cup to
note the correct angle of traction, rotation and External Cephalic Version
advancement of the head. External cephalic version is done to bring the favorable
13. The procedure should not take more than 30 minutes. cephalic pole in the lower pole of the uterus.
14. As soon as the head is delivered, the vacuum is reduced
by opening the screw release valve and the cup is then Indications
detatched. 1. Breech presentation
15. elivery is done normally. 2. Transverse lie
3. External podalic version
Complications
Procedures
Fetal:
External Version in Breech Presentation
1. Sloughing of the scalp
2. Cephalohematoma The maneuver is carried out as an outdoor procedure in
3. Subaponeurotic hemorrhage earlier weeks. But if performed in later weeks or under
4. Cerebral trauma (tentorial tear) tocolytic drugs, it should be performed in the vicinity of
labor delivery complex. Any oneof the following tocolytic
Maternal: Lacerations of cervix or vaginal wall.
drugs, if required, can be administered by intravenous
infusion with set up Ringer's lactate solution for about 15-30
Hazards minute prior hand. The maternal heart rate and blood
Fetal: pressure are measured every 5 minute. Areactive NST (Non
1. Sloughing of the scalp Stress Test) should precede the maneuver.
2. Cephalhematoma Drugs
3. Sub-aponeurotic hemorrhage (not limited by suture Terbutaline -0.25 mg Subcutaneous or Isoxsuprine 50-100
line as it is not subperiosteal) Mg intravenous could be used.
4. Intra-Cranial hemorhage (rare) Preliminaries
Maternal: The injury may be due to inclusion of the soft The patient is asked to empty her bladder. She is to lie on her
tissue such as the cervix or vaginal wall inside the cup. back with the shoulder slightly raised and the thighs slightly
540 MIDWIFERY AND OBSTETRICS FOR BSC. NURSING STUDENTS

A. Mobilization of the podalic pole to

the iliac fossa towards which the
back lies using both hands.

B. Rotation of the trunk holding the poles using both C. Change of hands of prevent crossing after
hands and maintaining flexion of the trunk the lie become transverse

D. Further mobilization of thecephalic pole to bring it to E. The lie becomes longitudinal with the cephalic pole
the lower pole of the uterus being brought to the lower pole of the uterus

FIGURE 8.42 Steps of external cephalic version-(Breech-L.S.A)

fixed. Abdomen is fully exposed. The obstetrician is to stand Instructions

on the right side. The presentation, position of the back and 1. The patient is advised to come on the next day to check
limbs is checked and FHR is auscultated. Some use dusting the corrected position.
powder on the abdomen to facilitate the hands to slide over 2. To report to the physician even earlier, if there is vaginal
the skin surface readily. The manipulation should be bleeding or escape of liqour amnii or iflabor starts.
temporarily stopped during Braxton-Hicks contraction and 3. Rh-negative non-immunized women must be
to be withheld, if thepatient is in pain. protected by intramuscular administration of 100g
anti-D Gammaglobulin.
 UNIT-8 ABNORMAL LABOR-ASSESSMENT AND MANAGEMENT 541

External Version in Transverse Lie Contraindication

The version is much easier than in breech. The association It must not be attempted in neglected obstructed labor if the
of placenta previa or congenital malformation of the uterus baby is living.
should be kept in mind.
Hazards
External Podalic Version
Maternal risk includes placental abruption, rupture of the
The external podalic version may be done in cases when the uterus and increased morbidity. The fetal risk includes
external cephalic version fails in transverse lie in case of the asphyxia, cord prolapse and intracranial hemorrhage, apart
second baby of twins. from all hazards of breech delivery leading to a high
perinatal mortality of about 50%.
Internai Version
Internal version is always a podalic version and is almost Bipolar Version
always completed with the extraction of the fetus. The bipolar version named after Braxton Hicks, is an
Indications obsolete maneuver in present day obstetric practice.
However, it may be a life saving procedure at places, specially
Internal version is hardly indicated -in a singleton in the rural areas ofthedeveloping countries, where it is not
pregnancy in present day obstetric practice. Its only possible to transport the patient with placenta previa to an
indication being the transverse lie in case of the second baby equipped medical centre. Its chief indication is lesser degree
of twins.
However, it may be employed in singleton pregnancy to of placenta previa, when the fetus is dead, deformed or
previable. The cervix must be at least two fingers dilated to
expedite delivery in adverse conditions where the cesarean facilitate manipulation by pushing up of the head to one
section facilities are lacking. Such conditions are:
iliac fossa and to grasp one leg at the ankle. Simultaneous
1. Transverse lie or head high up and baby is alive. manipulation by the external hand facilitates the procedure.
2. Transverse lie with fully dilated cervix. Bringing down of one leg facilitates compression over the
3. Cord prolapse. placenta and thereby stops the bleeding.
Conditions
MANUAL REMOVAL OF PLACENTA
The following conditions are to be fulfilled prior to internal
version: Manual removal of the placenta is the evacuation of the
1. The cervix must be fully dilated. placenta from the uterus by hand. It is always done under
general anesthesia. Ahand (sterile) is inserted through the
2. Liquor amnii must be adequate for intrauterine fetal vagina into the uterine cavity and the placenta is detached
manipulation. from uterine walland then removed manually. The steps of
3. Fetus must be living.
manual removal of placenta are as follows:

