The surgery of labour

From Primary Surgery

18.1 The two worlds of obstetrics

If labour does not proceed normally, you will have to intervene and help a mother. How best you should do this, and what methods you should use, depends greatly on where in the scale of advantage and disadvantage she is. This has been beautifully described by John Lawson: Obstetrically, there are now two worlds, with pockets of one world in the other, and every gradation between the two. In the advantaged mdustnal world Caesarean section is now so safe that it has done much to change the whole pattern of obstetrics there. In that world obstetric services are good, and theatres and blood banks well organised. If a mother needs a Caesarean section, it is done by a skilled obstetrician and an experienced anaesthetist. Antenatal care is available everywhere, transport is easy, and most mothers are sufficiently educated to understand why they should have a hospital delivery if they need one. Most of them only plan to have two or three children anyway, and are not frightened by the possibility that Caesarean section might reduce theu chances of havmg any more. Just because it is so safe, it is used electively for between 5. and 10% of mothers as a means of anticipating difficulty, rather than dealmg With disaster. It is done so efficiently that traumatic vaginal deliveries and perinatal deaths from bIrth injury have almost disappeared. . Most mothers in the developing world are less fortunate. A really dIsadvantaged one must have six or seven children, so that three or four will survive. If she has an obstructed labour in a distant village, she may arrive in your hospital after a long journey, dehydrated, ketotic, shocked, anaemic, or infected, or all of these things. If you have to do a Caesarean section, you may have to do it through infected tissues, so that it may be followed by pentomtls, which antibiotics may fail to control. When she has recovered, she may remember only a frightening operation followed by a difficult puerperium, and deliberately not seek hospital care. when she becomes pregnant again. If her baby died, she may blame the hospItal for hiS death and decide to have her next one at home. Unfortunately, Caesarean section seldom removes the factor which caused it, so that her narrow pelvis, which may have been the reason for her Caesarean section, is probably still there. But the scar in her uterus is now its weakest part, so that the chances of It ruptunng are great. How can you help a mother like this? She may have no antenatal care in her next pregnancy, and be unable to reach hospital for her next delivery. How can obstetrics be adapted to her needs, without being dominated by the practice of the industrial world? One answer is to make good use of the alternatives to Caesarean section, and one of the main purposes of this chapter is to describe them. Unfortunately, in many hospitals the methods used to assist a mother who is delayed or obstructed in labour are unnecessarly limited. If an oxytocin drip and a vacuum extractor fail, Caesarean section is automatic, and other possibilities are not considered. If her CPD (cephalopelvic disproportion) is mild, she can have a symphysiotomy (18.6, M 22.7). If her baby is dead, she can have a destructive operation (18.7). . An alternative, which is not practical, except in the hands of an expert obstetrician, is the standard type of mid-cavity rotational forceps, such as those of Kielland. In the hands of anyone else, these forceps are so dangerous that a mother and her baby will be safer if you do a Caesarean section, which you will have to learn to do anyway. So you will find that the only forceps mentioned here are Wrigley's pattern of outlet forceps ('low forceps', M 22.6). The only acceptable use of the standard mid-cavity forceps by non-experts is their application to the aftercoming head during a breech delivery. For this purpose outlet forceps can however usually be used instead. 257 Your first priority should be to see that, when a mother is admitted, she is examined by the most experienced person available. She must be carefully observed not less than four-hourly thereafter, and the observations that are made accurately recorded on her partogram. Unless this happens, the whole process of labour management breaks down. The team will need guidelines to know when to call you. For the most part, they are the same as those for which a health centre refers her to hospital (M 18.11). Make sure you are called too often, rather than not often enough. Besides the methods described here, you will also find the following useful: an oxytocin drip (M 22.2), vacuum extraction (M 22.3), symphysiotomy (M 22.7), and outlet forceps (M 22.6). (1) When you start any operative delivery make sure that the midwife who is assisting you knows how to resuscitate the baby, and has the equipment ready for doing this (19.12). In some hospitals, the results of not doing so are seen only too tragically, in the numbers of handicapped children who attend their paediatric clinics. (2) Don't forget to relieve pain when you can, so make proper use of pethidine (M 18.15), pudendal blocks (18.1a), and trichloroethylene (A 11.7). Lawson J. 'Embryotomy for obstructed labour'. Tropical Doctor. 1974;188-91.

18.1a Obstetric anaesthesia

Anaesthesia is often the most dangerous part of a difficult delivery. In most district hospitals general anaesthesia is best avoided in obstetrics, except for Caesarean sectIon, when the patient is bleeding, or is already hypovolaemic, or is very ill. It should be expert, and she must be intubated. It is dangerous in the circumstances of most labour wards, and the theatre may take dangerously long to get ready. Most Caesarean sections can be done under subarachnoid (spinal) anaesthesia, provided you take the necessary precautions (A 16.6). You can also use local anaesthesia (A 6.9). For a .vacuum extraction and outlet forceps, use a pudendal block, WIth local infiltration anaesthesia for the episiotomy. For a destructive operation, other than a transverse lie, use a pudendal block combined with intravenous pethidine and diazepam (A 8.8). For a transverse lie, she must have a general anaesthetic. For manual removal of the placenta, use intravenous pethidine and diazepam. Epidural anasthesia is excellent, but is probably impractical, except in specialized well-staffed obstetric units: The routine aseptic prcedures in your wards may not be rehable enough to justify its routine use, and you will probably not have the staff to monItor it. LOCAL ANAESTHESIA FOR AN OPERATIVE VAGINAL DELIVERY Primary Anaesthesia describes transvaginal pudendal block, but not the alternative perineal pudendal block, nor any method of local infiltration. These are described here. Use a total of 50 ml of 0.5% lignocaine or 1% procaine, both with adrenalin (A 5-1). LOCK ANAESTHESIA FOR AN A OPERATIVE ... VAGINAL DELIVERY '\ D E I, \1 Fig. 18-1 WCAL ANAESTHESIA FOR AN OPERATIVE VAGINAL DELIVERY. A, feeling for a patient's ischial spine for a transvaginal pudendal block. B, injecting for a transvaginal pudendal block. C, the injection site for doing a pudendal block through her perineal skin. D, local anaesthesia after a pudendal block. E, local infiltration alone from a single central puncture site. 1, her ischial spine. 2, her ischial tuberosity. 3, the site ofinjection for pudendal block through her perineum and for local infiltration anaesthesia after a pudendal block. After Howie, Beryl. (High Risk Obstetrics' Fig. 14-6 and 14-7. Macmillan Publishers, with kind permission. Transvaginal pudendal block: see Section A 6.13. Perineal pudendal block: raise a skin wheal half way between the patient's vaginal opening and her ischial tuberosities, as in C, Fig. 18-1. Use a 12 cm x1 mm needle to reach her ischial spines. Inject about 12.5 ml of solution on each side. Local infiltration anaesthesia is needed to supplement a pudendal block for most operative vaginal deliveries. For a low forceps delivery or episiotomy local infiltration alone may be enough. Keep the needle moving while you inject 25 ml of solution. After a perineal pudendal block, use the same needle to puncture and infiltrate, as in D, 18-1. After a transvaginal one make fresh punctures. For local infiltration alone, inject radially from a single central puncture site (E). CAUTION! (1) Premedicate her with pethidine and diazepam.

(2) Distinguish her ischial spines from her ischial tuberosities.

(3) ALWAYS withdraw the plunger before you inject. If you withdraw blood, move the needle, or you will inject the anaesthetic solution intravenously. (4) Give the anaesthetic enough time to act (at least 3 minutes).

18.2 Delay in labour Labour is seldom any problem if it goes at its proper pace. Most trouble starts when it is delayed. If you are going to manage delay, you must know as early as possible that it has occurred. To know this you will need an effective method of monitoring labour-the partogram (or in WHO's terminology, the 'partograph') which Primary Mother Care describes in detail (M 18.2). The most important part of this is the 'cervicograph' which plots the dilation of the cervix in centimetres, and the descent of the head in fifths above the brim, against the duration of labour in hours. The purpose of the partogram is: (1) To prevent obstructed labour and ruptured uterus (which cause of maternal deaths in some areas) by enabling peripheral health workers to monitor labour, so as to detect deviations from the normal more effectively, and thus to refer mothers at the optimum momentbefore it is too late. This is the purpose of the 'alert line'. Ideally, the partogram should only be used to monitor those labours which are expected to be normal; mothers with 'risk factors' should have already been referred. (2) To monitor all labours in hospital, so that you know when to intervene. This is the purpose of the 'action line'. If the 'progress line' of a mother's cervical dilatation moves to the right of the alert line, be extra vigilant. If she reaches the action line you must do something, if you have not already done it (see below). The partogram depends on the principles that: (1) The latent phase of labour should not last longer than 8 hours, hence the thick vertical line at this point. (2) The latent phase ends and the active phase starts when her cervix is 3 cm dilated (4 cm is sometimes used). (3) During the active phase her cervix should dilate at not less than 1 cm per hour. (4) A lag time of 4 hours is usually acceptable between the slowing of labour and the need to intervene; this is the distance between the alert and the action lines. The WHO partogram uses fixed alert and action lines and transfers her to the alert line as soon as she reaches 3 cm, as has been done for Mother C, in Fig. 18-2a. Name.......................... Gcavlda Para 1I0spltal No . Date of admission Time of admission Ruptured membranes hrs SOME CERVICOGRAPHS THE CRITICAL AREA IN A CERVICOGRAPH Fig. 18-2a SOME PARlOGRAMS. If you don't have enough partograms for every mother, put a clean sheet of X-ray film over one of them, write on this with a marker pencil, and then wash the film clean for the next patient. Mother A, was admitted at 3 p.m. 4 cm dilated in the active phase of labour; her progress line remained to the left of the alert line and she delivered normally. Mother B, was admitted at 9 a.m. 1 cm dilated; her latent phase lasted 8 hours and her active phase 3 hours. Mother C, was admitted at 1 p.m. 1 cm dilated with her baby's head head 5/5 above the pelvic brim. At the next vaginal examination (5 p.m.) his head was 4/5 above the brim and she was 5 cm dilated. She was therefor transferred to the 'alert line'; her cervix continued to dilate, his head descended, and she delivered normally. Mother D, was admitted to a health centre with her baby's head 4/5 above the brim and her cervix 3 cm dilated, so she was put on the alert line. At 12 midday she was only 6 cm dilated and had moved to the right of the alert line, so she was transferred to hospital. When she arrived at 4 p.m. she was still only 7 cm dilated and had reached the action line. His head was 3/5 above the brim, with a moulding score of3; it was not posible to put a finger between his head and her pelvic wall, so, following the indications in Section 18.4, she was sec tioned.

Fig. 18-2b THE CRITICAL AREA IN A PARTOGRAM.

In a peripheral unit, ifa mother's progress line reaches this area, she should be referred. In hospital, it is the area in which you should consider intervening; the darker the shading the more important this is. Don't let her cross the action line! Dilatation of the cervix and its relation to the action line is only one of the factors measuring the progress of labour, and the necessity to intervene. It and the descent of the baby's head are the only two factors plotted on the cervicograph. Although they are the most useful and the most easily plotted ones, there are others which determine what you should do and when you should do it, they include: his presentation, his moulding score, his condition (fetal distress), his mother's condition, and the strength and frequency of her contractions. Consider all these factors, and don't be guided only by the dilatation of her cervix in relation to the action line and by the descent of his head, critical though these are. The position of the action line is to some extent arbitrary, and some obstetricians like the alert and action lines closer together. Intervention needs to be earlier in a multip than in a primip, so some partograms have two action lines, one at 3 hours for multips and one at 4 hours for primips. Some hospital partograms leave out the action line altogether and take the alert line as the action line. The important point is that the further the progress line is from the alert line, the greater should be your vigilance, and usually the greater your need to intervene. When, later, we say "If she approaches the action line, do ..." what we really mean is that she has already crossed the alert line and is getting progressively nearer the action line (ifyour partogram has one). When this is happening, assess all the factors listed above (and others) and decide what to do next, using the guidelines below and in Section 18.4. Some hospitals consider that 1 cm per hour is 'too active', and leads to an unnecessarily high Caesarean section rate, which is not suitable for populations with an average of perhaps 8 children, and when Caesarean section has to be done under less than ideal circumstances in small hospitals, so they give the alert line a flatter slope. Partograms have proved so useful in reducing both maternal and perinatal mortality, that not to introduce them might almost be considered criminal neglect. If you don't already use them, you must/ There is full-size copy on an endpaper, and also an interim version of the the other side. A further version of this will be included in Primary Mother Care. 'Obstetrics Handbook', Faculty of Medicine, University of Natal, 1984. Philpott RH, 'Obstetric Problems in the Developing World', Clinics in Obstetrics and Gynaecology 1982;9:3. 'The Partograph'. Section One, 'The Principle and Strategy'. Section Two, 'A user's manual'. 1988 Maternal and Child Health Unit, Division of Family Health. WHO Geneva. ARE YOU AND YOUR CLINICS USING PARTOGRAMS? THE GENERAL METHOD FOR DELAY IN LABOUR Here is the general method for delay in labour. If the presenting part has not only failed to descend, but there have also been these signs, labour is not only delayed, it is also obstructed: severe moulding and caput, fetal distress, a stretched lower segment, bloody urine, etc. If so, see Section 18.3. DELAY IN THE LATENT PHASE (primips and multips) The latent phase is prolonged, if a patient who was 'admitted in labour' has not reached the active phase after 8 hours. First distinguish 'false labour' and a truly prolonged latent phase. False labour: her membranes are still intact, a nullip's cervix remains long and closed (or just admits a finger tip), a multip's cervix is not effaced (even though it may be 1 or 2 cm dilated). Explain that she is not in labour, and send her home if she wishes. If she insists that she feels painful contractions give her pethidine 100 mg, let her sleep, and then discharge or review her. Truly prolonged latent phase: Her cervix is completely effaced, but remains stationary at about 2 cm. Or it effaces and dilates very slowly. Either, (1) Sedate her with pethidine 100 mg, repeated if necessary, and wait. Or, (2) let her walk about. Or, (3) rupture her membranes and give her an oxytocin drip. DELAY IN THE ACTIVE PHASE primips If a primip's progress line approaches the action line, she may have primary uterine inertia, or there may be some mechanical reason for it. Section her if: (1) She has gross CPD (head 4/5 above the brim and marked moulding). (2) A malpresentation (breech, transverse lie, face, or brow, etc.).

(3) Fetal distress (M 20.4, M 21.3). If she has none of these things, manage her actively to decide if she has doubtful CPD, or no CPD. Manage her like this.

(1) Correct her dehydration and ketosis. Give her a drip of 5% dextrose.

(2) Provide adequate analgesia (A 2.9, M 18.15). Either give her a lumbar epidural block (A 7.2), or give her pethidine 100 mg and promethazine 25 mg, both intramuscularly.

(3) If you are sure she is in labour (that is her cervix is dilated 3 cm or more) and her membranes are not already ruptured, rupture them.

(4) Stimulate her uterus with oxytocin. Add 5 units of oxytocin to 500 ml of 5% dextrose, and start at 10 drops a minute. Increase the rate of the drip by 10 drops a minute at half-hourly intervals, until she is having contractions lasting 45 to 60 seconds at a frequency of 3 to 4 in 10 minutes. Make the first increment to 20 drops a minute, and half an hour later to 30 drops a minute. As soon as she has good contractions, don't increase the speed of the drip any more.

(5) Monitor her progress and her baby's condition carefully. Monitor his heart and watch for signs of fetal distress, especially slowing of the fetal heart (meconium staining of the liquor is common, and is an unreliable sign, M 20.5).

