the rebel surgeon

FORCEPS

Posted on by The Rebel Surgeon in FORCEPS

The advantages of forceps compared to vacuum extraction are:

  • Faster application
  • Faster extraction
  • No need for synchronized traction
  • More vigorous traction may be applied
    • For good and bad!

Application:

  • Determine rotational position of head
    • Palpate fontanelles
    • Feel for an ear
  • If exact position of the heads rotation is undetermined do not apply forceps

Two options:

  1. Apply the left branch (mothers left) first
    • Then the right branch over the left
  2. Apply the right branch first
    • Then the left branch under the right.
Forceps I
Forceps II

HYDROCEPHALUS

Posted on by The Rebel Surgeon in HYDROCEPHALUS
  • Not an indication for C/S per se
  • Avoid C/S

BREECH PRESENTATION

  • Vaginal delivery
  • Deliver the body
  • Leave body hanging
  • Puncture the head suprapubically with a wide bore needle
  • Drain the cerebrospinal fluid
  • Deliver the collapsed head with Mauriceau-Levret’s maneuver
Suprapubic Puncture of Hydrocephalic Head

CEPHALIC PRESENTATION

  • Puncture the head with a wide bore needle
    • Through the open cervix
    • Suprapubically
      • Technically easier

TRANSVERSE

  • Internal version and extraction on one foot or both feet
  • Deliver as a breech presentation  

AT CESAREAN SECTIO (in case of missed diagnosis)

  • Puncture head and drain cerebrospinal fluid before attempting to extract it through the uterine incision
  • Troublesome vaginal and/or uterine tears may otherwise be the result

Puncture and drainage of the head is not harmful to the child

INDUCTION

Posted on by The Rebel Surgeon in Okategoriserade

ALIVE FETUS

  • Oxytocin 10 units in 500 cc Normal Saline solution
    • Start i.v. infusion with 10 ml per hour
    • increase by 20 ml every 20 minutes until contractions occur

DEAD FETUS (IUFD)

  • Misoprostol (Cytotec)

Gestational age < 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 2 cc orally every 6 hours
  • VAGINAL ADMINISTRATION
    • ½ tablet in vagina every 6 hours

Gestationalage > 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 1 cc orally every 4 hours
  • VAGINAL ADMINISTRATION
    • ¼ tablet in vagina every 4 hours
    • One tablet diluted in 10 cc
      • 1 cc in vagina every 4 hours

MANEUVERS

Posted on by The Rebel Surgeon in MANEUVERS, Okategoriserade

MAURICEAU-LEVRET

For delivering head at Breech Presentation

  • Lift body vertically by the feet
  • Introduce index finger in the mouth
  • Let the body ride on your arm
    • On the abdomen
    • Legs hanging down on each side of the arm
  • Flex the head with index finger in the mouth
  • Apply traction with a forked finger grip posteriorly to the neck with the other hand.
  • Apply fundal pressure by assistant
  • Fundal pressure
  • Forked fingergrip
  • Index in mouth

Mauriceau-Levret’s maneuver

INTERNAL VERSION AND EXTRACTION

For delivering breech and transverse presentations

  • Introduce one hand in uterus
  • Search for small parts of the fetus
  • Identify one or both feet
    • Foot has a heal
    • Hand has a thumb
  • Grasp one or both feet with forked fingergrip from behind
  • Apply strong traction on the foot/feet
  • Rotate the fetus by a combination of
    • Traction on the foot/feet
    • Upward pressure on caput with the other hand on mother’s abdomen
  • Continue strong traction on foot/feet
  • Combined with pumping movements
  • Grasp the knee anteriorly with the other hand
  • Extract lower part of the body by a combination of
    • Strong traction
    • Pumping movements
  • Grasp pelvis with both hands
  • Extract upper part of body by a combination of
    • Strong traction
    • Pumping movements
  • Release the arms
  • Deliver head by Mauriceau-Levret’s maneuver
Internal Version and Extraction

ARM RELEASE

In Assisted Breech Delivery

  • Release the posteriorly positioned arm first
  • Use left hand when the back is turned to the (mother’s) right
    • And vice versa
  • Place left thumb on the frontal aspect of the truncus
  • Left index and middle fingers on the back
  • Slide the hand inwards
  • Along the truncus
  • Until the thumb reaches the axilla
  • With a sweeping movement across the head
  • Bring the arm down with index and middle fingers
  • Change hands
  • Release the anteriorly positioned arm
    • Using the same technique

BURN-MARSHALL

  • In Breech presentation
  • Let the baby hang a short moment by the head
  • To facilitate it’s descendens in the birth canal
Burn-Marshall

LOEVSET

For delivering the shoulders

  • Grasp lateral border of the scapula with four ulnar fingers of your hand
  • Rotate truncus 180°
  • Use right hand when the back is turned to the (mother’s) left
    • And vice versa
  • The birth canal is shorter anteriorly
  • Bringing the posterior shoulder anteriorly will deliver it
Loevset’s Maneuver
Loevset’s Maneuver with Delivery Hook

