Procedures and Surgery
Maternity
 
 
 
 
 
 
 
 
Gynaecology
 
 
 
 
Ultrasound scan
 
 
 
 
 
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Ultrasound Scan
 
 
 
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Delivery

There are 5 methods of delivery. The option will depend on mother and baby's condition.

1.

Spontaneous vaginal delivery (SVD)

2. Forceps delivery
3. Vacuum delivery
4.

Breech delivery

5. Lower segment caesarean section (LSCS)

Spontaneous Vaginal Delivery (SVD)

It implies the birth occurred without the need for forceps, vacuum, or any other instrumentation.

Procedures

1.
During labour the cervical opening itself will reached 10 cm in diameter to enable the baby to pass through the birth canal.
2.
The vagina and vaginal opening also will stretch and to the extreme.
3.
As the baby enters the vagina your skin and muscles stretch to the extreme.
4.
The labia and perineum (the area between the vagina and the rectum) will bulge to the extreme.
5.
At this point, your skin below will have burning pain like a "ring fire".
6.
If necessary, your doctor will perform an episiotomy which is a cut on the lower half of the vagina (right side).
7.
You will feel more discomfort. Your doctor will ask you to stop pushing momentarily. This allow the nurse to do suction and clear the mouth and nose of amniotic fluid and mucus.
8.
Then, you will be asked to push again to deliver the shoulders and the trunk.
9.
The baby's umbilical cord is clamped and then cut.
10.
Placenta is delivered by control cord traction. Little tension is applied to the cord to help the delivery of placenta. The doctor may rub your lower abdomen to help tighten the uterus and loosen the placenta.
11.
Your doctor will make sure the placenta is delivered in full. If there is placenta remaining in the uterine cavity the doctor will reach into your uterus to remove the leftover pieces.

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Forceps Delivery

Conditions required before forceps delivery

1.
The doctor will make sure that the cervix is fully dilated because an undilated cervix will be a barrier to the application of forceps.
2.
Presentations of baby must be vertex and face.
3.
The head has to be engaged.
4.

Bladder need to be emptied.

 Procedures

1.
The doctor will carefully assess the mother's bony pelvis as well as the position and station of the baby's head before inserting the forceps.
2.
You will be put your legs in 'lithotomy' position (your legs rest in stirrups at the side of the bed).
3.
A catheter will be inserted to your bladder to empty it.
4.
Your doctor will need to perform an episiotomy to enlarge the opening so that the forceps can be put round your baby's head.
5.
Once the forceps are in place, the doctor will pull while you push during a contraction to help your baby move down through the birth canal.

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Vacuum Delivery

Procedures

1.
The doctor assesses the size of the baby and the size of the mother's birth canal so that there is no obstruction during vacuum delivery.
2.
The baby's weight can be estimated by examination of the patient's abdomen and uterine size. Pelvis is assessed by digital vaginal examination
3.
You will have to put your legs in stirrups ("lithotomy" position)
4.
A rubber catheter will be inserted into the bladder to empty the urine.
5.
The doctor then inserts the vacuum cup into the vagina.
6.
The cup is applied to the baby's head and the doctor checks to ensure that no cervical tissue have been trapped between the cup and the baby's head.
7.
During the uterine contraction, the vacuum pressure is generated to 0.7 kg/cm2 using an electric pump and the doctor gently pulls the handle of the cup
8.

After adequate pressure has been produced, the doctor gently pulls on the handle at the base of the cup.

9.
Between contractions, the pressure is released.
10.
Episiotomy is required so that the vaginal opening will be large enough for the baby to be delivered. Once the baby's head has reached the vaginal opening (crowning), the vacuum pressure is released and the baby is delivered like spontaneous vaginal delivery.  
11.

Following delivery of the head, mucus in the baby's nose and mouth are sucked. After that the baby's shoulder and trunk are delivered.

12.
This is followed by  delivery of placenta by control cord traction.
13.
Any lacerations of the vagina are repaired using absorbable suture (stitches that do not need to be removed).

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Breech Delivery

There are 3 types of breech presentation:

  • Extended or frank breech - the hips are flexed, with the thighs and knees are extended
  • Flexed breech - hips flexed with thighs against the chest, and knees also flexed
  • Footling breech - the hips and knees are not flexed and the feet is the lowest most

Conditions required before breech delivery

Before breech delivery can be performed, these conditions must be fulfilled;

1.
The baby is not excessively small or large (less than 2.5kg)
2.
The pelvis is not excessively small.
3.
Baby is not in footling breech. Extended breech is the most favorable presentation for this type of delivery.
4.
Cervical os is fully dilated

Procedures

1. Local anaethetics is usually used during delivery.
2. Episiotomy is often used to allow a bigger vaginal opening.
3. The buttock will be delivered followed by the shoulder, trunk and head.
4. Forceps is sometimes used in breech delivery.
5. If there is any delay in delivery, the doctor will usually convert into caesarean section.

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Caesarean Section

Caesarean section is a form of delivery whereby a surgical incision is made through the mother's abdomen and uterus to delivery the baby. This is usually performed when vaginal delivery would put the baby's or mother's life or health at risk.

