Amarjeet Ramdhonee OBG instruments 1

1. Sims’ speculum/ duckbill post vaginal wall speculum

uses-
-for insertion of iucd; D&C and D&E; ant colporrhapy;vaginal hysterectomy to retract post
vaginal wall;
-to visualise cervix and inspect ant vaginal wall in cases of cystocoele, Vesicovaginal fistula or
Gardner’s cyst after placing the patient in Sims’ position( in this position with the intro of
instruments the air enters into the vagina by negative suction exposing the ant vaginal wall
and cervix. The pt lies on the left side with the chest, the right knee and thigh drawn up; the
left arm along the back)
-To collect the material from the vaginal pool for exfoliative cytology or Grams strain and
culture
-To inspect lesions in ant vaginal wall is
no
inflammation
-To look for vaginal or cervical discharge- vaginitis, bacterial vaginosis, chlamydial..
-For cytohormonal studies- Cx is exposed with the speculum without lubricants as they tend
to distort cell morphology…site- the lateral wall of upper third of vagina is most sensitive; take
material with the help of Ayre’s spatula and spread over a slide then put into fixative-95%
alcohol+ether for 30mins- and then sent for laboratory. Instructions to pt- avoid intercourse for
about 2 days; to withhold use of hormonal drugs; know age and first date of LMP, menstrual
pattern and any previous hormonal therapy.
-to take cervical mucous to check for ferning
How will you identify estrogenic or proliferative phase?
Estrogenic phase is suggested by large number of eosiniphilic cells with pyknotic nuclei, and
background is clear. Cervical discharge is huge in amount, thin, serous and stretchable( …
phenomena)

How will you identify secretory of progesterone phase?

Smear is suggested by large number of basophilic cells with vesicular nuclei. Background
looks dirty.
Yes
I
Ferning occurs at time of ovulation and is due to NaCl and low protein content in cervical
mucous due to oestrogen

What is Spinnbarkeit phenomena?- due to high oestrogen, mucous can tolerable stretching
unto
P distance of 10cm or more.
Tack
What is thread phenomena?
due to progesterone, cannot make thread with mucous
I

Before ovulation.
What is the pH of cervical mucous at time of ovulation?
/

6.8-7.4

How to sterilise sims speculum?

Boiling or autoclaving

Why sims speculum is called duckbill speculum?

Due to its peculiar shape
 Amarjeet Ramdhonee OBG instruments 2

2. Cusco’s bi-valve self retaining vaginal speculum

how to introduce?
with closed blades and slightly oblique to minimise trauma and pressure on the urethra and
then rotate to 90 degrees and open the blades inside.

uses-
same as sims speculum
other-
-to inspect the thread of IUCD and to remove IUCD

Why Cusco’s speculum is better than sim’s speculum for visualisation of Cx?
Because it can retract anterior and post vaginal wall so as to have a good look of the Cx

It is used with or without anaesthesia?

Without anaesthesia— OPD procedure

Also used for detection of cervical erosion.

What is cervical erosion?
Is a condition in which squamous epi of the ectocervix is replaced by columnar epi which is
continuous with the endoCx.

Also used for detection of acute or chronic cervicitis.

micoid
ExCeSSiV =
What are the symptoms of cervicitis?
-> Always
-XS cervical mucoid discharge- generally occurs after abortion or childbirth cuwiterly.
-H/o postcoital bleeding
-low backache
-congestive dysmenorrhea
-dyspareunia
-if acute- +fever and tachycardia
-chronic- no fever; presence of nabothian follicles- diagnostic feature

What are nabothian follicles?

Some of the gland mouths are closed by fibrosis or plugs of desquamated epithelial cells to
cause retention cyst= nabothian follicles
In chronic cervicitis- mucosa and deeper tissues are congested, fibrosed and infiltrated with
leucocytes and plasma cells
Amarjeet Ramdhonee OBG instruments 3

e
3. Ant vaginal wall retractor
uses-
Post
as
men
-to retract the sagging ant vaginal wall in obese and old its to have a good look on the Cx
while using Sims speculum
-in 2nd trimester- can be used as a blunt curette—how to differentiate from simple curette?—it
is a long instrument with spoon shaped ends which have transverse serrations on either
surface; the loops make an angle of 15 degree with the shaft and are angled in opposite
directions.

Schae

4. Auvard’s self retaining post vaginal speculum(shaped like king

cobra)
weight of instrument 1960g (around 2kg)
anaesthesia required
not suitable for OPD procedure
it is heavy- so cannot retract ant or lateral vaginal wall
uses-
- post vaginal wall retractor in operations like anterior colporrhaphy, vaginal hysterectomy and
repair of VVF and colpoperineorrhapy

What is ant colporrhaphy?

Procedure to correct cystocele or urethrocele.
The underlying principles are to cut a portion of relaxed ant vaginal wall; mobilise the bladder
and push it upwards after cutting the vesicocervical ligament; bladder is then permanently
supported by tightening the pubocervical fascia

What are the indications of vaginal hysterectomy?

-UV prolapse in post menopausal women or menopausal women
-UV prolapse in perimenopausal women along with DUB and unhealthy cervix( discharge or
cervicitis)
- as an alt to LAVH( laparoscopic assisted VH) in undescended uterus

What is vaginal hysterectomy?

