OBSTETRIC OPERATIONS/

PROCEDURES
 Objectives
By the end of this class you
Should be able to;
Demonstrate understanding of
the obstetric operations or
procedures including
Manage the patients undergoing
obstetric operations
 Caesarean Section

• It is an operative procedure which

is carried out under regional or
general anesthesia.
• The foetus and membranes are
delivered through an incision in
the abdominal wall and the uterus.
Standardized scheme for
urgency of CS
• 1. Immediate threat to the life of woman
or fetus
• 2. maternal or fetal compromise which
is not immediately life threatening
• 3. No maternal or fetal compromise but
needs early delivery
• 4. Delivery timed to suit woman or staff
 Indications

Most common indications

for caesarean section
 Cephalopelvic disproportion
 Prior cesarean
No reassuring fetal heart rate
Fetal malpresentation
 Maternal- fetal
indications
Placenta previa
Placenta abruptio
dystocia
 Fetal indications
Breech or transverse lie
Non-reassuring fetus
Maternal herpes
Birth defects e.g neural tube defects
Prior neonatal birth trauma
Cord prolapse
macrosomia
 General indications

Moderate or severe pre-eclampsia

A medical condition warrants exclusion
of maternal effort
 Diabetes mellitus
 Intrauterine growth restriction
 Antepartum hemorrhage
Maternal request
 Procedure

• There are two layers of peritoneum;

pelvic and abdominal peritoneum
respectively. As pregnancy progresses
the uterus grows up into the abdomen
and this peritoneum (pelvic) rises up
with the uterus and comes into contact
with the abdominal peritoneum. Each of
these layers must be incised. The
abdominal peritoneum is situated below
the abdominal muscle layer.
• This is done in two layers. The
peritoneum may then be closed over the
uterine wound to exclude it from the
peritoneal cavity. The rectus sheath is
closed, then the layer of fat and finally
the skin is sutured with the surgeon`s
choice of material commonly Vicryl.
 Anatomical layers

• 1. Skin
• 2. Fat
• 3. rectus sheath
• 4. Muscle (rectus abdominis)
• 5. Abdominal peritoneum
• 6. Pelvic peritoneum
• 7. Uterine muscle
Types of caesarean section

• 1. Elective caesarean section

The mother opts for an operative delivery
due to various reasons. Prior
arrangements are made by the mother
and her doctor.
 2. Emergency
caesarean section

This is carried out when adverse conditions

develop during pregnancy or labour.
Examples include; Cord prolapse, Uterine
rupture (dramatic /scar dehiscence),
Cephalopelvic disproportion diagnosed in
labour, Eclampsia, Failure to progress in
the first or second stage of labour, and
Fetal compromise and birth not imminent
 3. The lower segment
C/S
 This is the Procedure would be the operation of
choice and involves a transverse incision
 The main advantages of lower segment section are:
 Blood loss is minimal
 Incision is easy to repair
 The risk of rupture during labour is lessened as the
lower uterine segment has muscles and heals faster
 The operation is associated with lower incidence of
postoperative infection
 4.

Classical / Upper uterine segment caesarean section (UUSCS)

• ·The incision is made directly into the wall of

the body of the uterus. The procedure is
rarely performed, its indications are:
• Inaccessible lower uterine segment (fibroids)
• Cancer of the cervix
• Placenta previa which is anteriorly situated
• Anterior leiomyoma
• Transverse lie
 5. Caesarean Section Hysterectomy

This is also known as Porro’s Operation.

The removal of the uterus follows after
caesarean section, due to other conditions
of the uterus; such as placenta accreta,
multiple fibroid tumours of the uterus and
so on. On rare occasions and in conjunction
with other gynaecological disorders this
operation may be used for sterilisation
purposes.
 Pre-operative
management
Explain the procedure to the patient, relative, and
reasons for the operation and Obtain consent.
Pre-operative assessment, patient`s weight,
observations of blood pressure, pulse, temperature,
respirations, fetal heart rate are taken.
The woman should fast and take prescribed
antiacid therapy
 Cont…
 The patient is cleaned, dressed in theatre gown, jewellery
is removed, and wedding ring strapped.
 Prophylactic preoperative antibiotics are administered 30
to 60 minutes before incision is made to allow for
adequate tissue concentration
 Pre-operative management is as for any patient undergoing
abdominal surgery. The anesthetist reviews the patient.
Blood for grouping and cross matching is taken.
 Fix an indwelling urinary catheter
 Cont…
• At least 2 units of blood must be available.
Results of any requested blood tests are obtained
and a full blood count is carried out. In the case
of pre-eclampsia, urea and electrolyte levels are
examined and clotting factors assessed. The
patient will have fasted in an elective caesarean
section. Antacid therapy is given. A urinary
catheter is passed and left in situ and connected
to a urine bag. Pre-medication with atropine 0.6
mg intramuscularly is given. The patient is
wheeled to theatre with her notes
 Post operative
interventions
• Blood pressure, pulse and respirations should
be taken every 15 minutes. The temperature
should be recorded two hourly. The wound
must be inspected ½ hourly to detect any loss
of blood. Lochia should also be inspected.
Drainage should be small initially. The mother
should be nursed in left lateral or recovery
position until she is fully conscious. This is
because the risk of airway obstruction or
regurgitation and silent aspiration of stomach
contents are still present.
• Thromboprophylaxis should be
administered because of the increased
risk of venous thromboembolism. The
choice of prophylaxis include low
molecular weight heparin, early
mobilization and hydration
• Psychological support is also essential to
help the women overcome their fears
 Complications of
caesarean section
• Infection. Wound infection, serious
post –operative infection such as pelvic
abscess, septic shock, and septic pelvic
vein thrombophlebitis. Infection is
associated with previous rupture of
membranes and other factors such as
obesity. Prophylactic administration of
antibiotics is necessary.
• Thrombo-embolic disorders.
Pregnancy carries with it an increased
risk of thrombosis. All mothers going for
caesarean section should be assessed
for thrombosis and given
thromboembolic prophylaxis.
 Complications of
caesarean section
Blader injury
Uterine atony
Maternal mortality
 Obstetric Anaesthesia
Anaesthesia means absence of sensation and
freedom from pain. General anaesthesia is the
induction of unconsciousness, which may also
involve the giving of some analgesia.
Regional anaesthesia is when a group of nerves
is made free of sensation.
Local anaesthesia is when a specific area of the
body is anaesthetised e.g. the perineal area
when repairing an episiotomy perineal or
vaginal tear.
 General Anaesthesia

General anaesthesia can be rapidly

administered. Speed is important such as when
the fetus is in serious jeopardy. The patient is
pre-oxygenated prior to induction of
anaesthesia. They are given oxygen rich gas
mixtures for several minutes. A muscle relaxant
such as suxemethomium is given to allow safe
orotracheal intubation; a cuffed tube and
cricoid pressure are essential. They prevent
aspiration of stomach contents.
Orotracheal Intubation
• Maternal unconsciousness occurs within seconds.
Induction agents include thiopental and propofol.
Anaesthesia is sustained by inhalational
anaesthetic means using Fluothane or Ethane.
• There are minimal side effects and relatively few
negative fetal consequences at the time of birth
provided meticulous practices are in place.
However regional anaesthesia remains the safer
option for caesarean birth.
• The uterine incision to delivery interval is
predictive of neonatal status
 Complications
Mendelson`s syndrome
• It is a condition whereby gastric contents are
inhaled and result in chemical pneumonitis. This
regurgitation may occur during induction of
general anaesthesia and go unheeded. The acid
gastric contents then damage the alveoli,
impairing gaseous exchange. It may become
impossible to oxygenate the mother and death
may result.
• Predisposing factors are; pressure from the gravid
uterus when the woman is lying down, the effect
of progesterone hormone by relaxing smooth
muscle, and the cardiac sphincter of the stomach
being relaxed by the effect of anaesthesia
 Cont..
• Prevention of Mendelson`s syndrome
• (i)Antacid therapy
• A mother should be given two doses of Ranitidine 150 mg 8 hours
apart and 30 ml of sodium citrate immediately before transfer to
theatre.
• (ii) Cricoid pressure
• The most important measure to prevent pulmonary aspiration. The
oesophagus is occluded by use of cricoid pressure. Pressure is
applied on the one whole ring of tracheal cartilage, the cricoid
cartilage, thus occluding the oesophagus and prevents reflux.
Cricoid pressure is maintained by an assistant until the tracheal tube
is positioned by the anaesthetist. The seal of the cuff is verified for it
is essential. The correct use of this manoeuvre is essential in
preventing major incidents from occurring.
Difficulty or failed intubation
• This condition is more likely to occur in pregnant women
especially those who have had pregnancy induced
hypertension. Laryngeal oedema arises more frequently in
these women. If laryngeal oedema is anticipated, an
experienced anaesthetist should carry out the procedure.
• A well lubricated stylet or bougee may be used to aid
intubation. Management of failed intubation is continued
use of cricoid pressure (but not at the expense of
oxygenation) and ventilation by face mask until the effects
of suxemethomium and thiopental has worn off (and the
woman has gained consciousness and her cough reflex).
Instrumental
Delivery
(Vacuum Extraction
and forceps delivery)
 The Vacuum Extraction
(Ventouse) Delivery

The vacuum extractor is an instrument

that applies traction. The cup cleaves to
the baby`s scalp by suction and is used
to assist maternal effort.
 Indications for vaccum delivery

· Maternal cardiac, hypertensive or respiratory

disease (to shorten second stage)
• Fetal compromise in second stage of Labour
• Prolonged second stage of Labour
• Poor maternal effort/ maternal exhaustion
• The ventouse should be used when the head is
engaged and there is no Cephalopelvic
disproportion. It may be useful in the second
twin when the head remains high
• However the ventouse cup may not
be successful at securing birth and
therefore obstetric forceps should
be chosen if there is:
• suspected fetal macrosomia
• Excessive caput or moulding
• Gestation <34 weeks gestation
 Application of the cup

• The cup is applied on the sagittal suture, about

3 cm anterior to the posterior fontanelle and 6
cm posterior to the anterior fontanelle. The
cup is positioned over the sagittal suture. The
vacuum within the cup will be achieved more
rapidly this way. The silicone rubber cup is
shaped to the contour of the baby`s head. This
allows the cup to be placed further back on the
baby`s head to increase flexion, reduce the
diameter of the head and facilitate delivery
 Procedure

• The procedure is explained to the mother and

consent obtained. The bladder is emptied.
The mother is put in lithotomy position.
• Local anaesthesia (1% lignocaine) is
administered. An episiotomy is given. The
foetal heart rate is recorded regularly. The
cup is passed through the vaginal introitus
and fitted easily to the foetal head. The cup
of the ventouse is placed as near as possible
to, or on, the flexing point of the foetal head.
• Care should be taken that no part of the cervix
or vagina is caught in between the foetal head
and the cup. The vacuum in the cup is
increased gradually so as to achieve a close
application of this to a foetal head.
• Usually a vacuum 0.8kg/cm2 is reached, by an
increase of 0.2kg/ cm2 in stages, or an increase
of 0.2kg/cm2 to 0.8kg/cm2 is achieved directly.
When vacuum is achieved, traction is applied
with a contraction, with maternal effort.
• This traction is done in a
downward and backwards
direction, then in a forwards and
upward manner thus following the
curve of carus. No more than
three pulls is allowed. There
should be a noticeable descend
with each pull. No more than two
cup detachments are allowed.
Failed vacuum extraction
• The vacuum is released and the cup
released at the crowning of the foetal
head. Then delivery will continue as
normal. Write up the procedure fully;
time taken, cup size, number of pulls,
number of detachments and neonatal
condition
 Precautions
 care should be taken to ensure that no vaginal
skin is trapped in the edges of the cup
 prolonged or excessive traction should not be used
 ask for help, address the client, adequate
anaesthesia
 bladder should be empty
 cervix must be completely dilated
 determine the position of the foetus
 equipment and extractor must be ready
 NOTE
Remember:
Never use the cup actively to rotate the
baby’s head during the procedure.
Do not continue this procedure for more
than 30 minutes.
complications you should watch
out for, during and after the
procedure
Failure of the procedure
.Trauma to the foetal scalp
. Chignon, that is, oedema and bruising
where the cup had been applied, which
can occasionally get infected
.Some babies develop
cephalohaematoma
.Intracranial haemorrhage
.Necrosis /abrassion of the
scalp
Possibility of mother to child
