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Topics: Childbirth, Obstetrics, Caesarean section Pages: 8 (2483 words) Published: August 1, 2013
OPERATIVE DELIVERY

Komal Imtiaz
Roll No. 22
Gynecology

An operative delivery is performed if a spontaneous birth is judged to pose a greater risk to mother or child than an assisted one. Operations are divided into abdominal methods (caesarean section) and vaginal assisted deliveries (forceps delivery and vacuum extraction). Preparations for operative delivery:

* Discuss operative delivery with the woman and her partner (if time is short, at least outline what will happen) * Follow the woman’s wishes—no operative delivery can proceed without her consent even if the doctors think that the baby will die if it is not done * Get written consent for elective procedures

* A paediatrician should attend any delivery where problems are anticipated; local guidelines should be drawn up and followed for all operative deliveries Indications for caesarean section
* Cephalo-pelvic disproportion—When it is obvious either antenatally or in the early stages of labour that the fetus, presenting by the head, is not going to pass through the pelvis * Relative cephalopelvic disproportion—The fetus descends initially during labour but is then arrested, possibly due to a malposition such as occipito-posterior * Placenta praevia—Particularly if it is overlapping the internal os * Fetal distress—In the first stage of labour

* Prolapsed cord
* To avoid fetal hypoxia—When there is poor perfusion of the placental bed (for example, pre-eclampsia) * Malpositions—For example, brow
* Malpresentations—For example, transverse lie, breech
* Bad obstetric history
* Maternal request
Caesarean section
Use
The frequency of this operation in Britain has increased from about 5% in 1930 to about 16% now. In a survey of 327 obstetricians by Savage et al in Great Britain in the early 1990s, the main reason reported for this rise (cited by 48% of respondents) was litigation (defensive medicine). In the United States, where the rate for caesarean sections is even higher, close scrutiny by peers and consumer groups has been associated with a reduction; the same may happen in Britain. Even in Britain, the rates vary widely between units. Indications

The only absolute indications for caesarean section are
* cephalopelvic disproportion and
* major degrees of placenta praevia.
* The rest demand a judgment by the obstetrician that the risk of vaginal delivery exceeds the risk of the operation or that the mother’s perception is that it does. Caesarean sections are often carried out for debatable indications—for example, * breech presentation after 34 weeks. The safety of vaginal birth in these situations often depends on the skill of the birth attendants. The use of repeat caesarean section depends on the indication for the first caesarean section. If the indication was recurrent—such as a small pelvis—this demands a repeat caesarean section. If however, the indication was not necessarily recurrent—such as fetal distress—vaginal delivery can be tried. In Britain about two thirds of women who have had a caesarean section try a vaginal delivery in their next pregnancy, and in about two thirds of these a vaginal delivery is successful. Procedure

The usual approach is through a transverse lower abdominal incision (Pfannenstiel’s incision). Having opened the abdomen carefully, the obstetrician exposes the lower segment of the uterus. The visceral peritoneum is incised and the bladder pushed down, having previously been drained with an indwelling catheter. The uterus is opened slowly with a transverse incision, and when the bulge of membranes appears, this is pricked and the amniotic sac is opened fully with a finger from each side. The baby is delivered; if presentation is by the head, sometimes a pair of short obstetric forceps is helpful. With a breech presentation, the legs are brought down and a modified breech extraction is performed. If the lie is transverse, the obstetrician...
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