Removal of uterus through vagina
Correction of enterocoele, approximation of pedicles in midline to have a good support;
fixation of uterosaccral ligament to the vault to prevent vault prolapse; bladder support is
reconstructed utilising the broad ligament and round ligament as buttress; repair of cystocoele
Amarjeet Ramdhonee OBG instruments 4
and reconstruction of perineum(VH+PFR)

What is the advantage of this instrument?

- requires no assistance

Disadvantage of this instrument?

-heavy— prolonged use may cause perineal pain in post op period.

5. Punch biopsy forceps

has cup shaped ends. Margins of the cups are cutting type and one cup has tiny pin that fits
into a tiny depression.

anaesthesia is not needed.

uses-
- cervical biopsy/ vulval biopsy/ vaginal biopsy

indications of cervical biopsy?

-post coital bleeding with positive pap smear
-cervical erosions
-positive pap smear(screening test)
- abnormal colposcopic findings

Types of cervical biopsy:

- punch
Done without anaesthesia; biopsy taken from suspected area or from 4 quadrants using
punch biopsy forceps
If no lesion seen- stain with acetic acid- acetowhite lesions seen and then take material from
stained areas ; or lugol’s iodine- take biopsy from unstained area
Amarjeet Ramdhonee OBG instruments 5

-ring
Done under anaesthesia. In this whole of the squamocolumnar area of Cx is excised if growth
is seen, with the help of scalpel

-wedge
Done under anaesthesia.
Done when growth is seen. Take a wedge of tissue with the help of scalpel. Necrotic area
should be avoided.

-cone
Under anaesthesia. Involves removal of cone of Cx which includes entire SC junction, storm
with glands and endocervical mucous memb.
Conisation is done as a diagnostic and therapeutic procedure in CIN

What are the cases of CIN which are suitable for conisation?
- unsatisfactory colposcopic findings- entire margin of the lesion are not visualised.
- inconsistent findings on colposcopy and cytology
- positive endocervical curettage
- when biopsy shows CIS or Microinvasion to exclude gross invasive Ca.

Can take cone biopsy with help of scalpel or cold knife or CO2 laser.

Complications of conisation
- bleeding
- cervical stenosis if tightly sutured—leading to infertility|
- If no sutured properly— cervical incompetence— mid trimester abortions and preterm labour
- decreased cervical mucous secretion

6. Endometrial biopsy curette

it has a notch on the tip
uses- only used for infertility to detect ovulation. Only a single strip of endometrium is needed
to detect…
done without anaesthesia
Amarjeet Ramdhonee OBG instruments 6

what are the different causes of female infertility?

-tubal factors”(40%)
-peritoneal factor(36-44%)
-

At what day biopsy should be taken?

Between 21-23rd day of cycle

Barrier contraceptive should be used during cycle to prevent accidental pregnancy.

If cycle is irregular, then biopsy should be taken within 24hrs of menstruation.

What will be your finding on microscopy if ovulation has occurred?

Evidence of secretory activity in second half of cycle is suggestive of ovulation along with
presence of Corpus luteum.
Subnucleolar vacuolation is the earliest sign occurring 36-48hrs after ovulation.

What are other invx for ovulation?

-biopsy
-serial sonography- start on 10th, then 12th, 14th, and 16th day….just prior to ovulation, griffin
follicle is mature- 18-20mm in size.
Features of ovulation are collapsed graffian follicle and free fluid in pouch of Douglas
- laparoscopy with chromopertivation—pass methylene blue through vagina…can see corpus
luteum and free fluid in pouch of Douglas
-basal body temp
-spinnbarkeit phenomena
-ferning
-hormone estimation- LH surge

7. Female metal catheter(no notch compared to ED curette)

Amarjeet Ramdhonee OBG instruments 7
uses:
-to empty the bladder prior to major vaginal operations..It minimises inj to bladder.
-to confirm Dx of Gardner cyst from cystocoele
Gardner cyst is situated anteriorly or anterolaterally and is of variable sizes. Vaginal rugosities
are lost. Vaginal mucosa becomes tensed and shiny. Margins are well defined. It is not
reducible. There is no impulse on coughing. The metal catheter tip introduced per urethra fails
to come under the vaginal mucosa

Cystocoele- metal catheter comes under vaginal mucosa; reducible;

-used in PFR- pelvic floor repair; prior to operation to empty bladder

-to note limit of bladder before making the incision on the vagina
-at the end of operation, it is again passed to make sure about absence of any bladder injury

8. Uterine sound
can be confused with bladder sound. How to diff?
it is 30cm long and it is bent on an angle of 15degree; it is graduated(has markings)

uses-
- to confirm length of uterus(normal=7.5cm)
-sometimes used as a dilator
-to sound the uterine cavity in a case of IUCD with missing thread—if IUCD misplaced- no
resistance -negative finding

What are the causes of missing thread?

-thread coiled inside
-thread torn through
-device expelled outside unnoticed by the pt(increased chances during menses)
-device perforated uterus and is lying in peritoneal cavity
-device pulled up by the growing uterus in pregnancy

Methods of identifying missing thread?

- pregnancy is to be excluded first- therefore do preg test
- sounding uterine cavity by uterine sound— if negative finding-no resistance- XR pelvis after
introducing radiopaque uterine sound or another IUCD into uterine cavity; then not the
distance between misplaced IUCD and uterine sound/another IUCD; if this distance more than
2.5cm then IUCD is misplaced and lying in peritoneal cavity
- USG
- Hysteroscopy
Amarjeet Ramdhonee OBG instruments 8

How will you Dx uterine perforation if perforation is done by uterine sound?