transmission of HIV in case of
HIV patients
.Localised oedema
. Skin necrosis
These complications occur mainly
due to some degree of
disproportion where the cup has
been applied for long period and
forceful traction used
To the mother – Trauma to the
genital tract, tears of the genital
tract, and excessive blood lose
 Vacuum extraction is
considered to have failed if ;
Head does not descent with each pull
. Fetus is undelivered after 3 pulls with no
descent or after 30 minutes of active
procedure
. The cap slips off the head 2 times at the
proper direction of pull with maximum
negative pressure
. NOTE: Failure of vacuum extraction
warrants a C/S.
 Forceps Operations
 This procedure is performed by a forceps which is
an instrument that has two parts that cross each
other like scissors and lock at the intersection. The
lock may be of sliding type or of screw type. Each
part consists of a handle, a lock, a shank and a
blade.
 The blade is joined to the handle by a shank.
 The blade has two curves, cephalic curve to fit the
head, and pelvic curve that correspond with the
curved axis of the pelvis. The length of the handles
differ, so do the types of handles.
• There are several types of forceps
including Kielland’s, Simpson’s,
Wrigley’s, Neville- Barne’s, Haig-
Fwerguson’s, Milne-Murray and Diper
forceps among others
 Classification of obstetric Forceps
Low Forceps
Today the majority of forceps delivery is carried out
when the foetal head is on the perineal floor whereby
the internal rotation may have already occurred. This
is called outlet forceps or low forceps delivery.
Mid Forceps
This is when the head is higher in the pelvis but engaged
and the greater diameter has passed the inlet. This is
known as mid forceps.
High Forceps
If the head is not engaged, the procedure is termed high
forceps. This is an extremely difficult and dangerous
operation. A caesarean section is usually preferred to
mid/high forceps.
Wrigley’s forceps

• These are designed for use when

the head is on the perineum.
Wriggle`s are short and light type
of forceps, with both pelvic and
cephalic curves. They are also used
for the after-coming head of a breech
delivery, or at caesarean section
Neville-Barnes or Simpson`s forceps
• These are generally used for a low
or mid-cavity forceps delivery
when the sagittal suture is in
the anterioposterior diameter
of the cavity (outlet) of the
pelvis. They have cephalic and
pelvic curves and the handles
are longer and heavier than
those of the Wrigley`s.
Anderson and Haig-Ferguson`s
forceps are also similar in size and
shape.
Kielland`s forceps
• These were originally designed to deliver the
foetal head at or above the pelvic brim.
• They are generally used for the rotation and
extraction of the head that is arrested in the
deep transverse or in the occipito posterior
position.
• The blades have little pelvic curve and are for
traction. The shallow curve allows safe rotation
of the forceps in the vagina. The claw lock
allows sliding and corrects asynclitism of the
fetal head.
 Indications

• Indications for use of obstetric

forceps:
a. Delay in second stage of labour
b. Fetal compromise
c. Maternal distress
Delay in second stage may be due to:
• insufficient contractions (but this is
better corrected by oxytocin
infusion)
• Epidural analgesia
• Malrotation of the foetal head
• Maternal fatigue.
Fetal compromise may be due to:
• Prematurity
• Hypoxia
• Intrauterine growth restriction
• Maternal obstetric or medical
condition (e.g. pre-eclampsia)
Maternal distress may be caused by:

• Hypertension
• cardiac condition
• Maternal exhaustion or
prolonged labour.
 Pre-requisites for forceps
delivery
include:
Presentation must be suitable
 Head has to be engaged
 The pelvic outlet needs to be
adequate
 Good uterine contraction
 Membranes should be ruptured
Bladder must be empty
 Steps before application
Reassure the mother and explain the
procedure.
 Obtain consent from the mother.
Some form of analgesia is given.
Ensure requirements for catheterisation,
episiotomy and perineal sutures are at hand.
Resuscitation trolley must be ready.
Delivery trolley should be ready as for
spontaneous delivery. The specific type of
forceps as per doctor’s requirement
 Procedure

· The mother is given analgesia and

placed in the lithotomy position.
· The vulva is swabbed and draped.
· Catheterisation is done.
· The physician checks the exact position
of the foetal head by vaginal examination.
· The fingers of the right hand are passed
in the vagina.
 The left blade is applied first and held by the left
hand between the fingers and thumbs of the left
hand.
 · The blade is then passed between the head and
the palm or surface of the right fingers. The
handle is carried backwards towards the middle
well over the mother’s abdomen to the right side
almost parallel with her right inguinal ligament.
 · The above position of the blade will ensure the
instrument follows the directions of both the
pelvic and cephalic curve.
 · After ascertaining it lies in the correct position
next to the head, the fingers of the right hand are
withdrawn.
 Procedure ct….

The same procedure is carried out on the right

side. The external visible portion will be above the
blade.
Positioning the Forceps
The shanks are pressed backwards against the
perineum and the handle should lock and lie in a
horizontal position. If the handle does not lock, the
blades should be removed and the position of the head
re-examined.
The ordinary curved forceps, if correctly applied on
the foetal head, results in the fenestrate, 'window' of
the blade lying over the pariental eminence. The
fingers of the right hand resting on the cheek, guide
the tip of the blade.
 The Delivery Procedure

Before applying traction, ascertain that the cervix

is not nipped between the foetal head an the
forceps blade. Traction is applied during
contractions, which should not exceed 15 seconds.
 Encourage the mother to push with every
contraction. The lock on the handle should be
loosened between contractions to reduce the skull
pressure.
The direction of pull is altered as the head
descends to follow the curve of birth canal. If the
head is mid cavity the direction of the pull is
outwards.
The blades lie in submento vertical
while the biparietal diameter is grasped.
As the head descends, the handles are
gradually raised to about 45° above the
horizontal, and then episiotomy is
performed through a stretched
perineum.
The head is then gently guided through
the vulva until crowning takes place.
The handles of the forceps should be in
vertical position. After the head is
properly crowned and ready for
 Dangers of forceps
delivery
In the case of the mother, dangers arise from:
· Anaesthesia
· Laceration of cervix, vagina or perineum
· Postpartum haemorrhage
· Puerperium infection
In the case of the baby, danger may arise as a result
of:
· Intra cranial haemorrhage
· Facial palsy
· Cephalohaematoma
 Ct…

An opportunity should be given to

mothers to explore and express their
feelings, be they fear, disappointment
or frustration. This can be done in a
group or individual counselling
setting, where uncertainties and
misunderstandings can be clarified.
 Episiotomy .
The easiest and most important
operation is the episiotomy.
This is a technique each midwife should
master while in the labour ward.
This competence is achieved through
observing an experienced midwife
conducting the procedure.
It is an aseptic procedure.
 Definition

• This is an incision through

the perineal tissues which
is designed to enlarge the
vulval outlet during birth.
 Indications
 Thick or rigid perineum
 Foetal compromise during second stage of
labour
 Prolonged second stage of labour with foetal
head bulging at the perineum
 Maternal conditions where rapid delivery is
required e.g. cardiac disease
 Breech or assisted delivery
 Previous third degree tear
 Delivery of preterm babies where the perineum
is tight.
 Timing of the incision
• An episiotomy involves the fourchette, the superficial
muscles of the skin and the perineum, and the
posterior vaginal wall.
• It can successfully speed the birth if the presenting
part is directly applied to these tissues.
• If it is performed to early, it will fail to release the
presenting part and haemorrhage from cut vessels
will happen The levator ani muscle will not have had
time to be displaced laterally and may be incised as
well.
• If the episiotomy is performed too late there will not
be enough time to infiltrate with local anaesthetic
 Types of incision

• There are two main directions of incision.

