Day 8 Review DME 12 - Midwives Revision

Day 8 - Obstetric Operations | Nurses Revision Uganda

DAY 8 📅 Nov 17 (Sun)

⚔️ Obstetric Operations

DME 121: Life-Saving Surgeries

Caesarean Section (Indications, types, preparation)
Forceps Delivery (Types, indications, technique)
Vacuum Extraction (Ventouse, cup placement, traction)
Symphysiotomy (Rare, for CPD in low-resource)
Destructive Operations (Craniotomy - last resort)

⚔️ REMEMBER: Forceps types = Outlet, Low, Mid, High. Vacuum = anterior cup placement, correct angle!

🚨 KEY POINT: CS decision = maternal/fetal benefit vs risk. Informed consent always!

"Operations save lives when labour fails. Know when to cut!"

"There is a time for everything." - Ecclesiastes 3:1

1. OVERVIEW OF OBSTETRIC OPERATIONS

📚 Definition:

Obstetric operations are surgical or instrumental interventions performed to safely deliver the baby and/or placenta when spontaneous vaginal delivery is impossible or unsafe.

Principle: First, do no harm! Balance maternal/fetal risks vs benefits.

🎯 The Obstetric Operations Ladder - "From Simple to Complex":

🪜 MNEMONIC: "START SIMPLE, ESCALATE SMART"
Supportive care (position changes, hydration)
Trial of assisted delivery (forceps/vacuum)
Augmentation with oxytocin (if indicated)
Rupture of membranes (AROM if needed)
Transfer to hospital if fails

Symphysiotomy (rare, for CPD)
Incision (Caesarean Section)
Manual manipulation
Perform destructive op (last resort)
Last resort: Craniotomy

Escalate when maternal/fetal distress
Save life over preservation of genital tract
Consult senior always
Assess conditions carefully
Limit trauma to mother & baby
Anticipate complications
Teamwork is essential
Evacuate to specialist if needed

2. CAESAREAN SECTION (CS)

📚 Definition:

Delivery of fetus through surgical incisions in the abdominal wall (laparotomy) and uterus (hysterotomy).

Incidence: 10-25% of deliveries globally, increasing in Uganda.

🔴 Categories of CS - The "When Decision is Made":

Elective (Planned): Scheduled before labor (e.g., placenta previa, breech)
Emergency: During labor for maternal/fetal distress
Crash (Stat): Immediate threat to life (e.g., uterine rupture, severe abruption)

🎯 Indications - The "MUST DO CS" List:

🚨 MNEMONIC: "CS SAVES BOTH LIVES"
Cephalopelvic disproportion (CPD)
Severe pre-eclampsia/eclampsia (uncontrolled)

Scarred uterus (previous classical CS)
Abruption placentae with fetal distress
Vasa previa
Emergency: cord prolapse with live fetus
Shoulder dystocia (failed)

Breech presentation (unscarred uterus, no ECV)
Obstructed labor (failed augmentation)
Twins: 1st breech, 2nd transverse
HIV with high viral load (>1000 copies)

Large baby (>4kg with CPD signs)
Infection (active genital herpes)
Very preterm with distress
Elderly primigravida with other risks
Severe cardiac disease

Malpresentation (face, brow, compound)
Oligohydramnios with non-reassuring FHR
Thick meconium with fetal distress
Hemorrhage: Placenta previa major
Elective: Previous myomectomy entering cavity
Repeat CS with 2 previous scars

⚠️ CRITICAL DECISION: Before 34 weeks consider corticosteroids before CS (if fetal lungs immature). After 39 weeks for elective CS (if no complications).

🎯 Contraindications - When NOT to Do CS:

Dead fetus with obstructed labor: Craniotomy may be safer
Severe maternal hemorrhage/shock: Stabilize first (if possible)
Active uterine infection: Risk of wound sepsis
Inadequate facilities: Must have blood, anesthesia, post-op care

💡 EXAM STRATEGY: Always mention "Informed consent obtained" and "Decision based on maternal-fetal benefit vs risk" - these are exam points!

