OBSTETRICS AND GYNECOLOGY

INSTRUMENTS AND ALLIED PROCEDURES FOR PRACTICAL EXAM

FEBRUARY 1, 2022
SANTANU DAS
BATCH- 2017, BMC
 SIMS’ DOUBLE-BLADED METALLIC POSTERIOR VAGINAL WALL
SPECULUM
DESCRIPTION-

• Designed by Marion Sims

• Non-self-retaining vaginal speculum
• Available in different sizes
• End of the blades-Rounded (To avoid trauma)
• Blades at both the end are of different size- To
facilitate introduction into vagina depending upon space
available.
• Speculum has concave groove in the center- To
drain any secretion, blood etc.

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 ▪ Q & A-
1. HOW DO YOU INSERT THIS INSTRUMENT?
ANS- Patient lying with buttocks on the edge of table in dorsal position→ thigh flexed or in lithotomy
position→ Lubricate the blade of instruments→Separate the labia→Insert the transverse axis of blade
along the long axis of introitus→Once inside the vagina, rotate the blade by 90 degree and retract the
posterior vaginal wall→Cervix and vaginal wall examined.
2. WHAT ARE THE DISADVANTAGES OF THIS INSTRUMENT?
ANS- A. It is not a self-retaining speculum→An assistant is required to hold speculum→Extra manpower.

▪ EXTRA-EDGE-
1. DILATATION AND EVACUATION-
• INDICATIONS-
✓ Inevitable, incomplete and missed abortion
✓ MTP
• STEPS-
Misoprostol 400 mcg placed vaginally at least 4 hours prior to
procedure (to soften the cervix) → GA or LA is given →Patient is
placed in lithotomy position →Parts are cleaned and draped
→Bladder is drained → Per speculum and bimanual examination are
done to assess the cervical dilatation and the size, position of
uterus→ Sims’ speculum is introduced and the anterior lip of cervix is
held with sponge holding forceps →DILATATION (Done with serial
sized Hegar’s cervical dilators up to the desired dilatation)→Ovum

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 forceps is introduced and products of conception are removed
completely → Blunt uterine curette is introduced and gentle check
curettage of uterine cavity is done at the end of procedure→Inj.
0.2mg methergine IV/IM is given at the end of the procedure.
COMPLICATIONS OF D&E-

INTRAOPERATIVE COMPLICATIONS POSTOPERATIVE COMPLICATIONS

1. ANESTHETIC COMPLICATIONS 1. INFECTIONS
2. INJURY TO CERVIX 2. SEPTIC ABORTION
3. UTERINE PERFORATION 3. INCOMPLETE EVACUATION
4. BOWEL INJURY
5. HEMORRHAGE

1. SUCTION- EVACUATION-
• INDICATIONS-
✓ Inevitable, incomplete and missed abortion
✓ MTP
✓ Molar pregnancy
• STEPS OF SUCTION EVACUATION-
Misoprostol 400 mcg vaginally placed at least 4 hours before the
procedure→GA/LA→Lithotomy position→Pats are cleaned and
draped→Bladder is drained→ Per speculum and bimanual
examination to assess cervical dilatation and size and position of
uterus→Sims’ speculum introduced and anterior lip of cervix is
held→DILATATION of cervix with serially sized cervical dilators up to
desired dilatation→SUCTION CANNULA of appropriate size is
introduced through the cervical canal and pushed up to midway
inside the uterine cavity→ The cannula is connected to a suction
apparatus by rubber tubing→Negative pressure is created with
suction machine→Cannula is moved up and down and rotated in all
directions and the products of conception are sucked out till the
cavity becomes empty→Negative pressure is released and cannula is
removed→Gentle check curettage is done with a blunt curette→Inj.
of IV/IM methergine.
2. MANUAL VACUUM ASPIRATION-
• STEPS-

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 Steps up to cervical dilatation are same as suction- evacuation
except it is a OPD procedure and paracervical block is done and not
GA→Cannula is inserted gently until the tip reaches the fundus of
uterus and then slightly withdrawn →Manual vacuum aspirator is
assembled and negative pressure is created→the charged vacuum
aspirator is attached to the cannula and the valve is released to start
suction→cannula is rotated in all directions and moved up and down
till all the contents are completely aspirated→After closing the valve
,the cannula and aspirator are withdrawn.
Vacuum aspiration can be done to terminate a pregnancy up to 10
weeks.
• COMPLICATIONS OF BOTH SUCTION EVACUATION AND MANUAL
VACUUM ASPIRATION-
✓ Cervical injury
✓ Vasovagal attack(during dilatation)
✓ Uterine perforation
✓ Incomplete evacuation and infections

• DISADVANTAGES OF SUCTION EVACUATION/VACUUM ASPIRATION-

✓ Difficult to perform when fetal parts are well formed, that is
after 10 week of gestation.

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 ✓ The procedure requires vacuum aspirator or suction
apparatus.

CUSCO’S BIVALVED, METALLIC, SELF-RETAINING, VAGINAL SPECULUM

▪ DESCRIPTION-
• It has 2 metallic blades joined by a screw that allows the blades to
open and close.

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 ▪ TECHNIQUE OF INSERTION-
• Blades of the speculum are lubricated →Labia gently separated
→Instrument inserted with closed blades along the long axis of
introitus → Following insertion, instrument is rotated by 90 degree
→Blades are then opened to retract the anterior and posterior
vaginal wall →Depending upon the exposure is needed, fixation of
screws are done and tightened →While removing the speculum,
fixation screw is unscrewed and blades are closed →Removed.
▪ USES-
OBSTETRICS USE GYNECOLOGY USE
To inspect vagina and cervix a. Colposcopy
for- b. Cervical procedures- Pap smear, biopsy etc,
a. Any bleeding P/V c. Uterine procedures s/a endometrial sampling
b. Discharge P/V d. IUCD insertion and removal,
c. Leaking P/V e. During intra-uterine insemination(IUI)
It is mostly used in OPD procedure
setup. f. Diathermy cautery
a→e are diagnostic and f is therapeutic.