Mediolateral
• This begins at midpoint of the fourchette and
is directed at an angle of 45 degrees to the
midline towards a point midway between the
ischial tuberosity and the anus. This line
avoids the danger of damage to both anal
sphincter and Bartholin`s gland but it is more
difficult to repair
 Median

• This is a midline incision which follows

the natural line of insertion of the
perineal muscles. It is associated with
reduced blood loss but a higher
incidence of damage to the anal
sphincter. It is easier to repair and
results in less pain and dyspareunia.
Infiltration of the perineum

• The perineum should be adequately

anaesthetized. Lidocaine (lignocaine) is
commonly used; 0.5% 10 ml, 1% 5 ml.
Lidocaine takes effect 3-4 minutes to
take effect.
 Procedure

• The perineum is cleansed with antiseptic

solution. Two fingers are inserted into the vagina
along the line of proposed incision in order to
protect the foetal head.
• The needle is inserted beneath the skin for 4 – 5
cm following the same line. The piston of the
syringe should be withdrawn prior to injection to
check whether it is in a blood vessel. If blood is
aspirated, the needle is repositioned and the
procedure repeated until no blood is withdrawn.
• Anaesthesia is more effective if about 1/3 of the
amount is used at first, and two further injections
are made on either side of the incision line.
Incision
• A straight bladed, blunt ended pair of Mayo
scissors is usually used. The blades should be
sharp.
• Two fingers are inserted into the vagina as
before and the open blades are positioned.
The incision should be made during a
contraction when the tissues are stretched so
that there is a clear view of the area and
bleeding is less likely to be severe
• A single, deliberate cut 4-5cm long is
made at the correct angle.
• Birth of the head should follow
immediately and its advance must be
controlled in order to avoid extension of
the episiotomy. If there is any delay before
the head emerges, pressure should be
applied to the episiotomy site between
contractions in order to minimize bleeding
 Repair

• The episiotomy should be repaired as soon as possible

in order to secure haemostasis and before oedema
forms and while the tissues are still anaesthetized.
Prior to stitching the mother should be made warm
and comfortable. She is put in lithotomy position. A
good directional light is essential.
• The main requirements for the procedure is a trolley
with suture pack, 10ml syringe and needles,
Lidocaine, chromic catgut, needle holder, suturing
scissors, artery forceps, toothed dissecting forceps,
Mayo scissors,. The appropriate materials for the
procedure should be prepared before the mother`s
legs are put in the stirrups. This reduces the risk of
deep venous thrombosis
The midwife scrubs and puts on sterile gown
and gloves. The perineum is cleaned with
warm antiseptic solution. A taped vaginal
tampon is placed into the vault of the vagina
to absorb blood oozing from the uterus.
The tape is secured to the drapes by a pair of
forceps as a reminder that it is in situ. Both
insertion and removal should be recorded.
The full extent of the episiotomy is assessed
and explained to the mother.
The procedure for repair is also explained so
that she is aware of what is happening.
Aseptic technique should be observed.
Absorbable sutures are used
• The repair begins at the apex of the
vaginal wound. A continuous or
interrupted stitch is used, starting from
the apex to the fourchette bringing the
two edges of the wound together. The
perineal muscles are then sutured and
the skin is finally sutured. The stitches
should just be firm enough, not too loose
because oedema may take place, or too
tight making the mother uncomfortable
Care of the episiotomy

The patient should do the following:

Four hourly sitz births
Change perineal pad when wet
Avoid coitus until fully healed
Avoid constipation
Eat a balanced diet.
 Complications

Possible complications to be on the

look out for include:
Infections leading to broken
episiotomy
 Haematoma formation at the site of
the
Episiotomy
Haemorrhage
 Symphisiotomy

