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When isolated: (1) The tip should point upwards; (2) The cephalic curve is to be directed inwards and the pelvic curve fo1wards.

SHORT CURVED OBSTETRIC FORCEPS (WRIGLEY)

The instrument is lighter, about a third of the weight of an ordina1y long curved forceps. The instrument is short which is due to reduction in the length of the shanks and handles (Fig. 37.7C). It has a marked cephalic curve with a slight pelvic curve.
I KIELLAND'S FORCEPS
It is a long almost straight (very slight pelvic curve) obstetric forceps without any axis-traction device. It has got a sliding lock which facilitates correction of asynclitism of the head. One small knob on each blade is directed towards the occiput.

I CHOICE OF FORCEPS OPERATION (TABLE 37.3)
Outlet forceps: It is a variety of low forceps where the head is on the perineum (Table 37.3). Thus, all outlet forceps are low forceps but not all low forceps are outlet forceps operations.
Low forceps (90%): The head is near the pelvic floor or even visible at the introitus. It is commonly used nowadays with advantages.
Midforceps (10%): Prerequisites are: (i) Must be associated with less maternal morbidity than cesarean section, (ii) Should not cause any fetal damage. Unless the prospect of successful vaginal delive1y is high midforceps delive1y is best avoided. Manual rotation may be needed before traction. In a selective case, delive1y by rotational forceps by an expert is safe. Othe1wise, it is better to wait for the head descent and complete rotation. An oxytocin drip may be helpful if not contraindicated. Ventouse may be an alternative.
TYPES OF APPLICATION OF FORCEPS BLADES:
Cephalic application: The blades are applied along the sides of the head grasping the biparietal diameter in between the widest part of the blades. The long axis of the blades corresponds more or less to the occiput
mental plane of the fetal head. It is the ideal method of
•-Pl Chapter 37: Operative Obstetrics

Table 37.3: Classification for operative vaginal (forceps/ventouse) delivery (ACOG-2000).

Types of procedure Outlet

Low

Mid

High

Criteria
• Fetal scalp is visible at the introitus without separating the labia. Fetal skull has reached the level of the pelvic floor.
•
■ Sagittal suture is in direct anteroposterior diameter or in the right or left occiput anterior or posterior position. II Fetal head is at or on the perineum (Fig. 37.9).
•
Rotation is <45°.
Leading point of the fetal skull (station} is at +2 cm or more but has not yet reached the pelvic floor: (a} Rotation is 545°, (b} Rotation is >45°.
Fetal head is engaged. Head is 1/5 palpable per abdomen but station is above +2 cm but not above the ischial spines (Figs. 37.10A to C}.
Head is not engaged. This type is not included in classification.

application as it has got a negligible compression effect on the cranium.
Pelvic application: When the blades of the forceps are applied on the lateral pelvic walls ignoring the position of the head, it is called pelvic application. If the head remains unrotated, this type of application puts serious compression effect on the cranium and thus must be
avoided.

I LOW FORCEPS OPERATION
Preliminaries: Same as those mentioned (Table 37.4). The following are especially emphasized:
■ Anesthesia: Pudenda/ block supplemented by perineal and labial infiltration with 1 % lignocaine hydrochloride is quite effective in producing local anesthesia. A perineal block may be sufficient (regional block is required for a rotational birth).

Table 37 .4: Prerequisites for operative vaginal delivery (forceps or vacuum application} (SOGC-2004, RANCZOG-2002).

Fetal and Maternal Criteria
• Fetal head engaged (head 51/5 Bladder must be emptied
•
palpable per abdomen}. a Adequate maternal analgesia (regional ■ The cervix must be fully dilated block for mid-cavity or pudenda! block} ■ The membranes must be ruptured ■ Informed consent (verbal or written} with
•
Fetal head position is exactly known. prior clear explanation a Caput and moulding not more than +2.
■ Pelvis deemed adequate.

Others
■ Experienced operator. ■ Aseptic techniques.
■ Back-up plan and facilities in case of failure.
•
Presence of a neonatologist.
■ Willingness to abandon the procedure when difficulties faced.

Pelvic
brim

Head
-1 , -2 station

Head at
station "O"

Rotated head
at station +5

lschial
spine

Path of
fetal head

Centimeters from ischial spine
(approx)

Forceps may be only choice
a. Aftercoming head of breech delivery. b. Preterm delivery <34 weeks.
c. Mentoanterior face delivery. d. Suspected coagulopathy,
thrombocytopenia.
e. Situation where maternal pushing is absent.

Fig. 37.9: Different types of forceps operations (ACOG-2000).
Chapter 37: Operative Obstetrics mJL

Figs. 37.10A to C: (A) Engaged head with lower pole below the level of ischial spine appropriate for instrumental vaginal delivery; (B) Supermoulding of the head due to brim contraction with the lower pole at the ischial spines, yet not engaged, misleading the station of head; (C) Excessive moulding and caput formation often mislead the actual level of head in the pelvis. Abdominal palpation is essential before instrumental vaginal delivery.

■ Catheterization
■ Internal examination to assess: (a) State of the cerix, {b) Membranes status, (c) Presentation and position of the head, {d) Assessment of the pelvic outlet (sacro coccygeal plateau, TDO and subpubic arch).
■ Episiotomy: It is usually done during traction when the perineum becomes bulged and thinned out by the advancing head.
STEPS: The operation consists of the following steps: ■ Identification of the blades and their application ■ Locking of the blades
■ Traction
■ Removal of the blades.

Step I: Identification and application of the blades
The identification of the blades is to be made after articulation as mentioned earlier (Fig. 37.11). The left or lower blade is to be introduced flrst.
The four fingers of the semi-supinated right hand are inserted along the left lateral vaginal wall, the palmar surface of the fingers rest against the side of the head (Figs. 37.12A to F). The fingers are used to guide the blade during application and to protect the vaginal wall. The handle of the left blade is taken lightly by three fingers of the left hand-index, middle and thumb in a pen-holding manner and is held vertically almost parallel to the right inguinal ligament. The fenestrated portion of the blade is placed on the right palm with the tip (toe) pointing upwards. The right thumb is placed at the junction of the blade and the shank (heel).
The blade is introduced between the guiding internal fingers and the fetal head, manipulated by the thumb. As the blade is pushed up and up, the handle is carried downwards and backwards, traversing wide arc of a circle towards the left until the shank is to lie straight on the perineum. Utmost gentleness is required while introducing the blade. No assistant is usually required to hold the handle in low forceps operation. When correctly applied, the blade should be over the parietal eminence, the shank should be in contact with the perineum and the superior surface of the handle should be directed upwards.

-----Left
blade

Fig. 37.11: Identification of forceps blades. Articulated forceps are held in front of the perineum in a position that they are expected to assume after application. This practice is known as "ghosting".

Introduction of the right blade: The two fingers of the left hand are now introduced into the right lateral wall of the vagina alongside the baby's head. The right blade is introduced in the same manner as with left one but holding it with the right hand.
Step II: Locking of the blades
Proper application of blades is confirmed by-(a) Blades should be in bimalar and biparietal placement; (b) Posterior fontanel should be one fingerbreath above theplane of the shanks and midway between the blades (Fig. 37.12D); (c) Lambdoid suture should be equidistant from the upper edge of each blade (Fig. 37.13); (d) The sagittal suture should be perpendicular to the
mJ Chapter 37: Operative Obstetrics

Ii
Figs. 37.12A to F: Steps of low forceps operation: (A) Introduction of the left blade; (Bl The handle lying flat on the perineum after introduction; (C) Introduction of the right blade; (D) Showing perfect apposition and locking of the blades; (El Bimalar, biparietal placement of blades and position of the fingers during traction; (Fl Change in the grip in the final stage of delivery.

plane of the shanks (Fig. 37.12E) and (e) The blade fenestrations should barely be palpated (Fig. 37.128).
Minor difficulty in locking can be corrected by depressing the handles on the perineum. In case of major difficulty, the blades are to be removed, the causes are to be sought for (vide infra) and the blades are to be reinserted. The handles should never be forced to lock them.
Step III and IV: Traction and removal of blades
Before traction is applied, correct application of the blades is to be ensured. Correct application is evidenced by: (a) Easy locking, (b) The blades are equidistant from the lambdoid suture (Fig. 37.13), (c) Firm gripping of the head on the biparietal diameter-as judged by a few tentative pulls.
Principles: Steady but intermittent traction should be given with uterine contraction. Preferably it should coincide with maternal pushing efforts. Howevet; in outlet forceps, the only resistance to overcome is the perineum and the coccyx.
Gripping of the articulated forceps during traction: The traction is given by gripping the handle, placing the middle finger in between the shanks with the ring and index fingers on either side on the finger guard. During the final stage of traction, the four fingers are placed in between the shanks and the thumb which is placed on the undersurface of the handles and exerts the necessary force.
Direction of the pull: The direction of the pull corresponds to the axis of the birth canal (Fig. 37.14). In low forceps operation depending upon the station of the head, the direction of the

pull is downwards and backwards until the head comes to the perineum. The pull is then directed horizontally straight towards the operator till the head is almost crowned. The direction of pull is gradually changed to upwards and forwards, towards the mother's abdomen to deliver the head by extension. The blades are removed one after the other, the right one first.

Fig. 37.13: (a) The blades are equidistant from the lambdoid suture indicating correct application (Biparietal Bimalar application); (b) Sagittal suture is in the midline of both the blades.
Chapter 37: Operative Obstetrics &Dt.
♦ General anesthesia is preferable.

Fig. 37.14: Showing direction of traction along the axis of the birth canal-(1) Downwards and backwards; (2) Straight horizontal pull; (3) Upwards and forwards.

Following the birth of the head, usual procedures are to be taken as in normal delivery. Routine injection oxytocin 10 IU, MIM or intravenous methergine 0.2 mg is to be administered with the delivery of the baby. Episiotomy is repaired in the usual method. Lacerations on the vaginal walls or perineum are to be excluded.

Forceps traction should begin with uterine contraction. It should concise preferably with maternal pushing efforts. Descent should occur with each pull. Fetal heart rate should be monitored. Failure of descent after two or to three pulls following correctly applied forceps by an experienced operators, operative vaginal delivery should be abandoned in favor of cesarean delivery. "Sequential use ofvacuum" may be done very cautiously (it is not a routine).

I OUTLET FORCEPS OPERATION
Wrigley's forceps are used exclusively in outlet forceps operation. Perinea! and vulval infiltration with 1 % lignocaine is enough for local anesthesia. The blades are introduced as in the low forceps operation with long curved forceps except that two fingers are to be introduced into the vagina for the application of the left blade. Traction is given holding the articulated forceps with the fingers placed in between the shanks and the thumb on the undersurface of the handles {Fig. 37.12F). The direction of the pull is straight horizontal and then upwards and forwards.

I MIDFORCEPS OPERATION
The most common indication of midforceps operation is following manual rotation of the head in malrotated occipitoposterior position. The commonly used forceps is long curved one with or without axis traction device. Kielland is useful in the hands of an expert.

Procedures
♦ Midforceps delivery should be done by a skilled obstetrician.

♦ Introduction of the blades: The introduction of the blades is to be done with prior correction of the malrotation.
(a) Without axis traction device: The blades are introduced as in the low forceps operation. An assistant is required to hold the left handle after its introduction. {b) With axis-traction device: While applying the left blade, the traction-rod already attached to the blade is held backwards. During introduction of the right blade, the traction-rod must be held forwards otherwise it will prevent locking of the blades.
♦ Traction: (a) Without axis traction device: The direction of pull is first downwards and backwards, then horizontal or straight pull and finally upwards and fo1wards. (b) With axis-traction device: The traction handle is to be attached to the traction-rods. During traction, the traction-rods should remain parallel with the shanks. When the base of the occiput comes under the symphysis pubis, the traction-rods are to be removed.

I DIFFICULTIES IN FORCEPS OPERATION
The difficulties are encountered mainly due to faulty assessment of the case before the operative delivery is undertaken. However, there is hardly any difficulty in low forceps operation.
During application of the blades: The causes are: (1) Incompletely dilated cervix; (2) Unrotated or nonengaged head.
Dificulty in locking: The causes are: (1) Application in unrotated head, (2) improper insertion of the blade (not far enough in), (3) failure to depress the handle against the perineum, and ( 4) entanglement of the cord or fetal parts inside the blades.
Dificulty in traction: The causes of failure to deliver with traction are:
1. Undiagnosed occipitoposterior position 2. Faulty cephalic application
3. Wrong direction of traction 4. Mild pelvic contraction
5. Constriction ring.
Slipping of the blades: The causes are:
1. The blades are not introduced far enough.
2. Faulty application in occipitoposterior position.
The blades should be equidistant from the sinciput and occiput.
FORCEPS IN OCCIPITOSACRAL POSITION: Usual application of the blades as like that of occipitoanterior position is made. The blades should lie equidistant from the sinciput and occiput, otherwise the blades may slip during traction. Horizontal traction is given until the root of the nose is under the symphysis pubis. The direction is
II Chapter 37: Operative Obstetrics

changed to upwards and forwards to deliver the occiput. By a downward movement of the instrument, the nose and chin are delivered.
FORCEPS IN FACE PRESENTATION: Forceps delivery is only reserved for mentoanterior position. The blades are applied as in occipitoanterior position. But the handles should be kept well forward to avoid grasping of the neck by the tips of the blade. Traction is made like that of occipitoanterior to bring the chin well below and then round the symphysis pubis.
APPLICATION OF FORCEPS TO THE AFTERCOMING HEAD: The method has been described on p. 363.
I KIELLAND'S FORCEPS
The forceps was designed and named after Kielland (Kjelland) of N01way (Rotational forceps, 1916). In the hands of an expert, it is a useful and preferred instrument. Its advantages over the widely used long curved forceps are:
1. It can be used with advantages in unrotated vertex or face presentation;
2. Facilitates grasping and correction of asynclitic head because of its sliding lock (Figs. 37.15A and B).
IDENTIFICATION OF THE BLADES: The articulated blades are to be held in front of the vulva in a position to be taken up when applied to the head. The concavity of the slight pelvic curve should correspond to the side towards which the occiput lies. The blades are named anterior and posterior. The anterior blade is to be introduced first.
METHODS OF APPLICATION: There are three methods: 1. Classical (obsolete)
2. Wandering 3. Direct
Indications of rotational forceps are few. It is commonly used in deep transverse arrest with asynclitism of the fetal head. Wandering method is popular. The anterior (superior) blade is applied first. The blade is inserted along the side wall of the pelvis and then wandered by swinging it round the fetal face to its anterior position. The posterior blade is inserted directly under guidance of the right hand placed between the head and the hollow of the sacrum. The forceps handles are depressed down and the handle tips are brought into alignment to correct the asynclitism. The occiput is rotated anteriorly. Slight upward dislodgement of the head may facilitate rotation. The position is rechecked and traction is applied. Sitting on a low foot stool or kneeling is convenient for the operator.
LIMITATIONS: Because of complexity in the technique of its appli cation, one should be sufficiently trained before independent use.

■ Eclampsia, severe pre-eclampsia. ■ Heart disease.
■ Previous history of cesarean section. ■ Postmaturity.
■ Low birth weight baby.
■ To curtail the painful second stage. ■ Patients under epidural analgesia.

COMPLICATIONS: Fetal: Facial bruising, laceration, facial nerve palsy, skull fractures, intracranial hemorrhage. Maternal: Perinea! sulcus tear, complete perinea! tear. Deep mediolateral episiotomy is mandatory.
Piper forceps is a specialized forceps used to assist the deli ve1y of the aftercoming head of breech. It has a cephalic curve, English lock, reverse pelvic curve, long parallel shanks that permit the baby's body to rest against it during head delive1y. Snanks are long and parallel.
PROPHYLACTIC FORCEPS (ELECTIVE): This type of forceps operation was named after De Lee (1920). It refers to forceps delivery only to shorten the second stage of labor when maternal and/ or fetal complications are anticipated (Box 37.3).
It prevents possible fetal cerebral injury due to pres sure on the perineum and spares the mother from the strain of bearing down efforts. Prophylactic forceps should not be applied until the criteria of low forceps are fulfilled.
TRIAL FORCEPS: It is a tentative attempt of forceps delivery in a case of suspected midpelvic contraction with a preamble declaration of abandoning it in favor of cesarean section if moderate traction fails to overcome the resistance (Box 37.4). The procedure should be conducted in an operation theater keeping everything ready for cesarean section. The conduct of trial forceps requires great deal of skill and judgment. If moderate traction leads to progressive descent of the fetal head, the delivery is completed vaginally, if not cesarean section is done immediately. Many unnecessary cesarean sections or dificult vaginal deliveries can thus be avoided.

■ Maternal obesity (BMI 30).
■ Clinically big baby (weight 3 kg). ■ Occipitoposterior position.
■ Mid-cavity delivery.
■ When 1 /5th fetal head palpable per abdomen.

Figs. 37.15A and B: (A} Kielland's forceps; (B} Piper forceps.
Chapter 37: Operative Obstetrics ii
I COMPLICATIONS OF FORCEPS OPERATION

■ Incompletely dilated cervix. ■ Short maternal height.
■ Unrotated occipitoposterior position. ■ Cephalopelvic disproportion.
■ Unrecognized malpresentation (brow) or hydrocephalus. ■ Constriction ring.
■ Clinically big baby ( 4 kg). ■ Maternal BMI 30.
■ In a case with mid-cavity delivery.

Table 37 .S: Complications of Forceps Operation. Maternal Fetal Immediate Immediate
■ Injury: Vaginal laceration or sulcus tear, ■ Facial and scalp
cervical tear, extension of episiotomy to lacerations.
involve the vaginal vault, Obstetric Anal ■ lntracranial
Sphincter Injury (OASI) 10%. hemorrhage
■ Nerve injury: Femoral (L2, 3, 4), (rupture of the lumbosacral trunk (L4, 5) with midforceps great vein of
delivery. Galen).
■ Postpartum hemorrhage may be-(i) ■ Asphyxia
■ Cephalhematoma
(more with
vacuum), facial
palsy, skull
fractures, cervical
Traumatic or (ii) Atonic, requiring blood
transfusion or (iii) Both, may cause shock. ■ Anesthetic complications (following local
or general anesthesia).
■ Puerperal sepsis and maternal morbidity spine injury
■
Risk of VTE (score 1). (rotational forceps).
■ Jaundice Remote Remote
Painful perinea! scars, Dyspareunia, Low Cerebral or spastic backache, Genital prolapse, Stress Urinary palsy due to residual Incontinence, Urinary retention and Anal cerebral injury (rare).
Sphincter Dysfunction.

FAILED FORCEPS: When a deliberate attempt in vaginal delivery with forceps has failed to expedite the process, it is called failed forceps. It is often due to poor clinical judgment and skill. Failure in the operative delivery may be due to improper application (Box 37.5).
Prevention: It is a preventable condition. Only through skill and judgment, proper selection of the case ideal for forceps can be identified. Even if applied in wrong cases, one should resist the temptation to give forcible traction in an attempt to hide the mistake.
Management
1. To assess the effect on the mother and the fetus.
2. To start a Ringer's solution drip and to arrange for blood transfusion, if required.
3. To administer parenteral antibiotic. 4. To exclude rupture of the uterus.
5. The procedure is abandoned and delivery is done by cesarean section.
6. Laparotomy should be done in a case with rupture of uterus.

The complications of the forceps operation are mostly related to the faulty technique and to the indication for which the forceps are applied rather than the instrument. The complications are grouped into (Table 37.5):
♦ Maternal ♦ Fetal

VENTOUSE

Ventouse is an instrumental device designed to assist delivery by creating a vacuum between the cup and the fetal scalp. The pulling force is dragging the cranium while, in forceps, the pulling force is directly transmitted to the base of the skull.
INSTRUMENTS: Ever since Tage Malmstrom, in 1953, introduced and popularized its use, various modifications of the instruments are now available. Each, however, consists of the following basic components {Figs. 37.16A to C):
Metal cups were initially used. Soft cups (Bell-shaped), silicone cup [silicone rubber or disposable plastic (Mityvac)} cups have better adherence to the fetal scalp. These cups could be folded and introduced into the vagina without much discomfort. Silastic cup causes less scalp trauma and there is no chignon formation. The mushroom shaped cups are a hybrid of stainless steel and plastic devices {KIWI Omnicup). This cup can be placed on the flexion point in an asynchitic head {OP position). It is safe, effective and is useful for rotational delive1y (Table 37.6).
The cup is connected to a pump through a thick-walled rubber tube by which air is evacuated. Vacuum is created by a hand pump or by electric pump. The parts of the device are:
1. Suction cups with four sizes (30 mm, 40 mm, 50 mm and60mm).
2. A vacuum generator.
3. Traction tubings {Figs. 37.16A to C).
INDICATIONS of ventouse delivery are the same as those of forceps (Table 37 .2).

PROCEDURE
Preliminaries: The procedures to be taken are mentioned on p. 525. Pudenda! block or perinea! infiltration with 1 % lignocaine is sufficient. It may be applied even without anesthesia especially in parous women. The instrument should be assembled and the vacuum is tested prior to its application.
Step I: Application of the cup: The largest possible cup is to be selected. The cup is introduced after retraction of the perineum with two fingers of the other hand. The cup is placed against the fetal head nearer the occiput (flexion point) with the 'knob' of the cup pointing towards the occiput. Flexion or pivot point is an imaginary site located midsagittally about 6 cm from the center of the anterior fontanel or about 3 cm in front of the posterior fontanel. Traction over this flexion point either by ventouse or forceps facilitates flexion and presents
Chapter 37: Operative Obstetrics

- Manometer
(kg/cm2)

Pump

t1
Figs. 37.16A to C: (A) Malmstrom device; (BJ Mityvac pump with tube and soft cup; (CJ Kiwi vacuum devices with the flexible stem and hand-held pumps pressure gauze device.

Table 37 .6: Advantages of individual Instrument (Forceps or Ventouse) delivery, one over the other.

Agvantages of ventouse over forceps
■ It can be used in unrotated or malrotated head (OP, OT position). It helps in autorotation.
■ It is not a space-occupying device like the forceps blades. ■ Traction force is less (10 kg) compared to forceps.
■ It is comfortable and has lower rates of maternal trauma and genital tract lacerations.
■ Analgesia need is less. Pudenda! block with perinea! infiltration is adequate but for forceps regional or general
anesthesia is often needed.
■ Reduced maternal pelvic floor injuries and is advocated as the instrument of first choice.
■ Perinea! injury (3rd and 4th degree tears) are less compared to forceps.
■ Postpartum maternal discomfort (pain) are less compared to forceps.
■ Easier to learn comparing to forceps.
■ Simplicity of use in delivery makes it convenient to the operator (suitable for trained midwives).

Advantages of forceps over ventouse
♦ In cases, where moderate traction is required, forceps will be more effective compared to ventouse.
♦ Forceps operation can quickly expedite the delivery in case of fetal distress where ventouse will be unsuitable as it takes longer time.
+ It is safer at any gestational age baby (even <36 weeks). The fetal head remains inside the protective cage.
♦ It can be employed in anterior face or in aftercoming head of breech presentation where ventouse is contraindicated.
+ Lesser neonatal scalp trauma, retinal hemorrhage, jaundice or cephalhematoma compared to ventouse.
+ Higher rate of successful vaginal delivery as ventouse has got higher failure rates than forceps.
♦ Cup detachment (pop-off) occurs when the vacuum is not maintained in ventouse. No such problems once forceps blades are correctly applied.
♦ Different types of forceps are available for outlet, mid-cavity or rotational delivery. Traction force is more (about 20 kg for a primary and about 13 kg in a multigravida).

the smaller diameter to the pelvis (Fig. 37.17). The knob indicates the degree of rotation. Betadine (antiseptic) solution is applied to the rim of the malstrom metal cup.
A rapid negative pressure (compared to stepwise increment) of 0.2 kg/cm2 is induced by the pump slowly, taking at least 2 minutes. A check is made using the fingers round the cup to ensure that no cervical or vaginal tissue is trapped inside the cup. Alternatively the pressure is gradually raised at the rate of 0.1 kg/cm2 per minute (76 mm Hg) until the effective vacuum of 0.8 kg/cm2 (608 mm Hg) is achieved in about 10 minutes time. Negative pressure can be created within 2 minutes without any adverse effects. The scalp is sucked into the cup and an artificial caputsuccedaneum (chignon) is produced. The chignon usually disappears within few hours.
Step II: Traction-Practical guides are (Figs. 37.18A to C):

♦ Traction is released in between uterine contractions and maternal pushing efforts.
♦ Traction should be made using one hand along the axis of the birth canal. The fingers of the other hand are to be placed against the cup to note the correct angle of traction, rotation and advancement of the head.
♦ Operative vaginal delivery (forceps/ventouse) should be abandoned where there is no descent of the presenting part with each pull or when delivery is not imminent after three pulls (3) with correctly applied instruments by an experienced operator.
♦ Traction between contractions should be avoided. Traction in the absence of maternal pushing needs increased force and increases the risk of cup detachment. It is advised to complete the delivery in 3 to 4 uterine contractions.

