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DIFFICULT EXTRACTION
OF THE FETUS
• Obstetrics is not an exact science
Greater the difficulty
, greater the glory !!!
Many difficulties attend Caesarean section, and many disasters
can follow it
Difficulty in extraction of the fetus
Torre...
TRANSVERSE LIE
Deliver breech first
If instead of leg,
hand comes out
reposit it back and
then search for
buttocks
Legs are recognized
by...
Transverse lie
Preterm
labour
Upper
segment
inscision
f/b breech
extraction
Obstructed
labour
If baby alive
Vertical
insci...
• The dorsosuperior (back up) transverse lie may be
delivered as a footling breech through a low transverse
incision.
• Co...
• Video of Transverse Lie
EXTREMELY LOW BIRTH WEIGHT
BABY
• Extremely low birth weight infants (premature or growth
restricted) present many challenges at caesarean
delivery.
• The...
• Also, because of the markedly reduced foetal size, the
uterus is significantly smaller and occupies less of the
abdomen ...
DEEPLY IMPACTED
HEAD
• Deeply engaged foetal heads that are difficult to deliver
complicate about 1.5 percent of caesarean deliveries.
• These ...
• The best methods to dislodging the deeply engaged foetal
head include:
• Abdominovaginal delivery:
• An assistant cups t...
PATWARDHAN’S SHOULDERS FIRST
TECHNIQUE:
• The technique involves first delivering the anterior
shoulder and arm and then r...
MODIFIED PATWARDHAN’S
TECHNIQUE
• If back of the baby is posterior, anterior
shoulder is first delivered followed by the
c...
MODIFIED PATWARDHAN
TECHNIQUE
Patwardhan manoeuvre
Modified Patwardhan manoeuvre
Assistant can push head through vagina before opening
uterus.
Don't lev...
USE OF A HEAD
ELEVATORS
• Foetal head elevators or obstetrical
spoons are available in several
variations, including the C...
MURLESS HEAD EXTRACTOR
REVERSE BREECH EXTRACTION
TECHNIQUE:
• Described by Fong and Arulkumaran in Singapore in
1997.
• The operator's hand is in...
• Compared with the traditional abdominopelvic delivery
technique, the reverse breech extraction technique has
been report...
• Video of Deep Impacted Head
LSCS BREECH DELIVERY
• Abdominal delivery no different from vaginal breech
extraction with many of the risks
• Limb manipulated through natural...
• The abdominal and uterine incisions should be
sufficiently large to allow easy, atraumatic fetal
extraction.
• A low tra...
• Video of breech
USE OF FORCEPS
FLOATING HEAD
• Head might not be engaged during caesarean section with
a poorly formed and highly vascular lower uterine ...
• After amniotomy, the liquor should be allowed to drain
completely as this facilitates the descent of head
especially in ...
• Delivery of floating, non-engaged head can be facilitated
by:
Vectis / Forceps extraction or Vaccum :
• In some cases, s...
• Video of VECTIS Application for extraction of Fetal Head.
CONJOINT TWIN DELIVERY
• Conjoined twins are identical twins whose bodies are
joined in utero.
• It’s a rare phenomenon with an incidence of 1 in...
• Video of conjoint twins
• Management of conjoined twins begins when the
diagnosis is made.
• Elective termination is often advised when there is a...
OTHERS
• Inadequate incision or wrong abdominal incision
• Head stuck near previous lscs scar in the uterus
Reduction of tension
Wide U-shaped transverse incision
with the point of the '‘U' lying
across the middle of the scar
HEAD...
If Uterine incision tears
while removing head
Vertical tear
running behind
bladder with
heavy bleeding
Mobilize bladder
fu...
INJURY TO THE FETUS
“ATRAUMATIC DELIVERY IS THE GOAL
OF AN OBSTETRICIAN”
Possible causes of injury
• Haste or difficult delivery
• Inappropria...
SUMMARY
• BE SAFE
• BE SURE OF WHAT YOUR DOING
• BE SWIFT IN YOUR SURGERY
• BE SOUND IN YOUR CLINICAL AND SURGICAL SKILLS
...
Difficult extraction of the fetus presented in aicog 09.01.19
Difficult extraction of the fetus presented in aicog 09.01.19
Difficult extraction of the fetus presented in aicog 09.01.19
Difficult extraction of the fetus presented in aicog 09.01.19
Difficult extraction of the fetus presented in aicog 09.01.19
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Difficult extraction of the fetus presented in aicog 09.01.19

Techniques for delivering transverse lie,Deeply impacted head,LSCS breech delivery,Use of forceps in LSCS,Conjoint twin delivery

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Difficult extraction of the fetus presented in aicog 09.01.19

  1. 1. DIFFICULT EXTRACTION OF THE FETUS
  2. 2. • Obstetrics is not an exact science Greater the difficulty , greater the glory !!!