- there is sudden loss of resistance
- passage of instrument more than the length of uterine cavity
- undue mobility of instrument

How will you manage perforation?

- once suspected- following guidelines are to be followed:
a. To stop procedure immediately
b. Monitor vitals and vaginal bleeding
c. Give sedative like 15mg morphine IM
d. To formulate the definitive Rx
e. If small perforation by uterine sound—then monitor vitals and bleeding PV; give parenteral
antibiotics; check bowel sounds; discharge pt after 2 days if abdomen is soft with no signs of
peritonitis and vitals are stable(no repair needed)
f. If large perforation— repair of perforation should be done; either by laparoscopy or
laparotomy

What are the causes of elongation of uterine cavity?

- pregnancy
- fibroid uterus
- adenomyosis
- endometrial hyperplasia
- DUB
- Endometrial Ca
- chorioCa
- uterine polyp
- UV prolapse

What is the PV finding in acquired UV prolapse and congenital UV prolapse?

- acquired: elongation of supravaginal part of Cx due to the strain imposed by pull of the
cardinal ligament keep the Cx in position; uterus is retroverted and retroflexed; fornices are
shallow; vaginal Cx or infrvaginal part of Cx is normal in length
- congenital: elongation of infravaginal or vaginal part of Cx; fornices are deep; uterus is
anteverted anteflexed.

uses(contd)
- to prevent stenosis of cervical canal after cauterisation or cryosurgery
- to diff fibroid from uterine inversion
- to diff UV prolapse from uterine inversion

If uterine inversion- cannot pass uterine sound compared to UV prolapse

9. Tissue holding forceps= Allis tissue holding forceps

uses:
- to hold margin of vaginal flap in colporrhaphy operations
- to hold peritoneum or rectus sheath during repair of abd wall
- to hold the margins of vagina in abd hysterectomy
- to hold anterior lip of Cx in D&C operation
- to remove a small polyp from Cx and uterus
- to take out the tissue in wedge biopsy and in cone biopsy
- to catch hold the margins and angles of uterine flaps in LSCS if green… forceps is not
available
Amarjeet Ramdhonee OBG instruments 9

[Link]’s forceps
it has 2 fenestrated triangular blades.

uses-
- to dissect ureters in radical hysterectomy in Ca cervix
- to hold the fallopian tubes in tubectomy and tuboplasty operation(cut healthy part of tube)
- to hold fallopian tubes in salpingectomy in ruptured ectopic pregnancy(cut diseased part of
tube)
- to hold the intestines and appendix

Sterilisation methods-/tubectomy
Tubectomy-
Abdominal- laparotomy or mini laparotomy
Vaginal
> Pomeroys’ method(MC)
—procedure- put pt in supine position; give GA or LA; give transverse incision 2inches about
pubic symphysis if sterilisation done in interval period(6weeks after delivery/abortion)
For puerperal sterilisation- incision given 2 inches before umbilicus as uterus has not involuted
Then cut all layers of abdomen; identify fallopian tubes by fimbrial ends
After identification, a loop of tube is made by holding the tube by the back of forceps in such
a way that the major part of loop consists of isthmus and part of the ampulla.
Loop is made at the junction of proximal and middle part of tube; after that; needle is passed
through an avascular area in the mesosalpinx with chromic cat gut 1.0 and loop is firmly tied;
about 1-1.5 cm of the segment of loop distal to the ligature is cut; abdomen is closed in
layers; cut part of the fallopian tube is sent for histology

> modified pomeroy’s method

Amarjeet Ramdhonee OBG instruments 10
More common
Same as pomeroys method but we provide extra sutures at the stump of tubes with non
absorbable suture material—therefore less failure rate

> Irwing method

— the mid portion of tube is ligated and cut; the proximal end of tube is buried in the
myometrium; and distal end is buried is broad ligament
Failure rate is very loss
But difficult

> Albridge method

—a hole is made in the anterior leaf of the broad ligament and fimbrial end is buried into this.

> Cornual resection

—the cornual part of tube is resected
Not popular- because recanalisation not possible

> Uchida method

—the tubal serosa is stripped of the muscular layer in the mid segment of tube which is then
excised. The proximal end if ligated and buried in broad ligament

> fimbriectomy
—excision of fimbria; high failure rate; done by Kroener

> Madlener method

—a loop is made; then loop is crushed and ligated with non absorbable suture material
High failure rate

Mini laparotomy
Operation is performed through a small incision- 0.5-1inch
Any type of the above methods can be done through this

What is failure rate of pomeroys method?

0.04%

Vaginal tubectomy-
Put pt in lithotomy
Give incision in posterior formix or pouch of Douglas
Then identify tubes with fimbrial ends
Make a loop with [Link]
Cut the tube and ligate it
Note- increased chances of infection—therefore not popular

Male sterilisation- vasectomy

Can be done under LA
Palpate vas deferens at base of scrotum on both sides
Make a loop of vas deferens
Ligate and cut
Failure rate- more than tubectomy—3-4 HWY

Non-scalpel vasectomy—same as vasectomy- but here no incision given

—palpate vas at base of scrotum
—puncture base of vas through scrotum
—then identify and loop and tie

Complications of vasectomy-
Failure; infection; sperm granuloma; sperm hematoma; cellulitis
Amarjeet Ramdhonee OBG instruments 11
Instructions given to males
Avoid cycling, exercise, heavy weights

Males are infertile after 12 ejaculations

McDonald’s formula:
To know gestational age in weeks and months
Gestational age in weeks=Fundal height(cm)x8/7