▪ ADVANTAGES AND DISADVANTAGES-

ADVANTAGES
a. It is self-retaining and hence
does not need any assistant to
hold in position.
DISADVANTAGES
a. Anterior and posterior vaginal
wall both can not be visualized,
b. Speculum is space occupying and
hence provides limited view of
vagina and less maneuvers can
be done using this speculum.

SIMS’ ANTERIOR VAGINAL WALL RETRACTOR

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 ▪ DESCRIPTION-
• It is a long instruments having a shaft and oval fenestrated ends on
both sides with serrations→fenestration is there for the instrument
to fit in the rugosity of vagina and it also makes the instrument
lighter.

Ends are at 15 degree angle with the shaft.

▪ .USES-
• It is used to retract the anterior vaginal wall in conjugation with Sims’
posterior vaginal wall speculum to visualize the cervix and vagina,
• So uses are as same as Sims’ posterior vaginal wall speculum,
• It may be used as a blunt curette following delivery to remove the
placental bits and membrane→ONLY SAY IF THEY PERSIST ASKING
WHAT IS ITS OTHER USES.

AUVARD’S SELF-RETAINING SPECULUM

▪ DESCRIPTION-
• It is a single-bladed self-retaining posterior vaginal wall speculum,
• It has wider blades than the Sims’ speculum,
• It has a heavy weight attached to it, which acts as a self-retention
due to gravitational force at that weight.
• Uses are same as other posterior vaginal wall speculum,
• USES- In vaginal surgeries- vaginal hysterectomy, VVF repair,
Anterior colporrhaphy, TVT, TOT.
• Special points- it is always used under anesthesia, can not be used
for routine per speculum examination, can only be used in lithotomy
position.
• It is now rarely used due to post-operative pain and its heaviness.

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 SINGLE-BLADED POSTERIOR VAGINAL WALL SPECULUM

It’s uses are same as Sims’ posterior vaginal wall speculum, but it has an
advantage that – the patient need not be on the edge of the table like in double-bladed
speculum.

ALL THE SPECULUMS ARE STERILIZED BY BOILING OR AUTOCLAVE.

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James Marion Sims is the father of Gynecological surgeries.
Sims’ Speculum-Described earlier.
Sims’ Position-
✓ also called lateral recumbent position.
✓ Patient is asked to lie on a left lateral position with her left leg straight and right leg
flexed at hip and knee.
✓ Uses- i. Performing posterior vaginal wall examination, ii. Rectal examination using
Proctoscope- To see for rectocele and enterocele, iii. Giving enema.
Sims’ VVF repair surgery-described later.
Sims’ triad- Sims’ speculum+ position+ VVF Repair surgery →together these three are called
Sims’ triad.

Sims’ anterior vaginal wall retractor- described earlier.

SIMS’ POSITION

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 RAMPLEY’S SPONGE HOLDING FORCEPS
▪ DESCRIPTION-
It is a forceps with rings at the anterior(jaw) end with serration and a catch near
handle.

▪ USES-
GYNECOLOGICAL USES
▪ Antiseptic dressing of abdominal
and vaginal operations like
hysterectomy,
▪ Polypectomy
▪ Packing of roller gauze in
secondary hemorrhage following
vaginal and abdominal
hysterectomy,
▪ Can be used as anterior vaginal
wall retractor,
▪ To occlude ovarian vessels
during myomectomy
▪ If still examiner keep on asking-
say it can rarely be used instead
of ovum forceps.
OBSTETRICS USES
▪ Abdominal dressing and draping
during caesarean section, and
vaginal procedures like D&E,
S&E, any normal delivery,
instrumental delivery;
▪ To grasp lip of cervix for
diagnosis and repair of cervical
tear;
▪ To removes placental
membranes
▪ Hemostasis if needed during
caesarean section,
▪ Can also be used instead of
ovum forceps in removal of
placental bits during PPH or
septic abortions.

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 OVUM FORCEPS
▪ DESCRIPTION-
✓ It is a long metallic instrument with spoon shaped fenestrated blades
✓ Handle does not have any catch and hence it is atraumatic and prevents
crushing of tissues.
▪ USES-
GYNECOLOGICAL USES OBSTETRICS USES
▪ No such use in gynecology but ▪ To remove products of
can be used during hysterectomy conception in D&E,
or grasping ovum. ▪ To remove the retained bits of
placenta and membranes,
▪ Q&A-
1. HOW TO DIFFERENTIATE BETWEEN OVUM FORCEPS AND SPONGE HOLDING
FORCEPS?
→Ovum forceps does not have catch , sponge holding forceps has catch in its
handle and in ovum forceps the tip is spoon-shaped fenestrated whereas in
sponge holding forceps tip is ring shaped with fenestration and serration.
2. HOW TO MANIPULATE THE INSTRUMENT?
➔ It is to be introduced with blades closed, to open up inside the uterine
cavity→to grasp the products and to take out the instrument with slight
rotatory movement→rotatory movements not only facilitate detachment of
the products from the uterine wall but also minimize the injury of uterine
wall, if it is accidentally grasped.