MEDICATIONS

Posted on by The Rebel Surgeon in MEDICATIONS

MAGNESIUM SULFATE

  • 500mg /ml solution

FOR ECLAMPSIA

  • 4 g intravenous loading dose
  • Immediately followed by 10 g intramuscularly – 5 mg in each buttock
  • Followed by 5 g intramuscularly every 4 hours in alternating buttocks
  • Check patellar reflexes before each injection
  • If weak or absent wait another 4 hours before giving next injection

MISOPROSTOL

  • Tablet Cytotec 200 µg

FOR INDUCTION IN IUFD

Gestational age < 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 2 cc orally every 6 hours
  • VAGINAL ADMINISTRATION
    • ½ tablet in vagina every 6 hours

Gestational age > 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 1 cc orally every 4 hours
  • VAGINAL ADMINISTRATION
    • ¼ tablet in vagina every 4 hours
    • One tablet diluted in 10 cc
      • 1 cc in vagina every 4 hours

Use only exceptionally and with greatest precaution for induction with alive fetus

FOR POSTPARTUM BLEEDING

ORAL ADMINISTRATION (preferred)

  • 2 to 3 tablets orally

RECTAL ADMINISTRATION

  • 2 to 4 tablets rectally

VALIUM

For Eclampsia:

  • 5 to10 mg i.v. or rectally
  • Repeat after 10 to 15 minutes up to a maximum dose of 30 mg
  • If needed repeat after 2 to 4 hours.
  • Keep a syringe loaded with 10 mg at bedside
  • Give immediately i.v. when a seizure is noted

OXYTOCIN

FOR INDUCTION OF LABOUR

  • 10 units in 500 cc Normal Saline solution
  • Start i.v. infusion with 10 ml per hour
  • increase by 20 ml every 20 minutes until contractions occur

FOR POSTPARTUM HEMORRHAGE

  • 30 units in 500 CC Normal Saline
  • Infused over 2 to 4 hours

NEFIDIPINE

For Hypertension:

  • 10 mg 3 times daily

For Premature Labor:

  • 10 to 40 mg
  • Followed by 10 to 20 mg every 6 to 8 hours

LIDOCAINE

For Eclampsia:

  • 2mg/kg i.v. as a bolus

2mg/kg/h i.v. as maintenance

SALBUTAMOL

  • Tablets 4 mg

For Premature Labor:

  • 4 mg four times daily

OBSTRUCTED LABOUR

Posted on by The Rebel Surgeon in OBSTRUCTED LABOUR

Obstructed labor is caused by cephalopelvic disproportion (CPD) due to:

  • Large head
  • Narrow pelvis
  • Malposition (fetal malposition)

TREATMENT

  • Alive fetus
    • C/S
  • Dead fetus
    • Destructive delivery

BANDL’S RING

  • Late sign of obstructed labor
  • Represents the transition between a stretched lower segment and a contracted upper segment of the uterus
  • Ultimate result of unrelieved obstructed labour is UTERINE RUPTURE
  • Early
  • Late
  • Bandl’s ring
  • Impending rupture

PARTOGRAM

Posted on by The Rebel Surgeon in PARTOGRAM

The WHO partogram is complicated. This simplified version is easier for the staff to manage.

Simplified partogram
  • Mark the descent of the head as follows:

-2           or         “At Pelvic Inlet”                   or                   “Floating”

-1           –           “Above Spines”                   –                     “Dipping”

  0          –           “At Spines”                           –                     “Engaged”

+1          –           “Below Spines”                   –                      “Deeply Engaged” 

+2          –           “At Pelvic Floor”                  –                      “Active Pushing” 

  • Mark the dilatation of the cervix as follows:
    • 1 to 10 cm or 1 to 5 fingers
  • Connect the markings to form two separate lines
  • Expect delivery at the time corresponding to the point where the two lines intersect
  • Lines allmost parralell. Will not intersect within a reasonable timeframe.
    ACTION IS NEEDED
  • Lines intersect at 5 PM
    NO ACTION NEEDED
  • Delivery sooner than expected

PLACENTAL ABRUPTION

Posted on by The Rebel Surgeon in PLACENTAL ABRUPTION

Symptoms and signs:

  • Sudden onset of painfull uterine contractions
  • Vaginal bleeding
  • Shock
  • Uterus tender on palpation

FETUS ALIVE

  • Gestational age > 36 weeks   
    • Deliver by C/S
  • Gestational age < 36 weeks    
    • Vaginal delivery
  • Gestational age unknown
    • Use best guess

FETUS DEAD

  • Vaginal delivery 
  • Destructive delivery if needed    

The uterus appears battered: