Tag: rebel surgeon

ANESTHESIA

Posted on by The Rebel Surgeon in ANESTHESIA

SPINAL

  • All obstetrical procedures can be performed in spinal anesthesia
  • Preferred method for C/S
    • Unless patient is in chock

KETAMINE

  • When spinal anesthesia fails
  • When spinal anesthesia is contraindicated
    • Shock due to
      • Sepsis
      • Hemorrhage
  • Combine with
    • atropine
    • valium
  • Recommended doses:
    • 1-5 mg/kg  IV  
    • 5-10 mg/kg IM
    • 1-2 mg/kg at rate of 0.5 mg/kg/min as infusion
      • solution of 1 mg/ml in Normal Saline or Glucose

PUDENDAL BLOCK / SACRAL ANESTHESIA

  • Forceps Delivery
  • Episiotomy

LOCAL INFILTRATION ANESTHESIA

  • Episiotomy
  • Symphysiotomy
  • C/S

GENERAL INTUBATION ANESTHESIA

  • Uterine Rupture
  • C/S in Eclampsia.

BLOOD TRANSFUSION

Posted on by The Rebel Surgeon in BLOOD TRANSFUSION

In lack of laboratory equipment for typing and crossmatching:

  • Take small samples of blood from recipient and donor
  • Centrifuge blood samples
  • Place a drop of serum from recipient on a white surface
  • Place a drop of red blood cells (the sediment) from donor beside
  • Mix the two drops
  • Read the result.
  • Does it clump together or not?
  • NOT COMPATIBLE
  • COMPATIBLE

If blood transfusion set is not available:

  • Place recipient on floor
  • Place donor on a stretcher
  • Connect donor and recipient with an i.v. line
  • Enhance blood flow with venous stasis by a tourniquet on the donor’s arm
  • Stop transfusion when recipient and donor have same pink mucosal linings (equilibrium has been acchieved)

In lack of electric centrifuge:

Buy a handheld

Or make your own with a testtube and piece of string

Selfmade centrifuge

CESAREAN SECTIO (C/S)

Posted on by The Rebel Surgeon in CESAREAN SECTIO C/S

Surgical technique

  • Low transverse incision through the skin
  • Small transverse incision strictly in the midline throuigh the subcutaneous tissue and fascia
  • Split the fascia by sliding a pair of slightly opened scissors transversely to the right and left.
  • That will spare the subcutaneous vessels avoiding unnecessary bleeding
  • Stretch the wound manually in a vertical direction
  • Open the peritoneum bluntly with your fingers
  • Stretch the wound further by manual traction in a transverse direction
  • Place a retractor distally in the wound
  • Apply downward traction to the retractor by assistant
  • Small transverse incision in the upper part of the lower segment of the uterus
  • Maintain a safe distance away from the bladder.
  • The more the lower segment is stretched, the higher the incision should be
  • 3 to 5 fingers above the bladder.
  • Do not incise the bladder peritoneum and push down the bladder to make the incision low in the lower segment as described in many textbooks. That’s a recipe for troublesome vaginal tears.
  • Stretch the uterine incision manually in a transverse direction
  • Apply fundal pressure by assistant
  • Lift out the presenting part with
    • One hand
    • Sellheim’s Obstetrical Lever
    • One blade of pair of ordinary obstetrical forceps  
  • Deliver the baby
  • Clamp and cut the umbilical cord
  • Lift out uterus from the abdominal cavity
  • Squeeze out placenta by fundal pressure
  • Or remove it by hand from the uterine cavity
  • Close the incision in the lower segment with a continuous inverting suture from one corner of the incision to the other.
  • Use resorbable suture such as Chromic Catgut or Polyglycolic Acid.
  • One layer is enough.
  • Remove blood from the abdominal cavity
  •  Return uterus into the abdomen
  • Close the fascia with a continuous suture
  • Close the skin
  • Sellheim’s obstetrical lever
Cesarean Sectio

CHALLENGES WITH CESAREAN SECTIO

FULL BLADDER

Empty bladder by suprapubic puncture

Full Bladder in C/S

DEEPLY IMPACTED HEAD

There are two options:

  1. Have an assistant push the head from below with a hand in vagina
Pushing Impacted Head from Below

2) Perform internal version and extraction on a foot through the uterine incision

C/S with Internal Version

LATERAL TEARS OF THE UTERINE INCISION

  • Close the wound with two continuous sutures
  • Start suturing separately in each corner
  • Tie the sutures together in the midline

BLEEDING FROM UTERINE ARTERY

  • Clamp the artery above and below the bleeding point
  • Apply suture-ligation
Bleeding from Uterine Artery

MYOMA

  • Make the uterine incision in a convenient place
  • Avoid the myoma(s) in the incision
  • Do not try to shell out or remove the myoma(s)
  • It may cause torrential and fatal bleeding.
Myoma in C/S

HIV POSITIVE PATIENT:

  • Use protection
  • Give prophylactic medication before surgery

ABDOMINAL PACK

  • Be sure to remove all abdominal packs before wound closure
  • Suspect retained pack in septic complications
  • Intra abdominal sepsis
  • Leave wound open
  • DON’T DO IT AGAIN !
    • Keep counting

    CORD PROLAPSE

    Posted on by The Rebel Surgeon in CORD PROLAPSE
    • Palpate the prolapsed cord for pulsations

    Pulsations present:

    • Place the patient in knee-chest position (“a la vache”)
    • Push the presenting part proximally with a hand in the vagina
    • Prepare for urgent C/S

    Pulsations not present:

    • Proceed with vaginal delivery

    Doubtful whether pulsations are present or not:

    • Check if fetal heart beats are present
    • Preferable with Doppler or ultrasound
    • Proceed accordingly

    ECLAMPSIA

    Posted on by The Rebel Surgeon in ECLAMPSIA
    Eclampsia

    Treatment:

    • Controle convulsions with Magnesium Sulfate and/or Valium
    • Treat hypertension  
    • Deliver as rapidly and least traumatically as possible
      • FETUS ALIVE
        • Gestational age > 36 weeks
          • Urgent C/S
        • Gestational age < 36 weeks
          • Vaginal delivery
          • Induction and/or augmentation
            • Oxytocin
      • FETUS DEAD
        • Vaginal delivery
        • Induction and/or augmentation
          • Misiprostol (Cytotec)
        • Destructive delivery if needed
    • Monitor vital signs closely
    • Continue antihypertensive treatment
    • Give regular doses of Magnesium Sulfate and/or Valium to prevent convulsions
    • Keep a syringe with 5-10 mg valium at bedside for immediate i.v. administration to control breakthrough convulsions
    • Watch out for signs of DIC (HELLP)
    • Valium ready
    • Close monitoring

    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

    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