the rebel surgeon

PLACENTA PREVIA

Posted on by The Rebel Surgeon in Okategoriserade, PLACENTA PREVIA

Painless – sometimes massive – bleeding in the last trimester of the pregnancy strongly suggests previa.

Same treatment whether fetus is alive or dead:

  • Immediate resuscitation with fluids
  • Transfuse one or two units of fresh blood
  • Perform ultrasound examination
    • Total previa:
      • C/S
    • Marginal previa:  
      • Rupture the bulging membranes
        • Diminishes traction on the placenta
        • Reduces bleeding
      • Deliver vaginally

When ultrasound is not available

  • Bring patient directly to the operating theater
  • Prepare for urgent C/S
  • Perform gentle speculum examination
    • Total previa:
      • C/S
    • Marginal previa:
      • Rupture the bulging membranes
        • Diminishes traction on the placenta
        • Reduces bleeding
      • Deliver vaginally

Watch out for signs of DIC (HELLP Syndrome). Transfuse with fresh blood at the slightest suspicion

POLYHYDRAMNIOS

Posted on by The Rebel Surgeon in POLYHYDRAMNIOS
  • An overdistended uterus is unable to produce efficient contractions
  • Drain the excessive fluid
    • By rupturing the membranes
      • Risk of cord prolapse if cervix is open more than a finger
    • By external drainage with an i.v. cannula
      • No risk of cord prolapse

POST PARTUM HEMORRHAGE (PPH)

Posted on by The Rebel Surgeon in POST PARTUM HEMORRHAGE (PPH)

Causes:

  • Atony of the uterus
  • Retained placental parts
  • Uterine rupture
  • Cervical and/or vaginal tears
  • DIC (HELLP)

Treatment:

  • Resuscitate with fluids
  • Massage the uterus manually
  • Apply firm and continuous pressure suprapubically with a closed fist for a full 10 minutes
    • Eyes on the watch!
  • Oxytocin infusion i.v. (preferred)
    • 30 units in 500 cc in Normal Saline
    • Infused over 2 to 4 hours
  • Misostoprol (Cytotec) tablets (if oxytocin is not available)
    • 2 – 4 tablets
      • Oral or rectal adminstration

Bleeding does not subside:

  • Bring patient to operating theater
  • Place legs in stirrups
  • Examine by intracavitary palpation
    • Placental parts present:
      • Remove
    • Uterine rupture present:
      • Laparotomy and repair
    • Neither retained placenta nor rupture of the uterus is present:
      • Pack firmly with gauze
      • Remove gauze pack in the operating theater after 24 hours
  • Transfuse one or two units of fresh blood

  • Perform hysterectomy as a last resort

Speculum Examination:

  • It is usually difficult and messy to identify bleeding site(s) from cervical tears
  • Attempts to suture the friable tissue results in further tearing and bleeding
  • Proceed directly with gauze packing in the absence of retained placental parts or ruptured uterus.

PREMATURE LABOUR

Posted on by The Rebel Surgeon in Okategoriserade, PREMATURE LABOUR

PREMATURE CONTRACTIONS

  • Bed rest in left lateral position
  • Salbutamol
    • Tablets 4 mg four times daily
  • Nifedipine
    • Initial dose of 20mg
    • Followed by three further doses of 20mg every 30 minutes
      • As long as contractions continue
    • Maintenance dose is 20-40mg orally every 4 hours for 48 hours
      • No more than 160mg/24 hours
  • Potent corticosteroids
    • Accelerates lung maturity of fetus
      • Betamethasone 1 ampule i.m. 2 doses 12 hours apart
      • Dexamethasone 6 mg i.m. 4 doses 12 hours apart

INSUFFICIENT CERVIX

  • Cerclage with heavy non-resorbable suture
  • Remove suture when contractions start
    • Or deliver by C/S
  • Heavy suture
  • Cerclage suture tied
  • Patient information is crucial

PREMATURE DELIVERY

  • Maintain body temperature
    • Incubator is questionable high tech
    • Kangaroo method is more appropriate technology
      • No significant difference in survival rate between the two methods
    • Cover head
  • Feed with breast milk
    • Cup
    • Spoon
    • Gastric tube
  • Incubator is questionable
  • Feed with glucose solution untill breast milk is available
  • Kangaroo method with gastric feeding tube
  • Cover head
  • Cup feeding
  • Collecting breast milk

RETAINED PLACENTA

Posted on by The Rebel Surgeon in RETAINED PLACENTA

Early presentation:

Induce delivery of the retained placenta:

  • Nitroglycerine sublingually or nasally
  • Misostoprol (Cytotec)  
  • Oxytocin

Late presentation:

Manual or instrumental removal:

  • Introduce one hand into the uterus
  • Use the ulnar border of the intrauterine hand to dissect the placenta from the uterine wall
  • Apply contra pressure on outside of the uterus with other hand on abdomen
  • In case a closed or closing cervix does not allow the entire hand to enter the intrauterine cavity, two fingers are usually sufficient
    • If not, use instruments
    • A large sponge forceps (ring forceps) will do
Manual Removal of Placenta

Very late presentation with severe anemia and/or sepsis:

Supravaginal (subtotal) hysterectomy.