  3. 3. Many difficulties attend Caesarean section, and many disasters can follow it Difficulty in extraction of the fetus Torrential bleeding Disasters with the urinary tract and many other………. Fortunately, most of the others are rare. Some of these many difficulties are only seen in the developing world, where operators find themselves working under difficult circumstances.
  4. 4. TRANSVERSE LIE
  5. 5. Deliver breech first If instead of leg, hand comes out reposit it back and then search for buttocks Legs are recognized by feeling of the Heel, ankle is held like a cigarette butt between index and middle finger You may have to make an inverted ''T' incision on rare occasions Transverse lie
  6. 6. Transverse lie Preterm labour Upper segment inscision f/b breech extraction Obstructed labour If baby alive Vertical inscision , if required extend the upper end If baby dead : lower segment inscision f/b decapitation / evisceration Full-term Lower segment incision with breech extraction
  7. 7. • The dorsosuperior (back up) transverse lie may be delivered as a footling breech through a low transverse incision. • Consequently, a vertical incision in the uterus is usually employed in these cases. • If the foetal membranes are intact at the time the caesarean delivery is performed, intra-abdominal version of the foetus can convert the transverse lie to a cephalic or breech presentation allowing delivery through a low-segment transverse incision.
  8. 8. • Video of Transverse Lie
  9. 9. EXTREMELY LOW BIRTH WEIGHT BABY
  10. 10. • Extremely low birth weight infants (premature or growth restricted) present many challenges at caesarean delivery. • The lower uterine segment is less well-developed (thicker myometrium, smaller area). • Thus, the uterine incision is deeper and bloodier, and an adequate transverse incision to allow atraumatic extraction of the foetus may not be possible. • It is also easy to inadvertently lacerate the foetus, especially in the setting of premature ruptured membranes, if the deepest layers if the myometrium are not incised carefully.
  11. 11. • Also, because of the markedly reduced foetal size, the uterus is significantly smaller and occupies less of the abdomen and pelvis than larger, term pregnancies. Thus, the mother's intestines, which are usually confined to the upper abdomen in a caesarean delivery, frequently descend into the operative field and need to be manually displaced with either retractors or packing.
  12. 12. DEEPLY IMPACTED HEAD
  13. 13. • Deeply engaged foetal heads that are difficult to deliver complicate about 1.5 percent of caesarean deliveries. • These cases often follow a prolonged second stage and failed attempts at operative vaginal delivery. • The impacted head places the infant at increased risk of intracranial haemorrhage, skull fractures, neck fractures, and asphyxia injuries, while simultaneously increasing the risk of maternal complications, such as severe uterine lacerations, damage to the uterine vessels, and injury to the lower urinary tract.
  14. 14. • The best methods to dislodging the deeply engaged foetal head include: • Abdominovaginal delivery: • An assistant cups the foetal head vaginally in one hand and elevates to meet the operator’s hand. • The mother's legs are abducted into the "Whitmore" or "frog" position on the operating room table.
  15. 15. PATWARDHAN’S SHOULDERS FIRST TECHNIQUE: • The technique involves first delivering the anterior shoulder and arm and then rotating the foetus and delivering the posterior shoulder and arm. • The foetal trunk, breech, and lower limbs are then successively delivered through the incision using a combination of gentle traction on the arms, fingers beneath the thorax, and fundal pressure. • Once the body is delivered, the head is lifted out of the pelvis in the same manner as a reverse breech extraction.
  16. 16. MODIFIED PATWARDHAN’S TECHNIQUE • If back of the baby is posterior, anterior shoulder is first delivered followed by the corresponding lower limb. • Then the contralateral lower limb is delivered. The foetal breech and the truck are then successively delivered followed by the posterior shoulder and arm.
  17. 17. MODIFIED PATWARDHAN TECHNIQUE
  18. 18. Patwardhan manoeuvre Modified Patwardhan manoeuvre Assistant can push head through vagina before opening uterus. Don't lever head out with your whole hand, because this can cause vertical downward tears in the lower segment Difficulty in delivering head in obstructed labour
  19. 19. USE OF A HEAD ELEVATORS • Foetal head elevators or obstetrical spoons are available in several variations, including the Coyne spoon, the Sellheim spoon and the Murless head extractor. • All three instruments essentially function as obstetrical "shoe horns." • They take up less space than the obstetrician's hand, thus they are easier to get around a tightly impacted head.
