OPERATIVE DELIVERIES

By:-Debelo Etana Bacha( BSc, MSc)

 Learning objectives
At the end of the session the learner will be able to :-
 Know types of operative deliveries
 Discuss indications of Vacuum delivery
 Nursing management for Pre,Intra and post operative
delivery
 To know eligibility of TOLAC
 To identify nursing care in obstetric shock

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 Operative delivery
 Operative delivery is obstetric procedures in w/c active
measures are taken to accomplish delivery.

 Can be divided in to two:-

Operative vaginal delivery

Cesarean section/ delivery

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 Operative vaginal delivery
 Operative vaginal delivery refers to an assisted delivery in
which the operator uses obstetric forceps, vacuum/ventous, or
other devices to extract the fetus from the birth canal.

 The instrument is applied to the fetal head and then the

operator uses traction or rotation to extract the fetus.

 Can be divided in to two:-

Instrumental delivery (vacuum & forceps)

Destructive delivery ( for died fetus)

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 VACUUM DELIVERY

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 Vacuum Delivery
 Is an assisted instrumental vaginal delivery using ventouse
(vacuum).

 Its main components are the suction cup (metallic or plastic),

vacuum pump and traction devices.
 Indications: -
Prolonged second stage of labor

Non reassuring fetal heart rate pattern in 2nd stage.

To shorten second stage in Eclampsia, cardiac or pulmonary

diseases and cerebrovascular disease

Cord prolapse in 2ndBy:-stage

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 Vacuum Delivery…..cont’d
 Prerequisites for vacuum delivery:-

Vertex presentation

Fully dilated cervix

Engaged head:- station at 0 and below or not more than 2/5

above symphysis pubis

Ruptured membranes

Gestational age 34 weeks and above

 No CPD

No contraindication to vaginal delivery

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 Vacuum Delivery…..cont’d
 Preparation:-
Counsel and get consent which is documented on the notes.
Empty bladder
Local anesthesia infiltration for episiotomy.
Check all connections and test the vacuum on a gloved hand
Procedure of Vacuum Delivery
 Application:-
Identify the flexion point and Apply the appropriate size cup
that can fit near to the occiput.

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 Vacuum Delivery…..cont’d
– The edge of the cup should be at about 1 cm anterior to the
posterior fontanel and on the sagittal suture.

– Check for correct application and ensure that there is no

maternal soft tissue (cervix or vagina) within the rim of the
cup.

 Create a vacuum of 0.2 kg/cm2 or 200 mmHg negative

pressure then Gradually increase the vacuum to 0.8 kg/cm2
(600 mmHg) negative pressure and check that maternal tissue
(cervix or vagina) is not entrapped.

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 Vacuum Delivery…..cont’d
 Traction

– Start traction with contraction with a finger on the scalp next

to the cup to assess slippage and descent of the vertex.

– Pull in line with the pelvic axis and perpendicular to the cup.

– Between contractions, check FHB and cup application.

– As soon as the head is delivered, release the vacuum and

proceed with the delivery of the fetus.

 After delivery inspect the vagina and cervix, and repair if there
is any tear or episiotomy.
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 Failed Vacuum Delivery
 Diagnosis of failed vacuum is based on any one of the
following condition:-
– The head does not advance with each pull.
– The fetus is undelivered after 3 pulls with no descent.
– The fetus is not delivered within 30 minutes.
– The cup that is applied appropriately and pulled in the
proper direction with maximum negative pressure slips off
the head twice.
 If vacuum delivery fails, the fetus should be delivered by
Cesarean section.
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 Complications of vacuum delivery
Fetal complications
 Localized scalp edema (caput succedaneum)

– Formed under the cup, harmless and disappears in few hrs.

 Cephalohematoma

– requires observation and usually will clear in 3 to 4wks.

 Scalp abrasions (common and harmless)

– clean and suture if necessary.

 Intracranial hemorrhage
Maternal complications
 Tears of the vagina or cervix
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should be repaired.
By:- Debelo Etana Bacha 14
 FORCEPS DELIVERY

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 Forceps delivery
 is an assisted vaginal delivery effected using obstetric forceps.
 Classification:-
– Low forceps:- applied when the station is +2 or below.

– Outlet forceps:- applied when the fetal head is at station +3

(at the pelvic floor).
 Indications:-
– The same as indications for vacuum delivery.

– In addition, it can be applied for after coming head in breech

presentation, mentoanterior of face presentation and preterm
fetus.
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 Forceps delivery….cont’d
 Prerequisites:-

– The same as prerequisites for vacuum delivery

– In addition to Vertex presentation with occipito-anterior

and Face presentation with mento-anterior.

 Preparations:-

– Counsel and get consent which should be documented in

the notes.

– Local anesthesia infiltration for episiotomy

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 Procedure of forceps application in OA
 Identify the right and left blades.

 Lubricate the blades of the forceps.

 Insert two fingers of the right hand into the vagina on the side
of the fetal head.

 Slide the left blade gently between the head and fingers to rest
on the side of the head.

 Repeat the same maneuver on the other side, using the left
hand and the right blade of the forceps.

 Depress the handles and lock the forceps.

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 Procedure of forceps application…cont’d
 Check application is correct and no maternal tissue is entrapped.

 Difficulty in locking usually indicates the application is incorrect.

 After locking, apply traction with each contraction following the

pelvic curve.

 Between contractions check FHB and application of forceps.

 When the head crowns, make an episiotomy if necessary.

 Once the fetal head reaches the pelvic floor, lift the head slowly
out of the vagina.

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 Failed forceps delivery
 Failed forceps is diagnosed if:-
– Fetal head does not descend with each pull,
– Fetus is undelivered after three pulls with no descent or
after 30 minutes.
 After failed forceps, cesarean delivery is undertaken if the
fetus is alive
Complications
– Injury to facial nerves
– Lacerations of the face and scalp
– Fracture of the facial bones or skull bones
– Tear or laceration to the cervix, vagina
– Traumatic PPH
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 Cesarean section (delivery)
 is the delivery of the fetus, placenta and membranes through
an incision on the abdominal and uterine wall at or after 28
weeks of gestation.

Classification:-

 based on the time of decision

– Elective cs:- is a planned cesarean delivery performed

before the onset of labor

– Emergency cs:- is when the cs is done in labor, due to

development of complications.
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 Cesarean section (delivery)…cont’d
 According to number of the operation:-
– Primary caesarean section:- Cs done for the first time.
– Repeated caesarean section:-Cs done >1 times, or with
previous caesarean sections.
 Based on uterine incision:-
– lower transverse uterine incision:- commonest and
preferable type of incision.
– lower vertical uterine incision
– upper vertical uterine incision (classical incision)

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 Cesarean section (delivery)…cont’d
Indications of CS

 Previous CS not eligible for TOLAC(Trial of Labor after CS)

 Feto-pelvic disproportion (FPD) such as CPD,

 Failure to progress in labor despite adequate Ux contraction.

 APH

 Mal-presentations (breech, brow, face and shoulder presentation)

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 Indications of Cs…cont’d
 Non reassuring fetal heart rate pattern (NRFHRP)

 Cord prolapse or presentation

 Previous uterine incision (myomectomy, uterine rupture)

 Failed induction and Failed TOLAC

 Multiple pregnancy (first non-vertex, triplet or more)

 Macrosomia with EFW >4.5 kg

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 Preoperative preparation/care
 Check Hemoglobin, Blood group (ABO) and Rh factor.

 At least 2 units of cross matched blood should be prepared.

 Keep NPO for 8 hours for regular meal and 2 hours for clear fluid

 Revise the clinical history, anesthetic risk and medical illness.

 Obtain informed written consent.

 Secure IV bilaterally and Catheterization.

 Prophylactic antibiotic (Ampicillin 2g Iv)

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 Intra-operative care
 Record maternal VS before anesthesia and during the Cs.

 Position the mother on operation table.

 Ensure appropriate monitoring of vital signs.

 After delivery of the baby administer 20 IU oxytocin in 1000

ml of N/S or R/L at 60 drops per-minute for two hours.

 After delivery of the baby and placenta perform BTL or

insertion of IUCD if she is already counseled and has chosen
the method.

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 Post-operative care
 Check and record VS every 15 min, until she is fully awake,
every hour for 4 hrs and every 4 hours then after.

 Check for vaginal bleeding and make sure the uterus is

contracted.

 Check and record urine output every 4 - 6 hours.

 Provide analgesics as required.

 Initiate breast-feeding and skin-to-skin contact with the baby

as soon as the mother is awake.

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 Post-operative care…cont’d
 Start sips of fluid after ascertaining that she is conscious and
bowel sounds are active. Provide food when she is drinking
and tolerating fluids.

 Ambulate early.

 Look for evidences of PPH, pulmonary infection, UTI and

wound infection.

 Discharge after 48-72 hours if vital signs are within normal

range, mother has started regular feeding, breast-feeding is
initiated and there is no evidence of wound infection.
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 Postoperative complications
 Postpartum hemorrhage due to uterine atony.

 Anesthesia related complications

– Aspiration pneumonia

– Hypotension and headaches

 Deep vein thrombosis

 Wound infections

 The risk of scar rupture or dehiscence in future pregnancy

 Risk of repeated Cs in the future pregnancy

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 Trial of labor after cesarean section
or TOLAC
 is allowing vaginal birth by a woman who has undergone a
caesarean section in a previous pregnancy.

 A woman who has had one caesarean section in previous births

has two options of mode of delivery in a subsequent
pregnancy:

– Trial of Labor after CS (TOLAC) or

– Planned Elective Repeat Caesarean Section (ERCS).

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 Eligibility for TOLAC
 One previous lower uterine segment caesarian section

 Clinically adequate pelvis

 Singleton pregnancy

 Cephalic presentation

 No other uterine scars or repair for rupture

 Estimated fetal weight <4Kg

 Informed consent

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 Contraindications for TOLAC
 Clinically contracted pelvis

 Prior complicated caesarian section (extensions), classical or

T- shaped incision

 Prior uterine repair for rupture and trans fundal surgery

 Obstetric (placenta previa), medical or surgical condition that

prevent vaginal delivery

 More than one prior uterine scars

 Declined consent for TOLAC.

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 Management of TOLAC
 Delivery must be at hospital.

 Identify Indication for previous CS and EFW

 Asses and inform all individual risks and benefits of TOLAC

 Closely follow FHB pattern, Labor Progress and Maternal

condition (scar dehiscence)

 Clinical features of uterine scar rupture/dehiscence:-

– FHR abnormality and Vaginal bleeding

– Severe abdominal pain and tenderness

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 Management of TOLAC…cont’d
– Cessation of previously efficient uterine activity

– Maternal tachycardia, hypotension, fainting or shock

 Delivery Should be conducted like others.

 If failed TOLAC do emergency CS/ Laparatomy.

 When to declare failed TOLAC:-

– If labor doesn’t progress as expected

– If any evidence of scar dehiscence develops.

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Complications of third stage
of labor
 1. Post-partum Hemorrhage
 Excessive bleeding following delivery

– >500 ml in vaginal delivery

– >1000 ml in Caesarean Delivery

– a drop in Hct > 10% from the baseline (36-48%) for women

– bleeding resulting in derangement of vital signs.

 Classification:-

– Primary PPH:- PPH occurring within 24 hrs

– Secondary PPH:- PPH occurring from 24 hrs until 6 wks after

delivery.

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 Primary PPH
 Causes (5Ts)

Atonic uterus (Tone)

Genital trauma (Trauma)

Retained placenta (Tissue)

Coagulation failure (Thrombin)

Acute inversion of the uterus (Traction)

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 Atonic Uterus (Tone)
 is loss of tone in the uterine musculature
 Risk factors:-
– Prolonged labor, precipitated labor, induction or
augmentation of labor,
– Over distended uterus (multiple gestation, polyhydramnios,
fetal macrosomia),
– Previous history of PPH, high parity,
– Mismanagement of 3rd stage
 Diagnosis:-
– hypotonic (boggy) uterus with bleeding and expression of
clots when the uterus is massaged.
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 Genital tract trauma (Trauma)
 is lacerations of the genital tract in the process of delivery
(uterus, cervix or vagina).
 Risk factors:-
– Mismanagement of 3rd stage of labor,

– Feto-pelvic disproportion, instrumental deliveries,

– Large episiotomy and tight perineum

 Diagnosis:
– suspect when bright red bleeding occurs in the presence of
a contracted uterus.
 Mgt:- Repair the laceration.
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 Retained placental tissue (Tissue)
 is Failure to deliver the placenta and the membranes fully or
partially following active management of labor.

 Retained placenta is defined as placenta that has not undergone

expulsion after 30 minutes of birth.
 Risk factors:
– Mismanagement of third stage of labor,

– abnormal placentation (adherent placenta),

 Diagnosis:
– incomplete cotyledons and/or membranes,
– failure to deliver the placenta by CCT.
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Treatment of Retained Placenta (PPH with undelivered
placenta)

 Give additional 10 units of oxytocin IM, check the tone of the

uterus and attempt CCT.
 If placenta delivery fails, perform manual removal of the
placenta.
– Give analgesia

– prophylactic antibiotics (ampicillin 2 gm IV stat) and

– catheterize the bladder.

Treatment of Retained Placental Fragments

– Remove placental fragments by hand or ovum forceps.