♦ Traction must be at right angle to the cup.
♦ Traction should be synchronous with the uterine contractions.

♦ Twisting or Rocking the vacuum cup to facilitate descent of the fetal head is not recommended as it increases the
Chapter 37: Operative Obstetrics ED ....

--- -Anterior fontanel

a Any presentation other than vertex (face, brow, breech).
■ Preterm fetus (<32 weeks) chance of cephalhematoma, intracra nial hemorrhage, subg/ea/ hemorrhage or neonatal jaundice.
11 Suspected fetal coagulation disorder.
■ Suspected fetal macrosomia (:.4 kg).

:: +-;-- - --t- Flexion or pivot point

■ Unengaged fetal head.
11 Obvious CPD.
■ Prerequisites for operative vaginal delivery not fulfilled (Table

3cm ■

37.4).
Fetus having an acute bleeding diathesis (hemophilia).

<-- 9' -- Posterior 11 Patient's refusal; ■ Inexperienced operator. fontanel

Fig. 37.17: Ventouse cup should be placed on the flexion or pivot point (Figs. 37.18A to C).

risk of scalp laceration, intracranial hemorrhage and cup detachment.
♦ Correct application and traction and to maintain descent flexion and autorotation.
♦ Vacuum delivery: Completed by: 3 pulls (3 additional to ease head out of the perineum); Discontinue after: 2 pop off's.
♦ Repeated detachment (POP-offs) of the cup (:.2) during traction indicates evaluation of the site of application, direction of pull, maternal pelvis (Boxes 37.6 and 37.7).
♦ As soon as the head is delivered, the vacuum is reduced by opening the screw-release valve and the cup is then detached.
The delivery is then completed in the normal way.

COMPLICATIONS: Neonate: 1. Superficial scalp abrasion. 2. Sloughing of the scalp.
3. Cephalhematoma-due to rupture of emissary veins beneath the periosteum. Usually, it resolves by 1 or 2 weeks.
4. Subaponeurotic (subgalea]) hemorrhage (not limited by suture line as it is not subperiosteal).
5. Intracranial hemorrhage (rare).
6. Retinal hemorrhage (no long-term effect). 7. Jaundice:
■ Vacuum extraction is considered a trial and may fail at
achieving vaginal birth.
■ Maternal (Obstetric) Anal Sphincter (OASI) perinea!,
vaginal, injury are less compared to forceps (19-12%).

Silicon cup Suction cup (hybrid) 'Chignon' (schematic) 'Chignon' (dotted line)

Figs. 37.18A to C: Application of vacuum extractor (A to C) indicating the directions of traction at different stations of the fetal head. Traction over this flexion or pivot point either by ventouse or forceps promotes flexion and presents smaller diameter to the pelvis (Fig. 37 .17).
ID Chapter 37: Operative Obstetrics
Maternal: The injuries are uncommon but may be due to inclusion of the soft tissues, such as the cervix or vaginal wall inside the cup. However, failure rate is high. The sequential use of ventouse and forceps increases the risk of trauma both to the mother and the neonate. Outlet forceps may be used following failure ofventouse.
SUMMARY: Ventouse is an instrument designed to assist delive1y by creating vacuum between it and fetal scalp. The instrument, as deviced by Malmstrom, consists of:
1. Suction cup.
2. Vacuum generator.
3. Traction tubing device.
Silicon cups are found more convenient. The indications are same as those of forceps except that it cannot be employed in face or after coming head of breech. Vacuum: Causes lower rates of maternal trauma and genital tract lacerations, but causes more neonatal scalp trauma and cephalhematoma compared to forceps. Both the instruments (ventouse and forceps) are not inherently dangerous. The operator must have knowledge, experience and skill to use and also the willingness to abandon the procedure when felt difficult. All operative vaginal delivery procedures should be considered as a trial.
The rate of Obstetric Anal Sphincter Injury (OAS!) may be higher in forceps delivery. The risk of fetal injury associated with instrumental vaginal delivery is instrument specific. The sequential use of ventouse and forceps increases the risk of injury both to the mother and the neonate. This should be avoided.
Benefits and risks of operative vaginal delivery
Benefits: Most women desire a vaginal delivery. Safe and effective use of instrumental delivery fulfills women's desire and satisfaction. Many women (79%) have subsequent spontaneous vaginal delivery compared with women delivered by cesarean section (39%).
Maternal risks:
1. Perinea! trauma: Third or fourth degree perinea! injury is associated with primiparity, macrosomia, shoulder dystocia, prolonged pregnancy and operative vaginal delivery.
2. Urinary retention: Risk of retention is present. A post void residual should be documented. An indwelling catheter for 6-12 hours to relief retention especially following epidural is a good practice.
3. Urinary incontinence: Compared to spontaneous, vaginal delivery, urinary incontinence is not high following forceps or venture delivery.
4. Fecal incontinence: Operative vaginal delivery is associated with increased risk of perinea! injury (third and fourth degree lacerations). Long-term data as regard fecal incontinence is debated.
5. Infection: A single prophylactic dose of amoxicillin and clavulanic acid is recommended. Good standards of hygiene and asepsis is maintained.
Fetal risks: Forceps, Ventouse.
Vacuum: Retinal hemorrhages (twice to that of forceps). Forceps protects against neurologic injury.

VERSION
DEFINITION: It is a manipulative procedure designed to change the lie or to bring the comparatively favorable pole to the lower pole of the uterus.
TYPES: According to the methods employed:
♦ Spontaneous ♦ External ♦ Internal ♦ Bipolar
Spontaneous: Version process occurs spontaneously. The incidence of spontaneous version in breech presentation is nearly 55% after 32 weeks and about 8% after 36 weeks. It is more common in multiparous women.
External: The maneuver is done solely by external manipulation.
Internal: The conversion is done principally by one hand introducing into the uterus and by the other hand on the abdomen.
Bipolar (Braxton-Hicks): The conversion is done introducing one or two fingers through the cervix and by the other hand on the abdomen.
Manipulations are done through the abdominal wall. When an oblique or transverse lie is changed into longitudinal lie and the presentation is made cephalic it is called External Cephalic Version. When the manipulations are made inside the uterine cavity to make a breech presentation it is known as Internal Podalic Version.
I EXTERNAL CEPHALIC VERSION External Cephalic Version (ECV) is done to bring the favorable cephalic pole in the lower pole of the uterus.
INDICATIONS
♦ Breech presentation ♦ Transverse lie
Selection of time, contraindication, difficulties and complications have already been described.
The advantages of ECV at term are: (i) By this time spontaneous version will occur in many cases; (ii) If any complications occur during ECV, prompt delivery could
be done by cesarean section as the baby is at term. Success rate of BCV in general is 60%. Use of tocolytics (ritodrine) increases the success rate.
Benefits of ECV: (i) Reduces the incidence of breech presentation at term and of breech delivery, (ii) Reduces the number of cesarean delivery by 50%, (iii) Reduces maternal morbidity due to cesarean or vaginal breech delivery, and (iv) Reduces the fetal hazards of vaginal breech delive1y.

PROCEDURES: In breech presentation-the maneuver is carried out at 36 weeks in primi and 37 weeks in a multigravida in the labor delivery complex. Tocolytic drug (terbutaline-0.25 mg SC), if required, can be
Chapter 37: Operative Obstetrics

!J
Figs. 37.19A to D: Steps of External Cephalic Version (breech-LSA): (A) Mobilization of the buttocks to the iliac fossa towards the back using both hands; (Bl Rotation of the trunk holding the poles and maintaining flexion of the trunk; (C) Change of hands to prevent crossing after the lie becomes transverse; (D) The lie becomes longitudinal with the cephalic pole being brought to the lower pole of the uterus.

administered. Real-time ultrasound examination is done to confirm the diagnosis and adequacy of amniotic fluid volume. Uterine anomalies to be ruled out. A reactive NST should precede the maneuver.
Preliminaries: Informed consent is taken. The patient is asked to empty her bladder. She is to lie on her back with the shoulders slightly raised and the thighs slightly flexed. Abdomen is fully exposed. The presentation, position of the back and limbs are checked and FHR is auscultated.
Actual steps: 'Forward roll' movement.
Step I (Figs. 37.19A to D): The breech is mobilized using both hands to one iliac fossa towards which the back of the fetus lies. The podalic pole is grasped by the right hand in a manner like that of Pawlik's grip while the head is grasped by the left hand.
Step II: The pressure (firm but not forcible) is now exerted to the head and the breech in the opposite directions to keep the trunk well flexed which facilitates version. The pressure should be intermittent to push the head down towards the pelvis and the breech towards the fundus until the lie becomes transverse. The FHR is once more to be checked.

Fetal wellbeing is monitored intermittentity with Doppler or real-time ultrasound scanning. The procedure is abandoned in case of any significant fetal distress. The procedure is not to be attempted more then 4 times.

Tocolysis (ritodrine or terbutatine may be used). Epidural analgesia has also been used. Moxibuston (Chinese medicine) increases fetal movements and promote spontaneous version to breech.
Step III: The hand is now changed one after the other to hold the fetal poles to prevent crossing of the hand. The intermittent pressure is exerted till the head is brought to the lower pole of the uterus.
A reactive NST should be obtained after completing the procedure. There may be undue bradycardia due to head compression which is expected to settle down by 10 minutes. If, however, fetal bradycardia persists, the possibility of cord entanglement should be kept in mind and in such cases reversion may have to be considered. The patient is to be observed for about 30 minutes: (I) To allow the FHR to settle down to normal; and (2) To note for any vaginal bleeding or evidence of premature rupture of the membranes.

INSTRUCTIONS: (1) The patient is advised for follow-up to check the corrected position; (2) To report to the physician if there is vaginal bleeding or escape of liquor amnii or labor starts and (3) Rh-negative nonimmunized women must be protected by intramuscular administration of 100 µg anti-D gammaglobulin.
EXTERNAL VERSION IN TRANSVERSE LIE: The version is much easier than in breech. The association of placenta
-=·· Ei Chapter 37: Operative Obstetrics

previa or congenital malformation of the uterus should be excluded.
EXTERNAL PODALIC VERSION: The external podalic version may be done in cases when the external cephalic version fails in transverse lie in case of the second baby of twins.

I INTERNAL VERSION
Internal version is always a podalic version and is almost always completed with the extraction of the fetus.
INDICATIONS: Internal version is hardly indicated in a singleton pregnancy in present day obstetric practice. Its only indication being the transverse lie in case of the second baby of twins.
However, it may be employed in singleton pregnancy to expedite delivery in adverse conditions where the cesarean section facilities are lacking. Such conditions are: (1) Transverse lie with cervix fully dilated, and (2) Cord prolapse with cervix fully dilated with transverse lie or head high up and the baby is alive.
CONDITIONS TO BE FULFILLED: (I) The cervix must be fully dilated, (2) Liquor amnii must be adequate for intrauterine fetal manipulation, and (3) Fetus must be living.
CONTRAINDICATION: It must not be attempted in negle cted obstructed labor even if the baby is living.

PROCEDURES: Assessment of the lie, presentation and FHR is made by an experienced obstetrician by abdominal palpation, vaginal examination and/or transabdominal ultrasound examination. Close (continuous) FHR monitoring is essential. The steps are to be followed as mentioned earlier. Internal version should be done under general or epidural anesthesia. Actual steps (Figs. 37.20A and B):
Step I: Patient is placed in dorsal lithotomy position. Antiseptic cleaning, drapings and catheterization are done. Introduction of the hand-if the podalic pole of the fetus is on the left side of the mother, the right hand is to be introduced and vice versa. The hand is to be introduced in a cone-shaped manner. It is then pushed up into the uterine cavity keeping the back of the hand against the uterine wall until the hand reaches the podalic pole.
Step II: The hand is to pass up to the breech and then along the thigh until a foot is grasped. The identification of the foot is done by palpation of the heel. It is advantageous to grasp the first foot which one encounters.
Step Ill: While the leg is brought down by a steady traction, the cephalic pole is pushed up using the external hand.
Step IV: After one leg is brought down, there is no difficulty to deliver the other leg. The delivery is usually completed with breech extraction during uterine contractions.
Step V: Routine exploration of the uterovaginal canal to exclude rupture of the uterus or any other injury.