3. TYPES OF CAESAREAN SECTION

🔪 Classification by Urgency:

Type	Decision to Delivery Time	Examples	Preparation
Elective	Scheduled (days/weeks)	Placenta previa, breech	Full workup, fasting, consent
Emergency	30-60 minutes	Failed progress, fetal distress	Rapid prep, abbreviated consent
Crash/Stat	<15 minutes	Uterine rupture, cord prolapse	Immediate, often awake

🔪 Classification by Incision Type:

Lower Vertical: Vertical incision on lower uterine segment
Classical CS: Vertical incision on upper uterine body (rare now)
Lower Transverse: Transverse incision in lower segment (special situations)

🎯 MNEMONIC: "LOWER IS BETTER"
Less blood loss (avoids thick upper segment)
Operates easily (bladder reflection)
Wound heals stronger (muscle layer)
Easier next delivery (trial of scar possible)
Risk of rupture lower (thin scar)

In future pregnancies: Trial of scar possible!
Safe for mother
Better outcomes
Endorsed by WHO
Transverse incision
Tried first always
Except in special cases (anterior placenta previa)
Recommended standard

🩺 Pre-Operative Preparation:

🚑 MNEMONIC: "PREPARE FOR CS"
Pre-op check: Consent, indication confirmed
Review: History, allergies, previous surgeries
Ensure: IV line (2 large bore if possible)
Pre-medicate: Antacids (prevent aspiration)
Anesthesia: Spinal vs General (assess first)
Run fluids: 500-1000ml crystalloid preload
Empty bladder: Catheterize (prevents injury)

Fasting: 6 hours food, 2 hours clear fluids
Oxygen ready: For anesthesia
Run blood: Group & crossmatch 2 units (if emergency)
Check baby: FHR before incision
Shave abdomen: If time permits (antiseptic prep)

💊 Antibiotic Prophylaxis:

First generation cephalosporin: Cefazolin 1-2g IV (30 min before incision)
Alternative: Ampicillin 2g IV if allergic to cephalosporins
Add: Metronidazole 500mg IV if prolonged labor or ruptured membranes >12 hours

⚠️ CRITICAL TIMING: Give antibiotic 30 minutes BEFORE incision (not after cord clamping) - reduces wound infection by 50%!

🩹 Post-Operative Care:

Monitor: BP, pulse, urine output (hourly for 4 hours)
Analgesia: Pethidine 50-100mg 4-6 hourly or Morphine PCA
Fluids: IV until conscious, then oral after 6 hours
Catheter: Remove after 12-24 hours
Feeding: Light diet after 6 hours (if no complications)
Ambulation: Encourage early walking (24 hours)
Iron: Continue for 3 months postpartum

💡 EXAM TIP: Post-op fever = think of "5 W's": Wind (atelectasis), Water (UTI), Wound, Walking (DVT), Wonder drugs (reaction)!

4. VAGINAL OPERATIVE DELIVERIES - OVERVIEW

🎯 Definition:

Assisted vaginal delivery using instruments to expedite delivery when maternal effort or fetal condition requires immediate birth.

Prerequisites:

Full dilation (10cm)
Vertex presentation (OA optimal)
Membranes ruptured
No CPD
Fetal head at +2 station or lower
Experienced operator

⚠️ CRITICAL RULE: NEVER attempt operative vaginal delivery if you're not trained and experienced! Risk of severe perineal trauma and neonatal injury is high!