  • Supravaginal (subtotal) hysterectomy with retained placenta. Uterus pale due to severe anemia

SHOULDER DYSTOCIA

Posted on by The Rebel Surgeon in SHOULDER DYSTOCIA
  • Do not panic
  • Do not use forceful traction on head
    • May cause severe damage to both child and mother
  • Go systematically through following steps:
  • Wipe baby’s face clean
  • Keep airways free
  • Use suction to remove mucus and meconium
  • Make a generous episiotomy.
    • This alone might solve the problem
  • Apply Loevset’s maneuver
    • 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
    • As the birth canal is shorter anteriorly bringing the posterior shoulder anteriorly may deliver it
  • Repeat the maneuver
Loevset’s Maneuver
  • Fracture both clavicles
    • Decreases the overall dimension of the shoulders
  • Place the delivery hook under one axilla
  • Apply traction
  • Rotate truncus 180° (Loevset’s Maneuver)
Loevset’s Maneuver with delivery Hook
  • Perform symphysiotomy

SYMPHYSIOTOMY

Posted on by The Rebel Surgeon in SYMFYSIOTOMY

A cut through the symphysis will cause the pubic bones to separate and increase the pelvic circumference with three or more cm (two fingers). Sufficient to resolve a mechanical disproportion due to a large head and/or a narrow pelvis

Indications:

  • Fetal head stuck so firm and deep in the birth canal that C/S is not an option
  • Shoulder dystocia
  • Retained head in breech

To avoid damage to urethra a catheter in the bladder is most important . The urethra with the indwelling catheter is pushed aside when the cut through the symphysis is made.

OPEN SYMPHYSIOTOMY

Preferred method for unexperienced

  • Local infiltration anesthesia
  • Insert a catheter in the bladder
  • Make a 4 to 5 cm long vertical incision through the skin and subcutaneous tissue in front of the symphysis
  • Insert a self-retaining wound retractor
  • With two fingers in the vagina push the urethra to either side
  • Cut strictly in the midline with a scalpel
  • Confirm visually and by palpation that the pubic bones have separated
  • Deliver the baby
  • Close the incision
  • Keep the catheter indwelling for 24 hours
  • Mobilize the patient immediately and without any restrictions

CLOSED SYMPHYSIOTOMY

Preferred method for more experienced

  • Insert a catheter in the bladder
  • Local infiltration anesthesia
  • Use the injection needle to probe and define the exact location of the symphysis
  • Push the urethra to the side with two fingers in the vagina
  • Cut strictly in the midline with a scalpel
  • Confirm by palpation in vagina or suprapubically that the pubic bones have separated
  • Deliver the baby
  • The small incision does not need suturing
  • Keep catheter indwelling for 24 hours
  • Mobilize patient immediately and without any restrictions
Symphysiotomy I
Symphysiotomy II
Symphysiotomy in Breech

TRANSVERSE PRESENTATION

Posted on by The Rebel Surgeon in TRANSVERSE PRESENTATION

Transverse presentation is often accompanied by arm prolapse (compound transverse presentation).

  • Compound transverse presentation
    Alive fetus
  • Neglected compound transverse presentation
    Dead fetus

GESTATIONAL AGE < 32 WEEKS / WEIGHT < 1500 GRAM

  • Vaginal delivery

GESTATIONAL AGE > 32 WEEKS / WEIGHT > 1500 GRAM

ALIVE FETUS

  • Cervix closed:
    • Cesarean Sectio

  • Cervix closed and membranes intact:
    • External Version

  • Cervix fully dilated / Membranes ruptured recently / Contractions not very strong:
    • Internal version and extraction using one or both feet
      • 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 with a combination of
        • Traction on foot/feet
        • Upward pressure on caput with other hand on mother’s abdomen
      • Continue strong traction on foot/feet
      • Combined with pumping movements
      • Grasp front of knee with the other hand
      • Extract the upper part of 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 movementsRelease arms
      • Deliver head by Mauriceau-Levret’s maneuver

DEAD FETUS

  • Destructive delivery
    • Decapitation
    • Exvisceration

BETWEEN 32 – 34 WEEKS / 1500 – 2500 gram

Relay on your own judgement

TRIAL OF SCAR / PREVIOUS C/S

Posted on by The Rebel Surgeon in TRIAL OF SCAR

Repeat C/S whenever there is a scar after a previous one

  • Vaginal delivery after previous C/S – “Trial of Scar” – is risky
  • The scar from previous C/S may easily burst
  • High risk of uterine rupture
  • Do not perform vaginal delivery
    • Unless monitored continuously and closely
    • Staff member at bedside assigned exclusively for that purpose
  • Not recommended
  • Not recommended