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 KOCHER’S HEMOSTATIC FORCEPS
▪ DESCRIPTION-
✓ It is a long metallic instrument with a tooth at tip of one blade and a
corresponding groove to fit in the opposite blade.
✓ The handle has ratchet and catch,
✓ It has transverse serrations in the blade,
✓ It is of two types- straight and curved.
▪ USES-
GYNECOLOGICAL USES OBSTETRICS USES
▪ To hold uterus near cornual end ▪ To perform artificial rupture of
during abdominal membrane,
hysterectomy; ▪ Clamping the umbilical cord
▪ During polypectomy, during delivery,
▪ To clamp pedicels, ▪ For removal of membrane in
▪ To stop bleeders during vaginal and caesarean delivery,
abdominal surgeries, ▪ In obstetrics hysterectomy(in
cases of abnormal placentation,
uterine rupture, uterine atony,
extensive uncontrollable PPH).

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 ARTIFICIAL RUPTURE OF MEMBRANE-
• INDICATIONS-
✓ Surgical induction of labor
✓ Augmentation of labour
✓ Conditions requiring induction of labor by ARM-
▪ Confirmed post-dated pregnancy
▪ Abruptio placenta
▪ Severe pre-eclampsia or eclampsia
▪ DM
▪ IUGR
▪ Pregnancy in Rh negative mothers
✓ Contraindications of ARM-
▪ IUFD
▪ Cord presentation, vasa previa
▪ Where presenting part is high up→chances of cord prolapse,
▪ Polyhydramnios→fear of accidental hemorrhage and cord prolapse.
✓ Methods of Induction of labor-
▪ Medical-Prostaglandins, oxytocin
▪ Surgical- ARM, Amniotomy(amniotomy is preferred),
▪ Mechanical- stripping of membranes, extra-amniotic saline infusion,
transcervical balloon and hygroscopic cervical dilators
✓ STEPS OF ARTIFICIAL LOW RUPTURE OF MEMBRANE(ARM)-
▪ Patient position- thigh flexed, leg flexed and abducted,
▪ Anesthesia- not required,
▪ FHS- should be heard. If absent- avoid doing ARM.
▪ Bladder- Evacuated
▪ Internal examination
▪ Fundus of uterus is fixed by assistant
▪ Closed forceps is then passed through cervical canal and membranes are
touched
▪ Membranes are ruptured by sharp thrusting of the tip of forceps.
▪ If not successful, membranes are caught by forceps and torn by
pulling→care should be taken not to grasp the maternal tissue
▪ Color of the liquid is noted
▪ P/V examination is done to exclude any cord prolapse or any bleeding
▪ FHS is again auscultated.
✓ Dangers-
▪ Bleeding
▪ Cord prolapse
▪ Injury to maternal and fetal tissues
✓ IF LIQUOR IS THICK MECONIUM STAINED-
▪ It may be due to fetal distress→resuscitation measures are needed to be
taken→left lateral position, oxygen administration, 5% dextrose
infusion→decision may be taken for termination of pregnancy→LUCS.

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 ✓ WHY BLOOD COMES OUT FOLLOWING ARM-
▪ May be due to low-lying placenta or may be vasa previa
▪ Injury to maternal or fetal soft tissues
▪ Accidental hemorrhage
✓ WHAT IF LIQUOR DOES NOT COME OUT AFTER ARM-
▪ Oligohydramnios
▪ Engaged head
▪ In these cases, presenting part is pushed up and liquor is allowed to drain
down.
✓ Following ARM , labor generally starts within 12-24hours.
✓ But nowadays, combined method is used. Either by giving misoprostol 25mcg,
or dinoprost gel before ARM or Oxytocin drip immediately after
ARM→Antibiotics are given→If significant time passes by in spite of applying
combined method→Go for caesarean section.
✓ HOW TO DIFFERENTIATE BETWEEN LIQUOR AND URINE-
▪ Inspect per vaginally with a speculum and ask the patient to
cough→liquor comes out.
▪ By internal examination, membrane is not felt with fingers.
▪ Characteristic odor of urine.
▪ Fetal cells may be detected.
✓ SITE OF CORD CLAMPING-
▪ One forceps is fixed 5cm away from navel and second forceps is fixed 2.5
cm away from 1st clamping forceps→ cut in the middle of clamped
portion now.
▪ Usually 2 minutes after the cord pulsation ceases→cord is clamped.
▪ Length of cord is kept long in cases of→ a) prematurity, b)Rh negative
woman, c)Asphyxiated baby.
▪ Early cord clamping is done in→ a) multiple pregnancy, b)Rh negative
mother, c)prematurity, d)Asphyxiated baby, e)Diabetic mother.
▪ Contents of umbilical cord→ a) covering epithelium, b) Wharton’s jelly,
c)two arteries and one vein, d)allantois, e)remnant of yolk sac, f)vitelline
duct, g)obliterated extra-embryonic coelom .
▪ Significance of single umbilical artery→ associated with malformation of
fetus like genital anomalies and trisomy 18 and found in diabetic
mothers and multiple pregnancies mostly.
▪ High rupture of membrane is done with- DREW-SMYTHE CATHETER.

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 DREW-SMYTHE CATHETER
✓ PRESENTLY HIGH RUPTURE MEMBRANE IS NOT USED, PREVIOUSLY IT WAS
USED TO DRAIN FLUID IN POLYHYDRAMNIOS. SO THIS INSTRUMENT IS
OBSOLETE NOWADAYS.

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 ALLIS TISSUE HOLDING FORCEPS
▪ DESCRIPTION-
✓ It is a long metallic instrument with sharp, teethed jaw at one end and on other
hand, handle and rachet lock is present.
✓ It is generally used in grasping or retracting tough tissues such as fascia.