Gestation age in months=Fundal height(cm)x2/7

Johnson formula
To calculate estimated fatal weight(g)
k(n/11) if head if floating
k(n/12) if head is engaged

n=fundal height in cm
k=constant=155

[Link] artery forceps/ homeostatic artery forceps

uses-
-to catch a bleeding blood vessel for hemostasis
-can be used as a clamp in salpingectomy if pedicle clamp is not available

[Link] pedicle clamp

Amarjeet Ramdhonee OBG instruments 12
it is used to make pedicles in hysterectomy or salpingectomy
can be confused with kocher’s artery forceps
here, it is straight and has vertical grooves

[Link]’s artery forceps

curved
no vertical groove
has transverse serrations

Uses:
- for clamping of umbilical cord after delivery
- mainly for lower rupture of membrane(LRM) or artificial RM

LRM procedure
put pt in dorsal lithotomy position
anaesthesia not needed
Insert kocher art forceps
Rupture membrane(fore water) below presenting part
Check colour of amniotic fluid- should be colourless

Why LRM and not HRM?

Because it is approachable
Loss of amniotic fluid is only 200mL compared to 800mL in HRM-therefore chances of dry
labour in HRM
HRM is difficult- hind water rupture above presenting part

Indications for HRM

> Polyhydramnios- to remove 500mL of fluid at a time— If more at a time-chances of abrupt

placenta due to disparity between surface areas of placenta and uterus

Indications of ARM
> for augmentation of labour
Amarjeet Ramdhonee OBG instruments 13
How ARM is responsible of augmentation of labour?
- By liberation of prostaglandins

[Link] Armytage forceps

uses
- to hold the margins and angles of uterine flap in LSCS; 4 are required for CS

What are the absolute and relative indications of CS?

Why LSCS is better than classical CS?

- less chances of perforation of uterus in next pregnancy; peritonitis

How will you identify lower uterine segment(LUS)?

- LUS is close to Cx
- uterovesical fold lies between UUS and LUS
- thin and passive segment
But UUS may also be passive due to anaesthesia

Complications due to CS
Secondary; primary; remote; due to anaesthesia

If we have only 2 instruments, we have to hold angle first.. why not borders are held first?
- angles are held first to prevent extension of incision laterally

Prerequisites of LSCS
- NPO for at least 10-12 hrs
- put self retaining foleys catheter to prevent bladder injury
- take written consent for pt and her relatives
- if she is multiparous- take consent for tubectomy
- Hb should be at least 10 g/dL— if less than that- transfuse blood
- arrange 1 unit of blood
- give injection of ranitidine-H2 antihistamine; and injection reglan (metoclopramide) IV to
prevent gastritis and vomiting
- start IV fluids to prevent dehydration
- cleaning and shaving of abdomen, thighs and external genitalia
Amarjeet Ramdhonee OBG instruments 14

[Link] forceps
does not have any catch or lock
it has ring shaped ends

uses
- to remove dead conception in dilatation and evacuation
- to remove molar tissues in [Link]
- to remove small uterine polyp

How will you use this instrument?

- the instrument is introduced with closed blades and opened inside the uterine cavity
- the products are caught; then with twisting movements and simultaneous traction, products
are removed

[Link] needle
used to create pneumoperitoneum in laparoscopy
Amarjeet Ramdhonee OBG instruments 15

What are the indications of laparoscopy?

- sterilisation
- hysterectomy
- myomectomy
- cystectomy
- oophorectomy
- correction of endometriosis
- drilling of ovaries in PCOD
- correction of malformation of uterus

What is the procedure of laparoscopic sterilisation?

- Can be done under LA or GA
- put pt in head low position or trendelenburg position — so that intestine get displaced from
surgical field—low chances of intestine perforation
- done 6 weeks after delivery—only done in interval period
- a small sub umbilical incision is given- 2 inches below the umbilicus
- pneumoperitoneum created by inserting a verre’s needle at the angle of 45 degree( 90
degrees in obese pts) and introducing carbon dioxide—inert gas( oxygen- inflammable;
nitrous oxide- laughing gas)
- if CO2 not available, can use room air
- normally 1-4L of gas is needed to create pneumoperitoneum
- after creating pneumoperitoneum, remove verre’s needle and insert trochar and cannula
through the incision
- laparoscope is then introduced through cannula after removing the trochar
- tubes are identified by fimbrial ends
- tubes are picked up near the isthmic ends and make loop; then clipped with silastic bands or
titanium clips
- abdomen is closed in layer; gas is allowed to escape by pressing the abdomen

What is suggestive of proper pneumoperitoneum?

- loss of liver dullness is suggestive of symmetrical distension of abdomen with proper
pneumoperitoneum
- intra-abd pressure should not exceed 20 mmHg
- flow rate of gas should be 1L/min

What is the failure rate of laparoscopic sterilisation?

- 0.6 per HWY

What are the complications of laparoscopic surgery?

