Operative obstetrics

Madira Emmanuel
Lira university
Outline:
• Introduction
• Episiotomy, perineal tears and cervical laceration
Introduction
• Operative obstetrics- surgical procedures that help to deliver the fetus/products of
conception
Scope:
1. Episiotomy; Vacuum extraction; Forceps
2. Caesarean section; Destructive operations
3. Caesarean Hysterectomy; Hysterotomy
4. Subtotal abdominal hysterectomy
5. Management of PPH e.g. b-lynch, uterine artery ligation
6. Cervical /perineal tears
7. Uterine inversion
8. Abdominal pregnancy
9. Cervical cerclage
10. Amniotomy and amniocentesis
Episiotomy ,Perineal and
Cervical Tears.
Anatomy
Episiotomy
• Surgical enlargement of the vaginal orifice by an incision of the
perineum during the last part of the second stage.
• Most common operations performed on women.
• Rates vary widely from 1 percent (sweden) to 80 percent (argentina).
• ”Restrictive episiotomy policies appear to have a number of benefits
compared to routine episiotomy policies”.
• Timing- if done early-excessive blood loss, if done late- it fails to
protect the pelvic floor.
INDICATIONS:
• Episiotomy is recommended in selective cases rather than as a routine.
A constant care during the second stage reduces the incidence of
episiotomy and perineal trauma.
• Inelastic (rigid) perineum: Causing arrest or delay in descent of the
presenting part as in elderly primigravidae.
• Anticipating perineal tear: (a) Big baby (b) Face to pubis delivery (c)
Breech delivery (d) Shoulder dystocia.
• Operative delivery: Forceps delivery, vacuum extraction.
• Previous perineal surgery: Pelvic floor repair, perineal reconstructive
surgery.
Rationale For Episiotomy 
• Reduction in third and fourth degree tears
• Ease of repair and improved wound healing
• Preservation of the muscular and fascial support of the pelvic floor
• Reduction in neonatal trauma, such as with the premature infant (soft
cranium) or macrosomic infant (shoulder dystocia)
• Reduction in dystocia by increasing the diameter of the soft tissue
outlet
• Expedited delivery of fetuses with nonreassuring fetal heart rate
tracings
Other Indications (non-obstetrics)
• VVF Repair
• Colporaphy
Adverse Effects
• Extension of the incision, leading to third and fourth degree tears
• Unsatisfactory anatomic results (eg, skin tags, asymmetry, fistula,
narrowing of introitus)
• Increased blood loss
• Increased postpartum pain
• Infection and dehiscence
• Sexual dysfunction
• Increased risk of perineal laceration in subsequent deliveries
Technique
• Analgesia
• Timing
• Type
1. Median
2. Mediolateral
3. J Incisions
4. Inverted T
Technique
Perineal Tears/Lacerations
Class Extent of injury
First degree injury to perineal skin or vaginal mucosa only
Second degree injury to perineum involving perineal muscles but not the
anal sphincter

Third degree injury to the perineum involving the anal sphincter

complex

3a: less than 50% of EAS thickness torn

3b: more than 50% of EAS thickness torn.
3c: Both EAS and IAS torn
Fourth degree injury to perineum involving the anal sphincter complex
(EAS and IAS) and anal epithelium.

Obstetric anal sphincter injury (OAS) encompasses third and fourth degree
perineal tears.
Cervical injuries:
• Bleeding which does not appear to be arising from the vagina or
perineum and which continues despite a well contracted uterus, is an
indication for examining the cervix to exclude cervical injury.
• Minor cervical lacerations common but do not cause symptoms.
• Deep lacerations cause excessive bleeding and need to be managed in
theatre under anesthesia.
Causes of Cervical Lacerations
• Precipitate labor.
• Application of forceps with the cervix incompletely dilated.
• Rapid delivery of the head in breech presentation.
• A scar in the cervix may also tear
Management of Cervical Tears
• Prompt recognition is essential.
• Good light is essential so EUA is done
in theatre.
• Two pairs of sponge forceps are used
to inspect the whole circumference
accurately.
• Identification of the apex of the tear is
essential before commencing repair.
• Interrupted sutures can be inserted
through the whole thickness of its
wall.
Risk factors for tears
Nulliparity
Birth weight > 4kg
prolonged second
stage Shoulder dystocia
Instrumental
delivery Midline episiotomy
Occipitoposterior induction of labour
position at delivery
Epidural analgesia
Note: The overall risk of AS injury is 1% of all vaginal
deliveries.
Repair of episiotomy and lacerations
• Preoperative Preparation 
• Adequate light and analgesia, to determine the extent
of injury and severity of bleeding.
• Make sure uterus is properly contracted.
• Give analgesia
• Choice of suture is based on extent of repair.
• Absorbable 3/0 on tappered small needle for rectal
mucosa.
• Larger sutures for muscle and other soft tissue.
• Start 1 cm above apex to ensure that retracted vessels are ligated.
• Running or locking fashion is used though rectal submucosa.
• Identify anal sphincter.
• Hold edges with Allis forceps.
• Repair with several interrupted sutures.
• Repair rectal fascial layer to close dead space.
• Place a 3/0 suture 1cm above the apex of the vagina then run it to the
hymenal ring.
• At the ring approximate the edges carefully then extend to the
squamomucosal junction.
• Asses perineal body and place interrupted sutures to avoid dead
space in defect.
• close skin sub cutenously
• Closure of rectal mucosa
• Repair of anal sphincter
• Repair of rectal fascia
• Second layer closure of rectal
mucosa with recto vaginalfacsia
• Place anchor stitch
above apex
• Perineal body repair
• Subcuticular skin closure
Complications of episiotomy
• Immediate: (1) Extension of the incision to involve the rectum. This is likely in median
episiotomy or during delivery of undiagnosed occipitoposterior even with small
mediolateral episiotomy
• (2) Vulval hematoma
• (3)Infection—The clinical features are—(a) Throbbing pain on the perineum (b) Rise
in temperature (c) The wound area looks moist, red and swollen
• (4) Wound dehiscence is often due to infection, hematoma formation or faulty repair.
• (5) Injury to anal sphincter causing incontinence of flatus or feces. (6) Rectovaginal
fistula. (7) Necrotizing fasciitis i
• Remote : (1) Dyspareunia—This is due to a narrow vaginal introitus which may result
from faulty technique of repair or due to painful perineal scar (2) Chance of perineal
lacerations in subsequent deliveries (3) Scar endometriosis