COMPLICATIONS: Maternal risk includes placental abruption, rupture of the uterus and increased morbidity. The fetal risk includes asphyxia, cord prolapse and

Figs. 37.20A and B: Principal steps of Internal Podalic Version: (A) To introduce the right hand to grasp the upper leg in dorsoanterior position with the head lying on the right iliac fossa; (Bl To give traction on the leg gripping in a cigarette holding fashion, the other hand pushes up the head externally.

intracranial hemorrhage apart from all hazards of breech delivery leading to a high perinatal mortality of about 50%.

CESAREAN DELIVERY (CD)
DEFINITION: It is an operative procedure !l !l whereby the fetuses after the end of 28th
_
_
weeks are delivered through an incision
!I
on the abdominal and uterine walls. This ' · excludes delivery through an abdominal incision where the fetus lying free in the abdominal cavity following uterine rupture or in secondary abdominal pregnancy. The first operation performed on a patient is referred to as a primary cesarean section. When the operation is performed in subsequent pregnancies, it is called repeat cesarean section.
Nomenclature and history: Amidst controversy, it appears that the operation derives its name from the notification 'lex Cesarea' -a Roman law promulgated in 715 BC which was continued even during Caesar's reign. The law provided either an abdominal delivery in a dying woman with a hope to get a live baby or to perform postmortem abdominal delivery for separate burial. The operation does not derive its name from the birth of Caesar, as his mother lived long time after his birth. The other explanation is that the word cesarean is derived from the Latin
Chapter 37: Operative Obstetrics

♦ Rising incidence of primary cesarean delivery.
+ Identification of at-risk fetuses before term (FGR).
+ Identification of high-risk pregnancy (hypertension). + Wider use of repeat CS withoutTOLAC.
+ Rising rates of induction of labor and failure of induction.
+ Decline in operative vaginal (forceps, vacuum) delivery.

+ Decline in assisted vaginal breech delivery (malpresentation).
+ Increased number of women with age >35 years and associated medical complications (diabetes, heart disease).
+ Wider use of electronic fetal monitoring and increased diagnosis of fetal distress.
+ Fear of litigation in obstetric practice (medicolegal issue).
+ Cesarean delivery on maternal request.

Verb 'Cedere' which means 'to cut'. French obstetrician, Francois Mauriceau first reported cesarean section in 1668. In 1876, Porro performed subtotal hysterectomy. It was Max Sanger in 1882, who first sutured the uterine walls. In 1907, Frank described the extraperitoneal operation. Kronig in 1912, introduced lower segment vertical incision and it was popularized by De _Lee (1922). Although Kehrer in 1881 did the transverse lower segment operation for the first time, Munro Kerr in 1926 not only reintroduced the present technique of lower segment operation
but also popularized it.

INCIDENCE: The incidence of cesarean section is steadily rising. During the last decade there has been two-to threefold rise in the incidence from the initial rate of about 10%. The incidence of CD between 10% and 15% is optimum for maternal and perinatal health (WHO). Apart from increased safety of the operation due to improved anesthesia, availability of blood transfusion and antibiotics, the other responsible factors are (Box 37.8).
I INDICATIONS
Indications for cesarean delivery: Cesarean delivery is done when delivery is indicated but labor contraindicated or not inducible ( central placenta previa) and/ or vaginal delivery is found unsafe for the fetus and/ or mother.

The indications are broadly divided into two categories (Box 37.9).
♦ Absolute ♦ Relative (common)

TIME OF OPERATION ♦ Elective
♦ Emergency (Category l, 2 and 3)
Elective: When the operation is done at a prearranged time during pregnancy to ensure the best quality of obstetrics, anesthesia, neonatal resuscitation and nursing services.
Time
a. Maturity is certain: The operation is done about 1 week prior to the expected date of confinement.
b. Maturity is uncertain: Ultrasound assessment in first or second trimesters if available is corroborated. Amniocentesis for L:S ratio is used to ensure fetal maturity. Otherwise spontaneous onset of labor is awaited and then CS is done.
Factors reducing CS rate: (a) Support during labor; (b) Induction of labor at 40 weeks or more; (c) Main taining partograph; (d) No CTG for low risk women; (e) Membrane sweeping.

Absolute indications (labo rContra indic ated) Relative indications
Vaginal delivery is not possible. Cesarean is needed even with a Vaginal delivery may be possible but risks to the mother and/or baby dead fetus. are high
Indications are few: (More often multiple factors may be responsible). ■ Central placenta previa + Cephalopelvic disproportion (relative).
■ Contracted pelvis or cephalopelvic disproportion (absolute) + Previous cesarean delivery-{a) When primary CS was due to
,. Pelvic mass causing obstruction (cervical or broad ligament recurrent indication (contracted pelvis), (b) Previous two CS,
fibroid) {c) Features of scar dehiscence, (d) Previous classical CS.
+ Non-reassuring FHR (fetal distress).
Advanced carcinoma cervix
■ Vaginal obstruction (atresia, stenosis)
11 + Dystocia may be due to (three Ps) relatively large fetus (passenger),
small pelvis (passage) or inefficient uterine contractions (power)
m
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_
,
_
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i
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_
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_
_
_
,_com_ __ ndic _ ions__fcsare _an_se __on _______ , + Antepartum hemorrhage: (a) Placenta previa and (b) Abruptio
_
Primigravidae: placentae.
1. Failed induction ♦ Malpresentation: Breech, shoulder (transverse lie), brow.
2. Fetal distress (nonreassuring fetal FHR) ♦ Failed surgical induction of labor, failure to progress in labor. 3. Cephalopelvic Disproportion (CPD) ♦ Bad obstetric history-with recurrent fetal loss.
4. Dystocia (dysfunctional labor), nonprogress of labor ♦ Hypertensive disorders: {a) Severe pre-eclampsia, (b) Eclampsia-
5. Malposition and malpresentation (occipitoposterior, breech). uncontrolled fits even with antiseizure therapy.
6. On maternal request + Medical-gynecological disorders: {a) Diabetes (uncontrolled), heart
disease (coarctation of aorta, Marfan's syndrome); (bl Mechanical obstruction due to benign or malignant pelvic tumors (carcinoma
Mutigravidae:
1. Previous cesarean delivery
2. Antepartum hemorrhage (placenta previa, placental abruption) cervix), or following repair of vesicovaginal fistula. 3. Malpresentation (breech, transverse lie)
• On maternal request
········&I Chapter 37: Operative Obstetrics

Benefits and risks of elective operation: Reduction in perinatal morbidity and mortality as there is no hazard from labor and delivery process. Maternal benefits: No pelvic floor dysfunction (Table 37.7).
Maternal risks are: Longer recovery time and hospital stay. Risks of placenta previa and hysterectomy are more in subsequent delivery.
Category of CS (NICE): Emergency: When the operation is to be done due to an acute obstetric emergency (fetal distress). A time interval of 30 minutes between the decision and delivery is taken as reasonable.
Category 1: When there is immediate threat to the
life of the woman or the fetus. Decision delivery interval should be 30 minutes.
Category 2: When there is maternal or fetal compro mise which is not immediately life-threatening. CS should be done within 75 minutes of making decision.
Category 3: There is no maternal or fetal compromise but needs early delivery.
Category 4: Delive1y is planned to suit the woman, family members and the hospital staff. Planned CS after 39 weeks to J, RDS; if <39 weeks, steroid therapy is given.

TYPES OF OPERATIONS ♦ Lower segment
♦ Classical or upper segment
Lower Segment Cesarean Section (LSCS): In this operation, the extraction of the baby is done through an incision made in the lower segment through a transperitoneal approach. It is the only method practiced in present-day obstetrics and unless specified, cesarean section means lower segment operation. The operation done through an extraperitoneal approach to the lower segment in infected cases is obsolete.
Classical: In this operation, the baby is extracted through an incision made in the upper segment of the uterus. Its indications in present day obstetrics are very much limited and the operation is only done under forced circumstances, such as:
♦ Lower segment approach is difficult: (1) Dense adhesions due to previous abdominal operation; (2) Severe contracted pelvis (osteomalacic or rachitic) with pendulous abdomen.

♦ Lower segment approach is risky: (1) Big fibroid on the lower segment-blood loss is more and contemplating myomectomy may end in hysterectomy; (2) Carcinoma cervix-to prevent dissemination of the growth and postoperative sepsis; (3) Repair of high WF; (4) Complete anterior placenta previa with engorged vessels in the lower segment-risk of hemorrhage.
♦ Periml'tem cesarean section: It is done to have a live baby (rare). Perimortem section is an extreme emergency procedure. Classical section is done in a woman who has suffered a cardiac arrest. The infant may survive if delivery is done within 5 minutes of maternal death.

■ LOWER SEGMENT CESAREAN SECTION

PREOPERATIVE PREPARATION
Informed written permission for the procedure, anesthesia and blood transfusion is obtained.
■ Abdomen is scrubbed with soap. Hair may be clipped. ■ No premedicative sedative is given.
■ Nonparticulate antacid (0.3 molar sodium citrate, 30 mL) is given orally before transferring the patient to theater. It is given to neutralize the existing gastric acid.
■ Ranitidine (H2 blocker) 150 mg is given orally night before (elective procedure) and it is repeated (50 mg IM or IV) 1 hour before the surgery to raise the gastric pH.
■ The stomach should be emptied, if necessary, by a stomach tube (emergency procedure).
■ Metoclopramide (10 mg IV) is given to increase the tone of the lower esophageal sphincter as well as to reduce the stomach contents. It is administered after about 3 minutes of preoxygenation in the theater.
■ Intraoperative: Catheterization is not mandatory. If done, may be removed after the operation.
■ FHS should be checked once more at this stage.
■ Neonatologist should be present.
■ Cross-match blood when above average blood loss (placenta previa, prior multiple cesarean delivery) is anticipated.
■ Prophylactic antibiotic is given (IV) one hour before making the skin incision. It reduces postopoerative

Table 37 .7: Benefits and risks of Cesarean Delivery. Benefits
■ .. Traumatic injury to the genital tract. ■ .. Perinatal morbidity and mortality.
■ .. Anxiety and stress of labor and the time. ■ .. Injury to the pelvic floor muscles resulting
.. prolapse .. fecal or urinary incontinence. ■ .. Postpartum hemorrhage.

Risks
■ t Hospital stay.
t
■ Maternal morbidity.
■ t Need of blood transfusion.
■ t Risk of thromboembolism.
■ t Neonatal respiratory distress (RDS).
■ t Risk of placenta accreta syndrome (PAS) need for cesarean
delivery and need for hysterectomy.

endomyometritis and wound infection. Single dose therapy with first generation cephalosporin (cefazolin) or ampicillin is effective.
■ Thromboprophylaxis (depending on risk factors): To use mechanical graduated compression stockings or a pneumatic compression device during and after CD.
♦ IV cannula: Sited to administer fluids (Ringer's solution).
♦ Position of the patient: The patient is placed in the dorsal position with a lateral tilt to minimize vena caval compression. A 15° lateral tilt to her left using a wedge till delivery of the baby should be done.
♦ Anesthesia: It may be spinal, epidural or general. However, choice of the patient and urgency of delivery are also considered.
♦ Antiseptic painting: The abdomen is painted with 7.5% povidone-iodine solution or with chlorhexidine alcohol and is properly draped (nonadhesive) with sterile towels.
♦ Incision on the abdomen: The surgeon may choose either a vertical or a transverse skin incision. Vertical incision may be infraumbilical midline or parame dian. Transverse incision, modified Pfannenstiel is made 3 cm above the symphysis pubis. Transverse incision has certain benefits (Table 37.8). The rectus sheath is incised, the rectus muscles are retracted laterally. The posterior rectus sheath and peritoneum are now dissected. It can be done bluntly using fingers to enter the peritoneal cavity. This avoids any injury to the underlying bowels. Otherwise, peritoneum is opened up at a higher level to avoid bladder injury. Peritoneal cavity is opened.