▪ USES-
GYNECOLOGICAL USE
▪ To hold vaginal flaps –
 In vaginal hysterectomy
 Anterior colporrhaphy and
colpoperineorrhaphy
 During repair of VVF and
rectovaginal fistula.
OBSTETRICS USE
▪ In D&E to grasp the anterior
lip of cervix
▪ To hold anterior lip of cervix
during cerclage operation
▪ In caesarean section it is used
in various steps- in skin to
hold the skin margins, to hold
the peritoneal margins
▪ Four Allis tissue holding
forceps are used to hold cut
margins and two angles of
uterine wound.

It can be used as an alternative of Green-Armytage forceps and Vulsellum in few

procedures.

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 MULTIPLE TEETH VULSELLUM
▪ DESCRIPTION:
✓ This is a long instrument with gentle curved blades and tips of the blades
have three to four rat teeth.
✓ The gentle curve prevents the obstruction of vision when introduced in
vagina. It can be straight also.
✓ There is gap between two blades
✓ During insertion of the instrument the concavity should face upwards→no
obstruction of vision.
▪ USES:
GYNECOLOGICAL USES OBSTETRICS USES
▪ To hold anterior lip of cervix ▪ Rarely used in D&E operation,
during:- nowadays replaced by the
 Endometrial biopsy Allis tissue forceps as it is
 IUCD insertion lighter than vulsellum,
 IUI ▪ In pregnant cervix it should
 Vaginal hysterectomy not be used ideally.
 Cervical biopsy
▪ To hold posterior lip of cervix
during:-
 Posterior colpotomy
 Vaginal ligation
 To take biopsy from
anterior lip
 Vaginal hysterectomy,
Fothergill’s operation
before incision over
posterior fornix.

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 SINGLE TOOTH VULSELLUM
▪ DESCRIPTION:-
✓ It is a long instrument with tip of blade having single tooth. It has rachet
lock system on the handle.
✓ It can penetrate very deep and thus not used in obstetrics as it can cause
lacerations and cervical tears.
✓ It can be curved as well as straight.

▪ USES:-
✓ It is not used in obstetrics and this instrument will be on Gynecology table
only.
✓ It is used to-
 Catch nulliparous cervix
 To hold cervical stump after amputation of cervix
 To hold myoma during myomectomy
 During abdominal hysterectomy, after opening the vault of vagina,
cervical lip is held to cut the rest of the vault.
 It can also be used in alternative to multiple teeth vulsellum in non-
pregnant women.

SINGLE TOOTH VULSELLUM/TENTACULUM

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 DAS’S OR HEGAR’S DILATOR
▪ DESCRIPTION :-
✓ It is a double-ended dilators
✓ One side having lesser diameter and other side having 1mm more than the
other side- that is, if one side is having a diameter of 1mm the other side will
have 2mm.
✓ Das’s dilator series starts from 1/2mm and the largest size of 23/24mm;
therefore it is a series of 12 dilators having diameters from 1mm to 24mm.
✓ But nowadays only up to 15/16mm dilators are used.
✓ So nowadays a series of 8 dilators commonly found.
✓ Das’s dilators are generally longer than Hegar’s dilators.
✓ Das’s dilator has its name from its inventor Kedar nath Das.
✓ Uterine sound is used priorly to measure the length of the uterus before
inserting dilators; otherwise there is chance of perforation.
✓ The purpose of use of dilators is fulfilled when its maximum diameter
crosses internal os→(how to understand that the highest diameter has
crossed the internal os or not? →following resistance while inserting the
dilator there will be sudden loss of resistance during introduction and the
internal os grips the dilator, so it will not fall down if left without any
support.
▪ USES :-
GYNECOLOGICAL USES OBSTETRICS USES
▪ Used for dilatation of cervix in- ▪ For rapid dilatation of cervix
 Endometrial curettage during S&E procedure and in
 Hysteroscopy molar pregnancy
 Amputation of cervix and ▪ Diagnosis of cervical
cervical cone biopsy incompetence
 Cervical stenosis
 Primary dysmenorrhea

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 HAWKIN-AMBLER’S DILATOR
▪ DESCRIPTION-
✓ It is a single-ended dilators
✓ Lowest size is 3/6mm and maximum size is 18/21mm
✓ In 3/6mm 3 denotes diameter at the tip and 6 denotes diameter at the
widest part behind the tip in mm.
✓ Uses are same as Das’s dilators.

▪ WHAT IF DILATATION IS DIFFICULT?

✓ Start with very small dilator and good anesthesia
✓ Preoperative administration of misoprostol 200mg orally or vaginally before
4hours → makes the cervix soft and procedure easier.

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 OBSTETRIC FORCEPS
▪ WHAT IS THE NAME OF THE INSTRUMENT?
▪ It is a – long curved/ short curved / long straight obstetric forceps.

▪ WHAT IS THE PURPOSE OF THE INSTRUMENT?

▪ The purpose of the instrument is to perform vaginal extraction of fetal head
and thereby helping the delivery of fetus.
▪ It can be used through abdominal route in C- section.
▪ WHAT IS DAS’S FORCEPS?
▪ Sir Kedarnath Das from Calcutta developed an obstetric forceps suitable for
Indian babies.

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 ▪ WHAT ARE THE DIFFERENT TYPES OF OBSTETRIC FORCEPS PRESENTLY USED?
▪ Long curved forceps- Das’s forceps, Simpson’s forceps(fenestrated blades);
Luikart forceps(pseudo fenestrated blade); Tucker-McLane forceps(solid
blade).
▪ Short curved forceps- Wrigley’s forceps
▪ Straight long obstetric forceps- Kielland’s forceps
▪ DESCRIBE THE DIFFERENT PARTS OF A LONG CURVED OBSTETRICS FORCEPS?
▪ BLADE
▪ SHANK
▪ LOCK
▪ HANDLE
▪ FIXATION SCREW

▪ WHAT IS CEPHALIC CURVE?

▪ It is a curve on the flat surface which fits with fetal head during application
▪ The radius of the curvature is 11.25 cm
▪ Distance between two tip is 2.5cm
▪ The widest gap in between two articulated blade in maximum curvature area
is 9cm
▪ Gap between two tips is to avoid the grasping of neck and excessive
compression of fetal head.
▪ The widest gap is to fit the biparietal diameter of the fetal head without
undue compression.
▪ WHAT IS PELVIC CURVE?
▪ It is the curve on the edge of the blade.

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 ▪ It fits to the curve of the sacrum
▪ In pelvic application the pelvic curve concave anteriorly and convex
posteriorly
▪ Presence of convexity is due to fitting with the concavity of the sacrum.
▪ The radius of pelvic curve is 17.5cm.

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 ▪ DESCRIBE DIFFERENT PARTS OF SHORT CURVED OBSTETRIC FORCEPS?
▪ Shank Is very small
▪ Handle is small
▪ Cephalic curve is marked
▪ Pelvic curve is slight
▪ Instrument is lighter
▪ No provision of axis traction
▪ Fixation screw is absent.

❖ WHAT ARE THE DIFFERENT FUNCTIONS OF OBSTETRIC FORCEPS?

▪ TRACTION- While delivering , forceps can exert traction of fetal head. Traction of 18
kg is required in primigravida and 13kg in multigravida.
▪ PROTECTION- If properly applied , it acts as protective cage specially in premature
babies.
▪ COMPRESSION- The compression provides good grip of fetal head without any
harmful effect.
▪ ROTATION- Rotation can be done also with the help of Kjelland’s forceps.
❖ WHAT ARE THE INDICATIONS OF FORCEPS DELIVERY?
FETAL CAUSES Fetal compromise-
• Thick meconium stained liquor
• Pathological CTG- abnormal FHR
• Cord prolapse
• Scalp blood abnormal pH
MATERNAL CAUSES • Prolonged second stage of labor
• Maternal exhaustion
• Inadequate expulsive force
• Pre-eclampsia
• Eclampsia
• Post-caesarean section pregnancy
• Cerebrovascular disease

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 COMBINED CAUSES • When both maternal and fetal conditions co-exist.

❖ HOW TO DETERMINE SIDE OF THE FORCEPS?

▪ When two blades are given together-
 Blades are articulated in front of maternal pelvis
 Cephalic curve of two blades should face each other, and convex pelvic
curve forwards and the tips of the blade pointed upwards.
 The blade corresponding to the left half of maternal pelvis is the left
blade and other one is right blade.
▪ When only one blade is given-
 Tip of the blade directed upwards
 Convex side of pelvic curve is pointed forwards
 And cephalic concave curve is inwards.
 Now see which side of maternal pelvis it is corresponding
❖ HOW TO INTRODUCE THE INSTRUMENT IN MATERNAL PELVIS?
▪ How left blade is inserted-
 Left blade is held vertically in front of introitus by left hand in oblique pen
holding fashion, keeping it almost parallel to right inguinal ligament;
 Four finger of the right hand are introduced in between the fetal head
and left pelvic wall, keeping the thumb outside;
 With movement of the left hand , left blade is introduced in between
fetal head and four fingers of the right hand;
 The thumb of the right hand is placed over the convex curve of pelvic
curvature of the blade and the blade is pushed by thumb with a passive
movement of the left hand;
 Blade goes easily without any resistance in correct application
 The left blade is kept in that position without any assistance.
 In the same way, right blade is inserted using right hand and fingers of
left hand;
 Usually in correct application, locking can be accomplished very easily→If
any difficulty arise, handles are depressed in the perineum and locking
becomes easier;
 In correct application, the long axis of the blades corresponds to the
occipitomental diameter of 12.5cm which extends from chin to most
prominent portion of the occiput;
 Intermittent and steady pull given synchronously with uterine
contraction and along the long axis of birth canal;
 In lower forceps delivery, pull is first given downwards and backwards to
bring the head to the perineum→then pull is given horizontally forwards
the operator till head is towards crowned→pull is then given upwards

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 and forwards towards the mother’s abdomen and thus head is delivered
by extension.
 The traction is slow, deliberate and gentle to prevent any undue
decompression.
 Blades are removed→right followed by left one
 Injection 10 IU i/m oxytocin after delivery of the baby.
 Following removal of placenta, cervix and vaginal walls are thoroughly
inspected for presence of any tear or lacerations
 Episiotomy is repaired.
 All these procedures are done under either pudendal block or GA or
regional analgesia.
❖ COMPLICATIONS OF FORCEPS DELIVERY:-
MATERNAL COMPLICATIONS FETAL COMPLICATIONS
• Laceration of vagina and • Facial paralysis d/t compression
perineum of 7th CN
• Cervical tear- repaired with • Cephalohematoma, bruises and
interrupted catgut stitches abrasion of skin
• Femoral and lumbosacral nerve • Fracture of skull
injury • Asphyxia d/t prolonged
• Hemorrhage compression of fetal head
• Shock • Intracranial injury
• Sepsis • Soft tissue injury
• Dyspareunia • Jaundice d/t hemorrhages
• Anesthetic complications • Cerebral palsy rarely
• Cervical spine injury

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 UTERINE SOUND
❖ DESCRIPTION-
✓ It is olive pointed, metallic, graduated, malleable uterine sound.
✓ Graduation is due to measuring the length of the uterus.
✓ It is malleable to adjust the position of uterus.
✓ Olive pointed to prevent perforation of the uterus.
✓ Originally used for sounding of bladder stone.
❖ USES-
GYNECOLOGICAL USES OBSTETRICS USES
▪ To measure uterocervical ▪ Measure the length of
length during- uterine cavity in D&E
 Endometrial operation,
sampling ▪ Acts as first dilator
 Manchester repair ▪ To detect any foreign
 To probe for any body in uterine cavity
pathology inside
uterine cavity
▪ To detect the position of
uterus- anteverted,
retroverted or
midposition
▪ Acts as first dilators
▪ To diagnose cervical
stenosis
▪ To break adhesions in
Asherman syndrome.