Decide how you are going to deliver her within 6 hours of starting the the oxytocin drip. Section her if any of these things happen, they are probably all signs of severe CPD: (1) There is fetal distress. (2) At the end of 6 hours she is sti 11 dilating less than 1 cm per hour, and the head is not descending. (3) It remains high, with moulding. DELAY IN THE ACTIVE PHASE multips If a multip's progress line approaches the action line, this is serious, and you will need to assess her carefully. Don't try to stimulate her uterus with oxytocin, unless you are absolutely sure there is no CPD (see Section 18.4a). This is difficult to be sure about, and if you are wrong, and there is CPD, her uterus may rupture. One contributor advises no oxytocin for multips! If she is in definite labour (her cervix is 3 cm or more) and her membranes have not already ruptured, rupture them. If you are in doubt, observe her for 2 more hours with adequate analgesia, and then reassess her. Feel her contractions yourself. She may progress to full dilation even when there is major CPD. You can only detect this by finding severe moulding and caput, with failure of the head to descend, and delay (more than 20 minutes in the second stage). CAUTION! Some mothers have 6 or 8 normal labours, and then need section for CPD with their next pregnancy. DIFFICULTIES WITH DELAY IN LABOUR If a patient is referred because of DELAY IN THE LATENT STAGE (M 20.7), look carefully for hidden CPD. If there is no CPD, rupture her membranes, and give her an oxytocin drip. Clinics should refer these cases, because CPD is not easy to recognize. Provided there is a vertex presentation, it is always worth rupturing the membranes and waiting a little to see what happens. CPD is almost impossible to diagnose when the membranes are intact. 18.3 Obstructed labour The exact point at which the 'delay' discussed in the previous section becomes the 'obstruction' discussed in this one is arguable. Obstruction is 'the failure of the presenting part to descend in spite of uterine contractions' (M 23.1). What really distinguishes delay from obstruction is the secondary signs and complications that follow: severe moulding and caput, foetal distress, a stretched lower segment, bloody urine, fistulae and rupture of the uterus, etc. Whereas delay in labour is usually inevitable and readily treatable, and is comparatively harmless, obstructed labour is none of these things. It should never happen where care is adequate. .Obstruction may be due to: (1) An abnormality in a mother's pelvis (a contracted pelvis). (2) An abnormality in her baby (hydrocephaly, etc.). (3) An abnormality in the relationship between them. This can either be: (a) an abnormal lie or presentation (a breech, a brow, or a face, or a shoulder presentation, or a prolapsed arm in a transverse lie), or (b) an unfortunate coincidence of their relative sizes (CPD, cephalopelvic disproportion, he may be too big for her, or she may be too small for him). (4) Rarer causes, such as stenosis of the vagina, locked twins, or a pelvic tumour, particularly fibroids or an ovarian cyst. CPD is the most important cause (two-thirds of cases), and an impacted transverse lie is the next. This is much less readily anticipated antenatally, especially when it complicates the delivery of a second twin. Much of the purpose of antenatal care is to screen mothers who are at risk from obstructed labour. The purpose of the partogram is to detect it early. In practice, when the presenting part stops moving through the birth canal, you may not be able to tell if this is because: (1) the uterine contractions are weak (uterine inertia), or (2) because the baby and the pelvis are such that one will not go through the other (CPD). Often, there is a combination of inertia and CPD. Preventing obstruction depends on: (1) Good nutrition starting in childhood, so that mothers reach their genetically determined height, and their pelves their genetically determined size. (2) Universal antenatal care, so that obstructed labour can be anticipated from a mother's history, and any risk factors for it identified. (2) The monitoring of labour by skilled staff, so that she can be referred at the first sign of danger, before she obstructs. The detailed preventive measures are: (a) Screening for risk factors, especially short stature (M 5.3). (b) A pelvic assessment at 36 weeks (M 6.6). (c) The routine use of the partogram. When adequate antenatal care is impossible, and where health centre and hospital beds are limited, the establishment of a 'mother's waiting area' or a 'mother's village' is a useful alternative. Obstructed labour is a major failure of obstetric care. Unfortunately, it still happens, even in some hospitals. How often you will see it will defend on the prevalence of CPD in your area, and the quality 0 your antenatal and obstetric care. Alas, the poorest communities with the worst health services are usually those with the most CPD. In a labour that is going to obstruct, the first stage is often prolonged, but it can be normal or even short. A mother's membranes rupture, and her liquor escapes. Her uterus contracts and retracts, and forces her baby into its lower segment, which gradually becomes overstretched. Obstruction prevents his escape, so her lower segment moulds closely round him and thins. The contractions of her uterus become hypertonic, and relaxation between them poor. The placenta is poorly perfused, there is fetal distress, and he dies. Obstructed labour has two main dangers: (1) Her vagina, bladder, and rectum are trapped between his head and her pelvis, so that they become necrotic, slough, and develop fistulae. (2) Her uterus ruptures. Primips usually develop fistulae, and multips usually rupture their uteri, but both can do either, and rupture and fistulae can occur in the same patient. A primip begins to have trouble when her cervix fails to dilate normally. An oxytocin drip (M 22.2) may speed it up if her CPD is minimal, but cannot do so if it is gross. The result is that her labour usually obstructs before she is fully dilated, although she will usually reach full dilatation eventually. If her obstruction is not rapidly relieved: (1) It produces asphyxia in her baby, due to prolonged uterine contractions reducing the placental blood flow. (2) It may injure his head, so that he is born with a birth injury. (3) It causes a pressure necrosis, and sloughing of her anterior vaginal wall. As this slough separates, she develops a fistula between her bladder and her vagina (18.18), which may involve the proximal half of her urethra and/or the neck of her bladder, up to its ureteric orifices. Later, as the ring of necrosis in her vagina heals and contracts, it stenoses. Or, she may develop a fistula between her rectum and her vagina (18.19). If she does not die herslf, she delivers an injured, severely moulded dead baby. She is also at risk from septic shock (53.4), peritonitis, peritoneal abscesses, atonic postpartum haemorrhage (19.11a), and foot drop from the pressure of his head on her sciatic nerves. Even if her fistula can be repaired, and there is at best only about an 80% chance of this, she may be infertile, and her vagina may be so stenosed that sex is difficult. If it is repaired, and she becomes pregnant again, she must be sectioned to prevent the repair breaking down. If it is not repaired (in which case she is less likely to become pregnant), stenosis of her vagina is likely to prevent vaginal delivery. Here is one such primip. MPHO MOKETE (14 years, para 0, gravida 1) became pregnant after her first period. She hid her pregnancy from her parents, and so received no antenatal care. She arrived tired, exhausted, anxious, and febrile, with a fast pulse. Her contractions were strong and painful, with little relaxation between them. The head of her baby, who showed signs of fetal distress, was high, and overlapped the brim of her pelvis. Her liquor had drained, so that her uterus was moulded around him. Her vulva and cervix were oedematous, and although his head could be felt just inside her cervix, this was not because it had descended, but because his head was severely elongated. Abdominal examination showed that most of it was still above her pelvic brim. Her vagina was dry and 'hot', and her cervix not fully dilated. Her bladder was distended. Catheterizing her was difficult, and his head had to be dislodged by putting two fingers into her vagina, and pushing it up. Her bladder was drawn up so high that the catheter had to be passed a long way before any urine flowed; when it did so, it was blood-stained. Her baby was alive, and his head was 4/5 above the brim, so she was not suitable for symphysiotomy or vacuum delivery. She was therefore resuscitated with intravenous fluids, given antibiotics, and delivered by Caesarean section. He survived, but her wound became infected, and she developed a pelvic abscess, which was drained. She was in hospital a month, and was lucky not to develop a fistula. LESSONS (1) The decision to section her was correct, but it should have been done extraperitoneally (18.13). (2) She is only 14, so her pelvis will continue to grow. (3) She is at risk of a ruptured uterus in future, so she must deliver in hospital. A multip may show the same failure to dilate as a primip, or her cervix may dilate normally to begin with, and then slow during the active phase, only to dilate finally if she is left untreated. Meanwhile, the presenting part fails to descend. Here is one such multip. MAPULESA (35, para 8 gravida 10) arrived just before her uterus ruptured. She too was anxious, distressed, and febrile. Her cervix however was fully dilated. Her lower segment had continued to retract and thin, so that the junction between her upper and lower segments had risen in her uterus as far as her umbilicus. She had a 'three-tumour abdomen' - an oedematous distended bladder, a distended, tender lower segment, and a tonically contracted upper segment. A ring (Bandl's ring) could be felt through her abdominal wall between her upper and lower segments (G, Fig. 18-3). Her round ligaments stood out on either side of her ballooned lower segment, like the guy ropes of a tent. Vaginal examination revealed a brow presentation. She was resuscitated with intravenous fluids, and sectioned. At operation her uterus was found to have ruptured into her abdominal cavity. Her baby was alive, but was asphyxiated, and died in an hour. Her uterus was repaired, her tubes were tied, and she recovered uneventfully. LESSONS (1) Even a patient who has had many normal deliveries may OBSTRUCTED LABOUR Normal labour B c upper segment segment Obstructed labour ring Fig. 18-3 OBSTRUCTED LABOUR. A, B, and C, during a normal labour the hemispherical lower segment is converted into a cylinder: it thins but does not elongate. During the second stage the uterus shortens itselfbycontractionoftheuppersegment. Duringanobstructedlabour the uterus cannot empty, so the thinned lower segment elongates (D, and E). F, sometimes a palpable ring (Bandl's ring) forms between the upper and lower segments. G, you may sometimes see or feel three distinct abdominal swellings: (1) the bladder, (2) the lower segment, (3) the upper segment. Bandl's ring separates the lower and the upper segments. After Lawson JB and Stewart DB, 'Obstetrics and Gynaecology in the Tropics; Fig 11.2. Edward Arnold (1967), with kind permission. get an obstructed labour from a malpresentation or malposition. (2) A partogram would have given earlier warning of her impending obstruction. The critical event in a patient like this is rupture of her uterus. This usually starts in her thin lower segment, and extends downwards on one side into her vagina, as well as upwards towards her fundus. Several things can then happen: (1) The presenting part may remain jammed in her pelvis. (2) Her baby may be expelled through the rupture into her peritoneal cavity. (3) She may bleed from the rupture into her vagina. (4) Occasionally, her bladder also ruptures, especially if it has stuck to the scar of a previous lower-segment Caesarean section. Before rupture the signs that it is imminent are: (1) The failure oflabourto progress. Lack ofprogress should therefore alert you to the possibility that rupture might be imminent. (2) Bandl's ring. (3) A distended bladder which is difficult to catheterize. (4) Frequent strong uterine contractions, with little or no pause between them. If a patient is brought in on the verge of rupture, you may perhaps see it occurring, before you can treat her. After rupture, a mother may have little or no pain. If you ask her, she will tell you that contractions were strong, but then suddenly stopped, and were replaced by a lesser continuous pain, or no pain. She may be in severe hypovolaemic shock, with cold, sweaty skin, and a weak or absent radial pulse. She may be quite obviously collapsed, or alert and even talkative. You can feel no uterine contractions, but you can usually feel her baby through her abdominal wall lying free in her abdomen. For the management of a ruptured uterus, see Section 18.17. To summarize: (1) A primip's uterus seldom ruptures, but she often develops fistulae. (2) A grand multip's uterus often ruptures, but she seldom develops fistulae. (3) Failure to dilate is a useful warning signal in a primip, and in most multips. In a multip the first sign of obstruction may be failure of the presenting part to descend at full dilatation, in spite of strong and frequent contractions, and increased moulding of her baby's head. A multip who has not delivered after 20 minutes in the second stage is in great danger. 18.4 Managing an obstructed labour If a patient with obstructed labour is admitted from home, she may have been in labour for days, and tried many home remedies. Her stomach is likely to be full, and she can inhale its contents only too easily. She is thus a major anaesthestic risk. There are several ways in which you can deliver her, but the standard midcavity or rotational forceps, such as Kielland's, should never be one of them (18.1). Vaginal delivery is often possible, but try to avoid a difficult one. Learn to predict when it is going to be difficult, so that you can avoid a 'failed vacuum', and do a Caesarean section or a symphysiotomy (18.6, M 22.7) to begin with, especially when there is fetal distress. An operative vaginal delivery is absolutely contraindicated ifher uterus has already ruptured - do a laparotomy. Often, you will not know if it has ruptured or not, so do all vaginal operations for the relief of obstructed labour in the theatre, with a set of laparotomy instruments ready for instant use. Caesarean section has a limited role, and is likely to be a serious risk, so don't do it lightly. It is mainly indicated: (1) when a baby is alive and his mother is in reasonable condition. (2) When a destructive operation on a dead baby would be dangerous, because his head is mobile 3/5, or more, high above her pelvic brim (rare). Try not to section her, if she cannot be sure of adequate care in her next delivery, or if your skills and facilities for doing so safely are not good. If you have to section her, Section 18.8 will help you to decide on the most suitable method. A destructive operation (M 22.10) is indicated when her baby is dead, her cervix is fully dilated or nearly so, the presenting part is fixed in her pelvis, and her uterus has not ruptured, and is in no danger of doing so. Usually, you can be fairly sure that a uterus is not going to rupture. If you are in any doubt, the only way to find out is to do a laparotomy, and see if there is a rupture. If you don't find one, close her abdomen and deliver her vaginally. OBSTRUCTED LABOUR A mother in obstructed labour is in great pain, anxiety, and distress. In the bustle of treating her, don't forget to comfort and reassure her. If her baby is already dead, tell her. If you don't, she may blame you for his• death, and not come to hospital when she is pregnant next time. Many of the steps and complications are the same as for rupture of the uterus, so see Section 18.17. TH E DIAGNOSIS. Suspect obstructed labour when: (1) Her cervix does not dilate in spite of good contractions. (2) Moulding and caput increase, but her baby's head does not descend. (3) She becomes anxious and restless. (4) She develops hypertonic uterine contractions, with poor relaxation between them. Other signs are: (5) A stretched lower segment. (6) Bloody urine. (7) A cervix which is not well applied to the head (variable). An important differential diagnosis is a prolonged latent phase without obstruction. If she was made to push during the latent phase, she may be distressed and dehydrated, and her vulva and cervix may be oedematous. Her cervix will however not be dilated, or only slightly so, her membranes are likely to be intact, and there will be no Bandl's ring. Reassurance, analgesics, and fluids may be all she needs. The diagnosis of obstruction is certain if: (1) Bandl's ring (18-3) is present, or (2) she has a bladder fistula or necrosis. This takes 2 or 3 days to develop, so it is rare for her to present with one. When you diagnose obstructed labour, the next critical question is: has her uterus already ruptured? To answer this, see Section 18.17 on rupture of the uterus. If it has not ruptured, proceed as follows: HYPOVOLAEMIC SHOCK (very common). Resuscitation must be rapid, because delivery is urgent. Admit her directly to whatever high-risk area you have, usually the labour ward or the theatre, and resuscitate her there. This wi 11 allow you to operate as soon as she is in an optimal condition. Correct her dehydration, her electrolyte deficit, and her acidosis (A 17.2). Rehydrate her with 0.9% saline or Ringer's lactate, and continue with dextrose 5%; there is usually no need to give her bicarbonate. She may need blood, preferably the red cells only. If her haematocrit is raised as the result of dehydration, a transfusion, even of safe blood, may be harmful-she needs fluids. If possible, set up a central venous line and measure her CVP (A 19.2). If this is within the range of 5 to 8 cm of water, and she is still shocked, at least part of her problem is likely to be septic shock exacerbated by ketosis. Record her pulse, her blood pressure, and her CVP every five minutes during the operation. Monitor her urine output regularly. If it falls to less than 30 ml/hour, see Section 53.3. SEPTIC SHOCK (less common). If she is ill and weak, but not actually in septic shock (53.4), she probably soon will be, if you don't prevent it. So start the following regime prophylactically. Give her intravenous chloramphenicol and intravenous or rectal metronidazole (2.9). If, in spite of this, her blood pressure remains low, her urinary output is poor, and her vessels remain constricted, she needs a titrated infusion of dopamine (53.4). This will cause peripheral dilatation, and a fall in her CVP. Correct it immediately with more intravenous fluids. ANAESTH ESIA. If she is to have a Caesarean section, see Section A 16.6. If she is to be delivered vaginally, use a pudendal block (18.2, A 6.13), a saddle block (A 7.7), or an epidural block (A 7.3). Remember to insert a nasogastric tube. METHODS OF DELIVERY WHEN THE PRESENTING PART HAS SlOPPED DESCENDING You will probably find the following summary one ofthe most useful sections in this manual, since it is the key to this chapter. It covers a variety of situations in which the presenting part no longer descends in the birth canal. In some of them, the classical signs of obstructed labour (severe moulding, etc.) have yet to occur, so it is a combination of methods for the management ofdelay and obstruction. First the various methods are considered (episiotomy, etc.), and then the various clinical situations you might meet. Before you continue, you will need to: Assess the height of the baby's head (M 18.4). Don't assess the height of his head by vaginal examination only. There will be much caput, and this will mislead you. It is the descent of his skull that matters, not the descent of his caput! Assess his moulding score (18.6). Feel where his parietal and occipital bones touch one another. Bones still separate, score O. Bones touching, score 1. Bones overlapping, but separate when you press with a finger, score 2. Bones overlapping but not separable, score 3. Overlapping at both the sagittal and the lambdoid sutures, is more serious than overlapping at the lambdoid suture only (this is the suture between the parietal and the occipital bones). Watch for fetal distress. Count his heart rate for 30 seconds, before, during and after a contraction. Fetal distress is shown by: (1) A rate of < 120 or > 160. (2) Slowing which persists after a contraction (slowing during it is normal). CAUTION! (1) Don't use an oxytocin drip if there are signs of obstruction. On the correct indications, you can use it for delay (18.4a). (2) If there is obstruction or delay, don't use Kielland's forceps, or try internal version. (3) Never do an operative vaginal delivery ifher uterus has already ruptured-dO a laparotomy. You may not know if it is ruptured or not, so do all vaginal opera CHOOSING THE BEST METHOD TO DELIVER A MOTHER WITH A LONG SECOND STAGE AND A LIVE BABY

Fig. 18-4CHOOSINGTHEBESTMETHOD10DELIVERA MOTHER WITH A WNG SECOND STAGE AND A LIVE BABY. This is a table from 'Primary Mother Care' which advises midwives what they should do in health centres. You may also find it useful. It differs slightly from the instructions for similar situations given here. Kindly contributed by Hugh Phi/pott. tions for the relief of obstructed labour in the theatre, with a set of laparotomy instruments ready for instant use. EPISIOTOMY M 18.16 This is sometimes all that a primigravida needs, especially if her baby's vertex is in an occipito-posterior position. Putting her into the lithotomy position may make delivery easier. VACUUM EXTRACTION 18.5, M 22.3 INDICATIONS. (1) A live baby with less than 2/5 of his head above the brim. And, (2) only moderate moulding. Vacuum extraction may be very suitable, if obstruction is due to an occipito-transverse or an occipito-posterior position, without CPO, or with only mild CPD. CONTRAINDICATIONS. (1) A dead baby, unless delivery by vacuum extraction is very easy. (2) A live baby with more than 2/5 of his head above the brim. (3) Severe moulding. (4) Definite CPO contraindicates any kind of forceps or vacuum extraction. CAUTION ! (1) Delivery with a vacuum extractor or outlet forceps should never be a difficult operation. If fetal asphyxia is already present, it should merely be a 'lift-out'. (2) If you use the vacuum extractor, be sure to follow the rule of the 'Three pulls' (M 22.3). The first pull must dislodge his head from its arrested position, the second must bring his head to the pelvic floor, and the third must deliver, or at least crown it. If anyone of these three pulls does not achieve its purpose, stop, and try another method of delivery. This will have to be symphysiotomy or section, and not forceps, which are too dangerous for a baby after a failed vacuum. If possible, try to predict difficulty, and choose the right method in the first place. (3) If (a) she was >3 hrs dilating from 7 to 10 cm on the partogram, or (b) her fundal height is >40 cm, suggesting a large baby, expect difficulty. Do the vacuum extraction in the theatre, and prepare for section. OUTLET FORCEPS M 22.6 INDICATIONS. (1) In mento-anterior (face) presentations, because vacuum extraction is impossible (M 22.6). One contributor considers section safer. (2) When there is fetal distress, because outlet forceps are quicker than vacuum extraction. SYMPHYSIOTOMY 18.6, M 20.7 INDICATIONS, Symphysiotomy may be indicated if a baby is alive in a cephalic presentation, with not more than 2/5, or in some cases (see Section 18.6) 3/5, of his head above the brim. He should not be too big, or too small (2.5 to 4 kg), and his moulding score should be less than 3. An indication of his maximum size is that her fundal height should be <40 cm. DESTRUCTIVE OPERATIONS 18.7, 18.10 INDICATIONS FOR CRANIOTOMY. All the following conditions must hold: (1) He must be dead. (2) 2/5 or less of his head must be above the brim (if it is higher than this, Caesarean section is usually safer, although if you are expert you may be able to do a craniotomy at 3/5). (3) His head must be impacted. (4) Hismother'scervixmust beat least7cmdilated,and preferably fully dilated. (5) Her uterus must be unruptured, and not in imminent danger of rupturing. If she is a multip, and has been in labour for a long time, her lower segment will be very thin. If it is tender and distended, it is certainly very thin. She can only be saved by Caesarean section; any destructive operation, except pushing a needle into a hydrocephalic head, will rupture it. INDICATIONS FOR DESTRUCTIVE OPERATIONS FOR A TRANSVERSE LIE. The baby is dead and is lying transversely, her cervix is 8 cm or more dilated, and her uterus is not ruptured. CAESAREAN SECTION 18.9 INDICATIONS, (1) A live baby whose head is too high for vacuum extraction or symphysiotomy. (2) A dead baby who is too high to be deUvered by a destructive operation (rare). CONTRAINDICATIONS. (1) A head which is deeply engaged in the pelvis (2/5 or less above the brim). A vaginal delivery by vacuum extraction or symphysiotomy is safer. (2) A dead baby who can be delivered by a destructive operation. CLINICAL SITUATIONS WHEN THE PRESENTING PART HAS STOPPED DESCENDING Here we are mostly concerned with a vertex presentation, and a few curiosities. See elsewhere for a breech presentation (19.8), a transverse lie, and a brow or a face presentation (19.9). VERTEX PRESENTATION. Follow this scheme. If rupture is suspected but uncertain, section her. If her baby is alive and her cervix is not fully dilated, sec tion her. If he is alive and it is fully dilated, management depends on: (1) the height of his head, (2) the degree of moulding, and (3) signs of fetal distress. 0/5 above the brim, with minimal moulding-do an episiotomy and apply the vacuum extractor, or apply outlet forceps. 1/5 above the brim, with a moulding score of 0 to 1 and fetal distress-do a vacuum extraction or apply outlet forceps. 1/5 above the brim, with a moulding score of 2 or 3 and fetal distress-do a symphysiotomy. 2/5abovethe brim,with amouldingscoreof0or1orpossibly 2 and a live baby-do a trial of vacuum extraction in the theatre, with everything ready for symphysiotomy or section if you fail. Or section her anyway. 2/5 above the brim, with a moulding score of 3 or possibly 2 and fetal distress-do a symphysiotomy, if necessary followed by vacuum extraction. 3/5 above the brim, with a moulding score of 0 or 1-do a trial of vacuum extraction. If necessary and her pelvis is big enough (you can get your finger between the head and her symphysis) do a symphysiotomy. 3/5 above the brim, with a moulding score of 2 or 3-section her, unless you can get a fi nger between the head and her pelvic wall, indicating that a symphysiotomy might be possible. If he is dead, the major decision is between craniotomy and Caesarean section.

(1) If his head is firmly impacted in her pelvis, and his head is 2/5 or 3/5 or less above the brim, and her cervix is 7 cm or more dilated, a craniotomy should be fairly easy, provided you can get a finger between his head and her pelvis.

(2) If his head is mobile or more than 3/5 above the brim, a craniotomy will be dangerous. Section, with all its risks, will be safer.

A MENTO-POSTERIOR PRESENTATION. If her cervix is fully dilated and her baby is alive, section her. If he is dead, and her cervix is fully dilated, do a craniotomy. A CONGENITAL VAGINAL SEPTUM (rare) seldom causes trouble, because it usually quite thin, pushes to one side, and may never even be diagnosed during labour. If it does cause trouble, but is thin, you may be able to divide it. If it is thick, you may have to section her, and excise it later when she is not pregnant. A VAGINAL STRICTURE (quite common) caused by scar tissue from a previous delivery, or of uncertain cause, feels quite different from a cervix. If it is thin, incise it at 4 o'clock and 8 o'clock, let vaginal delivery proceed, and suture the laceration. If it is wide and fibrous, section her. AN OVARIAN TUMOUR OR A FIBROID. Section her. If she has an ovarian cyst or tumour, you can remove it at Caesarean section. If she has a fibroid, leave it and remove it subsequently if necessary. CAUTION ! Never try to remove a fibroid at Caesarean section. POSTOPERATIVELY AFTER A DIFFICULT VAGINAL DELIVERY Keep her in hospital for three or four days (14 days for a symphysiotomy). Observe her carefully. Before she goes home, make sure that she understands: (1) what operation she had, and (2) Why it was done. This will be important when she becomes pregnant again. Her baby has a greater chance of brain damage. This may be caused by: (1) The operation itself. (2) Lack of oxygen. (3) Her pelvis being too small for his head. Watch him carefully for signs of twitching, irritability, or fever. 18.4a Oxytocin Oxytocin is an invaluable drug for making the uterus contract: (1) To induce labour. (2) To accelerate labour. (3) To stop bleeding after abortion or delivery. The main dangers are that: (1) If you give too much too fast to a patient of high parity late in labour, her uterus may rupture. The sensitivity of the uterus to oxytocin varies greatly. Early in pregnancy it is comparatively insensitive; it becomes much more sensitive later, especially in multips. So in a pregnant patient always give it by intravenous infusion, starting with a small dose. If you do not get the effect you want, give more in an escalating (increasing) oxytocin drip. After delivery, or during an abortion, this rule does not apply, and you can safely give it by bolus intravenous injection, or intramuscularly. (2) In giving oxytocin by infusion, it is possible to give her too much fluid at the same time, especially when you use oxytocin to induce labour early in pregnancy, when you may need high doses. So when you give an escalating oxytocin drip, avoid the danger of water intoxication by giving it in 0.9% saline or Ringer's lactate, not in 5% dextrose, see Section 16.4. The primigravid uterus is sufficiently insensitive for oxytocin to be safe enough for midwives to give routinely to accelerate labour. Using oxytocin to accelerate labour in multips can be dangerous, so it should only be given when: (1) The midwifery team is experienced, and able to adjust the 'drops per minute' carefully. And, (2) after the doctor on duty has seen and examined the patient, and has excluded a brow presentation, and CPD (which may not be easy). At least one contributor considers that oxytocin should never be used to accelerate labour in multips. In Africa, the head is often high through much of the first stage. Speeding its descent with oxytocin is dangerous for the inexperienced. If a multip's labour is slow, and her previous deliveries were normal, she will probably deliver her present baby eventually, provided he is a cephalic presentation. So it is likely to be safer to leave her, after examining her carefully to exclude a brow, than to risk rupturing her uterus by giving oxytocin unnecessarily. OXYlOCIN Here are the main methods and indications for the use of ox OXYTOCIN Units per 10 20 litre INFUSION RATE IN MILLI-UNITS PER MINUTE 14 10 14 28 20 10 20 40 30 Drops per minute 40 1427 54 17 3468 50 20 4080 60 Fig. 18-5a AN OXY'IOCIN TABLE. The dose ofoxytocin received by the patient in milliunits per minute depends on the concentration ofoxytocin in the bottle and the speed ofthe drip in drops per minute. The table assumes a standard drip set delivering 15-20 drops per ml. The concentration ofoxytocin in the bottle is given in units per litre and not in units per 500 ml, as in the text. ytocin. See also: breech presentation 19.8, and multiple pregnancies 19.11, etc. ADJUST THE DOSE to the patient-'titrate it' against the response. Start with a low dose and increase it until you get the response you need. The dose rate ('drops per minute') is critical. Always start with a slow rate, and increase it if necessary every half hour, until she has the contractions she needs (usually 2 or 3 contractions every 10 minutes). Don't give more than 60 drops per minute, or you will give too much fluid. If you need more than 30 drops a minute, double the concentration and halve the drip rate for the next bottle. Note that we give the units of oxytocin to be added to 500 ml of fluid ('one bottle'), and not to one litre. TO INDUCE LABOUR: To induce labour between 10 and 28 weeks when the baby is dead (16.4). The uterus is much less sensitive than it is at term, and there is less danger of rupture, so start with 5 units in 500 ml, at 25 drops a minute, and if this does not work, increase the dose the next day, as in Section 16.4. 100 units in 500 ml is the absolute maximum. Read what Section 16.4 has to say about the dangers of water intoxication. To induce labour at term in primips or in multips <para-4 (19.3). Use 5 units in 500 ml at 10 drops a minute, and increase the speed of the drip to 60 drops/minute as necessary, as in Section 19.3. If a multip at term is >para-4, use 2.5 units in 500 ml. If the baby is dead at term, you can use up to 20 units/500 ml, except in multips > para-4. CAUTION! (1) Whenever you give oxytocin to induce labour, give it by day rather than by night, when monitoring her reliably will be more difficult. (2) You can increase the drip rate, but don't exceed the concentrations above for particular categories of patients. TO ACCELERATE LABOUR: To accelerate labour in primips. Give 2.5 units/500 ml, and don't increase the concentration. Start at 10 drops a minute and increase the drip rate by 5 drops each half hour as necessary, to a maximum of 60, until you obtain contractions lasting 45-60 seconds at 2-3 minute intervals. To accelerate labour in multips. This is controversial, so see above. Give the same dose as in primips, but with extra special care! A midwife must monitor the patient all the time. One contributor advises 1 unit in 500 ml. This is also the dose Primary Mother Care advises for the acceleration of labour, and then only in primips. TO MAKE THE UTERUS CONTRACT AND CONTROL BLEEDING after abortion (16.2) or delivery (19.11a). Forthis purpose you can give oxytocin as an intravenous infusion, or by bolus intravenous injection. You can also give it by intramuscular injection. For this it is best combined with 265 ergometrine as 'Syntometrine' (ergometrine 0.5 mg, oxytocin 5 units in 1 ml). If you are giving oxytocin in an intravenous drip to control bleeding after abortion or delivery, add 20 or (with a PPH) even 40 units (the maximum) to 500 ml of fluid. Usually quite a modest drip rate is sufficient to control bleeding, but in emergency, you can run the drip in 'fast'. CAUTION! (1) Never give a bolus intravenous injection of oxytocin before the baby has been delivered. (2) Intramuscular injections of ergometrine or oxytocin can only be used safely to empty the uterus and expel the placenta and membranes before 16 weeks. After 16 weeks use an oxytocin drip. BEWARE OF OXYlOCIN IN MULTIPS! 18.5 Vacuum extraction Ifyou are not an experienced obstetrician, you will find a vacuum extractor invaluable (M 22.3), so ifyou are not already using one, you must! It has many advantages in the confined space of the reduced pelves so common in many communities. Unlike forceps, the vacuum cup takes up no space in a mother's birth canal, and it is difficult to injure her accidentally. Her baby's head can rotate spontaneously at the optimum level, and ifit is deflexed, vacuum extraction will often flex it. Most importantly, a vacuum extractor is less likely to damage his brain than forceps. The indications for its use in a hospital are somewhat broader than those in a health centre (M 22.3). VACUUM EXTRACTION INDICATIONS. These indications only apply if the absolute requirements below are met. (1) Delay in the second stage-more than an hour in a primigravida, and 30 minutes in a multigravida, especially delay caused by malrotation of the occiput. (2) To reduce maternal effort if a mother has cardiac failure or gestational hypertension. (3) To minimize the strain on a scarred WHERE TO PUT THE CUP Fig. 18-6 WHERE TO PUT THE CUP OF THE VACUUM EXTRACTOR. You will find a vacuum extractor invaluable. Attach the cup as nearly as you can over his posterior fontanelle. , uterus. (4) Relative CPO due to deflexion and malrotation of the head. If there is absolute CPO don't use a vacuum extractor, it will be ineffective and potentially dangerous. Her cervix should be fully dilated. Some obstetricians app ly it at 8 cm, but this can cause tears, and should never be tried if there is any CPO. The rule of 'Three pulls' (M 22.3) still ap plies, but two 'extra pulls' are allowed to reach full dilatation; then you must deliver her in three pulls. (5) Vacuum extraction is occasionally indicated before full dilatation of the cervix when there is fetal distress in multips without any CPO. (6) Fetal distress in a second twin with a cephalic presentation when the cervix has closed down. The height of the head does not matter in this situation, provided you can get the cup on the occiput. (7) Prolapse of the cord in multips. CONTRAINDICATIONS, (1) Prematurity, because of the risk of intracerebral haemorrhage. (2) A malpresentation. (3) CPO and a dead baby-outlet forceps or a destructive operation would be safer. (7) An exceptionally uncooperative mother. CAUTION! The application of a vacuum extractor before full dilatation is rarely indicated, and is usually dangerous: the only exceptions are (5), (6), and (7) above. Oon't apply one for delay late in the first stage. If this does not respond to oxytocin, it is likely to be due to CPO. If (a) she was >3 hrs dilating from 7 to 10 cm on the partogram, or (b) her fundal height is >40 cm (suggesting a large baby), expect difficulty. 00 the vacuum extraction in the theatre, and prepare for section. ABSOLUTE REOUIREMENTS. (1) A proper indication. (2) Good uterine contractions, which means 3 to 4 every 10 minutes lasting over 40 seconds. (3) A cephalic presentation. (4) The baby's head must be 1/5 or less above his mother's pelvic brim. Always determine its station in relation to her pelvic brim, and not to her ischial spines; if her pelvis is shallow and there is much caput, you may be able to feel it below her spines before it is engaged. (5) The head must descend with contractions and bearing-down efforts. (6) You shouId know where the occi put is, because traction wi II be more effective if you can put the cup there. Co-operation by a mother who is fully conscious is desirable, but not essential. 18.6 Symphysiotomy Cutting a patient's symphysis allows the two halves of her pelvis to separate 2 to 2.5 cm. This increases its diameter by 0.6 to 0.8 cm, which is enough to overcome mild or moderate CPD, and so avoid Caesarean section. After delivery, its circumference re mains wider by about 1.5 cm, and its diameter by about 0.5 cm, so that her next deliveries may be normal. Symphysiotomy is thus particularly valuable if she wants a large family. This is one of the most contentious operations in this book. One school of thought considers it a "...barbarous operation done by expatriate doctors on the mothers of the developing world .. ," Another school, which includes all our contributors who practise obstetrics, considers it an invaluable operation which needs to be reinstated and given its proper place: (1) Unlike Caesarean section, especially with unskilled anaesthesia, it is never fatal, and seldom produces complications, particularly serious ones. (2) It does not leave a mother with a scar in her uterus which may rupture if she does not deliver in hospital when she is pregnant next time. (3) It may save her life if she delivers in a health centre and cannot be referred. Like many other medical procedures it has been evaluated by personal experience rather than by formal trials, and there is a particular lack of good data on how effective it is in the hands of paramedical staff on a community scale. We encourage you to investigate this, since, like the destructive operations, it is one of the few practical procedures which might really alleviate maternal mortality from obstructed labour. Symphysiotomy has fallen into disrepute because there was a time when it was used to overcome gross CPD, which led to serious complications. It is not used at all in parts of the world where CPD hardly exists, where trends are set-and where most textbooks are written. But, in countries where CPD is common, symphysiotomy is excellent-ifit is used for borderline cases only. If CPD is marked, a mother needs a Caesarean section. The skill is to recognize the difference. You will not need to do a symphysiotomy very often, and you will find that deciding when to do one needs more judgement than deciding when to section a mother. If a symphysiotomy fails you can still do a Caesarean section: but you should look upon this as an error ofjudgement, and try to do better next time. The indications for symphysiotomy in a hospital and a health centre are different: In hospital, symphysiotomy is used to its best advantage: (1) At the strategic moment in a well-planned trial oflabour, in which there is borderline CPD, and before there are any signs of fetal distress. If the indications are right, it is better than Caesarean section, and it avoids a difficult vaginal delivery. (2) In neglected obstructed labour it avoids a major abdominal operation in a highrisk mother. (3) It is occasionally useful in a breech delivery when the aftercoming head is arrested (9.8). Symphysiotomy is usually done in a primip, but you can do it in a multip. It is especially useful if a mother is isolated and cannot easily attend for antenatal care, if she is infected, and if your anaesthetic facilities are poor. In a health centre a symphysiotomy is an emergency method of delivering a mother, and securing a live baby, when she cannot be referred. It should never be an elective procedure there, because she cannot have a Caesarean section in a hurry if she needs one. There are two ways ofdoing a symphysiotomy, either: (1) Open through an incision which is large enough for you to see and feel exactly what you are doing, as described below. Or, (2) closed through an incision which is only just large enough to admit the blade of a scalpel, as described in Primary Mother Care. Opinions differ as to which is best. Of those obstetricians who do the operation, the large majority favour the closed method and some think that we should not even have described the open one. One exceptionally able and experienced contributor is however strongly in favour ofit. However you do it, you must divide the symphysis through its cartilage, exactly in the midline, because incisions which involve the bone to one side are more likely to lead to chronic pubic osteitis and long-standing pain, both of which are fortunately rare. Local infection in the soft tissue and cartilage is not important and heals without trouble. Experts can do a closed symphysiotomy through a very small skin incision. If you are not an expert, do it open. Use an ordinary scalpel to cut through the skin and subcutaneous tissue in the midline. Then, when you have found the cartilage, cut through its exact centre with a solid scalpel, or a short ordinary one. Be sure to support the patient's legs as described below, and don't fail to insert a catheter bejore you cut! SYMPHYSIOIOMY For closed symphysiotomy, see M 20.7. INDICATIONS, Mild or moderate CPO associated with any of these problems, most of which are interrelated:

(1) A failed trial of vacuum extraction when failure has occurred by a small margin. It will not work if CPO is gross, and vacuum extraction was done on the wrong indication. This is the most common indication. It is difficult to be sure that vacuum extraction won't work without havi ng a try!

(2) Obstructed labour with a live baby. If his head is deeply jammed into his mother's pelvis, perhaps with caput visible at her vulva, symphysiotomy will be safer for her. If you try to section her, his head will be difficult to deliver, and infection of her deeper tissues is more likely.

(3) A difficult vacuum extraction may succeed, but on Iy after prolonged traction and the risk of damaging the baby. Symphysiotomy will make delivery easier and safer for him.

(4) A prolonged second stage. If the criteria for symphysiotomy are met, and vacuum extraction alone is unlikely to succeed, symphysiotomy is better than trying vacuum extraction first.

(5) Mild or moderate CPD with a live baby, particularly in a primigravida, when his head is 1/5 or 2/5 above the brim, and is too tightly held for vacuum or low forceps alone.

(6) To deliver the arrested aftercoming head of a breech-if you are quick! CAUTION! Symphysiotomy is normally done at full dilatation, but you can do it when there is still a 1 or 2 cm ring of cervix. Another contributor considers that you should never do this! CONTRAINDICATIONS. (1) Severe CPO. (2) Malpresentations, with the exception of the aftercoming head of a breech (19.8). (3) A dead baby; if there is CPD he should be delivered by craniotomy or section, if there is no CPO a symphysiotomy is unnecessary. (5) A previous Caesarean section. (6) Abnormalities of a mother's legs or spine. (7) Severe obesity is a relative contraindication. (8) A baby more than 4 kg as estimated by the fundal height being >40 cm (who is too big to deliver by symphysiotomy), or less than 2.5 kg (who does not need one). (9) Poor uterine action in spite of an oxytocin drip, especially if dilatation is not complete. (10) A fetal head which remains >3/5 above the brim after rupture of the membranes. OPEN SYMPHYSIOTOMY Do a vaginal examination to check the dilation of the mother's cervix, and the descent and position of her baby's head. At this point decide if symphysiotomy is indicated or not. If his head is 1/5 above the brim a symphysiotomy is unnecessary. If it is 2/5 above symphysiotomy may be indicated. If it is 3/5 above, try to insert a finger vaginally between his head and her pelvis. If your finger passes too easily symphysiotomy is unnecessary. If it passes with difficulty, symphysiotomy is indicated. If it does not pass at all, CPO is too great, so section her. Note that this is somewhat less conservative than the indication for closed symphysiotomy given in Primary Mother Care, which advises that midwives should not attempt it, if the head is more than 2/5 above the brim. Listen to the fetal heart to make sure that he is alive. Put her into the lithotomy position, with her legs outside the lithotomy poles. CAUTION! Find two assistants and ask them to support each of her legs, so that her symphysis o,pens only to a max imum of 3 cm. This must be their only job; they must do nothing else. If they allow her legs to flop apart, the fibres of her sacroiliac joint may rupture, and she will have much postoperative pain. You will need these assistants anyway, even if you have lithotomy poles, to prevent too much abduction. Pass a stiff rubber or plastic catheter. Clean her skin with iodine and spirit. Palpate the bony margins of her symphysis .pubis. Infiltrate the skin and subcutaneous tissue over her symphysis with 20 ml of 1% lignocaine with adrenalin (this is a very vascular area). Allow 3 minutes to pass for it to act. Place the index and middle fingers of your left hand in her vagina, to displace the catheter in her urethra to her right side. CAUTION! You MUST displace her urethra, or you will cut it. This would be a major disaster! Incise the skin and subcutaneous tissue over her symphysis pubis in the midline, and find the exact position of the cartilage of the joint. Try locating it with a hypodermic needle first. Then use a standard scalpel to cut down on to it throughout its length. Clamp any superficial bleeding arteries. When you have exposed the joint throughout its length (it is better felt as a depression rather than seen), divide it using a sharp solid scalpel, or a standard one with a No. 20 or 21 blade. Cut it little by little with your right hand, keeping her urethra to the side with your left hand. Mop up any blood. When the joint is almost divided, it will begin to open. Continue cutting its fibres until it opens fully. Two cm is ideal, it should never open more than 3 cm. Its infrapubic fibres may rupture spontaneously, or need cutting. Judge this by how much it opens. If separation is inadequate, cut more joint fibres, usually the superior and posterior ones. CAUTION! (1) Always keep her urethra to one side with your left hand. (2) Don't cut above her symphysis pubis, because her uterus or bladder may be protruding there. A small cut in her uterus is not such a tragedy as cutting her urethra. (3) Never do a symphysiotomy without also doing an episiotomy. If you have operated on the right indications, she will deliver easily-usually after bearing down with 3 or 4 contractions. If she does not deliver spontaneously, apply the vacuum extractor. Give her ergometrine with the birth of the anterior shoulder. CAUTION ! Don't apply forceps after symphysiotomy, they may stretch her sacroiliac joint too much. If she bleeds from the incision, apply pressure. Suture her subcutaneous tissue, tie the vessels with 2/0 catgut, and suture her skin with 2/0 or 1/0 monofilament. Leave a self retaining catheter in place. Leave this in for 48 hours only, provided her urine is not blood-stained (the usual cause of this is obstructed labour), and release it 4-hourly. Keep her in bed for 48 hours-walking will be painful. Allow her to walk on the 3rd to the 5th day. Some patients can do this easily, others, especially the heavier ones, fail to walk until the 5th or 7th day. Remove her sutures on the 7th day. Most patients are walking well, and fit for discharge, on the 10th day. There is no need to bind her pelvis, her symphysis will heal to leave her pelvis larger that it was before. 01 FFICU LTI ES WITH OPEN SYMPHYSIOTOMY If she has FEVER postoperatively, suspect urinary infection due to the catheter. If she DOES NOT PASS URINE when the catheter is removed on the 3rd day, replace it and try on the 5th day. If she is INCONTINENT OF URINE, especially on standing, it may be partial so that she also passes urine, or it may be total. Insert a catheter and leave it in for 2 weeks. She will probably recover completely or partly. If she still has trouble it is likely to be partial. Advise her to empty her bladder 4-hourly. Incontinence rarely lasts more than 3 months. If necessary (rare), refer her for a sling operation. Loss of the normal angle where the bladder joins the urethra is probably the cause of temporary incontinence. As she heals this angle returns. If her wound shows signs of LOCAL INFECTION (common), give her ampicillin or chloramphenicol. Insignificant quantities will reach her baby, but avoid tetracycline or sulphonamides, which may harm him. Careful preparation of her skin with iodine and spirit reduces the incidence of infection. If she BLEEDS from the branches of her epigastric vessels, watch for a haematoma of her wound which may spread up into her abdominal wall. This is said to be more likely when the closed method is used. If necessary, drain it by removing one or two sutures. If, later, she develops chronic PAIN and DISCHARGE, she has chronic pubic OSTEITIS (rare). Treatment is difficult, treat her pain symptomatically. It probably only occurs when the incision involves bone, so keep strictly to the midline in the fibrocartilage of the joint. This is easier to achieve in the open method than in the closed one. Ifyou INJURE HER URETHRA, which should never happen, see Section 18.190. 18.7 Destructive operations For an obstructed labour with a dead baby a destructive operation is usually, but not always, better than a Caesarean section. You may need to do one for: (1) A cephalic presentation with a normal or hydrocephalic head. (2) A breech delivery when a normal or hydrocephalic aftercoming head has 'stuck'. (3) A transverse lie with a prolapsed arm. To cope with these situations you can: (1) Open his skull with large scissors, or a special perforator, and remove his brain (craniotomy). (2) Sever his neck from his body (decapitation), and then deliver them separately. (3) Cut his clavicles (cleidotomy).

(4) Open his trunk and remove the the organs from his chest and abdomen (evisceration or embryotomy). For a cephalic or breech presentation, craniotomy is usually all you need do. A transverse lie requires decapitation, and often evisceration also, which is more difficult than craniotomy; but even so, it is often wiser than Caesarean section (see Section 18.1), which is particularly dangerous for a neglected infected transverse lie.

These operations are sometimes said to be old fashioned, and to have no place in modern obstetrics. Old-fashioned perhaps, but they have some useful features: (1) They need few instruments and only simple anaesthesia, so that they can be done in the health centre where a mother is first seen. If she cannot be referred, they save her life. If referral is difficult, they avoid the risks and delays ofa longjourney (they are therefore also described in Primary Mother Care). (2) They leave her with an intact uterus, which will be less likely to rupture if she decides to deliver herself at home next time. (3) If she is already infected, they are less likely than Caesarean section to spread the infection to her peritoneum.

(4) She stays a shorter time in bed than she does after a Caesarean section.

The case for destructive operations is strongest in unsophisticated communities where people marry as children. A mother may not be fully grown when she first becomes pregnant, so that her pelvis is small and her first labour obstructs. It will continue to grow until she is 25, so, if she can be delivered vaginally with her first pregnancy, her later ones may be normal and without the risks of a scarred uterus. Besides their di'stasteful messiness, the main argument against these operations is that, in inexperienced hands, they are liable to be even more dangerous than Caesarean section. This is unlikely to be true-ifyou follow the instructions carefully! To those who decry them, we reply that, ifthe obstetriccircumstances ofdisadvantaged communities still existed in advantaged ones, destructive operations would be routine there too. DESTRUCTIVE OPERATIONS For destructive operations at Caesarean section, see Section 18.10. For destructive operations at a breech delivery, see Section 19.8. INDICATIONS FOR CRANIOTOMY. All the following conditions must hold: (1) The baby must be dead. (2) 2/5 or less of his head must be above the brim (if it is higher than this, Caesarean section is usually safer, although if you are expert you may be able to do it at 3/5). (3) His head must be impacted. (4) His mother's cervix must be at least 7 cm dilated, and preferably fully dilated. One contributor gives 5 cm as the minimum. (5) Her uterus must be unruptured, and not in imminent danger of rupturing. If she is multigravid and has been CRANIOTOMY if his shoulders are large. you may have cut his clavicles Fig. 18-8 CRANIOIOMY AND CLEIDOIOMY. For an obstructed labour with a dead baby a destructive operation is usually better than a Caesarean section. Kindly contributed by John Lawson. in labour for a long time, her lower segment will be very thin. If it is tender and distended, it is certainly very thin. She can only be saved by Caesarean section; any destructive operation, except pushing a needle into a hydrocephalic head, will rupture it. PREPARATION. Always do a destructive operation in the theatre with a laparotomy set ready for immediate use; unless you, and your theatre and obstetric team, are very quick and expert indeed (when you can do some destructive operations in the labour ward). You must be able to do an immediate laparotomy, either: (1) immediately instead of a destructive operation, if you find that the indications are unsuitable, or (2) immediately afterwards, if you discover that her uterus has ruptured. You wi 11 need an anaesthetist, a scrub nurse, and a 'runner'. In the labour ward confirm that the baby is dead, set up a drip, take blood for cross-matching, give her pethidine 50 mg and diazepam 10 mg intravenously, and shave her for a vaginal operation and a laparotomy. PER/OPERATIVE ANTIBIOTICS. Give her chloramphenicol 1 g intravenously. Or, give her penicillin 5 megaunits intravenously with streptomycin 1 g intramuscularly. See also 2.9. EOUIPMENT. For decapitation use a Blond-Heidler saw (16.1), or large blunt-ended scissors, preferably special embryotomy scissors. ANAESTH ESIA. General anaesthesia with intubation, especially if she has a transverse lie. If you cannot intubate her, use subarachnoid anaesthesia or local infiltration anaesthesia. FOR A CEPHALIC PRESENTATION CRAN IOTOMY. Put her into the lithotomy position, and clean and drape her vulva and perineum. If you are not using general anaesthesia, give her pethidine 25-50 mg slowly intravenously (check what she was given in the labour ward). And give her diazepam 5-10 mg slowly intravenously until she is just asleep (A 8.8). Infiltrate her perineum with 0.5% or 1% lignocaine (A 5-1). Catheterize her bladder. Ask your assistant to hold 1 or 2 Sims' specula in her vagina so that you can see the baby's head well. CAUTION! Ask another assistant, standing on a footstool if necessary, to steady the baby's head suprapubically, so that it is not pushed upwards whenever you do anything to it. With a scalpel make an 'X'-shaped incision through the skin of his scalp right down to the bone. Peel the four flaps of scalp off his skull. Put your fingers through her cervix to rest against his skull. Feel for a suture line or fontanelle. Push a closed pair of strong pointed scissors or, better, Simpson's perforator between the bones. For a face presentation, choose his hard palate or his orbit. Move the handles back towards her perineum, so as to point the blades at the centre of his skull. Open and close them a few times while you turn them round. Brain will flow from the hole. Put your finger into his skull, check that all brain compartments have been opened, and remove any remaining brain. His skull will now collapse. Try to remove all his frontal and parietal bones. If you don't remove them, they may tear her vagina as he delivers. Remove any loose pieces of bone. Attach 3-4 strong vulsellum forceps, Kocher's or Willet's forceps to his scalp and the remains of his skull. Pull on them and try to bring his posterior fontanelle under her symphysis. If sharp edges of bone stick out, protect her vagina with your finger. Wait until she has a contraction. Hold the three pairs of forceps together, and pull and twist. His collapsed head should now deliver. His body will follow. If a piece of his skull pulls off, reattach the forceps taking a deeper bite of skull closer to its base. Make a large episiotomy and deliver the remains of his head. CAUTION! (1) Don't include folds of her vaginal wall or cervix. (2) Use a good light and a large Sims' speculum, so as to make sure you grasp only his skull. If delivering his shoulders is difficult, put a hand behind a transverse Iie, see Section 19.9. For destructive operations at Caesarean section, see Section 18.10. EXAMINATION UNDER ANAESTHESIA. Prepare her in the labour ward and the theatre as for craniotomy. Good anaesthesia is even more important than it is for craniotomy, because you have to operate higher in her birth canal. Give her a general anaesthetic. Put her into the lithotomy position, clean and drape her vulva, and catheterize her bladder. Put one hand into her vagina and support her fundus with the other. Observe: (1) The dilatation of her cervix. If it is <8 cm, section is probably safer. (2) The condition of her lower segment; explore it as far as you can without using force. If it is ruptured, section her. (3) The exact position of the baby. Which of his arms have prolapsed? Where exactly, are his head and neck, chest, abdomen, and back? Choose between these 3 alternatives: (1) If his neck and body are still high in her birth canal, section her (18.10). (2) If you can reach his neck easily, decapitate him. (2) If his neck is difficult to reach, but his body is well down, eviscerate him. CAUTION! (1) Don't try an internal version without doing an evisceration first: you will rupture her uterus. (2) Don't attempt decapitation, or evisceration, through her vagina, if he is still high in her birth canal; you will not be able to protect her vaginal wall and cervix adequately. A Caesarean section is her only hope. DECAPITATION. Pull on his prolapsed arm with one hand, and feel for his neck with your other hand. If possible, bring an arm down (if it is not already down), and ask an assistant to pull on it. This: (1) prevents him being pushed upwards by your hand in her uterus, (2) prevents her distended lower segment being stretched, and (3) it brings his neck lower and makes it easier to feel. Feel his neck to find out how large it is, and how easy it is to put a finger round. If he is small and macerated, you can usually cut his neck with strong scissors. If he is larger, you wiII have to use the saw. him and try turning him through 90° or 180°. Then try delivering his shoulders again. Ifyou cannot bring down his shoulders byturning him, bring down his arms one by one. Put a hand behind him in her vagina and feel for his posterior arm. Gently pull it down. Don't worry if it breaks, but don't damage her vagina. Then turn him through 180° and deliver his other arm in the same way. Delivery should now be easy. Alternatively, cut his clavicles (cleidotomy, see below). DESTRUCTIVE OPERATIONS FOR A TRANSVERSE LIE INDICATIONS. Her baby is dead, the lie is transverse, hercervix is 8 cm or more dilated, and her uterus is not ruptured. For A TRANSVERSE LIE A Fig. 18-9 A TRANSVERSE LIE. A, if a community health worker meets this, she is advised to refer the patient to you urgendy! B, a shoulder presentation. (1) The incision for decapitation, leaving the head attached to an arm. (2) Caution! Don't try to remove an arm, leave it attached to the head or the body, to help you to bring these down. A, From David Werner's 'Where there is no Doctor'. B, from Howie, Beryl, 'High Risk Obstetrics: Macmillan, with kind permission. Fig. 18-10 DECAPITATION FOR A DEAD BABY will leave a mother with an intact uterus, which will be less likely to rupture ifshe decides to deliver herself at home next time. Cut through his neck with a Blond-Heidler saw. A, push the thimble round his neck. B, pull the loop of the thimble down the other side of his neck. C, saw through it. D, remove his head with forceps. Pieces ofrubber tube cover the outer third of each end of the saw. Kindly contributed by John Lawson. If you are using a saw, fix the thimble to it and put this on your right middle finger. Pass the thimble over his neck, and down the other side. If this is difficult, because there is little room between his neck, his head, and his chest, try putting the saw over his neck and under his arm. Or improvise a smaller thimble by fixing something else, such as a piece of wire, to the end of the saw. Remove the thimble, and fix handles to each end of the saw. Insert the rubber sleeves on the saw. Keep the handles close together, so that her vagina is not injured. Protect it with specula. Cut his neck with a few firm strokes. CAUTION! Hold the handles close together. If you don't do this, you wiII cut her tissues. To deliver his body, pull on his prolapsed arm. As you do so, use your hand to protect her vagina from any jagged pieces of bone in his neck. To deliver his head, put a hand in her vagina, and turn his head so that his neck points downwards. Grasp the stump of his neck with large forceps, and put a finger in his mouth. Then deliver his head, as if it were the aftercoming head of a breech. This will prevent the stump from injuring her birth canal. If his head is very large, you may need to do a craniotomy. Some operators leave an arm attached to his head to help delivery. If you delivered his head first, deliver his body by pulling on his other arm. Don't try version, his cut neck might damage her uterus. If you are using scissors, hook one or two fingers round his neck and pull it down. Ask an assistant to protect her vaginal wall with a speculum. Gently pull his arm. When you do this, you will feel his neck. Try to see what you are cutting with each cut. You can easily cut her uterus or bladder. Cut his neck a little at a time, then deliver him as above. CAUTION! (1) Don't cut if you cannot see his neck. After each cut, pull his neck. It will come a little further down with each cut until you have cut right through. OTHER DESTRUCTIVE OPERATIONS EVISCERATION for a transverse lie is indicated: (1) when his neck is difficult to reach, but his body is well down, (2) after decapitation. Ask your assistant to pull on his prolapsed arm, and find his axilla. Protect her vaginal wall with one or two specula. With a knife or strong scissors make a large opening in his abdomen or chest. Put one or two fingers into the opening and remove all his internal organs. Make sure you remove his liver, heart, and lungs. If necessary perforate his diaphragm with scissors. Now reassess the situation, and try whichever of these manoeuvres seems best: (1) Put two fingers behind his pelvis and hook his breech down. (2) Grasp a leg or foot and bring that down. (3) Try to bring his neck down for decapitation by pulling on his arm. (4) If all this fails, don't hesitate to section her. Alternatively, separate his prolapsed arm at his shoulder. Push the embryotomy scissors through his axilla and divide his internal structuresfrom inside his skin, while keeping your other hand between him and her uterus, as a constant guide. Finally, divide his skin and superficial tissues under direct vision, and deliver him in two halves. CRANIOTOMY FOR A HYDROCEPHALlC HEAD. Push a large needle through her abdominal wall. As the fluid is withdrawn, his head will collapse. Or, guided by your examining finger, you can push a large needle (2 mmx25 cm) through a suture from her vagina, and drain off as much fluid as you can. CLEIDOTOMY (division of the clavicles) on one or both sides, will reduce the width of the shoulders of a large dead baby. Use embryotomy scissors to make a small cut in the skin of his neck. Through this, guided by the fingers of your other hand, feel inside his skin, until you can snip a clavicle between the tips of the opened blades. Be sure it is his clavicle and not the spine of his scapula. The ends of his clavicle will then overlap and narrow his shoulders. DESTRUCTIVE OPERATIONS FOR THE 'STUCK BREECH' see• Section 19.8. POSTOPERATIVELY, AFTER ANY DESTRUCTIVE OPERATION Remove the placenta manually, and immediately feel for tears of her uterus and lower segment. Give her ergometrine 0.25 mg intravenously as he is delivered. Check her uterus by feel 270 ing inside it to make sure it has not ruptured. If it has ruptured, do a laparotomy and repair it (18.17). Check her cervix, vagina, and vulva for tears. If she has a tear of her cervix it will need suturing (18.15). If her uterus is not well contracted, set up an intravenous oxytocin drip with 5-20 units in 500 ml. Continue the saline drip for 24 hours. Continue the perioperative antibiotics (2.9). She is at risk from: (1) Postpartum haemorrhage in the first 24 hours. (2) Acute urinary retention in the first 24 hours. (3) Infection of her genital tract after 24 hours. (4) Infection of her urinary tract at 7 to 10 days. (5) A fistula (18.10). If his head has been impacted in her pelvis for many days, leave a Foley catheter in for 14 days. This will help to prevent a fistula. Obstructed labour with a transverse lie does not cause pressure necrosis of the vagina, so a few days' drainage is enough. CAUTION ! After any destructive operation, be sure your assistant wraps up the baby immediately he is delivered. His mother must not see him. AVOID CAESAREAN SECTION FOR OBSTRUCTED LABOUR AND A DEAD BABY, UNLESS YOU THINK VAGINAL DELIVERY WOULD BE 100 DANGEROUS 18.8 Which kind of Caesarean section? Caesarean section is the commonest emergency procedure in a district hospital. If you are inexperienced it will also be the one which you will be most frightened of doing. In unskilled hands it is often fatal, as the result of: (1) the inhalation of gastric contents, (2) the supine hypotensive syndrome, (3) haemorrhage, or

(4) sepsis. There are several kinds of Caesarean section:

(1) Classical Caesarean section, is done through a vertical incision in the upper segment of the uterus (18.12). It is largely outmoded, but there are some rare occasions when it may be indicated.

(2) A lower segment Caesarean section approaches the uterus through a transverse incision in the peritoneum over the lower segment. It has long been the standard operation because:

(a) a scar here ruptures ten times less often than the scar from a classical incision, (b) when it does rupture it does so less dangerously, (c) the incision in the uterus heals better, (d) the danger of spreading infection is reduced, (e) the placenta is less often directly underneath the uterine incision, (f) the gut is less likely to stick to the scar in the uterus, and (g) there are fewer postoperative complications.

But: (a) A lower segment operation needs more skill. (b) It is dangerous if there is intrauterine infection, although less so than a classical one. (c) You may injure the patient's bladder. (d) Bleeding from the ends of the incision is more difficult to control, especially if there are lateral extension tears, as may happen if the lower segment is thin and distended, or the baby is an awkward position, as in a transverse lie. These tears may bleed severely, and in trying to control bleeding you may tie or cut her ureters. (e) You may find it difficult to extract a distorted presenting part through a lower segment incision, and tear it as you do so. A tear will be dangerous, and the only way to avoid one, once you have begun a lower segment operation, is to extend it as an inverted-T incision. Unfortunately, this does not heal well, and is a very bad incision to have to make. So only make the standard transverse incision if it is safe. It is because of these dangers, that we describe the following three alternatives: (3) The de Lee incision (18.9) is a vertical incision, two-thirds of which are in the lower segment, and one-third in the upper one. It is thus a cross between the classical upper segment operation, and the ordinary lower segment one. Make a de Lee incision if a lateral tear is likely, as can happen if the lower segment is very thin, or the baby is in an abnormal position, as in a transverse lie.

(4) A transverse incision in the upper segment is occasionally needed if there is a transverse lie, or a contraction ring (Bandl's ring).

(5) Extraperitoneal Caesarean section (18.13) is indicated if there is established or potential intrauterine infection. It greatly reduces the incidence of peritonitis, especially if you do not have antibiotics, particularly metronidazole.

(6) Caesarean hysterectomy is occasionally necessary for rupture of the uterus (18.17), when you have to remove the uterus (usually subtotally), and the baby (usually dead). It is also occasionally indicated when the lower segment is severely bruised, or major uterine vessels have been torn, or there is is established or potential uterine infection.

If you enter the abdomen through a lower midline incision, you need not decide whether to do a standard or a de Lee operation, until you get inside. But, if you are going to do an extraperitoneal Caesarean section, you will have to decide to do this before you open the abdomen. WHICH KIND OF CAESAREAN SECTION? The indications as to when to do Caesarean section are discussed in Sections 18.1, 18.2, and 18.4, and in M 22.12. Here we are concerned with what kind of Caesarean section you do. One indication which is not accepted, is the need to tie a mother's Fallopian tubes. There are easier and safer ways of doing this (15.3). Always do the ordinary lower segment operation unless one of these others is indicated. CLASSICAL SECTION is indicated if neither a lower segment operation, nor a transverse incision in the upper segment are possible (unusual). This may happen if: (1) The lower half of the patient's upper segment is very vascular, or inaccessible as the result of adhesions from a previous operation joining her lower segment to her abdominal wall. (2) She has had a previous classical incision, which has healed poorly. (3) She has a very vascular lower segment, with many thick veins on it. This may occur with placenta praevia (Type Four, or Types One or Two if the placenta is anterior), or it may sometimes occur with a normally placed placenta. She will bleed much, if you do a lower segment incision in a uterus like this, so a classical one is better. (4) A poorly developed lower segment which does not allow a transverse incision of adequate length. For some special points concerning Caesarean section in placenta praevia, see Section 18.10. (5) You are very inexperienced indeed. Alternatively, make a transverse incision half-way up her upper segment, and as you gain experience, transfer the incision to her lower segment. (6) As a preliminary to Caesarean hysterectomy. CAUTION ! Don't let her wish to have her tubes tied favour the decision to do a classical section. DE LEE SECTION. Do this if her lower segment is likely to tear, because it is thin and distended, or because there is a transverse lie. EXTRAPERITONEAL SECTION. Do this if the contents of her uterus are infected and antibiotics are scarce. 18.9 Lower segment Caesarean section The first steps are to open the mother's abdomen through a lower midline incision, to reflect the peritoneum off her lower segment, and to reflect her bladder downwards at the same time. If you are not careful, you can easily cut her bladder: (1) When you enter her abdomen. You will be less likely to cut it, if you empty it with a catheter before the operation starts, leave the catheter in, and then carefully reflect her bladder downwards, before you open her uterus. (2) If It is stuck by scar tissue to her abdominal wall or lower segment. (3) Later, if her lower segment tears. With her bladder well out of the way, you can now open her uterus transversely. The size of the incision is important, and so is the way you make it. It should be about 10 cm long, with its ends curving gently upwards (the 'smile' incision). Both an incision which is too large, and one which is too small can cause serious bleeding from the uterine arteries. These arise from the internal iliac arteries, pass through the paracervical fascia close to the ureters, and then climb up the sides of her uterus. There are several reasons for severe bleeding: (1) You fail to allow for the fact that her uterus may be rotated-usually to the right. So, before you incise it, check for rotation by looking at her round ligaments. If you don't allow for rotation, you may cut her left uterine artery, because your incision is too far to the left. If you find that the left side of the incision always bleeds excessively, this is probably what you are doing. (2) She will bleed, if you let her uterus tear in an uncontrolled way, by pulling the baby out through an incision which is too small. (3) She will also bleed if you get him partly out, and then try to extend the incision by cutting. Avoid these mistakes by first cutting a small incision, and then extending it as described later. Never use ascalpel, or scissors, too far laterally towards the sides of the uterus! Deliver the baby, then clamp the edges of the incision, especially its outer angles, with Green Armytage forceps, which were designed for this purpose. Most bleeding takes place from the angles of the incision, and these forceps will control it. Wait for her uterus to contract, remove the placenta, and then close her uterus in two layers. Although you are unlikely to cut her ureters, you can easily obstruct them with misplaced sutures when you close her uterus, especially if there is much bleeding, and you suture wildly with a large curved needle. So: (1) Put a stay suture into her lower segment, just below where you are going to make your incision. This will help you to find it later, when you come to stitch it up. (2) Be sure to suture only her uterus, and not to suture too deeply downwards towards the vault of her vagina. Put a finger behind her broad ligament when you stitch the ends of the wound. Most operators place abdominal packs on either side of the uterus before they incise it, so as to prevent blood, liquor, and meconium from soiling the peritoneal cavity. Meconium is irritant, and if it becomes infected peritonitis may follow. Others rely on mopping it out afterwards. Normally, it is best not to bring the uterus out of the abdomen when you repair it: but if there is any problem this may be helpful. WAMBUE (35 years) had had three previous Caesarean sections, and went into premature labour one evening. The duty doctor took her to the theatre. Her lower segment was very vascular, and there were many adhesions from previous operations. When he incised it, he cut into the placenta (placenta praevia). Section was otherwise uneventful, her uterine incision was repaired, and all bleeding carefully controlled. He noted that her bladder was distended, but assumed that the catheter had come out. When she left the theatre her blood pressure was normal, and she was given a unit of blood. Her urine was however noticed to be bloodstained. Fiften minutes later he was summoned urgently to the ward because she was lying in a pool of blood, with no pulse and a systolic blood pressure of30 mm Hg. Her uterus was well contracted, she was given ergometrine, and rushed back to the theatre. She was resuscitated and her abdomen was reopened; there was no blood in it. She died on the table. At postmortem she had a large tear in her bladder; the upper edge of her uterine incision had been mistakenly sutured to the upper edge of her bladder, so that the lower edge of her uterus had been able to bleed freely into her bladder. The doctor was overcome by grief and felt very incompetent. LESSONS (1) The anatomy of a patient having her fourth section can be complicated. (2) Always insert a stay suture in the lower segment of the uterus, just below where you plan to make your incision, so that you can recognize it later. This may be difficult after delivery, especially if there are adhesions and the anatomy is complicated (many obstetricians never insert one). (3) If you find an abnormally adherent or vascular lower segment, do a classical operation. (4) As so often, disaster was the result of the combination of risk factors. A lower segment which has been the site of adherence of a placenta praevia, is apt to bleed postoperatively. Had she not also had a placenta praevia, she would probably have escaped with her life, and merely had a vesico-uterine fistula, which could have been repaired. (5) If you have to try to do your best in 20 expert fields simultaneously (see the frontispiece), you will, by the standards of 20 experts, not be as competent as they are, so you will inevitably meet tragedies of this kind, for which you cannot be blamed. One can but do one's best, and what that is will depend on who we are. What is reprehensible is not to care, and not to strive to improve one's standards. (6) A colleague in this condition needs support. IDWER SEGMENT CAESAREAN SECTION INDICATIONS. See Section 18.8. PREOPERATIVE COUNSELLING. Where appropriate, discuss with the patient the advisability of tying her tubes. Her husband, or in some cultures her mother, or preferably both, should consent. The indications are: (1) > 2 previous Caesarean sections. (3) Parity >6. (4) Age >35. (5) Medical problems which endanger her life, such as hypertension, diabetes, or heart disease. PERIOPERATIVE ANTIBIOTICS have been shown to halve the incidence of wound infection after Caesarean section. Most routines are expensive, but here is a cheaper one which is equally effective. If she is at special risk of infection (membranes ruptured for more than 8 hours, or if you are operating after a failed vacuum or forceps delivery, etc.) give her perioperative chloramphenicol and metronidazole as in Section 2.9. Continue metronidazole for 3 days postoperatively. If she is a routine case, give her 1 g of metronidazole with the premedication as a rectal suppository or as rectal tablets, and give her another gram 8 hours later. ASSISTANT. Find yourself a competent assistant. If the head is impacted in her pelvis, ask him to wear two gowns and two pairs of gloves, so that he can disimpact it and then discard the first pair (see below). A MIDWIFE TO RECEIVE THE BABY. Before you begin make sure that there is a midwife ready to receive the baby, with all the equipment that she needs to resuscitate him (19.12). EOUIPMENT. Use the Caesar set described in Section 4.12. This includes a large round-ended Doyen's retractor to fit over the bladder and protect it (or use a wide Deaver's or a Morris retractor), and 6 Green Armytage forceps (use sponge-holders if you don't have these). You will need '1' chromic catgut for the uterus, 2/0 catgut for the peritoneum of her vesico-uterine pouch, monofilament for her abdominal wall, and two roundbodied Mayo's needles, a large one for the first layer and a smaller one for the second. A narrow 20 cm steel ruler to measure the true conjugate. The anaesthetist must have a syringe of ergometrine with oxytocin ('Syntometrine') or plain ergometrine ready. You and he will both need suckers. PACKS. Five or six large abdominal packs with tapes. NEVER use single swabs, you can too easily lose them in the peritoneal cavity! ANAESTHESIA is discussed in detail in Sections 18.2 and in A 6.9 and A 16.6. You have a choice of: (1) Several methods of local anaesthesia (A 6.9). (2) Ketamine (A 8.1). (3) General anaesthesia (A 16.6) for which she must be intubated (A 13.3). (4) Subarachnoid (spinal) anaesthesia is satisfactory, provided you know the method and its complications in detail (A 7.1), you put up a drip and give her 1-2 litres of fluid fast, you tilt her to the left, and you observe the contraindications, which are: shock, severe anaemia, hypertension, and heart disease. An augmented saddle block is the safest form of subarachnoid anaesthesia (see below). If your anaesthetist is an expert, general anaesthesia with cricoid pressure and tracheal intubation will be best (A 16.5), especially if her circulation is unstable due to an APH, or advanced obstructed labour. If she is shocked, and you are inexpert, and single-handed, local infiltration (A 6.9) will be the safest. If she is not shocked, an augmented saddle block (A 7.7) is suitable, particularly if you are single-handed. An ordinary saddle block is inadequate, because it does not extend high enough. You need to combine it with local infiltration of the abdominal wall, as in Primary Anaesthesia Fig. 7-8. Explain what is going to happen. Put her on to the operating table before you induce her. PREVENTING THE ACID ASPIRATION SYNDROME. Don't assume her stomach is empty because she has not taken food for a long time. Labour slows stomach emptying. If she has a general anaesthetic, she is in particular danger from the acid aspiration syndrome (A 16.3). Remove her gastric contents with a stomach tube, give her 30 ml of magnesium trisilicate mixture, or 0.3M sodium citrate within 15 minutes of induction, and then leave a Ryle's tube down. You cannot give her sodium citrate prophylactically throughout labour. If she is given a general anaesthetic, she must be intubated using cricoid CAESAREAN SECTION-ONE preparation incising the peritoneum draping picking up the peritoneum F extending the opening in the peritoneum Fig. 18•11 CAESAREAN SECTION-ONE. A, catheterizing the patient's bladder. D, preparing her abdomen. C, draping her and covering her with an abdominal towel. D, incising the skin. E, picking up a fold of peritoneum to feel ifthere is any gut in it. F, incising her peritoneum. G, enlarging the opening in her peritoneum with scissors. pressure (A 16.5). If possible, as prophylaxis against acid aspiration, give her ranitidine 50 mg intramuscularly 1 hour before an elective section, or by slow intravenous injection immediately before an emergency section. Or, if you expect to section her, give her 150 mg by mouth at the onset of labour and then every 6 hours. POSITION. Stand on her right side. Prevent the supine hypotensive syndrome by tilting her about 50 to the left (A 16.6). Do this, either by tilting the table, or by putting a pillow or sandbag under her right buttock. Find some way of preventing her slipping off the table. A moderate Trendelenburg position will give you better access to her lower segment, and make delivering the baby's head easier, if there is a vertex presentation. It will also be an additional safeguard if she vomits. PREPARATION. Catheterize her in the theatre while she is still awake, and leave the catheter in (A, in Fig. 18-11). You can also do this in the maternity labour unit. At the same time, do a vaginal examination to make sure you do not miss unexpected progress, and thus the opportunity to do a vaginal delivery if this is indicated. If you have difficulty catheterizing her bladder before operating, raise the baby's head with your hands. If you fail to pass a rubber catheter on the first occasion, try again after she is anaesthetized, when pushing up his head will be easier. If you have to operate with a full bladder, be very careful as you open her peritoneum. Open it as far cranially as you can, opposite the upper quarter of the incision through her abdominal wall, and empty her bladder with a syringe from her abdomen. Shave or clip her from her mons pubis to above her umbilicus, and laterally to her iliac crests (optional). Prepare the skin of her lower abdomen (B), drape her with 4 plain towels, and cover these with a towel with a slit in it (C). LOWER MIDLINE INCISION. Cut through her skin and subcutaneous tissue down to the level of her rectus sheath (D). Extend the incision to within 3 cm of her umbilicus. Try not to carry the incision further down than the upper limit of her pubic hair. If she has had a previous Caesarean section, see Section 18.10. Separate her rectus and pyramidalis muscles in the midline as far as her symphysis. If necessary, extend the skin incision further down. A short downwards extension is more effective in improving access than an extension upwards. Use sharp and blunt dissection to expose her transversalis fascia and her peritoneum. Use two haemostats to pick up peritoneum near the upper end of the incision (E). This is especially important if her labour is obstructed, and her bladder is displaced upwards. Feel the fold of peritoneum you have picked up, to make sure there is no bowel or bladder in it. Make a small opening in it with a scalpel (F), and then open the rest of it with scissors (G), longitudinally from above downwards to just above the reflection of her bladder. If you hold her parietal peritoneum with a light shining through it, you will see a constant small vein running transversely across it. If you avoid this, you will avoid her bladder. If her bladder is high deviate to the side of the midline. CAUTION! If she has had a previous operation, including a previous Caesarean section, omentum or gut may have stuck to her abdominal wall, so that you can easily cut them. If you cut her gut by mistake, sew it up as in Fig. 9-6. If she has had several previous Caesarean sections, her anatomy will be much distorted by adhesions. Clamp any active bleeders if they are big, but postpone tying them until later. They usually stop bleeding on their own. Feel her uterus to find how it is rotated, and identify the presenting part. It is usually rotated to the right, so that her left round ligament is usually more anterior and closer to the midline than the right one. If her uterus is markedly rotated, turn it towards the midline. Place a large abdominal pack on each side of her uterus, to keep her gut out of the way. Attach artery forceps to the tapes of these packs, to prevent them being lost. THE CLASSICAL ALTERNATIVE. Consider doing a classical rather than a lower segment section if: (1) her lower segment seems abnormally vascular, or (2) it is abnormally adherent to her anterior abdominal wall. If you decide to do one, see Section 18.12. THE De LEE ALTERNATIVE. Considerdoing ade Lee incision if: (1) Her lower segment is so thin and distended, that it might tear when you extract the baby. (2) She has a transverse lie with a prolapsed arm, and a Iive baby. (3) A lower segment fai Is to form, as may happen with a prematoredelivery in a primip. To make a de Lee incision, incise her visceral peritoneum transversely, as described below but high on her lower segment. Mobilize her peritoneum and her bladder well down. Find the midline of her uterus. Insert a small transverse suture where the bottom end of your incision is going to be, to prevent it extending downwards behind her bladder. Make a longitudinal incision, two-thirds of it in her lower segment, and one-third in her upper segment. Later, repair a de Lee incision, with two layers of continuous chromic No. 1 or 2 catgut. Make sure you include her uterine fascia in the second layer, or it will continue to bleed. Repair her peritoneum, and pull it up high, so that the top of the incision is covered. If you incised her upper segment over a long distance, tie her tubes on the same indications as in a classical Caesarean section. THE ALTERNATIVE OF A TRANSVERSE INCISION IN THE UPPER SEGMENT m.ay be necessary if there is a transverse lie or a contraction (Bandl's) ring. Check that her uterus is wide enough. Incise her peritoneum over the lower part of its upper segment with a scalpel. Mobilize it away from the incision with scissors, and incise her uterus transversely in the midline. Enlarge the incision to the right and left, by stretching it with your fingers (it is usually too thick to be cut with scissors), and deliver the baby by breech extraction. Repair the incision in two layers with continuous chromic No. 1 or 2 catgut. Don't catch the full thickness of her uterine wall in the first layer: it is often too thick. Repair her peritoneum over the incision, preferably with a locking stitch. Tie her tubes. ORDINARY LOWER SEGMENT CAESAREAN SECTION If her baby's head is jammed in her pelvis and needs to be disimpacted from below, ask yourself if a symphysiotomy would not have been better, and remember this next time! Ask your assistant to put his hand into her vagina, and to disimpact it to the site where you are going to make your incision. He must do this before you incise her uterus. If he waits until after you have inCised it, the baby's shoulders may prolapse into the wound, and make delivery difficult. Having done this, ask him to take off his second gown and gloves (see above). Unfortunately, it is difficult to predict that the head needs disimpaction, until after you have opened the uterus. Pick up the loose peritoneum of her vesico-uterine pouch with dissecting forceps (H). Make a small cut in the peritoneum over her uterus, just below the point where the loose peritoneum becomes firmly attached to the anterior wall of her uterus. This is the abdominal marking of her lower segment. Then put the scissors into the cut, and extend the incision in her peritoneum to left and right, so as to separate it from her uterus underneath (I). As you reach the edges of her uterus, aim the scissors in a more cephalic direction, so that the incision in her peritoneum is curved (J). Aim to leave a bare area about 2 cm wide and 12 cm long. Don't cut into the muscle of her uterus yet. Use a swab in a holder, or on your finger, to separate the folds of peritoneum on either side of the incision, pressing on her uterus as you do so. This will help to separate her tissues in the right plane, and avoid tearing her peritoneum, or her bladder. Raise the lower fold, and her bladder with it for about 3 cm (K). CAUTION! (1) Take great care to avoid injuring her bladder, especially if this is pulled up high and is oedematous. (2) Don't raise it more than 5 cm. If her cervix is effaced and dilated, you may enter her vagina by mistake. Put the Doyen's retractor over her bladder, to protect it for the rest of the operation. Put a stay suture of 210 catgut or monofilament into her lower segment (L), and hold the end of it in a haemostat. Ask your assistant to hold up the stay-suture. A short, fullthickness central incision minimizes the danger of cutting the baby. If you extend it shallowly on either side, the uterus will tear open in the right direction. So, make a 3 cm horizontal incision through the uterine wall in the midline, just above the stay suture (M). Cut only the centre of her lower segment. This should be 2 cm below the peritoneal reflection, and at least 2 cm above her detached bladder. Put a finger either side of the incision and press as you cut (not shown). This will help CAESAREAN SECTION -TWO pick up the H loose peritoneum insert a stay suture extend the incision Fig. 18-12 CAESAREAN SECTION-TWO. H, pick up the peritoneum of the patient's vesico-uterine pouch with dissecting forceps and cut it. I, put the scissors into the cut, and open them, so as to separate her peritoneum. j, as you reach the edge of her uterus, cut in a more cephalic direction. K, raise the lower fold ofperitoneum with her bladder in it. L, put a strong stay suture in her uterus. M, incise her uterus. N, liquor will spurt out. 0, put your fingers into the incision and lengthen it. you to judge how deeply you are cutting. Deepen it little by little until the membranes bulge into the incision. Cut through them (some operators keep them intact at this stage). Liquor will spurt out (N). Ask your assistant to suck it away. Insert your closed scissors through the incision, and open them, so as to extend it enough to let you insert both your index fingers. Lengthen the incision by pulling them apart laterally, in the line of the muscle fibres, until it is 10 cm long (0). Her uterus will open naturally, with a curve upwards at each end. If she has had previous Caesarean sections, and her uterus is very fibrotic, you may have to extend the incision with scissors, curving it upwards laterally. Ask your assistant to suck it dry. Alternatively, and most contributors would say preferably, make a scalpel incision for 2 cm in the midline, without cutting the membranes. Use scissors to cut the uterus, leaving the membranes intact until the incision is complete. Cut in an upward curve from the midline to the left angle of the uterus, and then in a similar curve from the midline to the right angle. If her uterus tears, the tear will then be more likely to run away from the cervix than towards it. CAUTION! (1) The lower segment varies considerably in thickness. It is thick before labour and becomes thinner during labour, so be careful not to cut the baby. Protect him with a finger between the membranes and her uterine wall as you cut. (2) Don't make the incision too small, or the uterus will tear as you remove his head. (3) Should you decide to enlarge the incision by cutting, curve it upwards at its ends, so as to avoid the uterine vessels. Also, when you suture it, you will be less likely to suture her ureters. If she has a scar in her lower segment from a previous Caesarean section, make a shallow cut along it, where you want the rest of it to tear. If you can feel the baby's vertex through the uterine wall, the placenta is probably lying in the fundus or posteriorly, so you can expect to deliver him without difficulty. If you cut the placenta as you cut into the uterus, try to detach it, and deliver him round it. Only cut through it if you have to. He can bleed severely from a cut placenta, so clamp his cord quickly. See also Section 18.10. If the ends of the incision in the lower segment bleed severely, before he has been delivered, quickly deliver him, and then control bleeding as described below. If there are large veins over her lower segment, incise it precisely and carefully, and deliver him rapidly. The veins will probably stop bleeding as soon as you have delivered him. If necessary, clamp them and insert further haemostatic sutures. DELIVERING THE BABY AT CAESAREAN SECTION Remove the Doyen's retractor. Put your finger (only) into the uterus under the baby's head to relieve the vacuum, and make it easier for his head to rise in the incision. Then put your hand outside the lower flap of the incision, and lift his head up. If necessary, apply Wrigley's forceps (P). If, when you apply them, the incision is not long enough to deliver him without a lateral tear, extend its ends upwards and laterally with scissors, so as to make a U-shaped flap. Contributors differ in the way they deliver the head. Some think that you should not put the bulk of your hand into the uterus, because it may cause tears. In practice most do, because it is quicker than forceps. Now ask your assistant to press on the fundus to assist delivery. He may have to press hard. Do this carefully and gently, without hurrying. Before you deliver the baby's thorax, aspirate his nose and mouth, if convenient. Then deliver his shoulders and trunk. CAUTION! Don't try to suck him out with a big Yankauer sucker: it may injure him. Resuscitate him as in Section 19.12. ERGOMETRINE OR OXYTOCIN. If she has PIH, or eclampsia, or you are operating under local anaesthesia, some operators avoid ergometrine, and give her 5 units of oxytocin intravenously or intramuscularly. Otherwise, give her ergometrine intravenously as soon as you have delivered his head. Ergometrine occasionally makes a conscious patient sick, and may raise her blood pressure. TH EBABY. Before you clamp his cord, hold him up by his legs with one finger of your left hand between them, so that the mid CAESAREAN SECTION-THREE p applying Wrigley's forceps Fig. 18•13 CAESAREAN SECTION-THREE. P, ifnecessary, apply Wrigley's forceps. Don't put your whole hand into the patient's uterus, the extra bulk ofyour hand may tear it. Q, place the baby on his mother's thighs and resuscitate him as in Section 19.12. R, put clamps on the angles ofher uterus, and on any major bleeding points. S, remove her placenta by controlled cord traction and fundal pressure, but wait until her uterus is contracting first. T, start suturing just lateral to the ends of the incision. U, closing the second layer. V, closing the peritoneum. wife who is helping you can suck out his nose and mouth. Lay him head downwards between his mother's thighs (0). Ask your assistant to put two clamps on his cord and divide it between them, while you care for her wound, especially the angles, which may bleed. In placenta praevia especially, clamp his cord quickly, because he may bleed from the injured sinuses of the placenta. If necessary, resuscitate him (19.12). CONTROLLING BLEEDING. If you are a quick operator, apply two Green Armytage clamps, one on the upper flap and one on the lower one, just proximal to the angle (R). They will identify the angle for you and allow you to suture it more accurately. If you are a slow operator apply several Green Armytage clamps (or sponge-holders) all round the cut edges of her uterus, particularly at the angles. Make sure they don't grasp theposteriorwall ofheremptyuterus,as itIies on thepromontary of her sacrum; you can easily do this by mistake if bleeding has been brisk. The difficulty in applying many clamps is that they will get in your way. REMOVING THE PLACENTA AFTER CAESAREAN SECTION When her uterus is contracting firmly, remove her placenta by a combination of controlled cord traction and fundal pressure (S). If necessary, help it to contract by massaging her fundus from inside her peritoneal cavity. Pull gently on the cord, and press her uterus back with your left hand. This should deliver the placenta easily. If it has stuck, removing it manually from inside her uterus may cause severe bleeding. When the placenta is delivered: (1) Inspect her uterine cavity to make sure it is empty. Wipe it dry with a gauze pack to remove pieces of membrane and clots. (2) Make sure that the placenta is complete. If she has a secondary postpartum haemorrhage, you don't want to have to re-explore her uterus-see 'Stop Press'. CAUTION! Don't probe her cervix to improve drainage-keep out of her dirty vagina! SUTURING THE UTERUS AFTER CAESAREAN SECTION Do this in two layers using thick chromic catgut and a large round-bodied Mayo's needle. Don't use non-absorbable sutures, particularly not on the inner wall. Ask your assistant to hold the lower edge of her uterus forwards with the stay suture, while you sew from the angles inwards (T). Start the sutures just beyond the right extremity of the incision, work towards the middle, and then start at the left angle. In this way, you secure the angles first. Alternatively, put a separate stay suture in the right angle, and start a continuous suture from the left angle. Sew the first layer as a continous running suture. Ask your assistant to hold the free end of the catgut tightly, while you work towards the other end of the incision. Unless the sutures are tight, it will not stop bleeding. CAUTION! (1) Start suturing just lateral to the angle. (2) Don't sew the lower edge above the upper one, because this may advance her bladder up her uterus. (3) Don't include her bladder in your sutures. If you find you have included it, you will probably be wise to leave a catheter in for a few days, rather than removing the sutures and starting again, which will cause severe bleeding. (4) If you suture too deeply with a large needle at the angles of incision, you may obstruct her ureters. (5) Don't sew the front and back walls of her uterus together. So, before the first layer of stitches is completed, put two fingers into the uterine cavity, to make sure that its walls are free. If necessary, release the sutures and start again. (6) Don't stitch her gut to the back of her broad ligament. If you are in any doubt, put your fingers down behind it before you start to stitch the lateral extremities of the incision. COMPLETING THE REPAIR AFTER CAESAREAN SECTION When the first layer of sutures is completed, make sure again that the ends of the incision are adequately secured. If necessary, put in one or two interrupted sutures, especially if bleeding from the wound continues.. Now start the second layer of continous running sutures (U). Ask your assistant to maintain tension on the stay sutures, so as to show up the edge of her uterus. Put a large warm pack over her repaired lower segment, and leave it for 2 minutes while you remove the abdominal packs. When you remove it most of the bleeding will have stopped. Look carefully at your completed sutures. If there is still bleeding, put in some more interrupted or Mattress 'figure of eight' sutures. Don't close her peritoneum until you have controlled all bleeding. . When her uterus is no lon"ger bleeding, close the pentoneum of her vesico-uterine pouch with continous sutures of 2/0 catgut (V). Again avoid including her bladder with the lower edge of the peritoneum. If you are going to tie her tubes (15.4), now i.s th.e time to do it. Look for ovarian cysts. If you find one which IS >5 cm In diameter, consider ovarian cystectomy (20.7). CLOSING THE ABDOMEN AFTER CAESAREAN SECTION Clean all blood and debris from her peritoneal cavity, and especially from her paracolic gutters. They will be much cleaner if you previously inserted abdominal packs ('lap pads') beside her uterus. Inspect these by drawing her uterus to the side. Measure hertrue conjugate with asteel ruleras in Fig. 18-16. Displace her uterus to the right, and put one end of it on her sacral promontary. Let it rest across her symphysIs pubis, and mark the place where it crosses the posterior aspect of her symphysis with your right index finger. Remove the ruler, read off hertrue conjugate, and record it in her notes and in the summary of labour. It will be invaluable when you come to decide if she should have a trial of scar next time. Place her greater omentum over her uterus: it will usually reach her bladder. Close her abdomen (9.8). Don't insert a drain. Bend up her legs, and press on the fundus to express clot from her uterus and vagina. A uterus full of blood will interfere with retraction and encourage infection; you may later mistake blood in her vagina for a postpartum haemorrhage. Clean out her vagina with a sterile swab on sponge forceps. As soon as she has recovered from her anaesthetic give her baby to her. This close early contact is important in developing the bond between them. If she has had a local or subarachnoid anaesthetic, she can see him before the operation is over. POSTOPERATIVE CARE AFTER CAESAREAN SECTION Estimate her blood loss: it will probably be more than you think. The average loss is 1 litre. Unless you have expert staff, check her vital signs yourself. Check and chart her pulse, temperature, and respiration half-hourly, until she is awake, and then, when her condition is satisfactory hourly for 12 to 24 hours. Continue the intravenous infusion for 24 hours, or until she can take fluids by mouth and bowel sounds are present. Give her 3 litres of fluid in 24 hours (two bottles of 5% dextrose and one of 0.9% saline). Give her pethidine 100 mg up to 4 doses. If she bled much, arrange for a fast running drip of saline or Ringer's lactate, and see her yourself in an hour. You will be suprised how often a patient who left the theatre in reasonable condition is now collapsed, because the drip was too slow, or stopped. CAUTION! Watch for signs of infection: (1) Fever. (2) A large, soft, tender uterus. (3) Tender thickening in her lateral fornices. If her membranes had been ruptured for more than 24 hours before the operation, or there are other reasons for suspecting infection, continue perioperative antibiotics (2.9) for up to 5 days. If she has been in obstructed labour and her urine is bloodstained leave a catheter in her bladder for 5 to 10 days. If she vomits, or her abdomen becomes distended, start gastric suction. CAUTION ! Before she goes home, make sure that she and her relatives know that she must have future deliveries in hospital-this is ESSENTIAL! She must come regularly for antenatal care. Give her a card which says why Caesarean section was done, and what she should do about her next delivery. Ask her to show this card at the antenatal clinic, when she becomes pregnant again. 18.10 Difficulties with Caesarean section Many difficulties attend Caesarean section, and many disasters can follow it, so the list below is long. Torrential bleeding when you cut through a placenta praevia can kill a mother. Disasters CAESAREAN SECTION IN AFRICA, 1879 Fig. 18-13a CAESAREAN SECTION IN AFRICA IN 1879, as described by Robert Felkin. The mother was liberally supplied wih banana wine, which was also used to wash the operator's hands and her abdomen. A single rapid lower midline incision opened her abdominal wall and her uterus. Bleeding points were cauterized with a hot iron. After delivery her abdomen was closed with seven thin iron spikes. The baby was put to her breast 2 hours later. Both mother and baby did well. Felkin RW, 'Notes on Labour in Central Africa: Edinburgh Medical Journal 1884;29:922. As reported in Medicine Digest 1985;11:17-19. with the urinary tract are usually the result of very poor technique. Fortunately, most of the others are rare. Some of these many difficulties are only seen in the developing world, where Inexpert operators find themselves working under difficult circurnstances. DIFFICULTIES WITH CAESAREAN SECTION For difficulties with infection, see section 6.8. DIFFICULTIES WITH THE INCISION If a patient has had a PREVIOUS CAESAREAN SECTION, dense adhesions may have formed between her uterus and her abdominal wall. They would have been much less likely to have formed, if her omentum had been placed between her uterus and her abdominal wall, at the last operation. Excise the scar in her abdominal wall with an elliptical incision. If the sides of this might be difficult to join up accurately, make some scratch marks across it and align them later. Open her parietal peritoneum as far as you can. Lift it between haemostats to stretch the adhesions, and divide them with the points of scissors directed at her uterus. If you find a plane of loose connective tissue, free it with a finger or swab. Cut fibrous bands. If dissecting the adhesions is very difficult (unusual), give up and make an upper segment incision. CAUTION! (1) Stay close to her uterus to avoid her bladder. (2) Open her uterus between stay sutures (see the story of Wambue in Section 18.9). If she has had a PREVIOUS CLASSICAL CAESAREAN SECTION, you would probably be wiser to do a lower segment operation this time. If after a previous operation, HER BLADDER HAS STUCK TO HER LOWER SEGMENT, so that you cannot mobilize it with a finger or swab, incise the peritoneum on her uterus about 2cm above her bladder. Lift the lower edge in forceps to stretch the adhesions between her bladder and her uterus. Cut them close to her uterus, keeping the points of the scissors directed at it. If this is difficult, give up and make an incision about 3 cm above where her bladder and her uterus have stuck together. If the baby's HEAD IS STUCK TIGHTLY UNDER AN OLD SCAR IN HER UTERUS, an incision just above it will probably tear as you deliver him. Instead, make a wide V-shaped transverse incision with the point of the 'V' lying across the middle of the scar. This will divide it and reduce the tension. If her uterus does tear, it will do so near the midline, where you can more easily see and repair it. If the INCISION IN HER UTERUS TEARS as you remove his head, there will probably be a vertical tear in the corner which will run down behind her bladder, often with heavy bleeding. If you are alone with the scrub nurse, ask for an extra assistant. Identify the edges of the incision and the tear. Mobilize her bladder further downwards if necessary. If you cannot define the extent of the tear, carefully open her broad ligament by cutting her round ligament. This will let you feel her ureter, so that you can avoid it before you apply any clamps. Now apply Green Armytage forceps to the edges of the tear, and draw its angle into view. Apply direct pressure with a dry pack, find the bleeding vessels, and tie them. Use interrupted sutures in the area of the tear. They will be easier to unpick if you catch her bladder or her ureter by mistake. CAUTION! After repairing a tear, check that her ureter has not been caught in a stitch by mistake. If these measures fail, the only way to control bleeding may be to tie her both uterine arteries (See 'Stop Press') or her internal iliac artery on that side (3.5). If you are not able to repair her uterus, do a subtotal hysterectomy (very rarely needed, 20.12). 01 FFICU LTI ES WITH PARTICULAR PRESENTATIONS If her labour is OBSTRUCTED WITH A CEPHALIC PRESENTATION, enter her abdomen just below her umbilicus so as to avoid her bladder. If catheterization before the operation was impossible, empty her bladder now with a needle and syringe. Much of the swelling will be oedema, which will not go away. Mobilize her bladder free from her lower segment as usual. If an assistant is to push the baby's head up from below through her vagina, let him do so now before you open her uterus. If he waits until after you have opened it, the baby's shoulder may prolapse into the incision and make delivery more difficult. Make a transverse incision in the lower segment. Choose its level carefully. If it is too high, delivery will be difficult; if it is too low, you may enter her vagina. If delivering his head is difficult, don't panic. Everyone finds this a problem, especially when the uterus is tight around him. Take time to push back its wall from around his head, by inserting 2 fingers all round. You will then be able to apply forceps. If you still have difficulty, enlarge the wound upwards and laterally at its ends. CAUTION! (1) Don't lever his head out with your whole hand, because vertical downward tears in the lower segment. (2) If her liquor was purulent or infected, clean her abdomen carefully and wash out her pelvis with warm saline. If his BREECH is presenting, delivery may be be more difficult than with a cephalic one. Feel for a leg, or better, both legs, and deliver him breech-first as if you were delivering his head. Then deliver his head slowly, or you may damage it. If, by mistake, you take hold of an arm, replace it. Then feel for a leg; recognize it by feeling for his heel. If an arm comes out and will not go back, you are in trouble (unusual). You may have to make an inverted 'T' incision to get him out. When necessary, deliver his arms by a modified Lovset manoeuvre, and his head by a modified Mauriceau-Smellie-Veit manoeuvre (19.8). If there is a TRANSVERSE LIE, the choice of incision is important. See also 18.9. If she is in early labour, and her lower segment is poorly developed, with most of the baby in the upper segment, make a transverse incision in the upper segment and deliver him by breech extraction (19.8). If she is in early labour, her lower segment is well developed, and her membranes are still intact, make a transverse incision in her lower segment, and deliver him by breech extraction. If labour is obstructed, and most of him is in the overdistended lower segment, simple delivery through a transverse incision in the lower segment will cause large tears. So: Ifhe is alive make a vertical incision in the lower segment, and extend the incision into the upper one until it is big enough to deliver him. Ifhe is dead, make a transverse incision in the lower segment, decapitate or eviscerate him, and deliver him in any convenient way. If his hand is outside her vulva, separate his arm at the shoulder joint before Caesarean section starts. CAUTION! (1) Don't try to deliver him intact, because this will tear her lower segment severely. (2) Don't make a classical or inverted 'T' incision for a dead baby. DIFFICULTIES WITH THE PLACENTA If you anticipate PLACENTA PRAEVIA, expect difficulty, and 277 get help if you can. You can usually use the ordinary transverse lower segment incision. This is contraindicated if: (1) She has a poorly developed lower segment, which would not allow a transverse incision of adequate length. (2) She has a very vascular lower segment with large veins on it. (3) The presenting part is high, and he is lying transversely, indicating that the placenta praevia is probably central. If so, mobilize her uterovesical fold, as for a lower segment operation. Make a low vertical midline (de Lee) incision. Deliver him as for a low classical section. If there is severe bleeding, quickly feel for a foot. His half breech will plug the bleeding area, and you will have the situation under control. Some surgeons make a vertical or transverse incision in the upper segment. If you find PLACENTA IN THE INCISION: (1) Peel it away from her uterine wall and enter her uterus from above it. (2) If the edge of the placenta is too far away to allow this, cut through it quickly, and deliver him without delay through the hole that you have just made. If you meet his cord, clamp it before you deliver him, but don't waste time looking for it: you can clamp it immediately afterwards. Remember that a baby can easily bleed from an injured placenta. His mother can also bleed, so if you see a large bleeding vessel in the placental bed (unusual), control it with a figure of eight suture. If she BLEEDS POSTOPERATIVELY (not uncommon with placenta praevia), she is probably bleeding from her lower segment at the site of the attachment of the placenta. Give her oxytocin, and if necessary transfuse her. In desperation, pack her uterus (19.11a). DIFFICULTIES WITH BLEEDING See also under 'Difficulties with the incision' and 'Difficulties with placenta praevia' above. If you have a LOT OF TROUBLE WITH BLEEDING during the operation, it is often helpful to bring the uterus out of the abdomen. You can then reach behind it with your hand and place the sutures at the angle of the incision. It is usually safe to put sutures beyond the "end of the incision provided you suture only into the substance of the uterus. See 'Stop Press'. If she has SEVERE VAGINAL BLEEDING 8 to 14 days after delivery (secondary postpartum haemorrhage), the operation site is infected (common after an obstructed labour with sloughing of the tissues). Under perioperative antibiotic cover (2.9) take her to the theatre, and examine her under an anaesthetic. Put a gloved finger into her uterus through her external os and feel: (1) for a piece of retained placenta, and (2) for the inner wall of her uterine scar. If this feels weak, or has broken down, reopen her abdominal incision. You may find a soft necrotic bleeding uterus, with blood and spreading infection in her peritoneal caVity. What was the scar may now be an infected hole in her uterus. Under such circumstances she should have a total or subtotal hysterectomy (20.12). If you don't attempt one, she will die. Expect to find that her parametrium is acutely infected and swollen, so that it feels like cheese. Alternatively, and less satisfactorily, remove what slough you can and carefully pack the wound. You will probably be unable to find any obviously bleeding vessels. If this fails, you will have to try to remove her uterus or to tie her internal iliac vessels (3.5). Even so, you may fai I to save her. 01 FFICU LTI ES WITH THE URINARY TRACT See also 18.18 and 18.190 If you OPENEO HER BLADDER, identify the hole carefully, hold its edges with Allis forceps, mobilize the surrounding tissues if necessary, and bring its edges together with continuous inverting sutures of fine chromic catgut. Try not to penetrate its mucosa. Drain her bladder continuously with an indwelling catheter for 10 days. On the 10th day spigot it 2-hourly. If she is satisfactory (no leaks, no abdominal discomfort, and a good flow when you release the spigot), remove the catheter on the the 11th day. If you have INJURED HER URETER at operation, first check that her other ureter is intact. Either, repair it if you can. Or, insert aT-shaped drain into her ureter, bring it out to the surface, and close her abdomen. Later, refer her for expert help. Don't try to do a ureterostomy. If she has ANURIA: (1) This may be the result of severe hypotension,while she was in obstructed labour (not uncom mon). Hydrate her well and give her frusemide 40 mg, intravenously. See Section 53.3. (2) You may have tied both her ureters (fortunately, rare). Refer her. If this is delayed do a temporary nephrostomy on both sides (23.13). If she complains of a severe dull PAIN IN ONE LOIN postoperatively, you may have tied one of her ureters. Do an IVP to look for a hydronephrosis or a 'nonfunctioning kidney' (actually a poorly functioning one, because insufficient dye is excreted to show the calyces). If you think you have tied a ureter, refer her. If referral is delayed, do a temporary nephrostomy (23.13). Sometimes, when you tie a ureter, neither she nor you are aware of it: her kidney merely stops working. If URINE DISCHARGES FROM HER VAGINA 2 to 5 days postoperatively, check that: (1) Her bladder is not distended (overflow incontinence). This can happen if it has been bruised. (2) She has not got bladder/urethral incompetence. If you see her urethra leaking, ask her to cough. If urine spurts out, this is what she has. If it is disabling, refer her for a sling operation. (3) She may have a fistula. Treat her with salt perineal baths (Sitz baths). Examine her at 10 days, if necessary under anaesthesia (EUA), when examination will be easier. She may have one of three fistulae: (A) If urine is COMING FROM HER ANTERIOR VAGINAL WALL:

(1) She has a VVF due to pressure from the fetal head during a long and difficult labour. Refer her to have it repaired at 6 weeks, or repair it yourself (see Section 18.18). Or, (2) urine may be leaking from her ureter. To confirm this put cotton wool swabs in her vagina, and instil methylene blue through a catheter into her bladder. If the swabs are stained blue, she has a vesicovaginal fistula. If they are wet, but not blue, she has a ureteric leak (ureterovaginal fistula). The classical test is to insert 3 swabs. If only the lower swab is stained blue, she has stress incontinence. If the middle and upper ones are blue she has a VVF. If the upper one is wet but not blue, she has a ureteric fistula.

CAUTION ! Don't instil gentian violet into the bladder: it causes a chemical cystitis and a contracted bladder.

(8) If she has a URETEROVAGINAL FISTULA (uncommon), it was probably caused by damage to her ureter at Caesarean section by: (1) clamping it in error, not recognizing this, and leaving the clamp on for more than a few minutes, or (b) by including the ureter in a suture closing the uterine wound. An IVP will tell you which side it is on. The kidney on the affected side will show some degree of hydronephrosis. She mayor may not have pain in her loin.

A ureterovaginal fistula is more hopeful and less urgent than

(a) tied ureter(s), because it means that her kidney(s) will not stop functioning. You will be able to refer her for elective repair. Her ureter may need reimplanting into her bladder, or repair end to end. If she is to retain good kidney function, refer her without delay.

(C) If URINE IS COMING THROUGH HER CERVIX (a vesicouterine fistula), it is the result of cutting her bladder, not immediately recognizing and repairing it, and finally stitching up her uterus so that her bladder communicates with her uterine cavity. Refer her.

If you cannot refer her, wait for 4 to 6 weeks. Open her bladder as for cystotomy for stone (23.15), and repair her uterus and bladder in separate well-defined layers. Drain her bladder as for a VVF; a Foley catheter is an acceptable alternative to the 'button' method (18-23). OTHER DIFFICULTIES WITH CAESAREAN SECTION If she has a CONTRACTION RING (Bandl's ring), in her lower segment, or between the lower and the upper segment, deal with it like this: If her baby is entirely above the ring, make a transverse incision entirely above it. If it is round his neck, make a vertical incision across it. If she has FIBROIDS, leave them unless they are pedunculated and removal is very easy. Otherwise, leave them: they may settle and atrophy. Removing a fibroid, at delivery, from within the wall of the uterus causes severe bleeding. If she has OVARIAN CYSTS OR TUMOURS, remove them if they are >5 cm. Ovarian cystectomy is possible, but removing the ovary and tube will be quicker and safer. Smaller functionalluteal cysts will have usually disappeared spontaneously by the end of pregnancy. See also 20.7. If she has ADHESIONS, you will have to separate them suf 278 ficiently to get good access to her uterus. Don't try to remove them from around her tubes and ovaries; they will ooze and form again. If you have sewn up her uterus WITHOUT REMOVING HER PLACENTA, it will probably be delivered vaginally in a few hours. The danger is that it might be retained and become infected. Even so, it is probably wise not to reopen her uterus and remove her placenta operatively. If necessary, remove it manually through her vagina. 18.12 Classical Caesarean section In spite of the long list of rather rare indications in Section 18.8, a classical Caesarean section is seldom done by experienced obstetricians. We describe it mainly because it is slightly easier if you are inexperienced. Because rupture of the uterus is such a danger with subsequent pregnancies, perhaps as early as 28 weeks, sew up the patient's uterus with particular care, and do all you can to persuade her to have her tubes tied. Many steps are the same as for a lower segment operation, so refer to them where necessary. CLASSICAL CAESAREAN SECTION See elsewhere for the indications (18.8), the equipment, and anaesthesia (A 16.6). INCISION. The patient's bladder may be high in her abdomen, so take care not to injure it. Stand on her right side, and make a right paramedian incision, or a midline incision skirting her umbilicus, two-thirds of it below and one-third above her um bilicus. This is best if she has a Bandl's ring or a high bladder. Look for her round ligaments. Their position will tell you if her uterus is rotated or not. If it is rotated, centre it. Put large packs each side of her uterus to keep blood and liquor out of her peritoneal cavity (A, Fig. 18-14). If you fail to do this blood will run into her upper abdomen and flanks, and you will have to remove it before you finally close her peritoneal cavity. Make a 12 cm vertical midline incision in her uterus (B). The uterus is much thicker here than in the lower segment. Make it as low down as possible, extending into her lower segment taking care to avoid her bladder. If necessary, reflect this downwards (as in K, Fig. 18-12). Deepen the centre of the incision steadily, being careful not to wound the baby. As soon as you are in her uterine cavity, put two fingers into the wound and complete it upwards and downwards using scissors to cut between your fingers (C). If the placenta is in the way, try to displace it rapid ly, rather than cutting through it. Search for a leg, and deliver the baby as a breech, guiding his head with your other hand (D). As soon as he is being delivered, ask the anaesthetist to inject ergometrine with ox ytocin ('Syntometrine'), or ergometrine 0.5 mg, intravenously. Place two artery forceps on the cord, cut it between them, hand him to the midwife, who should be waiting to receive him, and see that he is resuscitated rapidly. Hold him by his legs with one finger between them as she does so. As soon as he is delivered, deliver her retracted uterus through the abdominal incision, by hooking your index and mid dle fingers into its cavity, helped, if necessary, by the fingers of your left hand behind it. As soon as her uterus has contracted, deliver her placenta and membranes (E). Remove any shreds of membrane that re main by wiping the inside of her uterus with a swab (F). If her membranes were not ruptured before the operation, the ap-' pearance of the lower pole of the bag wiII show you that you have removed them whole. If her uterus is slow to contract, as may happen if anaesthesia is too deep, wait for the ergometrine to act, and if necessary for lighter anaesthesia. Then, if necessary, remove her placenta manually. Meanwhile wrap her uterus in a hot ab dominal towel, and compress it. Inspect and feel her uterus to make sure that it is not rup tured. Repair it in layers with '1' chromic catgut. For the first layer stitch the decidua and the deep layer of muscle with a continous suture. For the second one, use the sutures shown in G, and H, to invert the peritoneal covering. CLASSICAL CAESAREAN SECTION c D A extending the incision downwards incising the uterus G removing the E F placenta and membranes scraping the membranes off the uterus packing gauze round the uterus delivering the baby H.

closing the uterus Fig. 18-14 CLASSICAL CAESAREAN SECTION. A, packing gauze round the patient's uterus. D, incising her uterus. C, extending the incision downwards. D, delivering the baby. E, emptying her uterus. F, removing the placenta and membranes. G, an anchor stitch has been inserted, and the wound is being closed by an inverting suture, which pierces each wound edge from within outwards. This buries the peritoneal surface of the wound, and minimizes the formation of adhesions. After 'Bonney's Gynaecological Surgery; Figs. 331-7. Bailliere, with kind permission. If a continuous suture is difficult, because her uterine wall is being pulled apart so that each suture cuts out, place several sutures of interrupted silk 1 cm apart. Ask your assistant to pull on all but one of them, so as to approximate the edges of the incision, while you tie the remaining one. The result will be neat and may give a stronger scar than catgut. If she has agreed to have her tubes tied, now is the time to do it. Remove and count the abdominal packs. Mop blood and exudate from her peritoneal cavity, and close it (9.8). Alternatively, put tension sutures in her abdominal wall, and leave them in for 10 days. Remove blood clot from her vagina, as in Section 18.9. As soon she has recovered from the anaesthetic, give her baby to her. POSTOPERATIVELY, follow the same regime as for the 'lower segment operation (18.9). Explain to her, and to her relatives, that, in her next pregnancy, she must come into hospital, or into a maternity village at 32 weeks. She should have an elective section at the 38th week, or earlier, if there is any suspicion of her uterus rupturing. 18.13 Extraperitoneal Caesarean section This operation dates from the pre-antibiotic era, and the introduction of metronidazole (2.7) has made it largely unnecessary. But if you don't have metronidazole, and you have to operate in the presence of sepsis, you may find it useful. It is one of the more contentious operations in this book and one contributor doubts its value. If you section a mother in the presence of intrauterine infection, or after a long labour, she runs the serious risk of multiple peritoneal abscesses or peritonitis. There is quite a chance that she will die. You can reduce the risk of peritonitis by excluding the incision in her uterus from her peritoneal cavity. To do this, reflect her parietal peritoneum from the inside of her abdominal wall, and her visceral peritoneum from the front of her lower segment, and tie them together. This will seal off her peritoneal cavity from the incision that you are about to make into her infected uterus. This takes longer than the standard method, and is not as easy as it looks, but it is worth trying, if she is badly infected. EXTRAPERIlONEAL CAESAREAN SECTION See also Sections 18.8 and 18.11. Many of the details for the standard lower segment operation apply here also. INDICATIONS. Any Caesarean section in which the risk of subsequent peritoneal infection is great, when you have no adequate antibiotic cover, and especially no metronidazole. In an obstructed labour the attempt to do an extraperitoneal Caesarean section may be an impractical addition to an already complicated situation. PERIOPERATIVE ANTIBIOTICS. Give what antibiotics you can, as in Section 2.9. EXTRAPERITONEAL CAESAREAN SECTION median umbilical ligament lateral umbilical ligament B c artery forceps on median umbilical ligament abdominal wall E ... Fig. 18-15 EXTRAPERllONEAL CAESAREAN SECTION. A, a view of the patient's anterior abdominal wall from inside her abdomen, indicating the structures to be cut. B, artery forceps attached to her median umbilical ligament. C, her peritoneum reflected off her anterior abdominal wall. D, her peritoneum is being reflected offher lower segment. E, her peritoneum tied in a purse string. Kindly contributed by Hugh Phi/pot!. INCISION. Enter the patient's abdomen through a vertical incision from her umbilicus to her symphysis pubis. Extend this down to her peritoneum, but not through it. To reflect her peritoneum, attach a haemostat to the root of her median umbilical ligament. Pull on this to allow you to mobilize her parietal peritoneum: (1) laterally towards the walls of her pelvis, and (2) down to the anterolateral aspect of her lower segment. CAUTION ! Be sure to mobilize her parietal peritoneum superiorly and laterally for several centimetres above the lateral extremity of her uterovesical pouch. If you don't mobilize it extensively the purse string that you are about to make will be too tight, and may leak. To enter her peritoneum, define and divide her median umbilicalligament. Extend the incision in her peritoneum laterally and downwards on each side towards her lower uterine segment. Cut her lateral umbilical ligaments (obliterated hypogastric arteries) as you do so, and keep close to the point of firm attachment to her bladder. Reflect her bladder downwards. Attach a curved haemostat to her uterovesical pouch in the midline, where it joins the base of her bladder. Divide her peritoneum between her bladder and her uterus, and extend your incision laterally to join the incision that you have made on entering her peritoneal cavity. Ignore the covering of peritoneum attached to the fundus of her bladder. Attach artery forceps to the upper incised margin of her uterovesical pouch. Use this to help you mobilize a flap of peritoneum off her lower segment. Mobilize it as far as the point of attachment to the upper segment. Sew the two layers of peritoneum that you have just mobilized with a continuous suture. Pull it tight to make a bunchedup button of peritoneal tissue. It should look watertight. Reflect her bladder off her lower uterine segment, and proceed with a lower segment operation in the usual way (18.9). At the end of the operation, close the incision in her uterus, and control bleeding carefully. If possible, lavage the wound with 2 g of kanamycin or tetracycline dissolved in 200 ml of warm saline. Don't attempt to remove this. If you use water only, remove it. Insert a 26 Ch fenestrated rubber tube extraperitoneally through her abdominal wall, to lie over the suture line in her lower segment. Introduce a tube drain in her opposite iliac fossa. This will enable you to irrigate her extraperitoneal space postoperatively. Ignore the peritoneum covering the remainder of her bladder, but stitch the remains of her median umbilical ligament to the back of her rectus abdominis' muscle. As you do so, include as much of the overlying transversalis fascia as you can conveniently gather together. Apply intermittent suction drainage through the rubber tube, and irrigate the antibiotic solution through the tube dressing drain. If suction drainage is impractical, insert two corrugated drains, one in each iliac fossa, extraperitoneally, leave them in for 48 hours, and then shorten them 3 cm, before you finally remove them. CAUTION! Don't try to insert intraperitoneal drains. The aim is to try to keep her peritoneal cavity uninfected. 18.14 Which is it to be? Elective section, 'trial of scar', or section early in labour? If a mother has had one Caesarean section the alternatives for her next pregnancy are: (1) An elective section, before she goes into labour. (2) Section in early labour. (3) An attempt at vaginal delivery (a 'trial of scar'). How can you choose between these three? A lower segment Caesarean section is sometimes done for such conditions as fetal distress, placenta praevia, or the prolapse of the cord or an arm, which are unlikely to happen again in a later pregnancy. When a mother like this becomes pregnant again, there is every reason to expect that her labour will be normal, except for the scar that she now has in her uterus. This will almost always give some warning before it ruptures, so you can safely let her have further attempts at delivering her babies vaginally. This is called a 'trial of scar'. She can have as many trials as she likes, provided the previous one was successful, but she must have had only one previous Caesarean section. If she has had two sections or more, always section her. Contributors differ greatly in their use of a trial of scar. One only does them in exceptional circumstances. "TWO CAESARS OR MORE, ALWAYS A CAESAR" When you do a trial of scar, admit her to hospital and observe her closely. Should her scar show signs of rupturing, section her immediately. These warning signs only last an hour or two, before her uterus ruptures, so you must admit her and observe her with the greatest care. If CPD was the reason for her Caesarean section, it reduces the chances of a successful trial of scar in this pregnancy, but does not exclude it, because: (1) The pelvis continues to grow up to the age of 25. (2) Uterine action is often poor in the under-16s. An accurate measurement of her true conjugate done at the time of her previous section, as in Fig. 18-16, helps. A trial of scar is unwise if it is <9 cm. It is contraindicated in a breech presentation if the true conjugate is <10 cm. A trial of scar is absolutely contraindicated if her previous Caesarean section was classical. ONE 'CLASSICAL', ALWAYS A CAESAR MEASURING THE TRUE CONJUGATE B Fig. 18-16 MEASURING THE TRUE CONJUGATE AT CAESAREAN SECTION. Ifyou pack a steel ruler in the the Caesar set, and measure a patient's true conjugate routinely, it will help you to decide ifa trial ofscar is indicated next time she goes into labour. Ifyou do it carefully, it will give you an exact measurement, and will enable you to check the vaginal measurement you made ofher her diagonal conjugate when you examined her in the antenatal clinic (it is 2 cm less). A, her uterus has been pushed to the right and the ruler placed across her pelvic cavity. Her bladder has been displaced, partly out ofthe wound. In reality her symphysis is covered by the lower end of the wound and by her bladder. H, put your finger down behind her symphysis on to its posterior surface, bring your finger and the ruler out together, and see where it comes on the ruler. 'X' is her true conjugate. Good care during a trial of scar means that her pulse must be taken reliably, and you must be able to section her immediately. If, for example, her uterus shows signs ofrupturing at 3 a.m., section must be possible before 4 a.m., not at 10 am the following morning. If the organization and discipline of your hospital are not such that it can provide care of this quality, elective section will give her a better chance of saving her baby, her uterus, and perhaps her life. If it takes several hours to find a driver, to fetch you, and to prepare the theatre, a trial of scar will be dangerous. Ideally, a uterus should never rupture during a trial of scar. If more than the very occasional one ruptures, patients should be referred to wait to go into labour at a larger hospital. Even when conditions are not ideal, a trial of scar may be justified, because the immediate and future risks ofa further section can be considerable. If mothers know that they cannot have a trial of scar in hospital, they may try to have trials themselves at home. A mother will usually understand if you say "We will give you a try, and if you have any difficulty, we will do another Caesarean section' '. Ask the clinics to refer all mothers who have had a previous Caesarean section, and who are sure of their dates, at 34 weeks, so that you can assess them as described below. If a trial of scar is not indicated, plan an elective section at 38 weeks, or in early labour, if a mother is not sure of her dates. The best indication that a uterine scar is going to rupture is a rise in her pulse rate. Take this half-hourly. If it rises above 100, or she has pain between contractions, her scar is probably rupturing, so section her. Other signs are described below. Elective Caesarean sections are one of the alternatives to a trial of scar, but they are not the complete answer: (1) They may not be popular, so find out what your mothers think about them. If they are unpopular, avoid them, but at the antenatal clinic make the decision to section a mother in early labour. (2) Her dates may be uncertain, but even if they are certain, they need to be confirmed by a corresponding fundal height in mid pregnancy, before 20 weeks. (3) She is easily sectioned too early, so that her baby is at risk from prematurity. HARBANS KAUR (38, gravida 4 para 3) was admitted at 9 a.m. on a Saturday, for a trial of scar, having had one previous Caesarean section with her first pregnancy. She was 7 cm dilated and had good contractions. At noon she was fully dilated and her baby's head was 3/5 above the brim. During the next half-hour it remained there. The doctor on duty was called for another emergency Caesarean section, so the intern was advised to attempt vacuum extraction. He failed, but in doing so, he included her cervix under the cup, and tore it. At 3 p.m. she developed pain, shock, and abdominal tenderness, and the fetal heartbeat disappeared. She was rushed to the theatre. Her uterus had ruptured, and the tear had extended into her bladder. The superintendent was called. He found that her ureter had been caught in a hastily applied suture. The following day she was found to be leaking urine vaginally. LESSONS. These are many, they include: (1) In multips the second stage should not last longer than 20 minutes.

(2) A vacuum extractor was applied when the head was 3/5 above the brim. It should be only 1/5 up or less (except for a trial of vacuum or symphysiotomy).

(3) When you apply the cup of a vacuum extractor, you should make sure that you don't include her cervix. (4) When a trial of scar is done, it must be possible to do an immediate Caesarean section if the trial fails.

WARNING SIGNS MAY ONLY LAST AN HOUR OR TWO BEFORE RUPTURE TRIAL OF SCAR INDICATIONS. (1) A patient who has had one lower segment Caesarean section, and the reason for it is absent in this pregnancy. For example, it might have been done for a malposition or malpresentation, maternal or fetal distress, or CPD due to hydrocephalus, etc. (2) The scar from a myomectomy (provided her uterine cavity was not opened during the operation), hysterotomy, or uterine perforation during a 'D and C'. CONDITIONS. (1) She must have had not more than one previous Caesarean section. (2) When labour starts, she must either be in hospital, or not more than one hour away from it, with certain access to suitable transport. (3) Caesarean section must be available any time of the day or night, within one hour of the decision to section her. (4) Her pregnancy must have been normal. (5) Her baby must be a vertex presentation in the occipito-anterior position (some obstetricians will do a trial of scar for a breech). (6) There must be no fetal or maternal distress. CONTRAINDICATIONS. (1) Two or more previous lower segment Caesarean sections. (2) One previous classical Caesarean section. (3) Any degree of CPO, or suspected CPO in this pregnancy, as suggested by a true conjugate of <9 cm or a diagonal conjugate of < 11.5 cm. Although this is the ideal figure, it is unrealistic in some countries; in New Guinea, for example, a figure of 10.5 cm is used for the diagonal conjugate. (4) An occipito-posterior presentation. (5) Any other form of malpresentation, or obstetric complication. (6) Sepsis following a previous section is a relative contraindication only. (7) Any need for an oxytocin drip. A request for tuballigation favours the decision to do an elective Caesarean section. On its own, it is not a sufficient contraindication to vaginal delivery, because a vaginal delivery followed by tubal ligation will be safer. If a patient arrives in labour, use the same criteria as if she arrived during pregnancy. ASSESSMENT. See all mothers with a previous section in the antenatal clinic at 36 weeks, and decide whether to do a trial of scar or not. Take a careful history. Assess her pelvis clinically and assess the size of her baby by measuring the height of her fundus; if it is >40 cm, don't do a trial of scar. If you have not previously measured her true conjugate, X-ray pelvimetry is useful but not essential. . METHOD. Ask her to avoid heavy work during the last month of pregnancy, or to come in for rest. If she can be sure to reach hospital within an hour of labour starting, let her wait at home until labour starts. Otherwise, admit her at 36 weeks for rest and observation. Allow her fluids only by mouth during labour. Don't induce labour. Unless your blood bank can be relied upon to have blood available within an hour, have it crossmatched, and ready to give if necessary. Record her pulse and the fetal heart rate carefuIly. You may sometimes be able to feel the scar in her lower segment, when you examine her vaginally. This will be easier if you are using epidural anaesthesia. If it bulges or feels weak, section her immediately. The tenderness of a scar is difficult to assess in labour, and is not, on its own, an indication for section. Assist her with outlet forceps, or vacuum extraction, if necessary. Abandon the trial if: (1) She crosses the alert line on the cervicograph! (2) Her pulse rises to 100. (3) She has pain between contractions. (4) Her pain is generalized. (5) She has unexplained vaginal bleeding. (6) Her uterine contractions cease. (7) She has rectal or vaginal tenesmus. Stay with her during labour so that you can examine her lower uterine segment vaginally immediately after delivery of the placenta, so as to be sure that it has not ruptured. One contributor considers this impractical, and only recommends it if she has had a PPH; others do it routinely. Examining it is uncomfortable, but does not need anaesthesia. If you find a rupture, repair it at laparotomy (9.2, 18.17). If she has a postpartum haemorrhage, the scar in her uterus has probably broken open; confirm this by doing a vaginal examination, and repair it abdominally if you find it. 18.15 Injuries of the birth canal Primary Mother Care describes the repair of episiotomies and firstdegree tears; here we describe the repair of more serious injuries. You can nearly always avoid third-degree tears by 'controlled pushing', and by making an episiotomy when this is needed. They follow instrumental deliveries more often than normal ones. Almost all obstetricians meet them sometimes: so recognize this, and don't blame the midwife. She will be upset anyway, and will be tempted to conceal such a tear if you are harsh. Suture second-and third-degree tears, either within 24 hours of delivery, or after several months, when a tear has epithelialized and is no longer infected. With a recent third-degree tear:

(1) Start by stitching the edges of theratient's rectum together.

(2) Cover these stitches with a layer 0 fascia. (3) Suture her anal sphincter with two or three interrupted sutures. (3) Close her vaginal and perineal skin. If a tear is old, you will first have to incise and reflect the skin which has grown over it.

TEARS OF THE BIRTH CANAL LESSER INJURIES If a patient has a second-degree tear, and it is less than 24 hours old, suture it (M 24.1). If it is more than 24 hours old, wait, and sit her in salt baths. Use a bowl of water containing enough salt to make it into half-strength saline. Sit her in this twice a day for an hour; after 2 or 3 days she can continue baths at home. Hertearwill heal itself in a few weeks, with littledeformity of her perineum. Don't try to excise it, or her introitus will stenose later. If her cervix is torn, it may have a single tear, which is large enough to sew, or numerous small ones. The bleeding from small tears is most easily controlled by packing, see Section 19.11a. Blood is more likely to be coming from a poorly contracted uterus, for which she needs ergometrine and oxytocin. If she has a haematoma of her vulva (unusual), incise it at its lowest point, and evacuate the clot. Insert a drain, and suture this in position. If it bleeds severely, pack the cavity for 24 hours. If you don't see the bleeding vessel immediately, don't waste time looking for it. These haematomas are usually unilateral, and cause great pain, and occasionally retention of urine and shock. If her clitoris is torn (rare), undersew it with continuous catgut. It may bleed severely. Enquire what happened; a corn 282 mon mistake is to support the perineum too vigorously, so as to force the head against the pubis, and tear the tissues over it. A RECENT THIRD-DEGREE TEAR Repair her tear as soon as possible. Don't wait to let her recover from her labour. If you have to delay> 24 hours or there is infection, leave it, and do an elective repair later when it has healed. CAUTION! This is not a minor operation. The best chance of success is the first attempt. If you fail, she is condemned, at best, to some episodes of faecal incontinence. EOUIPMENT. One pair of tissue forceps, 6 haemostats, needle-holders, and round-bodied curved needles. Use No.1 chromic catgut for all tissues except her skin. ANAESTH ESIA. (1) Repair her tear in the labour ward, using local infiltration with 1% lignocaine. Often, she has already had a pudendal block prior to vacuum extraction or forceps. Or, (2) take her to the theatre. Give her a general anaesthetic. Make sure you have a competent assistant. METHOD. Put her into the lithotomy position, with her buttocks hanging well over the edge of the table. Shine a good light on the wound. Clean it and the skin round it thoroughly. Put a large gauze pack with a tape attached to it into her vagina. This will keep the tear free from blood, but be careful that bleeding does not occur above it. Ask your assistant to retract her vaginal wall while you survey the tear. If the tear goes high up her rectum and vagina (fortunately quite rare), you will find that there is nothing between her rectal mucosa and her vaginal skin. These two must be repaired in separate layers, so first dissect them free from one another. Lower down, her perineal body separates them, so that there is no problem. Suture her rectal mucosa with interrupted or continuous sutures, starting at the apex of the tear, and tying the knots outside the lumen of her rectum. Use a round-bodied curved needle. If the tear is very extensive, pick up her prerectal fascia with a second row of sutures. These will reinforce the first layer. To close her external sphincter ani, look for the torn ends of this muscle. You will find them lying in little pits on each side of her anus. Often, one side is deeply retracted, so that you have to fish for it. Define the muscle on each side by dipping into the pits with artery forceps. Pu II the end of the muscle up, and put artery forceps across it. Do the same the other side. Bring the artery forceps on each side together, and put your little finger into her anus. It should just go in, but be held firmly. If it is not tight, you have not defined the sphincter properly on each side, so fish again. Then insert three catgut sutures through the muscle to exclude the forceps. Don't tie them until you have removed the forceps, as in A, Fig. 18-17. Take a deep bite with the needle laterally, so as to include the fascia surrounding the muscle. Tie the knots without too much tension, or they may tear out. Check that you have not inserted too many sutures, and made her vagina too narrow. You should be able to insert 2 fingers comfortably. To close her vaginal skin use a single layer of continuous catgut sutures. To close her levator ani muscles, take deep bites with the needle each side, so as to take a good hold of the muscles and the fascia covering both their surfaces. These thick sheets of muscle and fascia lie deep on each side of her rectum. Begin at the anal end and join them together. Put in three to five stitches like this. Leave them united until they are all in place. Then tie them with care, so as to avoid excessive tension. Suture the skin of her anal margin with a few interrupted catgut sutures. Close the skin of her perineum with interrupted monofilament. Put a dry dressing on her wound. CAUTION! Don't close her skin and vaginal wall too tight; leave room for drainage, in case she becomes infected or oozes. POSTOPERATIVELY, keep her on a fluid diet until the third day. If she does not open her bowels by the 4th or 5th day (unusual), give her a small enema. Give her a normal diet from Day 1. Give her liquid paraffin twice daily for two weeks, starting on the third day. Start salt baths from Day 1. REPAIRING A THIRD-DEGREE TEAR D