• It is the division of ligaments

holding the pubic bones
together at the symphysis. A
small suprapubic incision
produces an increase in the
available circumference of the
pubic ring and by widening
the suprapubic arch leads to
an increase in the available
anteroposterior diameter the
 Indications

when there is minor degree of

Cephalopelvic disproportion
which is causing delay near the
end of 1st stage of labour
when there is doubt whether
the patient will return for
caesarean section.
Method of symphysiotomy

The patient is placed in bed with her knees

apart on the bed. A midwife supports each
leg until the procedure is complete. The
pubic area is infiltrated with 10 ml 1%
lignocaine. The cartilage is incised over the
centre of the symphysis pubis.
Usually a vacuum extractor is applied. An
episiotomy is given to prevent pressure on
the urethra and bladder from the fetal head.
Nursing symphisiotomy care after

• Firm support bandages are applied around the

pelvis
• The patient usually stays in bed for 3 days
• The patient may be allowed to sit up or out of
bed on the third day
• She is encouraged to walk around from the 3rd
day gradually
• Usually she should be walking well by the 10th
day, but she should be advised to avoid heavy
loads for 3 months.
 Complications

• Bleeding
• Injury to the bladder
• Gait problems
• Stress incontinence
• Infection
• Unstable pelvis
 AMNIOCENTESIS

• It is the withdrawal of a
sample of amniotic fluid
surrounding an embryo in the
uterus by means of a syringe
inserted through the
abdominal wall.
• A puncture of the amniotic
sac usually through the
• Best performed between 15 and 20
weeks of pregnancy because
amniotic acid volume is adequate
and many viable fetal cells are
present in the acid by this time
• performed to determine genetic
disorders, metabolic defects, and
fetal lung maturity
 Procedure

• This is usually performed after 15 wks of

gestation since early amniocentesis has a
higher loss rate than chorionic villi sampling.
• The procedure involves trans abdominal
insertion of a fine needle into the amniotic
fluid cavity under continuous ultra sound
guidance. 15 mls of amniotic fluid is aspirated.
• Mothers who are Rh-ve should be given anti D
after the procedure to prevent antibody
formation.
 Indications for
amniocentesis
• Chromosomal analysis
• Estimation of concentration of Bilirubin
and Alpha Fetoprotein and DNA analysis
for fetal sexing and to detect certain
gene – carrying conditions, Duchene
Muscular Dystrophy, Sickle Cell Disease
and Thalassaemia.
 Indications for
amniocentesis ct…
• Open Neural Tube Defect ( at 16th – 18th
wk), when spina bifida or an Encephally
has occurred in a previous child or when
a significantly raised concentration of
Alpha FetoProtein is found in the
maternal serum, detected during a
prenatal blood screening programme.
• Prediction of sex. The parents may wish
for termination of such pregnancies
 Risks

• Hemorrhage in the birthing parent

• Miscarriage
• Fetal injury
• Infection
• Rh isoimmunization
• Abruptio placentae g. Amniotic fluid emboli
• Premature rupture of the membranes
 MacDonald stich/
Cervical stiches
• It involves the placement of a suture
in the cervical stroma or around its
perimeters to treat cervical
insufficiency or prevent preterm
delivery
• It is inserted at 12 to 14 weeks
• It s removed electively at 36 to 37
weeks
 Indications

• Increased risk of
spontaneous second –
trimester loss or
preterm delivery
• Cervical incompetence
 Management

• After cervical cerclage, the health care

provider will do an ultrasound to check the
baby’s well-being.
• The patient might experience some
spotting, cramps and painful urination for a
few days. As a precaution, the health care
provider might recommend avoiding sex for
at least one week and, afterward, using
condoms during sex.
• If the patient had cervical cerclage
because the cervix had already begun to
open or an ultrasound showed that the
cervix is short, they might need to
remain in the hospital longer for
observation. As a precaution, the health
care provider might recommend limiting
physical activity and sex until up to week
34 of pregnancy
 Complications

• Cervical stenosis
• Bleeding
• Infection
• PROM
• Read and make notes on
management of a pregnant woman
after amnioinfusion
 THE
END.
THAN
K YOU