➢ Normal length of uterocervical length-

• Uterocervical length- 6.5cm
• Length of cervix-2.5 cm
• Length of uterus cavity- 4cm
• Length of fundus- 1 cm
• Total length of uterus including fundus- 7cm
• Breadth- 5 cm
• Anteroposterior -2.5 cm
• At childhood cervix: corpus=2:1
• At puberty and thereafter, cervix: corpus= 1:2
➢ Conditions where length of uterus increases-
• Pregnancy
• Hematometra, pyometra

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 • Fibroid uterus
• Adenomyosis
• Endometrial cancer
• Uterine prolapse
• Congenital elongation of cervix
➢ Conditions where length of uterus decreases-
• Hypoplastic uterus- in Turner syndrome
• After menopause
• Submucosal polyp
• Uterine inversion
➢ Normal position of uterus-
• It is anteverted and anteflexed
• Anteversion- angle between axis of body of uterus and axis of vagina-
normal angle is 90 degree
• Anteflexion is angle between the axis of body of uterus and cervix-
normal angle is 140 degree.
➢ It is a long angulated instrument about 30 cm long with a blunt tip,
➢ At 7 cm from the tip is bent at and angle of 30 degree, which help to
negotiate the curvature of uterus.

UTERINE SOUND

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 VENTOUSE(VACUUM EXTRACTOR)
❖ DESCRIPTION:-
✓ It is a suction-traction instrumental device to deliver the fetal head by creating a
negative pressure between the instrument and scalp of the fetus in labor.
❖ PRINCIPAL USE:-
✓ A suction cup is placed and fixed over the fetal scalp→Resulting in artificial caput
by creating vacuum in between scalp and suction cup which through connecting
tubes, is attached with a glass bottle where negative pressure is created by
pump→Then giving traction→The fetal head is delivered.
❖ PARTS OF VENTOUSE-

✓ Suction cup-
• May be metallic or silicone rubber or plastic materials,
• Cup may be soft bell cup or rigid mushroom cup,
• Can be of different sizes- 40mm, 50mm, 60mm and depth of each cup 20mm
• Inside the cup there is a metallic plate which is fitted with traction chain and the
cup is also fitted with a rubber tube inside which the chain is passed
✓ Metallic traction bar/Handle-
• Fitted with suction cup by the chain
• Traction is given by holding this handle in between the fingers.
✓ Connecting rubber tubes-
• There is three rubber tubes-
 One connecting suction cup with handle
 One connecting handle to the vacuum bottle
 And last one connecting vacuum bottle and the pump
✓ Vacuum glass bottle-
• It is fitted with an airtight rubber cork
• There are three openings, two for connective tubes and the other is manometer
• With the help of hand pump or electric pump, vacuum is created inside the glass
bottle to create negative pressure in between suction cup and scalp

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 • The manometer(vacuum gauze)records the pressure inside the glass bottle and
is graduated either in kg/cm2 ranging from 0.1kg/cm2 to 0.8kg/cm2 or in mm of
mercury ranging from 0 to 760mm of mercury.
❖ INDICATIONS AND CONTRAINDICATIONS-
INDICATIONS CONTRAINDICATIONS
➢ Delay in the first stage of labor d/t ➢ Face presentation
uterine inertia not corrected by ➢ Premature baby
oxytocin. ➢ In acute fetal distress
➢ In case of incomplete rotation like ➢ Suspected fetal coagulation
in occipito-posterior and occipito- disorder
transverse position
➢ Second baby of twins , vertex
presentation – where there is
delay in descent and head is in
high up position
❖ COMPARISON WITH FORCEPS DELIVERY-
ADVANTAGES OF VENTOUSE ADVANTAGES OF FORCEPS DELIVERY
➢ It can be applied even before full ➢ Chance of mechanical failure is
dilatation of cervix i.e. in late first less in comparison to ventouse
stage of labor it can be applied where failure occurs commonly
➢ It can be used even when there is due to lack of proper airtightness
no full rotation of fetal head ➢ Delivery of preterm baby is safer
➢ Chances of maternal and fetal as forceps acts as a protective
injury is less in contrast to forceps cage for fetal head
➢ The requirement of traction force ➢ Forceps can be applied in non-
(10kg) is needed less vertex presentations
➢ Chance of cephalhematoma is less
than the ventouse

❖ COMPLICATIONS OF VENTOUSE-
FETAL MATERNAL
➢ Cephalhematoma ➢ Less common and occurs only if
➢ Abrasion and sloughing of the the tissues are entrapped in
scalp between suction cup and scalp
➢ Subaponeurotic hemorrhage
➢ Intracranial hemorrhage

❖ PREREQUISITE OF VENTOUSE APPLICATION-

✓ Patient should be at least in late first stage of labor- more than 6 cm of cervical
dilatation
✓ No pelvic contraction should be present
✓ Head should be in low down in single pregnancy
✓

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 ❖ WHAT IS ODON-
✓ It is a new device designed for instrumental vaginal delivery in which function of
both forceps and ventouse are present.