🎯 MNEMONIC: "HEAD DOWN READY FOR OUTLET"
Head at +2 station or lower
Engagement confirmed
Adequate pelvis (no CPD)
Dilation complete (10cm)

Deflexed head? (NO - must be flexed!)
Operative vaginal delivery indicated
Willing operator (experienced)
No fetal distress requiring stat CS

Ready for immediate CS if fails
Empty bladder (catheterize)
Anesthesia adequate (epidural/pudendal)
Dy NOT attempt if uncertain/
Yield to CS if no descent with traction

5. FORCEPS DELIVERY

📚 Definition:

Delivery of fetus using metal instruments applied to fetal head to provide traction and rotation.

🔪 Classification by Station - The "OUTLET-MID-HIGH" System:

Type	Station	Rotation	Difficulty	Experience Needed
Outlet	Visible scalp without separating labia Skull at pelvic floor (+3 or more)	OA only No rotation needed	★☆☆☆☆	Junior midwife under supervision
Low	≥ +2 station Not on pelvic floor	OA or OT ≤45° rotation	★★★☆☆	Senior midwife/medical officer
Mid	0 to +2 station	OA, OP, OT Any rotation	★★★★★	Senior obstetrician
High	Above 0 station	Any position	⚠️DANGEROUS⚠️	NEVER PERFORM

🚨 CRITICAL EXAM POINT: HIGH forceps = ABANDONED! Never perform forceps above 0 station! Risk of uterine rupture and fetal death is unacceptably high!

🎯 Indications for Forceps - "When to Pull":

Fetal distress in 2nd stage: Need immediate delivery
Maternal exhaustion: Cannot push effectively
Medical conditions: Heart disease, severe hypertension (avoid Valsalva)
Prolonged 2nd stage: >2 hours primip, >1 hour multip (with no descent)
After-coming head of breech: Piper's forceps (specialized)

💡 Advantages of Forceps:

More precise control of head
Can rotate head (OA to OP)
Work in poor contractions (better traction)
Less maternal pushing needed

⚠️ Disadvantages of Forceps:

Higher maternal trauma (3rd/4th degree tears)
Fetal facial injuries (facial nerve palsy, bruising)
Requires more anesthesia
Steep learning curve

6. VACUUM EXTRACTION (VENTOUSE)

📚 Definition:

Delivery of fetus using suction cup applied to fetal scalp to provide traction during contractions.

🔧 Types of Vacuum Cups:

Anterior cup (Malstrom): Metal, for OA positions
Posterior cup: For OP/OT positions (rarely used)
Silastic cup: Soft, flexible, less scalp trauma
Kiwi cup: Hand-held, disposable, no traction needed

🎯 Indications - Similar to Forceps:

Fetal distress in 2nd stage
Maternal exhaustion
Medical conditions requiring short 2nd stage
Prolonged 2nd stage with adequate contractions

⚡ Contraindications - When NOT to Use Vacuum:

Face/head presentation: No firm grip point
Fetal bleeding disorders: Hemophilia, thrombocytopenia
Vertex too high: Below +2 station only!
Uncertain CPD: Must rule out CPD first
GA <34 weeks: Soft skull increases risk of intracranial hemorrhage

⚠️ MNEMONIC: "VACUUM CONTRAINDICATIONS"
Very preterm (<34 weeks)
Assumed CPD (fetal-pelvic disproportion)
Cephalic not engaged
Uncertain position (face, brow)
Uterine inertia severe (no contractions)
Moulding 2+ (contraindication)

Clotting disorder (fetal)
Occiput posterior (difficult cup placement)
No operator experience
Traction fails with 3 pulls
Rapid delivery needed (forceps faster)
Alive & well fetus only (not stillbirth)
Instrument not available/good condition
No anesthesia/pain relief
Descent not occurring with traction
Infection risk (e.g., HIV? debate)
Cervix not fully dilated
Absolutely must have backup for CS
Time is critical (crash delivery needed)
Inexperienced assistant
Oxytocin contraindicated with vacuum
No resuscitation equipment ready
Severe fetal distress (CS better)

🎯 Technique - The "Angle-Traction-Release" Method:

🎯 MNEMONIC: "CUP CHECKS TRACTION"
Cup placement: Over flexion point (3cm from posterior fontanelle)
Unsure no maternal tissue under cup rim
Pump pressure: 0.2 kg/cm² initially (check hold)

Check application: Tug test (should hold)
Head traction: Only during contractions & with maternal effort
Elevate pressure to 0.8 kg/cm² during traction
Combine with maternal pushing
Keep angle: <30° from perpendicular (prevent cup detachment)
Stop between contractions (check FHR)

Traction: 3-4 pulls maximum (if no descent = CS)
Remove cup: When head delivers
Assess: Scalp for chignon, lacerations
Clean: Baby's head, check for injuries
Trace: Document in partograph
Inform mother of baby's condition
Observe for cephalohematoma
Note Apgar score

💡 Advantages of Vacuum:

Less maternal perineal trauma (35% vs 70% with forceps)
No facial nerve injuries
Easier to learn
Can be performed with less anesthesia
Can be abandoned midway (no CS scar on uterus)
Kiwi cup allows single-operator use

⚠️ Disadvantages of Vacuum:

Cephalohematoma in newborn (10-15%)
Scalp lacerations
Failed extraction more common than forceps
Cannot rotate head (well)
Traction less powerful than forceps
Requires good contractions

💡 EXAM COMPARISON: Vacuum = maternal benefits (less trauma) but Forceps = fetal benefits (faster delivery). Know when to choose which!

🆚 Forceps vs Vacuum - Head-to-Head:

Feature	Forceps	Vacuum
Learning Curve	Steep, difficult	Easier, shorter
Maternal Trauma	Higher (3rd/4th degree tears)	Lower (mostly minor tears)
Fetal Injury	Facial palsy, bruising	Cephalohematoma, scalp lacerations
Rotation	Can rotate (OT to OA)	Limited rotation
Anesthesia	Requires good anesthesia	Can do with pudendal block
Speed	Faster (instant traction)	Slower (build pressure gradually)
When to Use	Fetal distress needing rapid delivery	Maternal exhaustion, less fetal distress

🔺 CRITICAL EXAM POINT: Sequential use = DANGEROUS! If vacuum fails, proceed to CS, NOT forceps! Combined trauma to fetal head is severe!

7. SYMPHYSIOTOMY

📚 Definition:

Surgical division of the fibrocartilage of the symphysis pubis to increase pelvic outlet diameter by 2-3 cm.

Rarely performed: Only in selected cases of mild CPD where CS not available or contraindicated.

🎯 Indications - "Last Resort Before CS":

Mild CPD: Arrest of descent with moderate contractions
Live fetus: Head at +2 station or lower
Failed vacuum: Due to mild CPD (not fetal distress)
Equipment/Expertise: No CS available, transfer not possible
Genuine CPD excluded: Pelvis not severely contracted

🚨 CRITICAL LIMITATIONS: NEVER perform symphysiotomy if:

Severe CPD (conjugate <8.5cm)
Fetus >4000g with definite CPD
Malpresentation (breech, face)
No anesthesia available
No post-op care (wheelchair access, physiotherapy)

🩺 Technique - The "Cut-Spread-Deliver-Close" Method:

✂️ MNEMONIC: "SYMPHYSIOTOMY STEP BY STEP"
Sedation: Pudendal block + local anesthesia
You position: Lithotomy, legs abducted
Midline catheterization: Insert Foley (protects urethra)
Palpate joint: Identify symphysis surface landmark

Horizontal incision: 1.5cm skin midline over joint
You dissect: Blunt dissect to fibrocartilage
Spread tissues: Use retractors laterally

Incise cartilage: With guarded scalpel (midline)
Open joint: Spread to 2-3 finger breadths
Traction: With delivery, support perineum

Observe for bleeding: Direct pressure if needed
Monitor vitals: Watch for shock

You close skin: Simple sutures
Stabilize pelvis: Wrap with sheet (for 6 weeks)

Transfer to hospital: As soon as possible
Educate: No squatting, no heavy lifting for 6 months
Physiotherapy: Refer for pelvic floor exercises

→ Note: WHO only recommends in limited resource settings where CS unavailable!

