1. Operative Obstetrics. Laceration of birth Canal Doc. Stelmakh O.E.

2. Cesarean Delivery Cesarean section means delivery of a viable fetus through an abdominal incision (i.e., laparotomy) and a uterine incision (i.e., hysterotomy). The terms cesarean and section used together are actually redun­ dant, because both words imply incision.

3. Labor Contraindicated Under certain conditions, forceful uterine contrac­ tions, as in normal labor, constitute a real or potential hazard to mother or fetus, or both. Conditions in which the forces of labor increase the risk to the mother include central placenta previa, previous classic cesarean section, previous myomectomy tran­secting the uterine wall, previous uterine reconstruc­tion, and previous repair of a vaginal fistula. In such circumstances, normal labor and vaginal delivery may result in uterine rupture, hemorrhage, or serious lacerations of the birth canal, and may endanger the life or future health of the mother. Conditions in which the forces of labor increase the risk to the mother include central placenta previa, previous classic cesarean section, previous myomectomy tran­secting the uterine wall, previous uterine reconstruc­tion, and previous repair of a vaginal fistula. In such circumstances, normal labor and vaginal delivery may result in uterine rupture, hemorrhage, or serious lacerations of the birth canal, and may endanger the life or future health of the mother.

4. Conditions that have traditionally been cited as threatening the fetus and that may be worsened by labor include placenta previa, velamentous insertion of the cord or other forms of vasa previa, and cord presentation. The majority of cesareans are performed for fetal indications; a few are solely for maternal reasons, and some benefit both fetus and mother. Repeat cesarean accounts for approximately 33% of cesarean births in the United States, dystocia is the indication for up to 30%, and fetal distress, breech, and all other conditions are responsible for the remaining cases. Unfortunately, there are few data to suggest that the liberalized in­dications for cesarean section have reduced the in­cidence of cerebral palsy and other long-term disabilities The majority of cesareans are performed for fetal indications; a few are solely for maternal reasons, and some benefit both fetus and mother. Repeat cesarean accounts for approximately 33% of cesarean births in the United States, dystocia is the indication for up to 30%, and fetal distress, breech, and all other conditions are responsible for the remaining cases. Unfortunately, there are few data to suggest that the liberalized in­dications for cesarean section have reduced the in­cidence of cerebral palsy and other long-term disabilities

5. This is probably because most perinatal morbidity and mortality are caused by premature births, fetal anomalies, or antepartum events. Failed Induction In conditions such as isoimmunization, diabetes mel-litus, intrauterine growth retardation, and hyperten­sive disorders, which constitute an ever-increasing threat to the fetus, preterm delivery may be desirable. If attempts to induce labor are inappropriate or un­successful, cesarean section is the alternative In conditions such as isoimmunization, diabetes mel-litus, intrauterine growth retardation, and hyperten­sive disorders, which constitute an ever-increasing threat to the fetus, preterm delivery may be desirable. If attempts to induce labor are inappropriate or un­successful, cesarean section is the alternative

6. Common Indications for Cesarean Delivery Failed induction Failed induction Cephalopelvic disproportion Cephalopelvic disproportion Failure to progress in labor Failure to progress in labor Proven fetal distress Proven fetal distress Placental abruption Placental abruption Placenta previa Placenta previa Umbilical cord prolapse Umbilical cord prolapse Obstructive benign and malignant tumors Obstructive benign and malignant tumors Active genital herpes infection Active genital herpes infection Abdominal cerclage Abdominal cerclage Conjoined twins Conjoined twins Controversial (or Selective) Controversial (or Selective) Breech presentation Breech presentation Repeat cesarean Repeat cesarean Immune thrombocytopenia Immune thrombocytopenia Severe Rh immunization Severe Rh immunization Congenital fetal anomalies, major Congenital fetal anomalies, major Cervical carcinoma Cervical carcinoma Prior vaginal colporrhaphy Prior vaginal colporrhaphy Large vulvar condylomata Large vulvar condylomata