 History

There is a myth which states that the word "Caesarean" originates from "Caesar", the Roman ruler, who according to the legend, was delivered by Caesarean section. But this is doubtful as his mother, Aurelia Cotta, lived for many years afterwards. At that ancient time, Caesarean section was performed when the mother was dead or dying, as an attempt to save the baby. Caesarean section at that time was not intended to preserve the life of the mother. It will only perform when the mother is dying to save the baby.

Development of surgical techniques and anesthesia, later improves the procedure results in low morbidity and mortality. The first successful Caesarean section was done in 1882. However, there were complications due to poor facilities.

 Why do you need a Caesarean Section?

Out of the reported Caesarean deliveries, 50% are planned, i.e. Elective Caesarean; another 50% are Emergency Caesarean.

Elective Caesarean is planned for:

1. Multiple pregnancies
2. Baby in breech (buttock/ feet first) or transverse (lying horizontal) position
3. Placenta praevia (placenta obstructs the birth canal)
4. Mother having severe high blood pressure
5.

Previous history of birth complication

Emergency Caesarean is carried out:

1. To avoid complications during labor, eg. Fetal distress
2. When cervix does not open sufficiently
3. When mother in labor with baby's position unfavorable for vaginal delivery

 Procedures of Caesarean section

1.
Fasting 6 hours before Caesarean section.
2.
Prior to the procedure, the nurse will help you to put on a gown and shave your private area.
3.
A rubber catheter is inserted to empty your bladder.
4.

An intravenous (IV) line is inserted.

5.
The obstetrician will make an incision which is approximately 10 cm long at the bikini-line after you are under anaesthesia.
6.
The uterus is cut at the lower segment, therefore the procedure is known as LSCS, which means lower segment Caesarean section.
7.
Water bag (amnio sac) is broken.
8.
The baby is delivered and lifted out of the uterus.
9.
The cord is clamped and cut to separate the baby from the mother.
10.
The baby will be passed over to the care of paediatrician.
11.
The obstetrician will then separate the placenta and deliver it.
12.
The uterine incisions is stitched in 2 layers. The abdomen is closed in layers. The skin stitches are removed after 1 week.
13.
You will be removed to the recovery room for observation.

It generally takes 5 minutes from the time of skin incision until the baby is born. The rest of the surgery will take 30 minutes.

 What will happen to me after Caesarean delivery?

1.
You will need to stay in hospital for another 3 days.
2.
Immediately after the Caesarean surgery, you will feel drowsy.
3.
You will be given effective pain relief to minimize the pain when you wake up.
4.
You will find your abdominal muscles slack. Do not worry, after 6 weeks, you can start doing abdominal exercises to get back to shape.
5.
Try to start moving as soon as possible to improve your circulation and prevent blood clot in your lower limbs.
6.
Try to get out of bed a day after surgery. You can ask for assistance from the nurses if you need some physical supports.
7.
You should take everything easy and rest as much as you can. You should not lift anything that is heavier than your newborn.
8.
You may tend to 'stoop' when you stand up but remember it is important to stand up straight.
9.
Wear high-waist, soft underwear to avoid rubbing against your wound.
10.
For the first week, you have to sponge yourself (do not wet your wound).
11.
On the 7th day after delivery, you need to go back to the hospital for removing the stitches.
12.
After removal of the stitches, you may take a bath.
13.
Your new scar will appear like a fine red line just below your panty line.
14.
Sometimes the scar might be sensitive, itchy and uncomfortable for several weeks before it heals. Your wound should heal completely by 6 weeks post natal.
15.
Occasionally, lumpy tissues will form on your scar. You can get steroid cream from pharmacy to help to reduce the thickness of your scar.

 Myths

Myth 1:
Once a Caesarean, always a Caesarean.
Fact:
Many years ago, in classical Caesarean section, the incision was made vertically; the resulting scar was weak and had a risk of rupturing in subsequent vaginal deliveries. So, it was appropriate then once a Caesarean section, the subsequent delivery should be a Caesarean section. Nowadays, incision is made horizontally across the lower part of uterus. The new method reduces blood loss and the risk of uterine rupture. Thus, women are allowed to have vaginal birth after Caesarean (VBAC) if their conditions allow them to do so. However, after 2 or more Caesarean sections, the mothers are advised to have elective (planned) Caesarean section since it is believed that the risk of Caesarean scar to rupture increases with the number of previous history of Caesarean section. The risk of uterine rupture for a VBAC is about 1% and the risk of fetal death or significant complications (fetal or maternal) is about 10% to 30% when rupture occurs.
 
Myth 2:
Caesarean section will eliminate the risk of pelvic organ prolapse or urinary incontinence in the future compares to vaginal delivery.
Fact:
There is a correlationship between a prolonged or traumatic vaginal delivery and increased risk of pelvic organ prolapse and urinary incontinence. However, this should not be the reason for a Caesarean section. Those women who wish to avoid or prevent incontinence should take other steps such as maintain a healthy body weight and practice pelvic floor exercise (Kegel exercise) after delivery.
 
Myth 3:
t is possible to predict the mother who will deliver vaginally prior to deliver.
Fact:
Countless studies had shown that there is little accuracy to predict whether the pelvic is 'adequate' for a certain size of baby. Ultrasound has a 10% to 20% of inaccuracy in predicting fetal weight. So, most of the doctors assess adequacy of the vaginal delivery by trial labour.

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