- anaesthetic
- basal lung atelectasis
- metabolic acidosis due to CO2
-cardiac arrest
- hypoventilation due to trendelenburg position;

surgical complications
-omental emphysema and abdominal wall emphysema due to wrong placement of needle
(extraperitoneal)
Therefore- saline test should be done to know if intra or extraperitoneal—inject 5-6 drops N/S
through verre’s needle; if N/S comes back, then needle is extraperitoneal
- bleeding from superior epigastric blood vessels by trochar
- tearing of mesosalpinx
- uterine perforation
- wrong application of ring like putting the silastic ring on round ligament or mesosalpinx or
utero-ovarian ligament will cause failure of operation
- bowel injury
Amarjeet Ramdhonee OBG instruments 16
- bladder injury— therefore bladder should be empty to prevent this
- thermal injury to organs if using electrocautery
- CO2 embolism

Contraindications of laparoscopic sterilisation

- pt with cardiac or pulm disease— head low position and CO2 are contraindicated
- previous abd surgery— leads to adhesion formation and can lead to intestinal trauma|
- extreme obesity
- diaphragmatic or umbilical hernia
- PID— fallopian tubes are oedematous and can cause failure of operation
- in puerperial cases— tubes are oedematous and vascular; and may easily get torn; uterus is
not involuted; soft and can get perforated.
- malignancy— chances of spread
- pregnancy
- big pelvic tumour- eg ovarian cyst or fibroid
- generalised peritonitis
- pt is hemodynamically unstable
- intestinal obstruction
- pt on anticoagulant therapy

[Link] dilator
12 sets of heger’s dilator are available
smallest one is of 1-2mm
has 2 tips- one slightly narrow

uses-
- to dilate cx to facilitate intrauterine introduction of instruments like curette, ovum forceps,
IUCD or hysteroscope
- to dilate the Cx to facilitate drainage of intrauterine collection like pyometra, hematometra,
lochiometra
- to confirm patency of cervical canal after amputation of cx in Manchester operation
- to dilate urethra in urethral stricture
- in D&C operation

What are the indications of D&C?

- menorrhagia
- DUB
- endometrial hyperplasia and carcinoma
- fibroid uterus
- adenomyosis
- genital Tb
Amarjeet Ramdhonee OBG instruments 17

- in D&E operations
Indications of D&E?
- missed abortion
- incomplete abortion
- inevitable abortion
-septic abortion
-[Link]

- used to diagnose incompetent cervical os in non pregnant state. If passage of number 6-8
dilator without any resistance— cervical os is incompetent

Causes of pyometra
- genital Tb
- senile vaginitis
- endometrial carcinoma

Complications of D&C/E operations:

- infection
- bleeding
- anaesthetic complications
- perforation of uterus, intestine, bladder
- injury of Cx
- incomplete evacuation— cause bleeding and retention of product of conception
- excessive curettage— cause amenorrhea
- sepsis—cause Asherman syndrome due to adhesions in uterine cavity

Indications of hysteroscopy
- removal of fibroid aka myomectomy
- hysterectomy
- correction of incompetent cervical os
- correction of congenital uterine malformation
- removal of uterine polyp
- removal of displaced IUCD

[Link] removal hook

anaesthesia not needed
Amarjeet Ramdhonee OBG instruments 18
Indications of IUCD removal
- lifespan of IUCD has expired
- if pt is desirous of pregnancy
- complications like PID, bleeding, malignancy

[Link]
use- to check knee reflex in magnesium sulfate toxicity ( first sign- loss of patellar or knee
reflex)

[Link] cord clamp

2 are required
umbilical cord not clamped immediately
unless in HIV, Rh incompatibility, and preterm baby( to prevent hypervolemia)

[Link] abdominal wall retractor

- during abd surgery to reflect abd wall
Amarjeet Ramdhonee OBG instruments 19

[Link] toothed Vulsellum

(single tooth vulsellum is called teneculum)
not to be confused with allis’ forceps(straight and bigger)

uses:
- to hold the cervical lip in operations like D&C, D&E, anterior colporrhapy or vaginal
hysterectomy
- to remove a cervical polyp by twisting movement
- to hold the fundus of uterus and to give traction while the clamps are placed in operation of
total hysterectomy.

Function of volsellum is to make the Cx steady by traction. Anterior lip of Cx is held.

In nulligravida, teneculum is used to hold anterior lip of Cx.

In certain conditions, posterior lip of Cx are help for eg in:

- amputation of Cx in Manchester operation; vaginal hysterectomy when posterior
cervicovaginal mucous membrane is cut.
- in posterior colpotomy for drainage of pus or blood in ruptured ectopic pregnancy.
- vaginal ligation of tubes.
- growth in anterior lip of Cx
- during culdocentesis— is the transvaginal aspiration of peritoneal fluid from the Cul de Sac.

What are the indications of Culdocentesis?

- suspected ruptured ectopic pregnancy or other causes producing hemoperitoneum
- suspected cases of pelvic abscess

[Link] Curette
it has 2 ends- sharp and blunt. Sharp end is used in gynaecology
anaesthesia is needed
Amarjeet Ramdhonee OBG instruments 20
uses of sharp end:
- infertility for endometrial biopsy to detect ovulation. (Alternative to ED curette). Pt is called
between day 21 and 27 of the menstrual cycle for biopsy.
- for D&C in DUB
- tubercular endometritis
- endometrial hyperplasia
- endometrial Ca
- to Rx menorrhagia

Uses of blunt end:

- for termination of pregnancy during D&E in missed/ incomplete/ inevitable/ septic abortion;
[Link]

Why blunt end is used in pregnancy and not sharp end?

- Uterus is already soft and stretched due to pregnancy— therefore can lead to perforation

Why sharp end is used in gynaecology?