A. To introduce the right hand to grasp nthe upper B. To give traction on the leg gripping in a
legin dorso-anterior position with t head
cigarette holding fashion, the other
lying on the right iliac fossa hand pushes up the head externally

FIGURE 8.43 principle steps of internal podalic version

542 MIDWIFERY AND OBSTETRICS FOR BSC. NURSING STUDENTS
1. Check for the indications. 25. Examine the woman carefully. Check vital signs. Note
for any complications.
2. Explain the procedure to the mother (patient) and her 26. Provide comfortable position to the woman.
relatives.
3. Get a written consent signed.
4. Provide emotional support. Complications
5. Cet all the pre-procedural requirements done. 1. Hemorrhage (due to incomplete removal)
6. Start an I/V line and maintain hydration levels. 2. Shock
7. Ifneeded, start blood transfusion on the written orders 3. Injury to uterus
of the physician. 4. Sub involution
8. Give a single dose of prescribed antibiotic. 5. Thrombophlebitis
9. General anesthesia is given ifalreacdy set-up is available. 6. Embolism
10. In emergency condition when it is not possible to 7. Inversion (rare)
arrange for general anesthesia then the operation is 8. Infection
done under deep sedation with diazepam slow 10 mg
intravenously. Post Operative Care
11. The patient is placed in lithotomy position. 1. Check vitals every 15 minutes for the first hour and half
12. Bladder is catheterized by aseptic technique. an hourly for the second hour.
13. Hold the umbilical cord with a clamp. Pull the cord
gently until it is parallel to the floor. 2. Keep a keen observation until the woman is out of effect
of anesthesia.
14. Wear gloves and introduce one hand into the uterus
after smearing it with antiseptic solution in a cone 3. Palpate the uterine fundus to ensure that the uterus
remains contracted.
shaped manner up into the uterus.
15. With the other hand on the uterine fundus counter 4. Check for excessive lochia.
pressure is applied over the abdomen. Counter 5. Continue I/V infusion and antibiotics as prescribed.
pressure is given to prevent inversion of uterus. If in
case uterine inversion occur then reposition the uterus. CESAREAN SECTION
16. Move the fingers of the hand and locate the margins of Definition
placenta.
17. Detach the placenta from the implantation site by "It is an operative procedure whereby the fetus after the end of
keeping the fingers tightly together and using the edge 28th week isdelivered through an incision on the abdomina!
of the slowly to hand make a space between placenta and uterine walls"
and the uterine wall.
18. Proceed slowly all around the placental site or bed until Indications
whole placenta is detached from uterine wall.
19. If the placenta does not separate from the uterine These are mainly oftwotypes: Today, the cesarean section is
surface by gentle lateral movement of the fingertips at not performed as a last resort, but as a safe alternative to risky
the line of cleavage suspect placenta accreta and vaginal deliveries. As such due consideration should be
immediately go for laparotomy and possible subtotal given not only to the immediate safety of the mother and her
unborn baby but also to her remote obstetric future. The
hysterectomy. indications are broadly divided into two categories:
20. Hold the placenta and gradualy remove the hand from 1. Absolute
the uterus bringing the placenta with it. 2. Relative
21. Continue counter-traction to the fundus with other
hand in the opposite direction of the hand being 1. Absolute: These include:
withdrawn. a. Central placenta previa.
22. When placenta and its membranes have been removed b. Severe degree of contracted pelvis with true
then explore the uterine cavity and make sure that
it

conjugate less than 7.5 cm. b

nothing is left behind. c. Cervical or broad ligament [Link]
23. Give oxytocin 20 units in one litre of I/Vfluid (Normal d Vaginal atresia (vaginal phimosis).
Saline or Ringer lactate at 60 drops per minute). Also, e. Advanced carcinoma cervix.
inspect the cervico-vaginal region for any injury and All these conditions will produce insuperable
repair episiotomy in layers. obstruction, ifleft uncared for and there is no prospect
24. Examine the placenta and its membranes for its of vaginal delivery even with aids. In such condition,
completeness. If any placental lobe or tissue is missing delivery may have to be accomplished by cesarean
explore the uterine cavity to removeit. section even if the fetus is dead.