7. For example, fetal macrosomia occasionally causes CPD, but most cesarean births for abnormal labor involve a normal-sized infant. Dystocia also occurs because of soft tis­sue tumors and abnormal fetal presentations Fetal Distress Fetal Distress Electronic fetal monitoring probably increases the chances of detecting fetal distress and has contributed to the increased number of cesarean sections in the United States. Vaginal breech deliveries have been abandoned by many clinicians and replaced by cesarean delivery. In this situation, cesarean birth avoids the potential risk of intrapartum asphyxia or delivery-related trauma from head entrapment and umbilical cord prolapse Electronic fetal monitoring probably increases the chances of detecting fetal distress and has contributed to the increased number of cesarean sections in the United States. Vaginal breech deliveries have been abandoned by many clinicians and replaced by cesarean delivery. In this situation, cesarean birth avoids the potential risk of intrapartum asphyxia or delivery-related trauma from head entrapment and umbilical cord prolapse

8. Classic incision in the upper segment of the uterus.

9. Incisions in lower uterine segment. (A) Low transverse incision. (B) Low vertical incision.

10. On the other hand, reckless surgical techniques for rapid delivery of the fetus should be condemned. An induction-to- delivery time of 5 to 15 minutes is reasonable if maternal oxygen-ation, blood pressure, and displacement of the uterus are monitored and maintained with care. Preparation of the abdomen includes shaving the skin of the abdomen and mons pubis when necessary, scrubbing the area with an antiseptic soap, and pre­ paring the skin with an antiseptic agent such as non-organic iodide. The abdomen is draped so that the area between the umbilicus and the mons pubis is exposed. Preparation of the abdomen includes shaving the skin of the abdomen and mons pubis when necessary, scrubbing the area with an antiseptic soap, and pre­ paring the skin with an antiseptic agent such as non-organic iodide. The abdomen is draped so that the area between the umbilicus and the mons pubis is exposed.

12. The lower flap of peritoneum is elevated and the bladder is gently separated by blunt or sharp dissection from the underlying myometrium

13. The visceral peritoneum is grasped just above the bladder and incised in the midline.

14. A. The incision in a well-developed (thin) lower uterine segment is extended laterally and cephalad with the fingers. B. The incision in a thicker lower uterine segment is extended laterally with bandage scissors.

16. The fetal occiput is lifted toward the incision. Care is taken not to use the lower uterine segment as a fulcrum in order to avoid lacerations.

18. The body is delivered after the mouth and nares have been suctioned thoroughly.

19. The placenta is delivered by shearing it manually from its uterine attachment.

22. The second layer of closure imbricates the first; ab­sorbable suture is used in interrupted stitches in figures-of-eight, in Lembert stitches, or in a contin­uous suture placed such that the first layer of closure is completely covered. If, during the closure, any areas of bleeding are still apparent in the incision line, separate interrupted absorbable sutures in figures-of- eight should be placed in the bleeding area to secure hemostasis If, during the closure, any areas of bleeding are still apparent in the incision line, separate interrupted absorbable sutures in figures-of- eight should be placed in the bleeding area to secure hemostasis

24. A perplexing circumstance occurs in closing a trans­verse lower uterine segment incision when the junc­tion of the contractile and noncontractile portion of the posterior wall presents the appearance of the lower edge of the incision. Suturing this to the upper cut edge would create a closure of the corpus, but the error is usually recognized when the lower cut edge presents when peritoneal closure is attempted. The confusion can be resolved by careful identifica­tion of the upper and lower edges of the uterine in­ cisions at both angles. Suturing this to the upper cut edge would create a closure of the corpus, but the error is usually recognized when the lower cut edge presents when peritoneal closure is attempted. The confusion can be resolved by careful identifica­tion of the upper and lower edges of the uterine in­ cisions at both angles.

25. When the uterus and visceral peritoneum have been reapproximated, the packs are removed from the abdominal cavity and any residual blood or amniotic fluid removed by suction. If meconium soilage or exposure to infected amniotic fluid has occurred, the pelvic cavity should be lavaged with normal saline solution. Clinical studies have demonstrated in high-risk patients a reduction in postoperative infection rates if the uterine cavity is lavaged by saline solution If meconium soilage or exposure to infected amniotic fluid has occurred, the pelvic cavity should be lavaged with normal saline solution. Clinical studies have demonstrated in high-risk patients a reduction in postoperative infection rates if the uterine cavity is lavaged by saline solution

26. 1)forceps operations 2)Vacuum extractor Operative delivery

27. Simpson forceps

28. 2)Vacuum extractor

30. Laceration of birth canal