- Thicker wall— therefore more effort needed to take tissue if blunt end is to be used

[Link] holding forceps

around 22.5 cm long; has ring shaped ends with transverse serrations on the inner surface for
better grip; lock is present.

uses:
- antiseptic dressing in abdominal or vaginal operations
- to clean the vagina with gauze pieces following vaginal operations
- to hold the Cx in Cerclage operation during pregnancy
- for diagnosis of cervical tear during delivery
- if ovum forceps is not available in 2nd trimester, then can remove product of conception with
this instruments.
- to repair cervical tear.

What is cerclage operation?

- to correct cervical incompetence

Suspicions for cervical tear:

- PPH— traumatic— uterus well contracted
Amarjeet Ramdhonee OBG instruments 21

Procedure of diagnosis of cervical tear:

- put pt in dorsal lithotomy position
- anaesthesia not needed
- 2 sponge holding forceps are required
- 1 is put at 12 o'clock position and another at 3 o'clock position
- if any tear is there, repair it by chromic catgut 1.0
- if no tear, then open 12 o’clock position sponge holding forceps and put it at 6 o'clock
position
- if any tear then repair
- if no tear, open 3 o'clock position and put it at 9 o’clock position
- if any tear, repair it
- if not, open 6 o’clock position and put it at 12 o'clock position and repair the tear.

Can we use 4 instruments at a time?—No

- too much trauma to an already- soft Cx

[Link] scissor

What is episiotomy?
it is an incision on the perineum during 2nd stage of labour.

benefits of episiotomy
- speeds up 2nd stage of labour
- prevents tearing fo perineum|
- protects stress incontinence, UV prolapse, and pelvic floor relaxation
- heals easier than tears and is less painful
- easy to repair as compared to perineal tear

Indications of episiotomy
- breech delivery
- instrumental delivery
- fetal distress
- maternal distress
- primigravida
- twin pregnancy
- face to pubis delivery
- big baby
- narrow subpubic arch
- to cut short 2nd stage of Labour in heart disease, PIH, anaemia, and previous CS.
- premature baby— to minimise compression of the soft skull bones; thereby preventing
intracranial damage.
Amarjeet Ramdhonee OBG instruments 22
Types of episiotomy
- median
- mediolateral
- lateral
- J-shaped( rarely given)

Descriptions of incisions
- Median episiotomy- start from centre of fourchette and extend medially
- mediolateral: incision started in midline and then diverted laterally downwards away from
rectum
- lateral: incision starts from about 1 cm away from the centre of fourchette and extends
laterally; may be left or right
- J-shaped: incision begins in the centre of fourchette and is directed posteriorly along the
midline for about 1.5cm and then directed downwards and outwards along 5 or 7 o’clock
position to avoid the anal sphincter.

Disadvantage
- median: chances of involvement of rectum; not suitable for instrumental delivery and in
malpresentation; more dyspareunia
-mediolateral: more blood loss; difficult repair due to poor apposition of tissues; increased
chances of wound disruption
- lateral: chances of injury to Bartholin duct
- J-shaped: more blood loss; difficult repair due to poor apposition of tissues; increased
chances of wound disruption

Advantages:
- median: easy repair; good healing; less chances of bone disruption and less dyspareunia
- mediolateral: less chances of rectum involvement; incision can be extended if necessary
- lateral: NIL

Procedure of episiotomy:
- put pt in dorsal lithotomy position
- clean perineum with antiseptics 3 times and drape properly
- give 1-2% of 10-20 mL of xylocaine in fan- shaped manner at 5-6 sites
Precaution- before injecting- withdraw syringe to r/o presence of blood— if it goes in
circulation- can lead to cardiac arrest
- put 2 fingers in the vagina between the presenting part and the posterior vaginal wall
- incision is made by curved scissor— 1 blade of which is placed inside in between the fingers
and the posterior vaginal wall; the other on the skin.
- incision should be given at the height of uterine contraction where an accurate idea of the
extent of incision can be better judged from the stretched perineum
she will not feel extra pain of cutting as she is already in pain.
During contractions- blood vessels are constricted- so less blood loss
- episiotomy should be given at the time of crowning.( when BPD comes out to vagina— so
head won’t recede back)

Structures cut during episiotomy are:

- posterior vaginal wall
- superficial and deep transverse perineal muscles
- bulbospongiosus
- part of levator anii
- fascia covering those muscles
- transverse perineal branches of pudendal blood vessels and nerves
- subcutaneous tissue
- skin

Repair of episiotomy:
- done after expulsion of placenta
- done in 3 layers
Amarjeet Ramdhonee OBG instruments 23
- principles to be followed are:
— there should be perfect hemostasis
— obliterate the dead space to prevent hematoma formation
— suturing should be done without tension
— repair should be done in following order
— first layer is of vaginal mucosa and submucosal tissues; sutured by continuous suturing
— second layer is of perineal muscles by interrupted sutures
— third layer of skin and subcutaneous tissues by interrupted or mattress sutures
For suturing- absorbable chromic catgut 1 or 1.0

Skin can be sutured by either absorbable or non absorbable(silicon, nylon) suture material.

Suturing should be started 1 cm beyond the apex to prevent extension.