dissect laterally and free her rectum separate her anteriorly vaginal wall and on from her both sides rectum cut round her exposed mucous membrane F incise her extend the vaginal dissection wall in upwards the midline Fig. 18-17 REPAIRING A THIRD-DEGREE TEAR. A, a recent tear, B to T, an old one. From Parsons and Ulfelder, of Gynaecological Surgery; pp. 259 and 261. W.B. Saunders, with kind permission. Q excise R excess tissue on the :. vaginal flaps extend the plane of cleavage 18.16 Old third-degree tears If a third-degree tear occurs in hospital, it is usually repaired immediately. If it occurs elsewhere, a patient may present too late for an immediate repair. Or a tear which has been sutured immediately may break down, and need repair later. Sometimes, a tear epithelializes and heals itself. If it is not very extensive, and her levator ani muscles are little damaged, she may not want the operation, and only be incontinent of faeces when her stools are very loose. AN OLD THIRD-DEGREE TEAR This is more difficult than the repair of a fresh tear. If possible, refer her. Don't operate for at least three months after delivery, or the last attempt to repair it, because her tissues will still be oedematous and infected. PREOPERATIVE PREPARATION, Give her a low-roughage diet for 2 days, and then an enema preoperatively. ANAESTH ESIA, Give her a saddle block (A 7.7), or an epidural block (A 7.2), or a general anaesthetic. INSTRUMENTS. Use those listed in the previous section for a recent tear. A good light, plenty of swabs (she will bleed), an assistant, and a scrub nurse. METHOD. The patient in B, Fig. 18-17 has torn her perineal body. Cut round her exposed mucous membrane for the full thickness of her vaginal skin. Apply Allis forceps, and use scissors to gently separate her vaginal wall from her rectum (C). While you exert gentle tension on her vaginal wall, dissect laterally and free her rectum anteriorly and on both sides (D). Apply clamps to the cut edges of her vaginal skin, and hold them downwards. Extend the dissection upwards in the plane of cleavage between her rectum and her vagina, holding your scissors against her posterior vaginal wall (E). Incise her vaginal wall in the midline (F), to expose her rectum (G). Hold her rectum medially, and use the handle of your scalpel to extend the plane of cleavage between the vaginal flap and her rectal wall (H). If you can mobilize her rectum, you can close it without tension. Trim the remaining scar tissue from the edge of her rectal mucosa (I). Hold the upper edge of her torn rectum in Allis forceps, and invert its mucosa with a row of fine atraumatic catgut sutures (J). Continue them until you reach the mucocutaneous margin of her anal opening, so as to make her a normal anus. Reinforce and bury the first layer of sutures with a second layer (K). This will reduce the the size of her rectum, but only temporarily. Fish for the retracted ends of her sphincter ani muscles, which you will find buried in dimples at either side of her anus. Use hooks (L), or dip in with fairly fine artery forceps. Bring the hooks together to see if you have secured her sphincter (M and N). Bring the ends of her sphincter ani together with at least 3 1/0 catgut sutures. Place several interrupted sutures in her levator muscles (0 and P). When they are all in place, tie and cut them. Excise any excess tissue on the flaps of her vagina (a). Bring the raw edges of her vaginal wall together with interrupted catgut sutures (R, and S). Hold each one untiI the next is in position, and then cut it. When you have closed her vagina, close her perineal skin. The last two or three of these sutures should complete the formation of her anus, so that rugae radiate from it like the spokes of a wheel. If they don't, you have not done the operation as you should. POSTOPERATIVELY manage her as for an acute tear (18.15). 18.17 Rupture of the uterus Uteri can rupture before or during delivery, but in only about two-thirds of cases do you make the diagnosis before you deliver the baby. In the rest you make it afterwards, usually after some difficult obstetric manoeuvre, such as a retained placenta (18.14), or a destructive operation (18.7), or after a trial of scar (18.14). SUSPICIOUS EVIDENCE B of a ruptured uterus Fig. 18-18 SUSPICIOUS EVIDENCE. Ifa postpartum patient has a mass contiguous with the uterus (A), which does not disappear on catheterizing the bladder (B), but persists (C), it is probably a haematoma of her broad ligament due to rupture ofher uterus. Ifa previous Caesarean section has left scar D, suspect strongly that it was classical. Scar E, might be either. F, is almost certainly a lower segment scar. After Nash and Drouin with the kind permission of the Editor of Tropical Doctor Here we are mostly concerned with rupture of the uterus before delivery, as a complication of obstructed labour. Section 18.4 describes the management of obstructed labour. If a mother, particularly a multip, arrives too late, or you do not recognize that she has obstructed, her uterus is likely to rupture. This is a great obstetric disaster. If primary care is really bad in your district, 50% of the mothers referred to you may need an operative delivery, and of these 5% may have ruptured their The usual story, which is described in more detail in Se9tions 18.1 and 18.3, is that a mother is admitted from her village in obstructed labour, having waited a long time in a rural health centre for transport to hospital. She is often sufficiently clearheaded to be able to tell you that she had strong frequent pains which stopped suddenly. When her uterus ruptures there may be a direct communication between her uterine cavity and her peritoneal cavity (complete rupture), or her peritoneum or her bladder may separate the baby from her peritoneal cavity (incomplete rupture, less common). If her membranes ruptured some time before delivery, the contents of her uterus will be infected, and her uterine muscle bruised and in poor condition for repair. Never try to deliver a mother with a ruptured uterus vaginally. Aim to: (1) Resuscitate her and operate soon. (2) Remove the baby and the placenta. (3) Control bleeding. (4) Repair or remove her uterus on the indications given below. Unless the rupture is extensive, and her tissues are particularly bruised and oedematous, repairing her uterus is likely to be easier than removing it, because the distortion ofher anatomy makes hysterectomy difficult. But even repair is not easy, because the edges of the tear are ragged and not easy to bring together. Hysterectomy takes longer than repair, and causes more bleeding. A subtotal hysterectomy, which leaves her cervix and perhaps part of her lower segment, is easier than a total one; it causes less bleeding, and there is less danger to her ureters. If you have to remove her uterus, try to leave one ovary. The secret of success is to exert continued traction on her uterus (20.12), and to identify important structures and landmarks before you start to cut or suture them. Speed is critical. Most time is lost getting her to the theatre, and in getting it ready, so make sure that it always is ready. If you are notfamiliar with the anatomy, study Figures 20-16 and 20-17/ RUPTURE OF THE UTERUS DIAGNOSIS. Be aware of impending rupture when labour is obstructed, especially in a multip, and try to prevent it happening by intervening immediately. Impending rupture: (1) Bandl's ring between the upper and lower segments rises. (2) The lower segment becomes stretched and painful to touch, even between contractions, which increase in strength and duration. (3) The patient becomes anxious and restless, with a rapid pulse and irregular respiration. Actual rupture: (1) Her uterine contractions stop suddenly and are replaced by no pain (common), or less pain, or severe continuous pain (uncommon). (2) She is shocked and pale before delivery, or she becomes shocked afterwards, and does not repond to transfusion immediately (especially if the placenta is retained). (3) She may bleed from her vagina, sometimes quite severely, sometimes not at all. If the presenting part is jammed in her pelvis no blood can escape from her vagina. In this situation, see if she has a haemoperitoneum by aspirating both her iliac fossae. (4) Her uterus is tender to palpation (it may feel soft, or be permanently tense). Later, her entire abdomen may be tender. (5) The baby may be abnormally difficult to feel (common) or abnormally easy (uncommon). Sometimes, the shape of her uterus changes, and you may be able to feel him outside it (usually his limbs are close under her abdominal wall, a certain sign of rupture). If he is in her broad ligament, you will be unable to feel him. (6) His head may previously have been low in her pelvis, but has now risen higher and may now be no longer palpable vaginally. (7) Bloodstained urine. (8) The absence of a fetal heartbeat, unless the tear is a small one, and he is still in her uterus. (9) The appearance of the placenta at her vulva before he is delivered (uncommon). (10) The prolapse of loops of gut into her vagina (uncommon). Shock or severe vaginal bleeding may dominate the picture. Her blood pressure is low and her pulse is fast. She is usually lucid, and may even be talkative, which may delude you into thinking she is less ill than she really is. If she is in obstructed labour, and you are still not sure if she has ruptured her uterus or not, resuscitate her, prepare for laparotomy, give her a general anaesthetic, intubate her, and examine her vaginally in the lithotomy position. The presenting part may have disengaged, so that your hand passes through the rupture into her abdominal cavity, allowing you to feel the inner surface of her abdominal wall. You may find that the presenting part is unexpectedly easy to dislodge, and the attempt to do this is followed by a gush of blood. If it is not easy to dislodge, try to pass a catheter by pushing it up a little vaginally. If this fails, stop for fear of damaging her urethra. Pass your fingers anterior to the presenting part, into her uterus and feel for a rupture. If there is one, you will feel the inner surface of her abdominal wall. If there is no rupture, deliver her vaginally (18.7). CAUTION! (1) Dramatic symptoms of rupture are uncommon. (2) If you are about to attempt a vaginal delivery, but have any suspicion that her uterus may have ruptured, take her to the theatre. Be prepared to give her a general anaesthetic and to do a laparotomy, if necessary. 01 FFERENTIAL DIAGNOSIS. Rupture of the uterus is not the only cause of collapse during an obstructed labour, it can also RUPTURE OF THE UTERUS A Expect this! vertical tear large with horizontal haematoma extension in parametrium uterus almost divided in two Fig. 18-19 RUPfURE OF THE UTERUS. A, a ruptured uterus may look like this. D, a tear in the anterior wall with a vertical extension at one end. C, a tear involving the bladder. D, a tear in the lateral wall opening into the broad ligament. E, a transverse tear in the posterior wall. F, a tear which almost detaches the uterus. G, the tear from a classical Caesarean section. be due to septic shock (53.4), electrolyte imbalance, or dehydration (A 15.3) or: Suggesting abruption with a massive concealed haemorrhage but no rupture-a tense, tender uterus. The important sign of abruption is a closed or nearly closed cervix-it is always open in obstructed labour. CAUTION! Beware of diagnosing abruption in a patient with a previous Caesarean section. Rupture is much more likely, even if she has not been in labour long. RESUSCITATION. Do this vigorously in the theatre or the labour ward. Internal jugular or subclavian puncture (A 15.2) is better than a cut down. Give her at least a litre of 0.9% saline before anaesthesia starts, and 100 mmol of sodium bicarbonate to correct her acidosis. Operate as soon as you can, don't wait too long; adequate resuscitation is impossible if she is still bleeding inside. Continue to resuscitate her while you operate. Put up two drips, one for saline or Ringer's lactate given fast, and the other for blood (53.2, A 16.7). If she is sufficiently conscious to understand, explain that you would like to tie her tubes. If she is not fit enough to understand, her relatives will. It is seldom necessary to tie tubes without permission. As a general rule, no woman who has had a ruptured uterus should ever become pregnant again (see below). The only exception is an extraperitoneal (partial) rupture through a lower segment scar. CAUTION ! Don't try to deliver the baby before she is resuscitated, because this will remove his tamponading effect, increase shock, and perhaps extend the tear. PERIOPERATIVE ANTIBIOTICS. Start these (2.9). Avoid gentamicin before anaesthesia (A 14.3). EQUIPMENT. A 'Caesar set' and some large curved clamps or artery forceps. You wi 11 need a scrubbed second assistant, besides the scrub nurse, the anaesthetist, and a 'runner'. ANAESTH ESIA. Pass a nasogastric tube, aspirate her stomach, and instil 30 ml of magnesium trisilicate. (1) If you give her a general anaesthetic, intubate her under cricoid pressure (A 16.7). (2) If her condition is poor, local infiltration anaesthesia will be safest (A 6.9). (3) A ketamine drip (8.3). Avoid subarachnoid or epidural anaesthesia, because she is already hypotensive. EXPLORATION FOR RUPTURE OF THE UTERUS Clip or shave her, wash her abdomen, and pass a catheter. This will prevent you mistakenly opening a high full bladder. Make a low midline or paramedian incision (9.2), and insert a selfretaining retractor. You will see blood, and a tear in her uterus. Her dead baby (common) and the placenta (sometimes) may be in her peritoneal cavity. If the placenta is still attached to her uterus, he may be alive (rare), even if he is lying free in her peritoneal cavity. If it is detached, he wi 11 be dead, wherever he is. If he is lying free in her peritoneal cavity, the rupture is complete. Remove him. If he is in her broad ligament, open it. This is most easily done by dividing the round ligament over it. If he is still in her uterus, as with a posterior rupture, deliver him through a transverse incision in the lower segment, as for Caesarean section. Suck out blood and liquor. There may be bleeding, or this may have stopped, especially if the tear is transverse across the vessels. If you have not already given her ergometrine, give it as soon as he is delivered. Lower the head of the table and pack off her gut. Deliver the empty uterus into the wound and inspect it, especially its posterior wall-there may be a second tear. Find the edges of the tear along its whole length. Divide her round ligament if this makes the tear easier to see. The tear may: (1) Be in the anterior wall of her uterus, often with a vertical extension at one end, making it L-shaped (B, in Fig. 18-19). (2) Extend into her bladder (C). (3) Extend longitudinally, along the lateral wall of her lower segment, from her fundus to her vagina, opening up her broad ligament and involving a uterine artery (D). Tears of this kind are more common on the left. (4) Extend transversely across the posterior wall of her uterus (E, rare). (5) Detach the uterus almost completely (F, rare). (6) Be in the upper segment through the scar of an old classical Caesarean section (G). Often, one of her uterine pedicles is torn across. Feel for the placenta and detach it from her uterus with your fingers. Use swabs on a holder to remove as much of the membranes as you can. Control bleeding from her uterus with No. 2 chromic catgut. Or, clamp the edges of the tear with several pairs of Green Armytage forceps. Control bleeding from her broad ligament temporarily with pressure from a pack. If she has an extensive haematoma tracking up from the torn vessels on one side towards her kidney, evacuate it and tie them. REPAIR OR HYSTERECTOMY? The indications depend on: (1) The nature and extent of the rupture. (2) Your experience. If you are inexperienced, only do a hysterectomy if repair seems very difficult. If you have some hysterectomy experience, factors favouring a repair are: (1) A rupture which is not too large. (2) A rupture with clean edges which are easy to see and are not too oedematous. (3) Little or no infection. Factors favouring a hysterectomy are: (1) Extensive or multiple tears. (2) Edges which are very bruised and oedematous and not easy to define, especially some posterior ruptures, or ruptures extending down into her vagina. (3) Gross infection of her uterus. THE REPAIR OF A RUPTURED UTERUS Start by defining the position of her uterine pedicles, her ovarian pedicles, and her round ligaments. If the tear extends into her cervix or lower segment, reflect her bladder as for a lower segment Caesarean section. Avoid her ureter. Ask your assistant to pull her uterus forwards and to the other side. Lift her tube and ovary, so as to make her infundibulopelvic ligament, which carries her ovarian vessels, taut. Put your thumb and index finger on either side of this ligament, and slide them down. Feel for her ureter as a hard round cord near her pelvic brim. From there trace it down to the injured area. See also Fig. 20-16. . Remove all clot. If she bleeds a little, disregard it. If she bleeds much, apply haemostats or transfixion sutures. CAUTION! (1) Be sure to keep her bladder well away from the edges of the tear. (2) Don't excise any tissue unless it is obviously dead. Start at the apex of the tear; if convenient hold it with a stay suture. Suture it as for Caesarean section, using 2 layers of continuous catgut in a large half-circle round-bodied needle (size '2' or '3'). You can suture a vertical tear going down to the cervix from below upwards, but sometimes the other way round is easier. Traction on the suture will help to bring the lower end into view. Don't worry if the inner layer has to be placed inside her uterus. Make the second layer an inverting continuous suture. If necessary, use extra sutures to close off the corners, or repair her vagina (usually anteriorly). If the rupture is lateral and has extended into her broad ligament, open its peritoneal roof, and tie the bleeding vessels. Control any OOZing with under-running stitches. Avoid her ureter. With one finger inside her broad ligament and another behind it, feel for her ureter; if necessary, pass a tape under it to keep it out of the way. Start at the apex and work downwards. Exert traction on the running suture to expose the depths of the tear. Stop before you reach the lower edge, so as to leave room for a drain from her broad ligament into her vagina. If there is much oozing, pack her broad ligament with a gauze bandage, bring it out of her vagina, and close the visceral peritoneum over it. Remove the pack 12 hours later. HYSTERECTOMY FOR A RUPTURED UTERUS The following description differs from that in Section 20.12, and is modified for rupture of the uterus. Consult the illustrations in that chapter, and particularly the account of the anatomy of the ureters, vessels, and ligaments. Hysterectomy may be surprisingly easy when the tear is extensive and transverse, and the uterus almost completely detached. IN DICATIONS. (1) Complicated rupture of the uterus (also see above). (2) Postpartum haemorrhage, which is not responding to treatment, and when tying the internal iliac arteries (3.5) has failed to control bleeding. METHOD. Remove the baby and the placenta and clean away most of the blood and liquor. Insert a self-retaining retractor, and lift her uterus from her abdomen. Maintain traction on it with one hand, or insert a traction suture. Start by identifying: her uterus and round ligaments, her tubes and ovaries on both sides, her infundopelvic ligaments, the avascular area in each of her broad ligaments, her lower segment, her rectum, and especially her ureters. You will find this difficult, because of the size of her uterus, and the disturbance to her normal anatomy caused by bruising and oedema, both near the tear, and far from it. Deflect her bladder, and trace her ureters over the whole length of the operative field as described above (20-16). Find where they are in relation to the tear, in the distal part of their course. You will have difficulty deciding where her uterus ends and her vagina begins. Feel for a small ridge of tissue (the remains of her cervix) on the 'inside' - but even this may be absent. If you are still not sure, it will merely mean that you will not know if you have done a total or a subtotal hysterectomy. In view of her present state, this hardly matters. Find the tear and clamp the obvious bleeding points. Pull her uterus to the left, and divide her right round ligament between clamps about 2 cm from it. This will open the anterior ANATOMY FOR HYSTERECTOMY Fig. 18-20 ANAlOMY FOR EMERGENCY HYSTEREClOMY. The patient's uterus seen from behind before hysterectomy. It is tilted to the left and her adnexa (ovary and tube) have been lifted up to show them more clearly. For simplicity the tear is not shown. 1, the body of her uterus. 2, her right Fallopian tube. 3, her ovary. 4, her round ligament. 5, her ovarian vessels running in her infundibulopelvic ligament which is being stretched. 6, her uterine vessels. 7, her rectum. 8, her sacrouterine ligament. 9, the avascular area in her broad ligament. Kindly contributed by Frits Driessen. peritoneal leaf of her broad ligament. Enlarge this opening down towards her bladder. Lift her right tube and ovary with one hand, and push a finger of your other hand from behind through the avascular area in her broad ligament. CAUTION! Leave her ovary and tube in place on one or both sides. On the side on which you will remove her ovary, clamp her infundopelvic ligament between two artery forceps and cut it. On the other side, to retain her tube and ovary, clamp and divide her tube and her ovarian ligament near her uterus. If they are very thick and vascular, you may have to clamp and cut them in two steps. Transfix the pedicles of her round ligaments and infundibulopelvic ligaments with '2' multifilament or chromic catgut. Using the clamps that you have already applied, pull her uterus well up in the midline, and cut the peritoneum between her uterus and her bladder. Extend the incision laterally to meet the incisions you have made in the anterior leaves of her broad ligaments. Push her bladder off her lower segment for 2 or 3 cm with a swab on a holder. Pushing it further down can cause bleeding. If the rupture is anterior, put its edge on the stretch before you separate off her bladder. Now expose the back of her lower segment by pulling her uterus forwards over her symphysis pubis. Divide the peritoneum over the back of her lower segment at the same level as you did anteriorly. Extend the incisions laterally to join the openings in her broad ligament. Push the lower flap of peritoneum off her lower segment with a swab on a holder; or, if this is difficult, cut it loose with scissors. On either side of her uterus there will now be a bundle of loose connective tissue containing her uterine vessels. If necessary strip down the peritoneum of her broad ligaments to see them more clearly. Pull her uterus to the right and clamp her uterine vessels with strong Kocher forceps, just above the level where her bladder is stiII attached to her lower segment. CAUTION! Make sure the points of the forceps are close to her uterus. Place a second clamp inside the first, and cut her uterine vessels between them. Tie and transfix the pedicle. Use a double transfixion Iigature because of its width. Do the same thing on the other side. Excise her uterus through its lower segment, just above the level of her cut uterine vessels. Have artery forceps ready to pick up the cut edge of her lower segment, before it disappears in the depth of her pelvis. Clamp any bleeding vessels. If the tear extends across her lower segment, it will probably serve as the 'line of cutting' to remove her uterus. Examine the edge and remove any very oedematous and bruised tissue, again checking the position of her ureters first. If there is a downward tear in her cervix, repair this now, after making sure that her bladder and ureters are well out of the way. Alternatively, do a total hysterectomy, and remove her cervix. Suture the anterior and posterior walls of her lower segment with figure of eight stitches, being sure to include the angles on each side, because these bleed. If there are signs of infection, leave the centre open so that you can insert a drain; otherwise close it. Her pelvis should now be nearly dry. Tie any remaining bleeders. If her broad ligaments are oozing, place a drain near them and bring it out through her vagina. Close her pelvic peritoneum with a continuous suture. Start on the left at the pedicle of her infundopelvic ligament, and suture the anterior edge of her peritoneum to the posterior edge, placing all vascular pedicles under it. Let her remaining ovary and tube hang freely in her pelvis. CLOSING HER ABDOMEN (after hysterectomy or repair) Always tie her tubes after a repair, unless you have repaired a lower segment Caesarean scar, and she is likely to return for an elective section at the start of her next labour. If her condition is unstable, close her abdomen without delay. If it is stable search for additional injuries, especially to her bladder. Clean and wash her peritoneum with at least two litres of warm saline. Instill 1 g of tetracycline in 1000 ml of warm saline (2.9). Close it with No. 0 or 2/0 catgut. Close her abdominal wall as usual. Monitor her haemoglobin. 'Suck and drip' her (9.9, A 15.5). Keep a catheter in her bladder until her condition is satisfactory, and monitor her urine output carefully: it should be at least 1 mllkg/hour (A 15.5). If she has a postoperative diuresis, usually at 24 to 48 hours, be sure to give her potassium (A 15.5, 9.9). Watch for anuria (53.3), respiratory complications (9.11), peritonitis (6.2), and peritoneal abscesses (6.3). Remember her nutrition; if there are no signs of peritonitis, start feeding her orally with a high-energy high-protein mixture as soon as her bowel function allows it, a few days after the operation (58.11). If there are no complications this can usually start on the 3rd postoperative day. DIFFICULTIES WITH RUPTURE OF THE UTERUS If her BLADDER IS TORN, its wall near the opening is usually stuck to her lower segment, and needs mobilizing before you can repair it. You may find that her bladder is so torn that it lies flat like a handkerchief. Use Allis' forceps or Babcock clamps to stretch the wall of her bladder and her lower segment. Suck away the blood. Separate her bladder from her lower segment with a 'swab on a stick', or with scissors. Gently dissect it off the lower segment, taking care not to make the tear any bigger. Free the bladder wall round the opening for 1 or 2 cm. Close the opening in her bladder with two layers of 2/0 continuous catgut. Put the first layer through the full thickness of her bladder wall, but just submucosal if possible. If this is difficult, include the mucosa. Use the second layer to invert the first one. Insert an indwelling catheter and maintain open drainage (an unspigoted catheter) for 10 to 14 days. Unfortunately, complete closure of the bladder is often impossible; its edges are usually thin and necrotic, so that a fistula follows. If complete CLOSURE OF HER TORN BLADDER IS IM POSSIBLE, because there is much presure necrosis, or the opening extends far down into her urethra, you may have to close her bladder over a wide-bore suprapubic tube. If she develops a vesico-uterine fistula, repair it later, or refer her to have it repaired. If you think that you have CAUGHT HER URETER in a suture, unpick it; usually there is no permanent harm. Alternatively, open her bladder and cannulate it. If severe damage is confirmed, the only way to preserve the function of her kidney is to reanastomose it over a splint, or to reimplant it in her bladder. An intravenous injection of methylene blue or indigo carmine may help to show leaks in her ureter (18.10). If she is ANAEMIC after delivery with a BOGGY PELVIC SWELLING and deviation of her uterus, she probably has a PELVIC HAEMATOMA. This is really a rupture of her uterus which has bled into her broad ligament instead of into her peritoneal cavity. If you see her <24 hours after delivery, do a laparotomy and explore and repair her rupture. If you see her > 24 hours after delivery and she is stable, treat her nonoperatively in the hope that her haematoma will resolve. 18.18 Vesicovaginal fistulae (VVFs) Fistulae between the bladder and the vagina are the most exacting gynaecological problem in the developing world. Some hospitals in Northern Nigeria have waiting lists of more than 600 patients, most of whom will never be treated. They were once equally common in Europe. In the developing world VVFs are usually the result of obstructed labour in a young primigravida (18.3), and less often of a traumatic vaginal delivery (particularly with Kielland's forceps), ofunskilled Caesarean section, or of rupture of the uterus into the bladder, especially through the scar of a previous section. They can occur: (1) Near the cervix Uuxta-cervical). (2) In the middle of the vagina. (3) Near the urethra Uuxta-urethral). (4) As a massive combination of the first three. (5) In the vault of the vagina as the result of vaginal surgery. Wherever the patient's fistula, she usually thinks she is incurable, and, as it does not kill her, she is likely to endure great misery for a long time, especially if she is very young (16 is the average age in Northern Nigeria). She may have lain at home for weeks in a pitiable emaciated state with contractures and bed-sores from lying curled up on her side, expecting to be returned to her parents and divorced by her husband. Fistulae have the reputation of being almost impossibly difficult to repair. One contributor believes that there is no such thing as an 'easy' VVF, and that only the occasional generalist with 'golden fingers' can do them. Nevertheless, in one district hospital (Chogoria in Kenya) 15 VVFs were successfully repaired without any failures by a succession of general-duty doctors, all working 'from the book', and with no individual doctor doing more than two. So ifyou cannot refer VVFs, you may be justified in attempting to repair the smaller, less difficult ones, which do not involve a patient's urethra. If you succeed, she will be immensely grateful. If you get a reputation for repairing them well, patients will come to you from a long way away. As always, learn from an expert, if you can. These are very rewarding patients! Most VVFs are due to pressure of the child's head during a prolonged labour. The best time to repair them is about 6 to 8 weeks after delivery (one contributor waits 12 weeks), when the slough has separated and the tissues are no longer friable, but before they have had time to become fibrotic. If a patient presents later than this, fibrosis makes the operation much more difficult. As soon as you diagnose a new VVF, keep the patient in hospital and give her salt baths two or three times a day to keep the wound clean. These fistulae can be repaired abdominally through the bladder, but we only describe the vaginal route. Aim to incise round the edges of the fistula, and free three planes-her vaginal mucosa, her bladder mucosa, and if possible a layer of tissue in between them-ifyoucandefineit. Ifyoucansewupthese layersseparately, you will probably cure her fistula. See also Primary Mother 288 Care Section 24.3, and the reference below: Lawson JB, and Harrison K, 'Obstetrics and Gynaecology in the Tropics'. Edward Arnold. Second edition, expected 1989. VESICOVAGINAL FISTULAE ASSESSING THE FISTULA is best done 1 to 3 days before the repair, so that you know what to expect and are not obliged to repair a patient immediately after you have assessed her. Explain that you are only going to examine her. If you find that her tissues are not in an ideal state, examine her again later. If they are suitable for operation, anaesthetize her for examination only, and put her into the lithotomy position. You will be able to see large and medium-sized fistulae with a speculum and a catheter. If you have difficulty finding a smaller one, infuse a coloured fluid, such as dilute methylene blue, into her bladder with a catheter and a funnel. Stress incontinence is the main differential diagnosis. (1) How big is the fistula? (2) How far it is from her urethral orifice? (3) What is the state of the surrounding tissues? Are they soft and friable, or soft and healthy? Mildly, or severely fibrosed? (4) Is her urethra stenosed or obstructed? (5) Is her vagina narrowed, or almost obliterated by scar tissue? (6) Does she seems to have 'lost her urethra'? See Section 20.14. INDICATIONS FOR BEGINNERS, If you are a beginner, and you cannot refer her, only operate if her fistula is: (1) Less than 1 cm in diameter. (2) More than 2.5 cm from her urethral meatus. (3) Not significantly fibrosed. Otherwise, you are unlikely to succeed until you are much more experienced. PREPARATION. She may well be malnourished, anaemic, tuberculous, or have some chronic bowel disease. Her urinary leak may have caused an ammoniacal dermatitis which has ulcerated. So be sure to restore her general health and make her as fit as you can before you operate. Build up her morale and enthuse your ward and theatre team. If possible, admit her next to a patient who has just had a successful repair. POSITION. This is critical and depends on the skill of your anaesthetist, and your personal preferences as to which way you like to operate. (1) If your anaesthetist is skilled, you can lie her on her front, her thighs abducted as far as possible, and her legs supported in double lithotomy stirrups, as in Fig. 18-21. REPAIRING A VVF assistant retracting vagina B intubated for controlled ventilation Fig. 18-21 REPAIRING A VVF. Note the way in which the patient's legs are held, and how the supports are padded. There is a pillow under her chest, her abdomen is free, she has been intubated, and the table has a 5° head-down tilt. It can be more steeply tilted (20°) and her legs slightly more flexed than this. Bandage her legs to the poles, have her buttocks clear of the table, and an overtable just below her. Tilt her 5° head-down, and raise the table to a convenient height to let you see into her vagina. One contributor tilts the table at 20° and slightly flexes her thighs over the end of the table so as to stop her slipping down. This is not an easy position to arrange on many theatre tables. (2) If your anaesthetist is less skilled, operate on her while she is lying on her back in the exaggerated lithotomy position, with a steep (30°) head-down tilt, her buttocks well over the edge of the table, and her shoulders supported by shoulder rests. This is more difficult, and is like working on the sump of a car without a pit. But it is not too difficult-if you get the table high enough with plenty of headdown tilt. Gynaecologists soon get used to it. ANAESTH ESIA. If she is lying prone, use general anaesthesia, intubate her, use relaxants, and control her ventilation. Put a pillow under her chest, and another smaller one under her pubis; make sure that her abdomen is free. Don't rely on spontaneous ventilation, because she will not ventilate adequately. CAUTION ! No patient should lie prone under general anaesthesia, and be expected to breathe spontaneously. Hypoxia, cardiac arrest, brain damage, and death may follow. Add a 1•mg ampoule of 1/1000 adrenalin to 100 ml of saline. You will need 10 to 25 ml or more of this solution to infiltrate the tissues round her fistula. It will show up her tissue planes and reduce bleeding. BLOOD, Cross-match two units. EOUIPMENT. A knife with a curved No. 12 blade, an ordinary NO.10 blade. Sims' specula. Langenbach retractors. Fine 16 cm dissecting forceps, toothed and plain. 12 cm fine curved artery forceps. Two vulsellum forceps. A pair of 20 cm light curved scissors. Two standard needle-holders. A 14 to 16 Ch catheter. A funnel for the catheter. A good sucker, two fine ends for it, and a probe to clear them. ASSISTANTS, You will need three. (1) An assistant on the right side of the table (viewed from your end), at the level of her abdomen, to hold up her posterior vaginal wall with a Sims' speculum, using both his hands, and resting them against her sacrum if necessary. (2) An assistant immediately on your right. (3) An assistant on your left, with the trolley, to hand you the instruments. REPAIRING AN EASIER VVF If her fistula is high in her vagina, near her cervix, it is usually easier to suture the first layer transversely, as in Fig. 18-22 and the description below. If it is low Ouxta-urethral) near her vesicourethral junction, suture it longitudinally, as in Fig. 18-22a. Provided she still has a centimetre or two of good urethra, you can repair quite a low fistula. Place an ordinary Jacques rubber catheter in her urethra, to make sure that you don't close it by mistake. Distend the layer between her vaginal wall, and her bladder, with adrenalin in saline. Open the fistula at its margin, as near as possible to the place where her bladder and her vagina meet. If necessary, cut within her vaginal epithelium. If you cannot see the edges of her fistula, pull downwards with a vulsellum forceps applied to the vaginal wall covering her urethra. . Use a scalpel with a No. 12 blade to open up the layer between her vagina and her bladder, keeping near to her vagina. Extend the separation with scissors, using sharp and blunt dissection, until you have separated a good margin, say 1 cm towards her cervix, and 0.5 cm laterally and towards her urethra. This may be difficult, and you may have to cut with the No. 12 blade. Try to define and dissect an intermediate layer of tissue (her precervical or pubovesical fascia), by separating it from her bladder wall. This may be difficult, if her fistula is large and fibrotic. One contributor considers the separation of an intermediate layer impractical. She may bleed. If you can suck the blood away adequately, and it does not obscure your vision, accept it. Bleeding will probably stop. If necessary, use a transfixion suture. Avoid diathermy, especially near the walls of her vagina and bladder, because it destroys tissue, and reduces the blood supply. Suture her bladder, starting at each end and working towards the middle. Using '0' catgut on a 5/8-circle atraumatic needle, AN EASIER VVF Fig. 18-22 AN EASIER VVE The patient is lying prone, as in the previous figure. A, the three layers oftissue round her fistula have been separated; the deepest bladder layer is being sutured. H, the intermediate layer is being sutured. e, her vagina is being sutured. Separate the vaginal and bladder layers for at least 0.5 cm. The tissue between them forms an intermediate layer. D, opening the fistula at its margin, as near as possible to the place where her bladder and her vagina meet. E, starting to sew up her bladder. F, her bladder has been sutured, and the sutures from each direction are now about to be tied. G, the intermediate layer has been sutured, and so has the superficial layer. Note that she is prone. place continuous or interrupted sutures about 3 mm apart. If the fistula is high in her vagina near her cervix (juxta-cervical) it is usually easier to suture the first layer transversely. If it is juxta-urethral, the first layer is best sutured longitudinally. Check the patency of the repair you have just done by instilling coloured fluid into her bladder. If it leaks, insert more sutures, or take them out and start again. For the following two layers use reliable '0' slowly absorbed sutures-polyglycolic acid ('Vicryl', best or 'Dexon')-or failing these chromic catgut. Close the intermediate layer (if you have been able to define it) with interrupted sutures, and A DISTAL VVF B A F Fig 18-22a REPAIRING A DISTAL (juxta-urethral) VESICOVAGINAL FISTULA at the junction of the bladder and urethra. A, mobilize and excise the fistula track. B, the track excised. C, the fistula is low in the vagina, so it is being closed longitudinally in three layers. D, mobilizing and closing the precervical fascia. E, closure of the precervical fascia is complete. F, the vaginal wall has been closed. After Poldratz KC, the Mayo Foundation. Permission requested. eliminate all dead space. Close her vaginal wall with interrupted sutures. If possible, place the line of sutures transversely. Otherwise place it whichever way the edges lie easiest. Try to arrange the sutures on the three layers so that they don't immediately overlie one another. Check again that the repair does not leak. CAUTION ! (1) Don't use non-absorbable sutures. (2) Obliterate all dead space. (3) With larger fistulae take care to avoid her ureters. Close the intermediate layer (if you have been able to define it) with interrupted sutures, and eliminate all dead space. Close her vaginal wall with interrupted sutures. If possible, place the line of sutures transversely. Otherwise place it whichever way the edges lie easiest. Check again that the repai r does not leak. INSERTING THE CATHETER. A bladder drain is required, which will not press on the repair, as a Foley catheter might, and will not slip out, as would a simple Jacques catheter. Use a big curved post-mortem needle to insert one in the following way. SECURING A CATHETER IN THE BLADDER A 9" M by catheter Fig. 18-23 SECURING A CATHETER IN THE BLADDER. The purpose of this procedure is to hold a catheter in the bladder, without its pressing on the site ofthe repair ofa VVF. A, covering a post-mortem needle with a catheter. B, introducing the catheter into the bladder. C, the needle in the urethra, the ensheathing catheter removed, and the definitive catheter being tied to the needle. D, the needle being pushed through the abdominal wall. E, the catheter secured with a suture and button. Push a piece of plastic tubing, or a catheter with its distal end cut off, over a curved post-mortem needle, so that the point of the needle is protected inside the catheter. Introduce this protected needle through her urethra into her Remove the catheter, leaving the needle in place. Then, using No. 2 monofilament, tie the catheter which is to be used for drainage to the eye of the needle, leaving a length of 12 cm or more free. Push the needle through her tissues, so that it emerges through her anterior abdominal wall, just above her symphysis pubis. Pull it through with the suture following, so that the end of the catheter lies in her bladder. Tie the suture emerging from her abdominal wall over a button. The catheter should lie freely in her bladder, and not against its wall, and yet not be so loose that it can be pulied out. POSTOPERATIVE CARE FOR A VVF Drain her bladder continuously for 10 (or 12) days. Ideally, use a bag with a non-return valve. Ask the nurses to empty this hourly and sign the chart to make sure that it has been emptied. Ifthe catheter blocks, the repair is in danger of breaking down. It is in the greatest danger of doing so between the 5th and the 8th day. On day 11 spigot and release the catheter 2-hourly. On day 12 do it 4-hourly. If this is satisfactory, remove the catheter and for a day or two check that she passes urine normally. If she leaks, examine her on a couch in the left lateral position, to find out if urine is coming from the fistula, or from her urethra. If she leaks from her urethra, this may be because it has been dilated by the catheter. If so, send her home to return in 6 weeks. This urethral incompetence may settle spontaneously. If she is no better, a urethroplasty may be indicated; refer her. If she leaks through the fistula, continue to drain her bladder for 20 days. It may still close, but this is not very likely. If it does not close in 20 days, remove the catheter, start salt baths again, and reassess her in 2 to 4 weeks. If you cannot refer her, and think you might succeed, try to repair her fistula again, about two months after the original operation. In most series of repairs for large VVFs, about 80% succeed the first time; 50% of the remainder heal the second time when the fistula is much smaller. Marion Sims, the pioneer of these repairs, succeeded for the first time on his thirteenth attempt! If possible, culture her urine just before you remove the catheter, and if it is infected, give her a 5-to 7-day course of the appropriate antibiotic. Warn her that if she becomes pregnant again she must have a Caesarean section, her repair may break down and a second attempt at repair will be more difficult. For difficulties with fistulae, see Sections 18.10, and 18.190. 18.19 Rectovaginal fistulae (RVFs) Fistulae between the rectum and the vagina (RVFs) are less common than those between the bladder and the vagina (VVFs). When a patient has a large VVF, she often has an RVF too, because both fistulae are caused in the same way-by pressure from the presenting part during a neglected obstructed labour. This causes the adjacent rectal and vaginal walls to necrose; as they heal they unite to form a fistula. The diagnosis is obvious-faeces start to leak through a patient's vagina 2 to 4 days after an obstructed labour, as necrotic tissue starts to separate. To distinguish an RVF from a third-degree tear, clean away her faeces, and look at her perineum. Closing an RVF can be very difficult, because it is so difficult to get at. If you have not repaired one before, make your decision to do so in her best interests. How difficult will it be to repair her, or to refer her? If you cannot refer her, you may have to try to repair her yourself. Unless someone repairs her fistula, she will have to remain with a permanent colostomy. REClOVAGINAL FISTULAE Keep the patient in hospital, and give her salt baths three times a day. Ifpossible refer her. On Iy if you cannot refer her, consider proceeding as follows. Make a defunctioning sigmoid colostomy (9.5) as soon as the diagnosis is made, and her condition is satisfactory. Continue with salt baths for about 6 weeks. ASSESSMENT. Under general anaesthesia explore her vaginally, pass a proctoscope, and, if necessary, a sigmoidoscope to see her RVF. How big is it? Is it clean, with all slough gone? Are its edges oedematous? Decide if it will be easier to close from above or below. If you are going to• refer her, do so now, while her tissues are healthy. Delay may lead to the formation of fibrous tissue round the fistula, but less so than with a VVE If her fistula is at her pelvic brim (common), plan to repair it from above. If her fistula is within easy reach vaginally (up to 8 cm from her fourchette, less common), plan to repair it from below. If she also has a VVF, repair this first. Now that she has a colostomy, faeces no longer leak into her vagina. REPAIR FROM ABOVE (common) ANAESTH ESIA. (1) General anaesthesia and intubation, with a relaxant if possible. (2) Subarachnoid (spinal) anaesthesia. Blood for transfusion is usually not necessary, but should be available. Pass a tube. POSITION. Lay her supine with a 5 or 10° head-down tilt. Stand on her left. INCISION. Make a left lower paramedian or subumbilical midline incision. Carefully pack her gut out of the way with a large damp pack, marked by a tape, to which a haemostat is attached. You will recognize the RVF as the place where her rectum is fixed to her vagina, and often to her bladder also, perhaps with considerable fibrosis. The attachment of her rectum to FISTULAE A The arrows show where the mother's cervix is being pinched between her baby's head and her spine and pubis Fig. 18-24 FISTULAE. A, the mechanism offistula formation. B, various fistulae. C, a vesicovaginal fistula. 1, a vesicovaginal fistula (commonest) is almost always due to pressure from the child's head in a prolonged obstructed labour. 2, a urethrovaginal fistula (not uncommon) is usually an extension from a vesicovaginal fistula, and seldom occurs in isolation, unless it is mistakenly produced surgically. 3, a vesico-uterine fistula (uncommon) is due to damage to the bladder at Caesarean section which is not recognized and repaired (18.10). 4, a rectovaginal fistula (next commonest after a VVF) is usually fairly high in the vagina and is due to pressure necrosis ofthe child's head against the sacral promontary and upper sacrum. (5) An ileovaginal fistula (very rare). Fistulae between the ureters and and the vagina also occur (rare, 18.10), but are not shown here. her bladder may obscure her upper vagina. Use fine curved dissecting scissors to separate her rectum from her vagina. As you do this, you will open into the fistula. As you separate her rectum from her bladder and vagina, avoid cutting through any normal tissue-or you may create another fistula! The area is rather inaccessible, because an RVF usually lies at the brim of the pelvis and extends into it. Freshen the edges of the rectal wound and close it transversely with continuous '0' chromic catgut on a 5/8 atraumatic needle. If it is large, this may be diffiCUlt, but avoid closing it longitudinally, because this will narrow her rectum. If access to her vaginal defect is easy, close it. Otherwise leave it. It wi 11 heal spontaneously, now that her rectal defect is closed. REPAIR FROM BELOW (uncommon) ANAESTH ETIC. Give her a general anaesthetic. Blood is not often necessary, but it should be available. Lay her supine in the lithotomy position, and work through her vagina. Have an assistant to help you on your right, and a trolley assistant on your left. Infiltrate the tissues around the fistula with adrenalin solution, as for a VVF. Use a No. 12 blade to dissect the fistula and separate her vagina from her rectal wall. Extend the incision with curved dissecting scissors. Close her rectum with continuous '0' catgut on an atraumatic 5/8 needle. Use similar, but interrupted, sutures for her vaginal wall. There is no intermediate layer, like the one which you may be able to define between her bladder and her anterior vaginal wall. POSTOPERATIVELY, (both approaches) care for her as if she had had a large gut repair (9.5). At about 4 weeks, inspect the repair vaginally and with a proctoscope and a sigmoidoscope. Pass a rectal tube (26 to 30 Ch) up to the colostomy. If all is well, close it. If she becomes pregnant again section her. DIFFICULTIES WITH FISTULAE (VVFs and RVFs) For vesico-uterine and ureterovaginal fistulae, see Section 18.10. If she has SEVERE VAGINAL STENOSIS associated with an RVF or VVF, which cannot be reconstituted, she may need a hysterectomy (20.12)-which should be subtotal, if you are Inexpenenced. She and her relatives may be reluctant to accept this. So you may have to wait until she has pain from a haematometra, before she will accept it. She and her husband or a relative must sign for it, before you do it. If she has a URETHROVAGINAL FISTULA (not uncommon) it is usually an extension from a vesicovaginal fistula, and seldom occurs in isolation, unless it is mistakenly produced surgically. ,If it involves the proximal half of her urethra only, and you are experienced, repair it as part of a VVF repair. If she is still incontinent after this, and her fistula has closed, her bladder/urethral junction is incompetent. Refer her for a sling urethroplasty. If it is more extensive (rare, unless caused by bad surgery, such as a disastrous symphysiotomy), refer her. She is likely to need ureteric diversion. If you are operating on a JUXTA•URETHRAL VVF or a fistula which involves her urethra, (not advised until you become expert), you will find a Martius graft useful. Repair the first two layers as usual. Leave her vaginal mucosa open for the moment. Make a longitudinal incision in a labium majus and retract the skin edges. Use scissors and dissector to separate a broad.-based finger-like pedicle of fibro-fatty tissue from her underlying fascia, taking care to preserve its blood supply. Base It posteriorly and and extend it to about the level of her clitoris: make It long enough to reach her urethra without tension. Before closing her vaginal skin, use scissors to make a tunnel under her labium minor and surrounding skin, through from your present incision to the fistula repair. Stretch the tunnel until it easily accommodates the pedicle. Pass a strong catgut stitch through the tiP of the pedicle, draw it into its new bed and suture it over the repair with 2/0 catgut sutures. Finally cover its tip with her vaginal mucosa. The pedicle will fill dead space, separate her bladder and vaginal mucosa, and improve the repair. If necessary do it on both sides If she has a 'GISHIRI CUT', it may extend into her bladder or divide her urethra and cause a formidable defect which is almost impossible to close. Traditionally, the Hausas of Nigeria cut the anterior vaginal wall on a variety of indications. Most cuts on non-pregnant women are small and easily repaired. If SEVERAL ATTEMPTS AT REPAIRING A VVF FAIL her ureters will have to be diverted into her colon, but only after the most skilled surgeon in the region has done all he can Diversion of the ureters has an appreciable operative mortali: ty, and urinary infection will shorten her expectation of life. If she has an unrepaired VVF and succeeds in becoming PREGNANT AGAIN, she is at risk of premature labour. Severe scarring (18.4) may prevent delivery of even a small fetus.