Chapter 37: Operative Obstetrics

The Doyen's retractor (Fig. 42.14) is introduced. Introduction of Doyen's retractor and approach to the lower segment is done.
Uterine incision (Figs. 37.22A to E)
Peritoneal incision: The loose peritoneum of the uterovesical pouch is cut transversely across the lower segment with convexity downwards at about 1.25 cm (0.5'') below its firm attachment to the uterus. No dissection for bladder flap is done.
(a) Muscle incision (Figs. 37.22A to C): The most commonly used incision (90%) is low transverse. Advantages are: • ease of operation (Table 37.9); • no bladder dissection, • less blood loss, • easy to repair, • less adhesion formation, • less risk of scar rupture when trial (TOLAC) of labor is given for subsequent delivery.
(b) A small transverse incision is made in the midline by a scalpel until the membranes of the gestation sac are exposed. Two index fingers are then inserted through the small incision down to the membranes and the muscles of the lower segment are split transversely across the fibers. This method minimizes the blood loss but requires experience. Alternatively, the incision may be extended on either side using a curved scissors to make it a curved one of about 10 cm (4") in length, the concavity is directed upwards.
Other types of uterine incisions are (Figs. 37.21A to E): (a) Lower vertical-it may be extended upwards when needed. (b) Classical incision (upper segment). (c) 'J' incision-upward vertical extension of the initial transverse incision. (d) Inverted 'T' incision-upward extension from the mid-transverse incision. Indications of vertical uterine incision: (i) Lower segment poorly developed (26-28 weeks). (ii) Fetus with transverse lie with dorso inferio1; (iii) Anteriorly located myoma obstructing lower uterine segment, (v) When the placenta is anterior and previa and/or accreta.
Delivery of the head (Figs. 37.22D and E): The membranes are ruptured if still intact. The amniotic fluid is sucked out by

Table 37.8:Transverse abdominal incision (modified Pfannenstiel Incision).

Advantages
■ Postoperative comfort is more.
■ Less interferance with postoperative respirations.
■ Fundus of the uterus can be better palpated during immediate postoperative period.
u Less chance of wound dehiscence. ■ Less chance of incisional hernia.
■ Cosmetic value.

Disadvantages
■ Takes a little longer time and as such unsuitable in acute emergency situation.
■ Blood loss is slightly more.
■ Requires competency during repeat section. u Unsuitable for classical operation.

m
Figs. 37.21A to E: Uterine incisions for cesarean section; (A) Lower segments transverse; {B) Lower segment vertical; {C) 'J' incision; (D) Classical incision; (E) Inverted 'T' incision.
- Chapter 37: Operative Obstetrics

Table 37.9: Merits and demerits of lower segment transverse over lower segment vertical incision.

Parameters Extension of incision

Bladder dissection Uterine closure Muscle apposition Reperitonization
lntraoperative bleeding Subsequent adhesions
Risk of scar rupture

Lower segment transverse
■ May occur to involve the
uterine vessels
• Minimal ■ Easy
■ Good
■ Complete ■ Less
■ Less
■ 0.S-1.0%

Lower segment vertical
•
May occur to involve the upper segment or downward the bladder.

• More when extends inferiorly. ■ Difficult
■ Often imperfect ■ Often imperfect ■ More
■ More
■ 0.8-2% (risk of scar rupture in cases with Tor J shaped incision is 2-6%).

Lower segment transverse incision: Wound healing is perfect and the scar is sound. This is due to: (a) Perfect muscle apposition; (b) Less wound hematoma; (c) Less gutter formation; and (d) Wound remains quiescent during healing. The risk of scar rupture is less. Choice of suture materials are
given in Ch. 42; p. 629.

continuous suction. The Doyen's retractor is removed. The head is delivered by hooking the head with the fingers which are carefully insinuated between the lower uterine flap and the head until the palm is placed below the head. The head is delivered by elevation and flexion using the palm to act as a fulcrum. As the head is drawn to the incision line, the assistant is to apply

pressure on the fundus. The head can also be delivered using one blade of Wrigley's forceps or ventouse.
Delivery of the trunk: After the delivery of the head and shoulders, intravenous oxytocin 10 units or methergine 0.2 mg is to be administered. The rest of the body is delivered slowly and the baby is placed in a tray placed in between the mother's thighs.

Fundal pressure

Ii
Figs. 37.22A to F: Steps of LSCS: (A) The loose peritoneum on the lower segment is cut transversely; (Bl A short incision is made
in the midline down to the membranes; (C) The incision of the lower segment is being enlarged using index finger of both hands; (D) Sagittal section showing insinuation of the fingers between the lower uterine flap and the fetal head until the posterior surface is reached; (E) Methods of delivery of the head; (F) Placenta is being delivered.
Chapter 37: Operative Obstetrics

D
Figs. 37.22G to I: Steps of LSCS: (G) Inserting the continuous vicryl or chromic catgut (No. 'O') suture taking deeper muscles excluding
the decidua; (H) Similar method of continuous suture taking superficial muscles and fascia down to the first layer of suture; (I) Continuous peritoneal catgut suture (optional).

Delayed clamping of the cord (60-90 sec) is done. The cord is cut in between two clamps and the baby is handed over to the pediatrician. The Doyen's retractor is reintroduced.
The optimum interval between uterine incision and deli very should be less than 90 seconds. Interval >90 seconds are associated with poor Apgar scores. There is reflex uterine vasoconstriction following uterine incision and manipulation. IV oxytocin 10 JU in 500 mL crystalloid is given after the baby is delivered as a measure to prevent PPH.
Removal of the placenta and membranes (Figs. 37.22F): By this time, the placenta is separated spontaneously. The placenta is extracted by gentle traction on the cord with simultaneous pushing of the uterus towards the umbilicus per abdomen using the left hand (controlled cord traction). Routine manualremoval should not be done. Advantages of spontaneous placental separation are: Less blood loss and less risk of endometritis. The membranes are carefully removed preferably intact and even a small piece, if attached to the decidua should be removed using a dry gauze. Dilatation of the internal os is not required. Exploration of the uterine cavity is desirable.
Suture ofthe uterine wound (Figs. 37.22G to I): The suture of the uterine wound is done with the uterus keeping in the abdomen. Some, howeve1 prefer to eventrate the uterus prior to suture. The margins of the wound are picked up by Allis tissue forceps or Green-Armytage hemostatic clamps (four are required, one each for angle and one for each margin). The uterine incision is sutured in two layers.
Uterine suture: Commonly double layer closure is done. Single layer closure may done if the patient has completed her child bearing (concurrently bilateral tubal ligation is done).
First layer: The first stitch is placed on the far side in the lateral angle of the uterine incision and is tied. The suture material is No. 'O' chromic catgut or vicryl and the needle is round bodied. A continuous running suture taking deeper muscles excluding or including the decidua (very difficult to exclude) ensures effective apposition of the tissues; the stitch is ultimately tied after the suture includes the near end of the angle.
Second layer: A similar continuous suture is placed taking the superficial muscles and adjacent fascia overlapping the first layer

of suture. Uterine muscles may be closed using a continuous single layer stitch taking full thickness muscle and less decidua.
Double layer closure has reduced risk of scar rupture in subsequent pregnancy.
Nonclosure of visceral and parietal peritoneum is preferred.
Concluding part: The mops if placed inside are removed and the number verified. Peritoneal toileting is done and the blood clots are removed meticulously. The tubes and ovaries are examined. Doyen's retractor is removed. After being satisfied that the uterus is well contracted, the abdomen is closed in layers. The subcutaneousfat tissue is closed separately when the thickness is ?.2 cm. The skin may be closed using absorbable interrupted stitches or using a delayed absorbable subcuticular stitch or by metal staplers. The vagina is cleansed of blood clots and a sterile vulva! pad is placed.
I POSTOPERATIVE CARE First 24 hours: (Day O)
■ Observation for the first 6-8 hours is important. Periodic checkup of pulse, BP, amount of vaginal bleeding and behavior of the uterus (in low transverse incision) is done and recorded.
11 Fluid: Sodium chloride (0.9%) or Ringer's lactate drip is continued until at least 2.0-2.5 L of the solutions are infused. Blood transfusion is helpful in anemic mothers for a speedy postoperative recovery. Blood transfusion is required if the blood loss is more than average during the operation (average blood loss in cesarean section is approximately 0.5-1.0 L).
11 Oxytocics: Injection oxytocin 5 units IM or N (slow) or methergine 0.2 mg IM is given and may be repeated.
11 Prophylactic antibiotics ( cephalosporins, metroni dazole) for all cesarean delivery is given for 2-4 doses. Therapeutic antibiotic is given when indicated.
■ Analgesics in the form of pethidine hydrochloride 75-100 mg is administered and may have to be repeated.
ll Chapter 37: Operative Obstetrics

Table 37.10: Merits and demerits of lower segment operation over classical.
Lower segment (transverse) Classical

Techniques

Postopera-tive

Wound healing

During future pregnancy

■ Technically slight difficult. ■ Blood loss is less.
■ The wall is thin and as such apposition is perfect. ■ Perfect peritonization is possible.
■ Technical difficulty in placenta previa or transverse lie.
• Hemorrhage and shock-less.
■ Peritonitis is less even in infected uterus because of perfect peritonization and, if occurs, localized to pelvis.
■ Peritoneal adhesions and intestinal obstructions are less. ■ Convalescence is better.
■ Morbidity and mortality are much lower.

The scar is better healed because of:
■ Perfect muscle apposition due to thin margins. ■ Minimal wound hematoma.
■ The wound remains quiescent during healing process. ■ Chance of gutter formation is unlikely.

Scar rupture is less 0.5-1.5%

■ Technically easy. ■ Blood loss is least.
■ The wall is thick and apposition of the margins is imperfect. ■ Not possible.
■ Comparatively safer in such circumstances.
■ More
■ Chance of peritonitis is more in presence of uterine sepsis. ■ More because of imperfect peritonization.
■ Relatively delayed.
■ Morbidity and mortality are high.

The scar is weak because of:
■ Imperfect muscle apposition because of thick margins. ■ More wound hematoma formation.
■ The wound is in a state of tension due to contraction and relaxation of the upper segment. As a result, the knots may slip or the sutures may become loose.
■ Chance of gutter formation on the inner aspect is more.
More risk of scar rupture 4-9%

■ Ambulation: The patient can sit on the bed or even get out of bed to evacuate the bladder, provided the general condition permits. She is encouraged to move her legs and ankles and to breathe deeply to minimize leg vein thrombosis and pulmonary embolism.
■ Thrombophophylaxis: Based on risk factors.
■ Baby is put to the breast for feeding after 3-4 hours or sooner, when mother is stable and relieved of pain.
Day 1: Oral feeding in the form of plain or electrolyte water or black tea may be given. Active bowel sounds are observed by the end of the day.
Day 2: Light solid diet of the patient's choice is given. Bowel care: 3-4 teaspoons of lactulose is given at bed time, if the bowels do not move spontaneously.
Day 5 or day 6: The abdominal skin stitches are to be removed on the D-5 (in transverse) or D-6 (in longitudinal).
Discharge: The patient is discharged on the day following removal of the stitches, if otherwise fit. Usual advices like those following vaginal delive1y are given. Depending on postoperative recovery and availability of care at home, patient may be discharged as early as third to as late as fifth postoperative days.

I CLASSICAL CESAREAN SECTION
Indications: (a) Placenta previa; (b) Transverse lie; ( c) Preterm delivery where lower segment is poorly formed; (d) Dense adhesions limiting access to LUS; (e)

Planned caserean hysterectomy; (f) PAS; (g) Perimortem CS. Uterine wound is closed in three layers.
This is relatively easy to perform (Table 37.10). Abdominal incision is always longitudinal (paramedian) and about 15 cm (6") in length, I/3rd of which extends above the umbilicus. A longitudinal incision of about 12.5 cm (5") is made on the midline of the anterior wall of the uterus starting from below the fundus. The incision is deepened along its entire length until the membranes are exposed which are punctured. In about 40% cases, the placenta is encountered. In such cases, fingers are slipped between the placenta and the uterine wall until the membranes are reached. The baby is delivered commonly as breech extraction. Intravenous oxytocin 5 IU IV (slow) or methergine 0.2 mg is administered following delive1y of the baby. The uterus is eventrated. The placenta is extracted by traction on the cord or removed manually.
Suture of the uterine incision: The uterus is sutured in three layers:
1. A continuous suture is placed with chromic catgut No. 'O' or vicryl taking deep muscles excluding the decidua.
2. A second layer of interrupted sutures (1 cm apart) using chromic catgut No. 'l' or vicryl taking the entire depth of superficial muscles down to the first layer of suture.
3. The third layer of continuous suture taking the serious coat with the adjacent muscles using chromic catgut No. 'O' and round-bodied needle.
The uterus is returned back into the abdominal cavity. Packings are removed; peritoneal toileting is done and the abdomen is closed in layers.