Postoperative care:
- wound is to be cleaned each time following urination and defection with antiseptic.
- give analgesics and oral antibiotics.
- stool softeners to prevent constipation— opening of sutures
- advise Sitz’s bath or hot water bath
- removal of stitches on 6/7th day is non- absorbable suture material is used for repair of skin
- pt should not sit on floor with crossed legs.
- avoid sexual intercourse for 6 weeks

Complications of episiotomy:
- infections
- if too tightly sutured— deep dyspareunia; chances of perineal laceration in next labour
- if not sutured properly— hematoma formation
- wound dehiscence or disruption
- scar endometriosis

[Link] forceps
- consists of 2 blades which are articulated by lock
- forceps are of 2 types- long and short
- are also called as outlet forceps/ Wrigley’s forceps
- length -27.5cm
- lighter in weight
- short which is due to reductio in length of shanks and handles
- Has 4 parts- lock, blades, handle and shank
- 2 blades- left and right in relation to maternal pelvis
- blades are fenestrated to facilitate a good grip of fetal head
- blade has 2 curves- pelvic and cephalic
- cephalic curve is more marked than pelvic curve
- shank— part between blade and lock— it facilitates locking of blades outside the vulva
- lock— is English lock— such type of lock requires introduction of left blade first
- handle— the handles are opposed when the blades are articulated. There is a finger guard
on which a finger can be placed during traction.

How to identify blades- right or left- when blades are isolated?

- the tip should point upwards
- the cephalic curve is to be directed inwards and the pelvic curve forwards
- the lock is downwards if right blade
Amarjeet Ramdhonee OBG instruments 24
Types of forceps operation:
The operations are classified according to the station of fetal head

- high forceps operation/ application — in floating/ non-engaged head

Not used nowadays— go for CS

- mid forceps operation/ application— refers to application of forceps where the BPD has
crossed the inlet (engaged head) but has not passed the ischial spine. Station of head is either
-1 or -2. (Station of head at ischial spine is zero).

- low forceps operation— refers to application of forceps where the BPD has passed the
ischial spines. Station is either zero or +1. In this we use long forceps= Kiellands forceps

- outlet forceps application— uses of short forceps. Station is +2 or +3. Forceps are applied
on the fetal head laying on the perineum and is visible at the introitus
Sagittal suture should lie in the AP diameter of the outlet of pelvis.

[Link] forceps
- length 40 cm
- has same parts as short forceps
- has 2 curves- pelvic ad cephalic
- but pelvic curve is slight
- there is no left and right blade
- there is anterior and posterior blades in relation to fetal head
- lock is sliding lock to correct parietal asynclitism= parietal bones not at same level— either
anterior or posterior

[Link] with axis traction device:

Also called as Bill’s axis traction device
- it provides traction in the correct axis of the pelvic curve and as such less force is necessary
to deliver the head.
- It consists of 2 traction rods- left and right; and a traction handle

Functions of forceps:
- main— traction—in primigravida- traction/ force/ pull is required of about 18kg and in
multigravida- it is around 13kg.
- its compression effect on cranium should be minimum when correctly applied over the
biparietal plane.
- rotation of head can be done by Kiellands forceps in deep transverse arrest
- to provide a protective cage for the head from the pressure of birth canal in premature baby
or to control the deliver of after-coming head in breech to lessen the dangers of sudden
decompression.
- one forceps blade may be used as a vectis to assist delivery of head in CS.

FORCEPS OPERATION
Indications of forceps operation:
Fetal indications
- delay in 2nd stage due to uterine inertia
- fetal distress
- cord prolapse
- after-coming head of breech
- preterm baby
- post-term baby

Maternal indications-
- maternal distress
- PIH
- pregnancy with heart diseases
Amarjeet Ramdhonee OBG instruments 25

Prerequisites of forceps applications:

- presentation or position of foetus may be suitable for forceps application eg cephalic
presentation, anterior face presentation and after-coming head of breech; positions-
occipitoanterior and occipitoposterior
- cx must be fully dilated- 10cm; and fully effaced-100%
- membranes must be ruptured- intact memb makes the grip slippery
- head must be engaged
- pelvis should be adequate - no CPD
- bladder and rectum must be empty
- uterus should be contracting and relaxing

Procedure of forceps application:

- put pt in lithotomy position
- cleaning of genitalia and thighs x 3
- give pudendal nerve block—10-20mL of 1-2% xylocaine at the level of ischial spine on both
sides. Pudendal nerve is a mixed nerve and root value is S2-S4
- give episiotomy
- identification of blades
- left blade is to be introduced first. The 4 fingers of the right hand are inserted along the left
lateral vaginal wall.
we hold blade in pen holding manner and is held vertically.
the blades should be over the parietal eminence.
- introduction of right blade— the 2 fingers of left hand are now introduced into right lateral
wall of vagina alongside the baby’s head. The right blade is introduced in the same manner as
with left one.
- Locking of blades:
When correctly applied, the blades should be articulated with ease. Minor difficulty in locking
can be corrected by depressing the handles on the perineum. The handles should never be
forced to lock them.
- Traction and removal of blades:
Before traction is applied, correct application of blades is to be ensured. Correct application
is evidenced by easy locking; blades are equidistant from the lambdoid suture; firm griping the
head on the BPD.
Traction is given during contraction by gripping the handle; placing the middle finger in
between the shank with the ring and little fingers on the either side on the finger guard.
Direction of pull:
- in Wrigles forceps- corresponds to the axis of birth canal.
- Outlet forceps- straight horizontal and upwards and forwards
- Kiellands forceps- downwards and backwards, then upwards and forwards.