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 Manual removal of placenta

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 Coagulopathy (Thrombin)
 is any derangement of hemostasis resulting in excessive
bleeding
 Risk factors:
– Platelet dysfunction and inherited coagulopathy,
– use of anticoagulation,
– DIC (from sepsis, placenta abruption, amniotic fluid
embolism or IUFD),
 Diagnosis:
– bleeding from other sites in addition to the genital tract.
– perform bedside coagulation tests and determine platelet
count.
 Mgt:- blood transfusion.
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 Acute inversion of the uterus (Traction)
 Is when the uterus turns inside-out partially or completely
during or after delivery of the placenta.

 Classification

1st degree: Fundus is within the uterus not extending

beyond the cervix

2nd degree: the inversion extends out of the cervix and is

limited to within the vagina.

3rd degree: complete in version to the perineum

4th degree: total inversion of the uterus with the vagina

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 Acute inversion of the uterus…cont’d
 Risk factors:

– Mismanagement of 3rd stage of labor, adherent placenta,

– short cord, fundal placenta, morbid placental adherence

 Diagnosis:

– sudden maternal collapse with active vaginal bleeding and

– a fleshy mass in or out of the vagina with small or absent

uterus on abdominal palpation.

 Mgt:- Manual replacement

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 Manual replacement

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 Initial Treatment of PPH
– Shout for help

– Initiate resuscitation and Monitoring VS

– Position the patient flat.

– Oxygen by face mask

Treatment of atonic uterus

 Uterine massage

 Uterotonic drugs

– IV oxytocin 20-40 units in 1L NS at fastest flow rate.

– Ergometrine 0.2 mg IM, repeat after 15 minutes.

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 Treatment of PPH
 Bimanual compression of the uterus and aortic compression

 Bimanual compression:-

– If there is no response, perform bimanual compression of

the uterus as a temporary measure.

 Aortic compression:-

– compress the abdominal aorta until bleeding is controlled

or alternative measures can be taken.

 Uterine/ utero-ovarian artery ligation if bleeding not resolved.

 Hysterectomy is final option.

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 Causes
Secondary PPH
– Sub-involution of the uterus,
– infection, retained pieces of placental tissue or clot,
– wound dehiscence
 Specific management depends on underlying cause:-
– Sub-involution: Oxytocin drip or ergometrine (Po 1tablet BID
for 3 day).
– Infection: broad spectrum Antibiotics
– Retained placental tissue: Evacuate the uterus using manual
vacuum aspiration with large sized cannula.
– Hysterectomy may be done if there is indication.
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 2. Adherent Placenta
 Morbidly adherent placenta occurs when the placenta fails to detach
from the uterine wall due to abnormal implantation at the basal plate.
 Classification
Placenta accreta:- when placental villi penetrates endometrium
and attached to the myometrium.

Placenta increta:- when placental villi invade myometrium and

implanted over perimetrium.

Placenta percreta:- when placental villi penetrates through

perimetrium and radiated to nearby organs.

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 Adherent Placenta….cont’d
 Risk factors
– Previous caesarean section
– Placenta previa
– Previous uterine surgeries
 Diagnosis
– Ultrasound and MRI
 Management

– Is usually hysterectomy.

– Some times doctors leave it to be absorbed through

autolysis by putting the mother on the antibiotics.

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 3. Shock in Obstetrics
 Shock is a condition resulting from inability of the circulatory
system to provide oxygen and nutrients to the tissues.

 Occur wen blood volume is too small to reach the vital organs.

 It is life threatening condition w/c requires immediate

treatment.

Types and Causes:-

– Hypovolemic shock:- Due to excessive blood loss.

– Septic shock (Endotoxic shock):- generalized vascular

disturbance due to release of toxins by bacteria.
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 Shock….cont’d
 Cardiogenic shock:- due to ineffective contraction of the
cardiac muscle.

 Anaphylactic shock:- caused by sensitivity to drugs.

 Classic Clinical Picture of Shock:
– Low blood pressure and Rapid weak pulse
– Pallor, Cold clammy sweat
– Cyanosis of the fingers.
– Dimness of vision and unconsciousness
– Restlessness and Oliguria or anuria.
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 Management of shock
Urgent interference is indicated as follow:-

 Detect the cause and arrest hemorrhage.

 Establish an airway and give oxygen by mask.

 Elevate the legs to encourage return of blood from the limbs to

the central circulation

 Two or more intravenous ways are established for blood, fluids

and drugs infusion

 Restoration of blood volume by blood transfusion

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 Management of shock
 Vasopressors: To increase the BP so maintain renal perfusion.

– Dopamine : 2.5m g/ kg/ minute IV is the drug of choice.

 Antibiotic therapy is starting immediately if infection is

suspected as the cause of the shock.

– Ampicillin 2gm Iv QID + Gentamycin 80mg Iv TID +

Metronidazole 500mg Iv TID.

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