I COMPLICATIONS OF CESAREAN SECTION

The complications are related either due to the: ■ Operations (inherent hazards), or due to
■ Anesthesia: The complications are grouped into: ♦ Maternal ♦ Fetal
The maternal complications may be: ■ Intraoperative
■ Postoperative

I INTRAOPERATIVE COMPLICATIONS
♦ Extension of uterine incision to one or both the sides. This may involve the uterine vessels to cause severe hemorrhage, may lead to broad ligament hematoma formation.
♦ Uterine lacerations at the lower uterine incision-may extend laterally or inferiorly into the vagina.
♦ Bladder injury-is rare in a primary CS but may occur in a repeat procedure. Should a bladder injury occur, repair is done with a two-layer closure with 2-0 chromic catgut. Continuous bladder drainage is then maintained for 7-10 days.
♦ Ureteral injury is rare (1 in 1,000 procedures). Injury occurs during control of bleeding from lateral extensions.
♦ Gastrointestinal tract injury is rare unless there is prior pelvic/abdominal adhesions.
♦ Hemorrhage may be due to uterine atony or uterine lacerations. Medical management should be started. Surgical management is done where there are wound lacerations. Blood transfusion is needed.
♦ Morbid adherent placenta (placenta accreta) is commonly seen in cases with placenta previa who had prior cesarean delivery. Total hysterectomy (cesarean) is often needed for such a case to control hemorrhage.
I POSTOPERATIVE COMPLICATIONS MATERNAL: ♦ Immediate ♦ Remote
IMMEDIATE
■ Postpartum hemorrhage: The blood loss in cesarean section is more often underestimated. It is mostly related to uterine atony but blood coagulation disorders may rarely occur.
■ Shock: While most often it is related to the blood loss, it may occur when the operation is done following prolonged labor without correcting pre-existing dehydration and ketoacidosis.
■ Anesthetic hazards: These are mostly associated in emergency operations. The hazards are related to general anesthesia: aspiration of the gastric contents. The result may be aspiration atelectasis or aspiration pneumonitis (Mendelson's syndrome). Others are: (neuroaxial) Hypotension and spinal headache.

Chapter 37: Operative Obstetrics gr·
■ Infections: The common sites are uterus ( endomyo metritis ), urinary tract, abdominal wound, peritoneal cavity (peritonitis) and lungs. Septic pelvic thrombo phlebitis may be associated with endometritis. Risk factors for infection are: Prolonged duration of labor and that of rupture of membranes, repeated number of vaginal examinations. Prophylactic antibiotics reduce the risk significantly.
■ Intestinal obstruction: The obstruction may be mech anical due to adhesions or bands, or paralytic ileus following peritonitis.
■ Deep vein thrombosis and thromboembolic disorders are more likely to occur following cesarean section than vaginal delivery. Septic thrombophlebitis is also a known complication.
■ Wound complications: Abdominal wound sepsis is quite common. The complications which are detected on removal of the skin stitches are: (1) sanguineous or frank pus, (2) hematoma, (3) dehiscence (peritoneal coat intact), ( 4) burst abdomen (involving the peritoneal coat), and (5) rarely necrotizing fasciitis.
■ Secondary postpartum hemorrhage.

REMOTE COMPLICATIONS
■ Gynecological ■ General surgical ■ Future pregnancy
Gynecological: Menstrual excess or irregularities, chronic pelvic pain or backache.
General surgical: Incisional hernia, intestinal obstruction due to adhesions and bands.
Future pregnancy: There is risk of scar rupture.

FETAL COMPLICATIONS: Iatrogenic prematurity and development of RDS is not uncommon following cesarean delivery. This is seen when fetal maturity is uncertain. Accidental scalpel injury to the baby may occur.

MATERNAL AND PERINATAL MORTALITY: Maternal: Overall maternal mortality ranges between 6 to 22 per 100,000 procedure. But with adverse patient profile and suboptimal circumstances which are often interrelated, the maternal mortality ranges from 0.1 to 1%. The causes of death are:
1. Hemorrhage and shock. 2. Anesthetic hazards.
3. Infection.
4. Thromboembolic disorders.
Fetal: The perinatal mortality ranges from 5 to 10% and the deaths are mostly related to emergency operations and the complicating factors for which the operations are done. The causes of death are: (I) Asphyxia may be pre-existing, (2) RDS, (3) Pre-maturity, (4) Infection, (5) Intracranial hemorrhage-attempting breech delivery through a small incision.
:.. &J Chapter 37: Operative Obstetrics
i
Table 37 .11: Measures to reduce cesarean births.

Cases with:
(AJ Fetal distress
♦ To confirm fetal acidosis by fetal scalp blood sampling
♦ Scalp stimulation as a means of assessing fetal acid-base status
(BJ vaginal birth aftercesarean section ♦ In selected cases VBAC is successful (CJ Amnioinfusion
♦ Management of cases with variable or early FHR deceleration due to oligohydramnios, meconium-stained liquor
♦ Amnioinfusion for repetitive variable fetal heart decelerations

(PP: Primiparous; MP: Multiparous)

Safe prevention of cesarean delivery (ACOG-2014J

Labor: Normal and dsystocia
1. Latent phase >20 hours in PP women and>14 hours in MP women is not dystocia and not an indication of CD.
2. First stage of labor
(a) Active phase of labor starts at 5 cm cervical dilatation. Before 5 cm dilatation CD is not indicated for dystocia.
(b) Active phase arrest is diagnosed at or beyond 5 cm with rupture membranes and failure of progress for 4 hours of adequate uterine contractions or 6 hours of oxytocin administration due to inadequate uterine activity.
3. Second stage of labor: Second stage to continue if maternal and fetal conditions permit:
(a) In MP women: 2 hours pushing and 3 hours in the second stage. (b) In PP women: 3 hours pushing and 4 hours in the second stage. Long duration may be appropriate in situations: epidural analgesia, malposition as long as progress is documented. (c) To perform other alternatives to CD: operative vaginal delivery in the second stage (forcesps/ventouse).
(d) Manual rotation in cases with OP and operative vaginal delivery.
4. Induction of labor to be considered at or after 39 weeks. It is done for a well selected case. 5. Breech presentation: Practice of ECV, assisted vaginal breech delivery-in selected cases. 6. Twin gestation: First twin is cephalic-vaginal delivery is an option.
7. Destructive operations: Craniotomy in a selected case of obstructed labor with hydrocephalus, dead or moribund fetus.

Complications of cesarean section could be reduced to a great extent when the measures to reduce cesarean section are adopted (Table 37.11).
Extraperitoneal cesarean section was practiced in the past in cases with severe infection. Lower segment is approached extraperitoneally by dissecting through the space of Retzius. Currently, with the availability of potent antimicrobial agents, this is rarely performed.
Cesa1·ean hysterectomy: Cesarean hysterectomy refers to an operation where cesarean section is followed by removal of the uterus. The common condi tions are:
1. Morbid adherent placenta.
2. Atonic uterus and uncontrolled postpartum hemorrhage.
3. Big fibroid (parous women).
4. Extensive lacerations due to extension of tears with broad ligament hematoma.
5. Grossly infected uterus. 6. Ruptured uterus.
Peripartum hysterectomy is the surgical removal of the uterus either at the time of cesarean delivery or in the immediate postpartum period (even following vaginal delivery). Subtotal hysterectomy is commonly done as an emergency (unplanned) procedure. Benefits of subtotal hysterectomy are: Less operating time, less blood loss, less risk of injury to other organs (bladder, ureter) and less postoperative morbidity.
Pel"imortem cesarean delivery refers to the cesarean delivery of a woman who is expected to die within next few
moments or has just died. It is done within 4-5 minutes of start of Cardiopulmonary Resuscitation (CPR) when

the fetus is alive. Irreversible brain damage occurs by 4 to 6 minutes. The gravid uterus reduces venous returns and hence reduces cardiac output (CO) by 60% secondary to compression. So urgent delivery of the fetus and placenta improves venous return and CO. This also facilitates chest compression and improves ventilation. Maternal and fetal survival is 50%. Read more Dutta's Clinics in Obstetrics, Ch. 56.

DESTRUCTIVE OPERATIONS
The destructive operations are designed to diminish the bulk of the fetus so as to facilitate easy delivery through the birth canal. In modern obstetric practice, virtually there is hardly any place for destructive operations. Neglected obstetrics requiring destructive operations are completely preventable. These procedures are difficult and may be dangerous too unless the operator is sufficiently skilled. Unfortunately, one may have to perform such operations while working in the unorganized sector. Some commonly performed operations are discussed here. There are four types of operations:
1. Craniotomy 2. Evisceration 3. Decapitation 4. Cleidotomy
I CRANIOTOMY
DEFINITION: It is an operation to make a perforation on the fetal head, to evacuate the contents followed by extraction of the fetus.
INDICATIONS
■ Cephalic presentation producing obstructed labor with dead fetus: This is the most common indication
Chapter 37: Operative Obstetrics

Pressure by assistant
,r

Figs. 37.23A and B: (A) Perforation of the head while an assistant fixes the head suprapubically; (B) Separation of the blades by compression of the handle (for better display, the fingers of the left hand are removed).

of craniotomy in the referral hospitals of the developing Countries.
■ Hydrocephalus even in a living fetus: This is applicable both for the forecoming and the aftercoming head.
■ Interlocking head of twins.
CONDITIONS TO BE FULFILLED: (1) The cervix must be fully dilated, and (2) Baby must be dead (hydrocephalus being excluded).
CONTRAINDICATIONS: (i) The operation should not be done when the pelvis is severely contracted so as to shorten the true conjugate to less than 7.5 cm (3"). In such condition, the baby cannot be delivered, as the bimastoid diameter (base of the skull) of7.5 cm cannot be compressed. (ii) Rupture of the uterus where laparotomy is essential.
PROCEDURES: Preliminaries: The preliminary prepara tions are the same as mentioned above. The operation is to be done under general anesthesia.
Actual steps
Step I: The two fingers (index and middle) are introduced into the vagina and the finger tips are to be placed on proposed site of perforation. However, when the suture line cannot be defined because of big caput, the perforation should be done through the dependent part.
Sites of perforation: Vertex: On the parietal bone either side of the sagittal suture. Suture is avoided to prevent collapse of the bone thereby preventing escape of the brain matter. Face: Through the orbit or hard palate. Brow: Through the frontal bone.
Step II: The Oldham's perforator (Fig. 42.33) with the blades closed is introduced under the palmar aspect of the fingers protecting the anterior vaginal wall and the adjacent bladder (as shown in Figures 37.23A and B) until the tip reaches the proposed site of perforation.
Step Ill: By rotating movements, the skull is perforated. During this step, an assistant is asked to steady the head per abdomen in a manner of first pelvic grip. After the skull is perforated,

the instrument is thrust up to the shoulders and the handles are approximated so as to allow separation of the sharp blades for about 2.5 cm.
The blades are again apposed by separating the handles. The instrument is brought out keeping the tip of the blades still inside the cranium. The instrument is rotated at right angle and then again thrust in up to the shoulders. The handles are once more to be compressed so as to separate the blades for about 2.5 cm. The perforated area now looks like a cross. The instrument with the blades closed is then thrust in beyond the guard to churn the brain matter. The instrument with the blades closed is brought out under the guidance of the two fingers still placed inside the vagina.
Alternative to Oldham' s perforator, similar procedure could be performed using a sharp-pointed Mayo's scissors.
Step IV: With the fingers, brain matter is evacuated. The idea is to make the skull collapse as much as possible.
Step V: When the skull is found sufficiently compressed, the extraction of the fetus is achieved either by using a cranioclast or by two giant volsella (Fig. 42.34). Giant volsella are used to hold the incised skull and scalp margins.
Step VI: The traction is now exerted in the same direction as like that mentioned in forceps operation.
Step VII: After the delivery ofthe placenta, the uterovaginal canal must be explored as a routine for evidence of rupture uterus or any tear.
Injection methergine 0.2 mg is to be given intravenously with the delivery of the anterior shoulder. The rest of the delivery is completed as in normal delivery.
Forceps versus craniotomy in a dead fetus: If the delivery of the uncompressed head can be accomplished without much force with consequent injuries to the mother, forceps delivery is preferred. But if it is found difficult and damaging to the mother, craniotomy is safer.
I DECAPITATION
DEFINITION: It is a destructive operation whereby the fetal head is severed from the trunk and the delivery is completed with the extraction of the trunk and that of the decapitated head per vaginam.
Chapter 37: Operative Obstetrics

INDICATIONS: (1) Neglected shoulder presentation with dead fetus where neck is easily accessible; (2) Inter-locking head of twins. It is rarely done these days. It is rarely done in current obstetric practice.
I EVISCERATION
The operation consists of removal of thoracic and abdominal contents piecemeal through an opening on the thoracic or abdominal cavity at the most accessible site. The object is to diminish the bulk of the fetus which facilitates its extraction. If difficulty arises, the spine may have to be divided (spondylectomy) with embtyotomy scissors. It is rarely done in current obstetrics practice.