Difficulties in forceps operation:

- mainly due to faulty assessment of the cases

- during application of blades:

Incompletely dilated Cx
Unrotated or floating head

- difficulty in lock:
Application in unrotated head
Improper insertion of blades
Failure to depress the handle against the perineum
Entanglement of cord/ fetal parts inside the blades

- difficulty in traction:
Undiagnosed occipitoposterior position
Faulty cephalic application
Wrong direction of traction
Mid pelvic contraction
Presence of constriction ring
Amarjeet Ramdhonee OBG instruments 26

Complications:
- maternal:
1. Immediate:
Extension of episiotomy to involve rectum or vaginal wall
Cervical tear; vaginal tear
PPH- traumatic or atonic
Shock due to blood loss
Sepsis
Anaesthetic complications
2. Remote:
Chronic low backache due to tension imposed ob the ligaments guarding the lumbosacral
or sacroiliac joints during lithotomy position
Genital prolapse
Urinary incontinence

- fetal:
1. Immediate:
Asphyxia due to prolonged compression
Facial palsy
Abrasion on soft tissues of face and forehead by forceps blades
2. Remote:
Cerebral and spastic palsy
Amarjeet Ramdhonee OBG instruments 27

Prophylactic forceps or elective forceps

- first done by Dele
- it refers to forceps delivery to shorten the 2nd stage of labour when maternal or fetal
complications are anticipated.

Indications of prophylactic forceps:

- eclampsia and pre-eclampsia
- heart disease
- post term pregnancy
- to cut short 2nd stage of labour
- pt under epidural anaesthesia

Advantage:
It prevents possible fetal cerebral injury due to pressure on the perineum and spares the
mother from the strain of bearing-down efforts.

Trial forceps
- it is a tentative attempt of forceps delivery in a case of suspected mid pelvic contraction.
- procedure done in OT; keeping everything ready for CS.

Failed forceps
- when a deliberate attempt in vaginal delivery with forceps has failed to deliver the baby is
called failed forceps
- mainly due to lack of skill with poor judgement

Causes:
- incompletely dilated Cx
- unrotated occipitoposterior position
- CPD
- undiagnosed brow presentation
- hydrocephalus
- fetal ascites
- constriction ring
- big baby with shoulder dystocia or shoulder impacted at brim

Management of failure of forceps application

- pt should be shifted to a tertiary centre
- to assess the effect on the mother and foetus
- start IV fluid and arrange for BT
- administer parenteral antibiotics
- exclude rupture of membrane— can cause failure of forceps
- formulate plan of delivery— rectify cause; or CS if unsuccessful

[Link] cannula
Amarjeet Ramdhonee OBG instruments 28

[Link]

- an instrumental device designed to assist delivery by creating a vacuum between it and the
fetal scalp
- the pulling force is dragging the cranium of foetus while in forceps- the pulling force is
directly transmitted to the base of skull
- it has suction cups with 4 sizes- 30, 40, 50, 60 mm—depending of cervical dilatation; a
vacuum pump and a traction rod device

Indications:
- deep transverse arrest(DTA) with adequate pelvis
- delayed in descent of floating head in case of second baby or twins
- as an alternative to forceps operation except in face presentation; after-coming head of
breech; fetal distress; preterm baby

Advantages of ventouse over forceps:

- can be used in unrotated head and mal-rotated occipitoposterior position of head
- can be applied even when Cx is not fully dilated
- not a space-occupying device
- lesser traction force is needed- 10kg required
- can be used when head is floating in 2nd baby or twins
- comfortable with minimum risk to the mother and baby especially with cardiorespiratory d/s
- requires less technical skills

Advantages of forceps over ventouse:

- forceps operation can quickly deliver the baby in a case of fetal distress where ventouse will
be unsuitable as it takes longer time.
- safer in preterm babies; the fetal head remains inside the protective cage
- can be used in anterior face presentation or after-coming head of breech
- simplicity of instrument; less costly; and handy

Contraindications of ventouse
- fetal distress
- face presentation
- premature baby
- after coming head of breech
Amarjeet Ramdhonee OBG instruments 29
Prerequisites of ventouse delivery
- pelvis should be adequate
- no CPD
- Cx at least 6cm dilated

Procedure:
- put pt in lithotomy position
- bowel and bladder evacuated
- cleaning of thighs and external genitalia x3
- give prudential nerve block
- give episiotomy
- application of cup:
cup is introduced after retraction of perineum. With 2 fingers, the cup is placed on the
occiput of foetus with the knob of cup pointing towards the occiput. This will facilitate flexion
of the head and knob indicates the degree of rotation.
a vacuum of 0.2kg/cm2 is induced by the hand pump slowly taking at least 2mins.
a check is made using the fingers around the cup to ensure that no cervical or vaginal tissue
is trapped inside the cup.
the pressure is gradually increased at the rate of 0.1kg/cm2/min until the effective vacuum of
0.8kg/cm2 is achieved in about 10mins time.
the scalp of foetus is sucked into the cup and an artificial caput succedaneum is produced=
Chignon
the chignon usually disappears within few hours of birth

- traction:
Must be at right angle to the cup
Should be given during contraction
Hand should be placed against the cup to know the angle of traction, rotation and
advancement of head
If there is no advancement during 4 successive uterine contractions, procedure should be
abandoned.
On no account traction should exceed 30mins
As soon as the head is delivered, the ventouse is reduced by opening the screw release vault
and cup is detached. Delivery is then completed in normal way.

Complications of ventouse:
- fetal:
Sloughing os feat scalp
Subaponeurotic hemorrhage
Intracranial haemorrhage
Cephalohematoma

- maternal:
Injury to cervix or vagina due to inclusion of soft tissue inside the cup.