⚠️ Complications - The "Watch For These":

Immediate: Hemorrhage, urethral/bladder injury, pain
Early: Infection, urinary retention, difficulty walking
Late: Pelvic instability, gait problems, stress incontinence

🌍 UGANDA CONTEXT: Symphysiotomy is NOT RECOMMENDED at HC III level! Only done at regional referral hospitals in extreme emergencies with no CS capability. Most midwives will never perform this!

8. DESTRUCTIVE OPERATIONS

📚 Definition:

Intentional destruction of fetal parts to reduce size and facilitate vaginal delivery when:

Fetus is dead or has lethal anomaly
CS is contraindicated or impossible
CPD exists with obstructed labor

LAST RESORT - ONLY WHEN NO OTHER OPTION!

🎯 Types - The "When to Use Each":

☠️ MNEMONIC: "DESTRUCTIVE OPS FOR DEAD FETUS"
Craniotomy: Most common
• When: Head impacted, dead fetus
• How: Perforate skull, evacuate brain, compress cranium
• Route: After-coming head or cephalic

Cleidotomy: Division of clavicles
• When: Shoulder dystocia with dead fetus
• How: Cut clavicles to narrow shoulders

Spinal column transection: For locked twins
• When: Conjoined twins or interlocking
• How: Divide vertebral column

Craniocentesis: Drain CSF before delivery
• When: Hydrocephalus preventing descent

Septicemic fetus: Consider risk to mother
• When: Dead >48 hours, infection risk

→ ALL REQUIRE ACTIVE MANAGEMENT OF 3RD STAGE (risk of hemorrhage!)

🚨 CRITICAL PRE-REQUISITES:

Confirm fetal death: NO FHR for ≥1 hour, no fetal movements
Consent: Explain thoroughly, document carefully
Anesthesia: Pudendal block or ketamine
Post-op care: Watch for PPH, infection
Psychosocial support: Mother needs counseling

💔 Craniotomy Step-by-Step:

Anesthesia: Pudendal block + local infiltration
Examine: Confirm position, station, sutures
Perforate: Use craniotribe or large bore needle through fontanelle/suture
Evacuate: Brain tissue removed (compresses skull)
Deliver: Traction on trunk/perforator, head compresses
Post-delivery: Active management 3rd stage, tetanus prophylaxis

⚠️ Complications - "Mother at Risk":

Immediate: Hemorrhage, sepsis, uterine rupture
Early: Infection, PPH, retained bone fragments
Psychological: Severe grief, depression, PTSD

🌍 UGANDA CONTEXT: Destructive operations are LEGALLY SENSITIVE! Must be performed by senior obstetrician only. Midwives should focus on recognizing need and referring early. Documentation must be impeccable!

💡 EXAM STRATEGY: When asked about destructive ops, emphasize: "Last resort, only for dead fetus, consent essential, PPH risk high, psychosocial support mandatory" - these are exam points!

LIKELY EXAM QUESTIONS FOR DAY 8

1. FILL-IN-THE-BLANK (2 marks)

The station requirement for a vacuum extraction is ______ or lower, and the maximum number of traction pulls should not exceed ______.

ANSWER: +2 station, 3-4 pulls

2. MULTIPLE CHOICE (3 marks)

A primigravida has been pushing for 2.5 hours with adequate contractions. The fetal head is at +2 station, OA position, no caput, normal FHR. The most appropriate next step is:
A) Continue pushing for another hour
B) Emergency Caesarean section
C) Outlet forceps delivery ⭐ CORRECT
D) Symphysiotomy

EXPLANATION: Prolonged 2nd stage (>2 hours primip) + head at +2 + no CPD signs = ideal for outlet forceps

3. SHORT ANSWER (5 marks)

Outline five indications for emergency Caesarean section.