I CLEIDOTOMY
The operation consists of reduction in the bulk of the shoulder girdle by division of one or both the clavicles.
The operation is done only in dead fetus (anencephaly excluded) with shoulder dystocia. The clavicles are divided by the embryotomy scissors or long straight scissors introduced under the guidance of left two fingers placed inside the vagina.

POSTOPERATIVE CARE FOLLOWING DESTRUCTIVE OPERATIONS

♦ Exploration of the uterovaginal canal must be done to exclude rupture of the uterus or lacerations on the vagina or any genital injury.
♦ A self-retaining (Foley's) catheter is put inside, especially following craniotomy for a period of 3-5 days or until the bladder tone is regained.
♦ Dextrose saline drip is to be continued till dehydration is corrected. Blood transfusion may be given, if required.
♦ Ceftriaxone 1 g IV infusion is given twice daily.

COMPLICATIONS: (1) Injury to the uterovaginal canal; (2) Rupture of uterus; (3) Postpartum hemorrhage-atonic or traumatic; (4) Shock-due to blood loss and/or dehydration; (5) puerperal sepsis; (6) Subinvolution; (7) Injuty to the adjacent viscera-bladder-vesicovaginal fistula or rarely to rectal wall leading to rectovaginal fistula; and (8) Prolonged ill health.

SYMPHYSIOTOMY
Symphysiotomy is the operation designed to enlarge the pelvic capacity by dividing the symphysis pubis. In the tropical countries, its place has to be duly considered in the perspective of wide prevalence of obstructed labor cases which are rushed to the referral hospitals in a bad shape.
The cases are judiciously selected and symphysiotomy may be done as an alternative to risky cesarean section when there is a likelihood of scar rupture in subsequent labors. Moreover, symphysiotomy produces permanent enlargement of the pelvis, as such future dystocia will be unlikely. The operation should be done in established obstruction and not when it is only anticipated. The conditions to be fulfilled are: (1) The pelvis should not be severely contracted; isolated outlet contraction is ideal, (2) Vertex must be presenting, and (3) the FHS must be present.
The operation consists of dividing the symphysis pubis strictly in the midline from above downwards until the arcuate ligament is cut. The fingers of the left hand in the vagina displace the urethra, while catheter is in, to one side. The baby is delivered spontaneously with liberal episiot omy or by traction-ventouse (preferable) or forceps.
Complications: Retropubic pain, osteitis pubis, stress urinary incontinence and rarely vesicovaginal fistula.

► The operation, 'Dilatation and Evacuation' (D & E) consists of dilatation of the cervical canal and Evacuation of the Retained Products of Conception (ERPC) from the uterine cavity.
► Indications of D & E are many; of which, incomplete abortion is most common.
► In suction evacuation (S & E) operation, the products of conception are sucked out from the uterus with the use of a cannula fitted to a suction apparatus.
► Indications of S & E are many; of which, MTP during first trimester is most common.
► _End point of suction is important to understand. This reduces the complications of the operation.
► Vacuum aspiration either as manual (MVA) or electric (EVA) is highly effective (98-100%) for MTP up to 12 weeks of pregnancy.
► Episiotomy is a planned incision over the perineum and the posterior vaginal wall to enlarge the space for safe delivery. It is done in a selective case only.
► Of the different types, mediolateral and median types are commonly done. Both have got relative merits and demerits. ► The procedure, repair and the postoperative care of episiotomy are important to minimize its complications.
► Obstetric forceps are used to extract the fetal head thereby to deliver the fetus. However, forceps has got other functions also. ► Of the different types of forceps delivery, outlet and low forceps deliveries are commonly done (Table 37.3).
► Both the forceps and ventouse are safe instruments. Operator should determine the superiority of one instrument over the others (Table 37.6) for an individual patient.
► Maternal and fetal criteria must be carefully assessed to determine the indications of forceps/ventouse delivery.
► Prerequisites for application of forceps/ventouse, must be fulfilled to avoid the difficulties and the failure of the procedure. The prerequisites for application of forceps or vacuum are the same.
Contd...
Chapter 37: Operative Obstetrics

Contd...
> There should be descent of the fetal head with each pull while doing forceps/ventouse delivery. When there is no descent after the third pull, the procedure should be abandoned.
> Prophylactic forceps delivery is done to shorten the second stage when maternal and/or fetal complications are anticipated (Box 37.3).
> Trial forceps and failed forceps have different clinical criteria. The causes are different (Box 37.4).
► Correct assessment of criteria and application of the instrument (bimalar, biparietal placement for forceps and for ventouse cup on or close to the flexion point) is essential for successful delivery and to minimize the complications.
► Sequential use of different instruments to deliver the baby, increase the risk of complications to both the neonate and the mother. ► In trial labor as well as in failed forceps delivery, the operator should have the willingness to abandon the procedure in case of
difficulty and should go for immediate cesarean delivery. This reduces the rates of morbidity and mortality both for the neonate and the mother.
► The outcomes of midcavity forceps delivery have been compared with cesarean delivery. There is no increase in the risks of neonatal adverse outcome in terms of birth trauma, Apgar score and NICU admission.
> Factors for rising cesarean section (CS) are many including the CS on maternal request (Box 37.8).
> Indications of CS are mostly relative (CPD) and absolute indications are a few. Based on time, CS may be done either as an elective or an emergency procedure.
► Common indications of CS are: Failed induction of labor, fetal distress, previous cesarean delivery, antepartum hemorrhage, ma Iposition or malpresentation and cephalopelvic disproportion (Box 37.9).
> Lower segment CS is commonly done with low transverse abdominal incision. There are merits and demerits of lower segment transverse versus classical uterine incision (Table 37 .1 O).
► Complications of cesarean section may be: (a) Due to operation itself or (b) Due to anesthesia.
> Maternal complications may be: (a) lntraoperative or (b) Postoperative (552). Visceral injury (bladder), hemorrhage, anesthetic hazards (aspiration), wound sepsis are the important complications.
► Prophylactic antibiotics during CS are used to reduce the frequency of sepsis. First dose to the mother is given one hour before the skin incision is made.
► Forceps has little or no effect on subsequent urinary incontinence.
► The risk of the fetal injury with vacuum delivery are cephalohematoma, subgaleal and retinal hemorrhages; forceps delivery are: injury to the scalp and the face, facial bruising).
► Different destructive operations are: Craniotomy, evisceration, decapitation and cleidotomy. In modern obstetrics, there is hardly any place for destructive operations.
> Safe prevention of CD include: ECV; assisted vaginal breech delivery in selected cases, avoiding CD in latent phase and in first stage labor before 6 cm dilatation and for second stage (Table 37 .11 ).

Safe Motherhood, Epidemiology of Obstetrics

CHAPTER

CHAPTER OUTLINE
❖ Safe Motherhood
❖ Clinical Causes of Maternal Deaths ❖ Country Targets
❖ Ending Preventable Maternal Mortality
❖ Sustainable Development Goals (SDGs)

❖ Reproductive and Child Health (RCH) Care
► RCH Interventions
❖ Epidemiology of Obstetrics ► Maternal Mortality
► Maternal Near Miss

► Maternal Morbidity ► Perinatal Mortality
► Important Causes of Perinatal Mortality and Main Interventions
► Stillbirths
► Neonatal Deaths

SAFE MOTHERHOOD
In an attempt to reduce maternal deaths in the low and middle income countries, the WHO in 1987 conceived the idea of 'Safe Motherhood Initiative' at a conference in Nairobi, Kenya. It is a global effort to reduce the maternal deaths by at least half by 2000 AD, and was extended to 2015 now extended further to 2030.
Maternal and child health promotion is one of the key commitments in the WHO constitution. Ending Preventable Material Mortality (EPMM) is the world's most critical challenges (WHO).
Maternal death: As estimated 30,300 maternal deaths in 2015 yields an overall global Maternal Mortality Ratio (MMR) 216/100,000 live births for 183 countries. Global targets are to increase equity in maternal mortality between countries. The steps are:
a. By 2030 all countries should reduce maternal mortality (MMR) by at least two thirds of their 2010 baseline level.
b. The average global target of MMR is less than 70/100,000 Live Birth (LB) by 2030.
c. The supplementary national target is that no country should have a MMR greater than 140/100,000 LB (a number twice the global target) by 2030.
About 99% of the estimated total maternal deaths occurred in the developing regions. Majority (80%) of these deaths are preventable.
In the developed regions, the MMR is 12 (range 11-14) per 100,000 live births. The lifetime risk of dying from pregnancy related complication for a woman of developing region is one in 150 compared to one in 4900 in the developed regions. This reflects the huge difference in national commitment.

Safe Motherhood Initiative (SMI) is a global effort and it is designed to operate through partners: (a) Government agencies, (b) Non-government agencies, and (c) Other groups and individuals. Worldwide MMR has fallen from 342 in the year 2000 to 211 in 2017 (WHO).
The MMR in India has declined by about 70% from 398/100,000 LB (in 1997-98) to 99/100,000 (90-108) in 2020 (Table 38.1).
Worldwide MMR has fallen from 342/100,000 in 2000 to 211/100,000 (about 40% of the absolute decline was derived from fewer maternal deaths in India).
Experts from WHO, UNFPA, UNICEF, IPPFF, the World Bank Group, UNPD regions, the population council and other national and international agencies concerned with safe motherhood concluded that it is possible to reduce maternal mortality significantly with limited investment and effective policy interventions (Table 38.2). According to national and international human rights treaties (1948) safe motherhood is considered a human rights issue. Therefore, it is

Table 38.1: Goals ancj targets to reduce maternal deaths: Global and in India.
Organization Year Target of MMR reduction Target year
Sustainable 2015 • MMR reduction 2030 Development QO per 100,000 LB
Goals • Neonatal Mortality Rate (NMR)
■ NMR <12 per 1000 LB
MMR in India (SRSJ Worldwide MMR
1997-1998 2020 2000(WHO) 2017 398 99 342 211
Reduction in MMR (70%)
Chapter 38: Safe Motherhood, Epidemiology of Obstetrics - ·---

Table 38.2: National Sociodemographic Goals (2030) (SDG) National Population Policy, National Health Mission (NHM).
Parameters 2030 Total fertility rate <2.1 Maternal mortality ratio (per 100,000 live births) <70 Infant mortality <12 Antenatal care (%) 100 Institutional deliveries (%) 80 Deliveries by skilled personnel(%) 100

considered that maternal death is the reflection of 'social disadvantage' not merely a 'health disadvantage'.
Basic facts underlying the clinical causes of maternal deaths are:
♦ Social inequalities and discrimination on grounds of gender, age and marital status, are considered the major determinants of maternal mortality. In low resource countries, girls and women face the following difficulties such as: (i) Limited access to economic resources, (ii) Less opportunity for basic education, (iii) Less opportunity in decision making as regard their own health and reproduction, (iv) Unplanned childbirth that are too early, too frequently, too many or too late, and (v) Less utilization of essential obstetric services.
♦ Poor nutrition contributes to poor maternal health and results in poor pregnancy outcome.
♦ Less utilization of available resources.
♦ Lack of skilled attendant during the time of delivery, appropriate referral system, Emergency Obstetric Care (EmOC), sex education, family planning and safe abortion services are the important areas.
Country targets to increase equity in maternal mortality
The global MMR <70 by 2030 target may not necessarily apply to individual countries. However, regardless of its

baseline MMR, each country should accelerate efforts in achieving the global target (Figs. 38.IA and B).
11 Countries with baseline MMR <420 in 2010 (the majority worldwide) should reduce its MMR by at least two thirds by 2030 (Fig. 38.IA).
11 Countries with baseline MMR >420 in 2010 should not have an MMR greater than 140 by 2030 (Fig. 38.IB).
11 Countries with baseline MMR <10 in 2010 should aim to achieve equity in MMR for vulnerable populations at the subnational level.
11 A special target for all countries in addition to reducing their national average MMR, is to reduce the extremes of between-country inequity.
■ Countries with the highest MMRs (MMR >420) need to reduce their MMR at an Annual Rate of Reduction (ARR) greater than 5.5%. Countries with the lowest MMRs (MMR <10) that may find it difficult to achieve a two-thirds reduction from baseline. Such countries need to achieve within-country equity in maternal survival in subpopulations with higher risk of maternal death.
In an attempt to improve the maternal mortality situation in India, all the states have been categorized into groups: (A) Empowered Action Group (EAG and Assam): The states in this group are Bihar, Jharkhand, MP, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand and Assam. (B) Southern states: Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and (C) Other states: The remaining states and the union territories. Government of India pointed out three types of delays that results in an increase in maternal mortality and morbidity.
1. Delay-I: Delay in recognizing the problem and deciding to seek care (lack of birth preparedness).
2. Delay-II: Delay in reaching the health facility (due to nonavailability of transport referral facility (lack of complication readiness).