UTERINE CURETTE
❖ DESCRIPTION-
✓ May be blunt curette or sharp curette
✓ The curette may be single ended or double ended
✓ One curette may be both blunt and sharp types
✓ Flushing curette- It is a special type of blunt curette where there is facility of
flushing of uterine cavity with antiseptic solution
✓ Sharman’s curette- It is used for taking biopsy from uterine cavity. It is used only
for gynecological purpose and can be done as office procedure.
❖ USES-
✓ Sharp curette is commonly used in gynecology for curetting endometrial cavity
✓ Blunt curette for D and E

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 ✓ Flushing curette- it is blunt curette used in dilatation evacuation and especially
in old incomplete abortion. Placental polyp can be curetted with the help of it.

KARMAN’S SUCTION CANUNULA

❖ DESCRIPTION-
✓ Karman’s cannula is a long tubular structure made of plastic or metal
✓ Depending on the constituent, the cannula can be rigid or flexible
✓ A plastic cannula is preferred as it is less traumatic , transparent and disposable.
✓ It is available in sizes varying from 4 to 12 mm diameter.
The approximate size to be used corresponds to the weeks of pregnancy to be
terminated. For example 10mm cannula is used for a 10 week pregnant uterus

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 ✓ The distal end of cannula is fixed to the suction tubing or apparatus. The
proximal end , which is introduced into the uterine cavity , has two sides
openings to collect the contents
✓ It is sterilized by keeping it in savlon solution for 12 hours.
❖ USES-
✓ Used for suction evacuation during surgical abortion
✓ Used for suction evacuation of molar pregnancy
➢ INDICATION OF SUCTION EVACUATION-
✓ Inevitable abortions
✓ Incomplete abortion(recent)
✓ Missed abortions
✓ H. mole
✓ For medical termination of pregnancy
➢ ADVANTAGES OF SUCTION EVACUATION-
✓ More simple and safe
✓ can be done as OPD procedure and time required is less
✓ Blood loss is less(20-25cc)
✓ Chances of injury are less
✓ Chance of perforation is less
✓ Milder form of anesthesia is sufficient to perform S & E
✓ Complications are less
➢ WHAT WILL YOU DO IF SUCTION CANNULA IS BROKEN AND PART OF IT RETAINED
INSIDE UTERUS?
✓ Dilatation of cervical canal is done with a large- sized dilator and the broken
part is removed with the help of an ovum holding forceps
➢ WHAT IS THE IMPORTANCE OF DOING BLOOD GROUPING OF THE PATIENT
UNDERGOING D & E AND S & E OPERATIONS?
✓ If woman is Rh-negative , 100 mcg anti-D-gamma globulin is to be
administered to prevent maternal antibody formation

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 MYOMA SCREW
❖ DESCRIPTION-
✓ The instrument has a spiral corkscrew with a pointed tip and a ring-shaped
handle for gripping.
❖ USES-
✓ During myomectomy
✓ During hysterectomy to fix the uterine fundus.

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 EPISIOTOMY SCISSOR
❖ DESCRIPTION-
✓ This scissors has angulated blades and one of the blades has a blunt tip
❖ USES-
✓ Episiotomy
✓ Cutting of umbilical cord
➢ BLADE INTRODUCED INSIDE VAGINA- blade with blunt end-to prevent any injury to
fetal parts
➢ ADVANTAGE OF ANGULATION- for mechanical advantage and better visualization.
➢ IT IS THE COMMONEST OPERATION PERFORMED IN OBSTETRICS.
➢ INDICATIONS OF EPISIOTOMY-
• In almost all cases of primigravida
• Multigravida with rigid perineum
• Abnormal presentation and positions like occipitoposterior , face and breech
• Instrument delivery-forceps operation
• To cut short the second stage of labor in some maternal condition like heart
disease and eclampsia
• Some fetal condition like prematurity
➢ MATERNAL BENEFITS OF EPISIOTOMY-
• Avoid perineal laceration , complete perineal tear
• Planned incision- easy to repair and heals well
• 2nd stage of labor can be shortened
• Prevent genital prolapse and urinary incontinence d/t minimal tear to pelvic
floor
➢ FETAL BENEFITS-
• Minimize trauma to fetal head
• Easy delivery of aftercoming head of breech
➢ TYPES OF EPISIOTOMY-
• MEDIOLATERAL- incision starts from the midpoint of fourchette and directed
backwards and outwards in a straight line up to the midpoint of anus and
ischial tuberosity
• MEDIAN- starts from midpoint of fourchette and extends posteriorly for about
2.5cm in the midline
• LATERAL- starts from midpoint of fourchette and directed laterally more
lateral to mediolateral .
• J SHAPED- starts from midpoint of fourchette and extended in a curved
fashion in downward and outward direction.
➢ STRUCTURES CUT IN EPISIOTOMY-
• Vaginal mucosa
• Superficial and deep transverse perineal muscles, bulbospongiosus and few
fibers of levator anii with its fascia

