Obstetric procedures Flashcards
Caesarean hysterectomy
Indication: PPH or placenta accreta
Consent:
Pre-op considerations: G+H, CBC, anaesthetic review
OT:
Attempt conservative measures, ecbolics, barki balloon and B lynch sutures.
Laparotomy if required
Dissection of the broad ligament, UV fold, salpingectomy and dissection of OL.
Clamp and cut the cardinal ligaments/UA dissection down to the level of the external os.
Entry sharply into the vagina anteriorly and placing clamping into the vagina and on either side of the uterus to remove it.
Suturing the vault and tying the cardinal ligaments together
0 PDS to rectus sheath, interrupted sutures subcut layer and 3/0 monocryl to skin.
Operation note documenting plan for CBC, mobilisation, E+D, TROC, debrief
Caesarean classical
Indication: preterm CS, uterine abnormalities,
Consent:
Pre-op considerations: G+H, CBC, anaesthetic review
OT:
WHO sign in
TED/SCDs, allergies
positioning, time out, abx, IDC, prepped and draping
Midline incision sub-umbilical down towards symphysis pubis
Separation of rectus sheath sharp then bluntly.
Blunt entry into peritoneum
Protection of bladder, reflection of bladder if required
Vertical sharp incision to centre of uterus with careful entry into uterine cavity.
Careful delivery of baby, DCC -> paeds
IV oxytocin, placental delivery
3 layer closure with 1 vicryl in continuous sutures, last layer in baseball sutures to approximate uterine serosa
0 PDS to rectus sheath, interrupted sutures subcut layer and 3/0 monocryl to skin.
Vagina swabbed out.
Operation note documenting plan for CBC, mobilisation, E+D, TROC, debrief
Instrumental delivery
Indication: Prolonged second stage. Maternal exhaustion. Fetal distress. Maternal conditions needing to reduce second stage
Consent: Failure of procedure, fetal injury, vaginal trauma including 3rd, pain
Procedure:
VE with consent, abdo examination.
Bladder care.
Analgesia.
Cup placed on flexion point or forcep blades placed with pincer grip, right hand protecting wall of left side and locking blades.
3x tractions with contractions, episiotomy made with crowning of head.
Restitution of head, delivery of baby.
DCC.
Active 3rd stage, PR exam, repair, PR exam.
Post op note, VTE etc
ECV
Internal artery ligation at PPH
Placenta percreta
Third/fourth degree tear
CVS/amniocentesis
CVS: Indication:
Consent
Procedure
Post-procedure
Amniocentesis: Indication: high risk result, torch infection, after 15/40 weeks
Consent: pain, failed procedure, risk of miscarriage less than 1;200, rh- status.
Procedure
- Lying supine, USS performed to check liquor, placental position
- Prep and drape, local anaesthetics
- USS guidance of a 22g needle to the largest pocket of fluid.
- Aspirate 20mLs of fluid, check FHR
Post procedure
- Discharge, FU
B lynch suture
Counselling of twin vaginal delivery
Options: VD vs CS
Contraindications: Non cephalic leading twin, maternal request for CS, another reason for CS
Benefits/risks: Fast recovery, reduced surgical risks. RIsk of requiring CS during labour or for 2nd twin.
Prerequisites: In hospital, IVL, G+H/CBC, Obs SnR in room/SMO in room. Continuous CTG, OT, anaesthetics and paeds aware. Epidural recommended.
Procedure: Cephalic twin A delivery standardly, DCC, USS/stabilisation, consider oxytocin, VE and delivery (consider internal manoeuvres)
Cervical cerclage
Indications: History indicated, USS indicated, examination indicated
Contraindications: pre-viability <12, fetal demise, contractions, bleeding, infection.
Benefits: reduced risk of PTL
Risks: PROM, infection, bleeding, VTE, precipitating labour, pain
Management:
Pre-op checks - anaesthetics, USS, vaginal swabs, bloods
Analgesia, tocolysis, McDonald technique: 360 degree suture placement above the external os tied in double knots with non absorbable suture such as mersliene tape.
May need to place membranes superiorly.
Ensure above to PU post op.
Anti D/FHB
Document/Debrief
Consider progesterone
Return advice/pelvic rest
FU in MFM 2 weeks, 2 weekly cx length to 24-26 weeks, 4/52 growth scans and suture out at 36 weeks