ANSWER GUIDE: 1 mark each
• Severe fetal distress in 1st/2nd stage
• Obstructed labor (failed augmentation)
• Cord prolapse with live fetus
• Placenta previa with bleeding
• Severe pre-eclampsia unresponsive to treatment
• Failed vacuum/forceps
• Uterine rupture
• Abruptio placentae with fetal distress
(Any 5 = full marks)

4. PRACTICAL SCENARIO (10 marks)

A woman at 28 weeks gestation has a dead fetus with hydrocephalus (head circumference 40cm) and obstructed labor. CS is not available. What is the management? Outline steps and precautions.

ANSWER:
Diagnosis: Obstructed labor with dead macerated fetus + hydrocephalus - 2 marks

Management: Craniotomy - 1 mark

Steps:
• Confirm fetal death (auscultate 1 hour) - 1 mark
• Obtain consent (explain to mother) - 1 mark
• Pudendal block + local anesthesia - 1 mark
• Perforate skull through fontanelle - 1 mark
• Evacuate brain tissue - 1 mark
• Apply traction, deliver head - 1 mark
• Active management 3rd stage - 1 mark

Precautions: Watch for PPH, infection, provide counseling - 1 mark

5. TRUE/FALSE (2 marks each)

a) Vacuum extraction can be performed when the fetal head is at 0 station.
b) Forceps delivery is faster than vacuum extraction.
c) Symphysiotomy is the first choice for CPD in Uganda HC III level.

ANSWERS:
a) FALSE - Must be at +2 or lower
b) TRUE - Forceps provide immediate traction
c) FALSE - Symphysiotomy is last resort, only where CS unavailable

6. LIST QUESTION (8 marks)

List four prerequisites for vacuum extraction and four complications to monitor after the procedure.

ANSWER:
Prerequisites: Full dilation, membranes ruptured, +2 station, OA position, no CPD, live fetus GA>34w, experienced operator, anesthesia adequate (any 4)
Complications: Cephalohematoma, scalp lacerations, PPH, maternal perineal tears, retained placenta, neonatal jaundice, subgaleal hemorrhage (any 4)
MARKING: 1 mark per correct answer

📊 STATISTICS: CS questions appear in 95% of exams! Forceps/vacuum in 70%. Know the station requirements and decision-making!

📚 DAY 8 SUMMARY: OBSTETRIC OPERATIONS

🎯 The 4 Operations in Hierarchy:

Caesarean Section: Most common, safest for CPD
Forceps: Fast, precise, but steep learning curve
Vacuum: Gentler, easier, but slower
Symphysiotomy: Rare, last resort for mild CPD
Destructive: Last resort for dead fetus only

🎯 THE "STATION RULE" MEMORY AID
+2 OR MORE = OPERATIVE VAGINAL
+3 OR MORE = OUTLET ONLY
0 TO +2 = MID-FORCEPS (SENIOR ONLY)
BELOW 0 = NEVER TOUCH!

3 PULLS = MAXIMUM FOR VACUUM
NO DESCENT = STOP & DO CS

VACUUM FAILS = CS, NOT FORCEPS!

🎯 The 5 Pre-Op Checks for ALL Operations:

Confirm indication: Is this necessary?
Check prerequisites: Station, dilation, presentation
Obtain consent: Explain risks/benefits
Prepare equipment: Check instruments function
Backup plan ready: CS theatre on standby

⚠️ FINAL EXAM TIP: In any scenario, always ask: "What is the station?" If not at +2 or lower = NO operative vaginal delivery! This single check prevents disasters!

"Obstetric operations are double-edged swords. Use them wisely, skillfully, and only when clearly indicated. The lives you save will thank you!"

"For everything there is a season, and a time for every matter under heaven." - Ecclesiastes 3:1