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 • Blood vessels- anterior branches of internal pudendal vessels
• Branches of pudendal nerves
• Subcutaneous tissue and perineal skin
➢ STRUCTURES CUT IN MEDIAN EPISIOTOMY-
• Vaginal mucosa
• Few fibers of perineal muscles
• Subcutaneous tissue
➢ STRUCTURES CUT IN LATERAL EPISIOTOMY-
• More muscle bulk are cut
• Labial branch of external pudendal artery is injured
• More fatty tissue are damaged
➢ WHEN TO PERFORM AN EPISIOTOMY-
• When the head does not recede in between contractions
• Perineum becomes bulged , thin and threatens to be ruptured
• Just before crowning
➢ STEPS OF MEDIOLATERAL EPISIOTOMY-
• Position- supine, thighs flexed and knees flexed, patient is on labor table
• Antiseptic swabbing and draping
• Bladder catheterization
• Per vaginal examination
• Anesthesia- perineal infiltration with 10ml 1% xylocaine pudendal block with
perineal infiltration
• Two fingers or left hand are placed between the presenting part and the
posterior vaginal wall , and the perineum is cut with the scissor(blunt blade
inside vagina) starting from midpoint of fourchette and extending downward
and backward on right or left side
• The fetus and afterbirth are delivered
• A sanitary pad is pressed in the episiotomy wound to prevent bleeding
• If there is any spurting vessel , i.t should be caught with an artery forceps
• The repair of episiotomy wounds are done immediately after placental
delivery.
➢ REPAIR OF EPISIOTOMY-
• Lithotomy position
• Good light source
• Catheterization
• Cleaning of the wound with antiseptic solution
• Local infiltration of xylocaine (already given)
• Repaired in three layers- first vaginal mucosa then perineal muscles and lastly
perineal skin(usually 1-0 chromic catgut stitches are given).

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 ➢ COMPLICATIONS-
IMMEDIATE DELAYED
 Wound extension  Painful scar
 Complete perineal tear  Dyspareunia
 Severe hemorrhage  Bartholin cyst
 Vulval hematoma  Scar endometriosis
 Retention of urine
 Infection
 Excessive pain
➢ MANAGEMENT OF COMPLETE PERINEAL TEAR-
• Repair of vaginal mucosa
• Repair of rectal mucosa
• Apposition of anal sphincter
• Repair of perineal muscle
• Repair of perineal skin
➢ MANAGEMENT OF VULVAL HEMATOMA-
• Resuscitation with I.V. fluids and antibiotics
• Blood grouping, cross matching, blood requisition and blood
transfusion if needed
• Immediate drainage of hematoma in OT setup under GA
• After incision all blood clots are removed and bleeding points are
secured
• Repair with deep mattress stitches obliterating the cavity
• A suction drain rubber drain is kept for 24 hours
• Vagina may be need to be packed
➢ PUDENDAL BLOCK ANAESTHESIA-
• TRANSVAGINAL ROUTE- one 15cm 18-20 gauge spinal needle is fitted with
20ml syringe containing 1% xylocaine is introduced under the guidance of left
index and middle finger at the site of ischial spine through vagina. The needle
is reached above the tip of ischial spine. After assuring that it has not pierced
any blood vessels 10ml is injected at the site. In the same manner another 10
ml is injected in the opposite side. This is commonly used method.
• TRANSPERINEAL ROUTE- following local nitration of 1% lignocaine at the point
midway between anal canal and ischial tuberosity.

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 AYRE’S WOODEN SPATULA
❖ DESCRIPTION-
✓ It is a wooden spatula, 15-20cm in length ; one end has a smooth bifurcated edge
that fits into the ectocervix and the other end is broad
✓ It is made up of wood so that the cells can adhere to its porous surface.

❖ USES-
✓ To take pap smear
✓ To take surface biopsy in carcinoma cervix
✓ To collect vaginal secretions from lateral fornix for hormonal cytology
✓ To take buccal smear
➢ HOW IS A PAP SMEAR TAKEN?
• The long bifurcated end of ayre’s spatula is introduced into cervical canal and
rotated 360 degree.
• The exfoliated cells are smeared on a glass slide and the slide is placed in
Koplin jar containing the fixative(ether and alcohol in equal amount)
• The broad end is used for taking buccal smear, and smear from lateral vaginal
wall for hormonal cytology.

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 CERVICAL PUNCH BIOPSY FORCEPS
❖ DESCRIPTION-
✓ This instrument has a smaller blade with sharp cutting edge that fits into a larger
blade and can punch out the tissues when approximated.

❖ USES-
✓ To take punch biopsy from cervix or any growth
➢ HOW BLEEDING CAN BE CONTROLLED FOLLOWING BIOPSY?
• Bleeding following biopsy procedure can be controlled by applying local
pressure or by applying chemical cautery agent such as ferric subsulfate
solution (Monsel’s solution)

DOYEN’S RETRACTOR
❖ DESCRIPTION-
✓ Doyen’s retractor is a non-self-retaining, heavy abdominal retractor having a
large curved blade with an inward-turning margin.
✓ It is used to retract the abdominal wall and bladder during abdominal surgeries.
❖ USES-
OBSTETRICS GYNECOLOGY
• Cesarean section • Abdominal hysterectomy
• Cesarean hysterectomy • Myomectomy
• Laparotomy for ruptured • Exploratory laparotomy
ectopic pregnancy • Sling surgeries

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 DEAVER’S RETRACTOR
❖ DESCRIPTION-
✓ Deaver’s retractor is a non-self-retaining, abdominal retractor having a large
curved blade.
✓ It is available in different sizes
✓ It is used to retract the abdominal walls and bladder during abdominal surgeries.
❖ USES-
OBSTETRICS GYNECOLOGY
• Cesarean section • Abdominal hysterectomy
• Cesarean hysterectomy • Myomectomy
• Laparotomy for ruptured • Exploratory laparotomy
ectopic pregnancy • Sling surgeries

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 UTERINE DRESSINGS FORCEPS
❖ DESCRIPTION-
✓ It has long blades which are curved and transversely serrated
❖ USES-
✓ It is used to dress the endometrial cavity following surgical evacuation
✓ To dilate the cervix to drain pyometra or lochiometra in puerperium
✓ Pelvic abscess can be drained through posterior colpotomy approach
✓ It can be also be used for introduction of laminaria tent

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