  20. 20. MURLESS HEAD EXTRACTOR
  21. 21. REVERSE BREECH EXTRACTION TECHNIQUE: • Described by Fong and Arulkumaran in Singapore in 1997. • The operator's hand is inserted into the uterus towards the fundus to grasp the foetal feet, which are then pulled to perform a footling breech extraction. • When grasping, and pulling the feet, care must be taken to apply traction only parallel to the axis of the legs to avoid fracturing the foetal tibia and/or fibula.
  22. 22. • Compared with the traditional abdominopelvic delivery technique, the reverse breech extraction technique has been reported to reduce uterine lacerations/extension of the incision, as well as maternal infectious morbidity and blood loss.
  23. 23. • Video of Deep Impacted Head
  24. 24. LSCS BREECH DELIVERY
  25. 25. • Abdominal delivery no different from vaginal breech extraction with many of the risks • Limb manipulated through natural range of movement Delivery of after coming of head • Avoid trapping of the after coming of head retracting uterus especially in premature breech • Mauriceau Smellie Veit maneuver • Forcep application
  26. 26. • The abdominal and uterine incisions should be sufficiently large to allow easy, atraumatic fetal extraction. • A low transverse hysterotomy incision is adequate in most term or near-term pregnancies
  27. 27. • Video of breech
  28. 28. USE OF FORCEPS
  29. 29. FLOATING HEAD • Head might not be engaged during caesarean section with a poorly formed and highly vascular lower uterine segment. • Foetus should be manipulated in longitudinal lie and steadied with lateral support.
  30. 30. • After amniotomy, the liquor should be allowed to drain completely as this facilitates the descent of head especially in cases of polyhydramnios. • The floating foetal head is difficult for the obstetrician to grasp or establish traction; it cannot readily be pulled and guided through the incision. • Applying fundal pressure is often inadequate and tends to push the head laterally rather than towards the hysterotomy.
  31. 31. • Delivery of floating, non-engaged head can be facilitated by: Vectis / Forceps extraction or Vaccum : • In some cases, single blade of the forceps can be used as a Vectis for baby delivery. • Previously Barton’s forceps, which had a hinged anterior blade and sliding lock, was used. • Preference is to place an obstetrical vacuum extractor over the flexion point to deliver the foetal head.
  32. 32. • Video of VECTIS Application for extraction of Fetal Head.
  33. 33. CONJOINT TWIN DELIVERY
  34. 34. • Conjoined twins are identical twins whose bodies are joined in utero. • It’s a rare phenomenon with an incidence of 1 in 50,000- 100,000 births. • The incidence is somewhat higher incidence in Africa and Southwest Asia. • Females are affected more often than males.
  35. 35. • Video of conjoint twins
  36. 36. • Management of conjoined twins begins when the diagnosis is made. • Elective termination is often advised when there is a cardiac or cerebral fusion, as separation is rarely successful, and is often considered if severe deformities are anticipated after separation. • If the pregnancy is continued, elective Clasical cesarean section or Inverted T shape incision on Lower uterine segment extending to upper uterine segment.
  37. 37. OTHERS • Inadequate incision or wrong abdominal incision • Head stuck near previous lscs scar in the uterus
  38. 38. Reduction of tension Wide U-shaped transverse incision with the point of the '‘U' lying across the middle of the scar HEAD IS STUCK TIGHTLY UNDER AN OLD SCAR IN HER UTERUS, If her uterus does tear, it will do so near the midline, where you can more easily see and repair it
  39. 39. If Uterine incision tears while removing head Vertical tear running behind bladder with heavy bleeding Mobilize bladder further downwards If tear not seen clearly Open broad and round ligament to avoid injury to ureter Direct pressure on bleeding edges and vessels Interrupted sutures in the area of tear IF BLEEDING NOT CONTROLLED THEN TO DO SYSTEMATIC DEVASCULARISATION PROCEDURE
  40. 40. INJURY TO THE FETUS
  41. 41. “ATRAUMATIC DELIVERY IS THE GOAL OF AN OBSTETRICIAN” Possible causes of injury • Haste or difficult delivery • Inappropriate or inadequate uterine incision trapping the fetal parts • Deep or uncontrolled uterine incision lacerating the fetal parts
  42. 42. SUMMARY • BE SAFE • BE SURE OF WHAT YOUR DOING • BE SWIFT IN YOUR SURGERY • BE SOUND IN YOUR CLINICAL AND SURGICAL SKILLS • DO SURGERY RELENTLESSLY & BLOODLESS • OBSTETRICIANS SHOULD HAVE LADIES FINGERS • LIONS HEART • EAGLES EYES • & GOOD HAND DEXTERITY

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