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Figs. 38.lA and B: (A} Countries with baseline MMR <420; (Bl Countries with baseline MMR >420.
·m1 Chapter 38: Safe Motherhood, Epidemiology of Obstetrics

3. Delay-III: Delay in receiving treatment at the center [(due to unequipped health facility, lack of trained personnel, medicines, blood, etc., (lack of facilities readiness)].
Decline has been observed in all the delays.
WHO published five strategies towards Ending Preventable Maternal Mortality (EPMM).
1. Addressing inequities in access to and quality of sexual, reproductive, maternal and newborn health care (Ethiopia, Vietnam).
2. Ensuring universal health coverage for comprehen sive sexual, reproductive, maternal and newborn health care (Rwanda, Bangladesh).
3. Addressing all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities (Nepal, Maldives).
4. Strengthening health systems to respond to the needs and priorities of women and girls (Indonesia, Cambodia).
5. Ensuring accountability to improve quality of care and equity (Mangolia, India).
Name of the countries that have made significant reductions in maternal mortality are mentioned within the parenthesis.
Other areas that need to improvement to achieve this target:
WHO stresses on the need for good quality data collection. Each count1y need Civil Registration and Vital Statistics (CRVS) systems. Under reporting need to be avoided. Actual number and the cause of deaths can help to make correct strategies to reduce maternal deaths.
Strategic framework and program implementation: 1. Empowering women, girls and communities.
2. Protecting and supporting the mother-baby care.
3. Ensuring country ownership, leadership and supportive legal, technical and financial frameworks.

Abortion (8%)
Embolism (3%)

4. Applying a human rights framework to ensure that high-quality reproductive, maternal and newborn health care is available, accessible and acceptable to all who need it (WHO-2015).
Lifetime risk is defined as the probability of dying of a woman in her reproductive age (15-49 years), due to causes in pregnancy, childbirth or within 6 weeks of childbirth. In India, presently, it is 0.3%.
OBSTETRIC CARE AND THE SOCIETY: Obstetric care is by and large a preventive medicine. Social obstetrics is defined as the obstetric care of a community that can be provided in the perspective of its social, economic, environmental and cultural background.

SUSTAINABLE DEVELOPMENT GOALS (SDGs)
The United Nations General Assembly adopted the new development agenda in September 2015. The 2030 agenda comprises 17 Sustainable Development Goals (SDGs) (Fig. 38.3). It integrates all three main dimensions of developments (economic, social and environmental). Health is placed in the central position of 2030 agenda with one comprehensive goal SDG3. SDG3 includes 13 targets covering all major health topics. These include: reproductive, maternal, newborn and child health care, infectious diseases, Noncommunicable Diseases (NCDs), mental health, road traffic injuries, UHC and environmental health consequences. There are 26 proposed indicators. The indicators for SGD targets 3.1 and 3.2, include maternal and under-five mortality. Sole objective is to achieve the SDG target of MMR 70 per 100,000 live births by 2030.

The global annual rate of reduction of MMR should be 5.5% at least. Globally, under-five mortality rate, at present, is 42.5 per 1000 live births. SDG target of under five mortality in 2030 is 25 per 1000 live births. SDG target of neonatal deaths in 2030 is 12 per 1000 live births.

Indirect-.,,, (28%)

Hemorrhage (27%)

Other-- direct (10%)

Sepsis (11 %) Hypertension, eclampsia (14%)
Fig. 38.2: Important causes of maternal deaths. Fig. 38.3: Sustainable development goals (SDG-3).
Source: Global causes of maternal death: a WHO systematic analysis. Lancet Glob Heal. 2014;2:323-33.
Chapter 38: Safe Motherhood, Epidemiology of Obstetrics

Table 38.3: Selected SDG targets and proposed indicators.
Type of SDG
indicator target Proposed indicators by 2030
Impact ■ Reduce maternal mortality to
3.1
3.2 <70/100,000 LB
3.7
■ Reduce neonatal mortality to 12/1000 LB
■ Ensure universal access to sexual and
reproductive health care including family planning information and education. lnte-gration of reproductive health into national
strategies and programs
Coverage 3.1 ■ Birth attended by skilled health 3.7 professional
3.8 ■ Family planning coverage
■ UHC: RMNCH (family planning, antenatal
and delivery care, full immunization coverage, health-seeking behavior for
suspected child pneumonia

Selected SDG targets and proposed indicators linked to reproductive, maternal, newborn and child health by type of indicator is shown in Table 38.3.
The key five strategies towards Ending Preventable Maternal Mortality (EPMM) by 2030 are:
■ To address inequities (WHO 2015) in access to and quality of sexual, reproductive, maternal and newborn healthcare services.
■ To ensure universal and comprehensive healthcare for sexual, reproductive, maternal and newborn health.
■ To address all causes of maternal mortality, morbidities and related disabilities.
■ To strengthen health system for the needs and priorities of women and girls.
■ To ensure accountability to improve quality care and equity.
There is a wide variation between rich and poor countries and between urban and rural areas. Poor women get either inadequate care or no care at all.

REPRODUCTIVE AND CHILD HEALTH {RCH) CARE
(a) Safe motherhood: Risk assessment is not once only but a continued procedure throughout and the woman is referred to a higher level of care when needed (Table 38.4).
(bl Adolescent and reproductive health: 20% of the total population in India are adolescent (age group of 10-19 years), of which half are either sexually active or married. Problems to overcome are: (i) Early motherhood-risk of the mother and her newborn, (ii) Undernutrition and anemia, (iii) Psychological immaturity and vulnerability, (iv) Consequences of unprotected sex-unwanted pregnancy, unsafe abortion, Sexually Transmitted Infections (STis) and Reproductive Tract Infections (RTis).

(c) Reproductive Tract Infections (RTls) and Sexually Transmitted Infections (STls): RTis are mainly due to unsafe abortion, uncleaned delivery, poor menstrual hygiene and unhygienic IUD insertion. All these are avoidable by proper preventive and curative measures under the RCH program.
(d) Others: RCH II, skilled birth attendant and uni versal immunization to children: In India, RCH II highlights the following areas-(i) Community Need Assessment Approach ( CNAA), (ii) Up gradation of facilities at First Referral Unit (FRU) for comprehensive emergency obstetric and newborn care at the subdistrict levels, (iii) Permission for skilled birth attendant to administer certain life-saving drugs and to perform certain life-saving interventions under specified situations (see below).
Life-saving drugs are: Misoprostol [prevention of Postpartum Hemorrhage (PPH)], injection Oxytocin (man
agement of PPH), injection MgS04 (eclampsia), ampicillin, metronidazole (infection) are the life-saving interventions

Table 38.4: Measures for safe motherhood.

Antenatal care
Essential obstetric care:
•
•
Early registration of pregnancy (<12 weeks)
Minimum 4 antenatal visits (WHO). (1st visit: 12-14 weeks; 2nd visit: 14-26 weeks; 3rd visit:
28-34 weeks and 4th visit: 36-40 weeks) Identification of high-risk factors Provision of prompt referral
•
•
•
•
•
Essential newborn care
Early and exclusive breastfeeding
Immunization with tetanus toxoid and
supplementary lron-Folic Acid (IFA) therapy
daily for at least 100 days after the first trimester

tntranatal care
• Institutional deliveries
in 80% cases and 100%
deliveries by skilled persons
Postnatal care
•
Support to restore the health of mother and care of the
newborn
•
Family planning services
to prevent unplanned
pregnancy
•
•
Safe abortion services
Breastfeeding-early and
exclusive

I
Essential newborn Comprehensive EmOC
care (at FRUs under NHM scheme)
•
•
Clean delivery ■ Vacuum extractions
Resuscitation at ■ Anesthetic services
•
birth Blood transfusion facilities
■ Prevention of ■ Cesarean delivery
hypothermia ■ Manual removal of placenta
•
Prevention of ■ Suction evacuation (MVA) ■ Safe abortion services
infection
Ten
baby-friendly
■ hospital initiatives ■ Contraceptive services Referral of sick ■ Sterilization operations
(IUCDs)
•
newborn
■ Referral and transport
facilities
t
r
°
p
:.

BJ Chapter 38: Safe Motherhood, Epidemiology of Obstetrics

are: Digital removal of products of conception (incomplete abortion with bleeding, active management of 3rd stage of labor, maintaining a partograph [early diagnosis of pro longed and obstructed labor need a skilled person.
Emergency Obstetric Care (EmOC) is life-saving, as the time between onset of an emergency during delivery and start of treatment is very crucial.
Emergency obstetric care has a major role to improve maternal mortality. Many women died in the facilities when obstetric complications were faced as emergency and unanticipated.
The reduction of maternal deaths suggest successful initiatives by the government and stakeholders through the Safe Motherhood Programme (1992). Reproductive and Child Health Programme (1997), National Health Mission (2005), Janani and Sishu Suraksha Karyakram (JSSK-2017).
The comprehensive EmOC that has to be provided at FRUs are: anesthetic service, vacuum delivery, blood transfusion facilities, cesarean delivery, manual removal of placenta, safe abortion services, contraceptive services, including sterilization and facilities of referral with transport.

EPIDEMIOLOGY OF OBSTETRICS
The sensitive index of the quality of the healthcare delivery system of a country as a whole or in part, is reflected by its maternal and perinatal mortality rates (Table 38.5). Fertility regulation, safe abortion procedure, quality antenatal care, presence of skilled birth attendant (SBA), have been recognized as the key elements to reduce maternal and perinatal deaths in the low resource settings.

I MATERNAL MORTALITY
DEFINITION OF MATERNAL DEATHS: Death of a woman while pregnant or within 42 days of the termination of pregnancy irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

MATERNAL MORTALITY RATIO (MMR): The MMR is expressed in terms of such maternal deaths per 100,000 live births. In most of the developed countries, the

MMR varies from 11-14 per 100,000 live births. In the developing countries, it varies from 27-546 with India having 99 per 100,000 live births. Good quality data is essential to identify the trends and the cause of maternal deaths. It is also useful to prevent future deaths. The tools for quality data collection are:
■ Confidential Enquiry into Maternal Death (CEMD) established in England and Wales since 1952.
■ Maternal Deaths Surveillance and Response (MDSR) established in India, Congo, Nigeria and few other countries.
■ Digital innovations using mobile devices. This is used to connect front line health workers to the national health systems.

MAGNITUDE OF THE PROBLEM: One woman in 150 die of pregnancy-related complications in Low Income Countries (LIC) compared to one in 4,900 High Income Countries (HIC). Here lies the major discrepancies in global health. It is further estimated that for one maternal death at least 16 more suffer from severe morbidities.
MATERNAL MORTALITY RATE: Indicates the number of maternal deaths divided by the number of women of reproductive age (15-49). It is expressed per 100,000 women of reproductive age per year. In India, it is about 120 as compared to 0.5 in the United States.
The term reproductive mortality is used currently to include maternal mortality and mortality from the use of contraceptives.

CLASSIFICATIONS
♦ Direct ♦ Indirect ♦ Non-obstetric
■ Direct obstetric deaths (75%) are those resulting from complications of pregnancy, delivery or their management. Such conditions are abortion, ectopic gestation, pre-eclampsia-eclampsia, antepartum and postpartum hemorrhage and puerperal sepsis (Table 38.6). Suicidal death is considered as a direct death.
■ Indirect deaths (25%) include conditions present before or developed during pregnancy but aggravated by the physiological effects of pregnancy and strain of labor. These are anemia, cardiac disease, diabetes, thyroid disease, etc., of which, anemia is the most important single cause in the developing countries.

,Table 38,5: Maternal mortalitxestimates (WHO, UNICEF, UNFPA, World Bank) .. ' .; .. . : Maternal mortality ratios in the HIC
SWEDEN USA UNITED KINGDOM SINGAPORE 3 23.8 9.7 (2016-17) 10
I I I
I
I I
Maternal mortality ratios in South-East Asia
I I I I
I
I I
I
SRI LANKA THAILAND INDIA2020 CHINA BANGLADESH
30 20 99 56 178

I
I

' • > /.,'"
, ,

JAPAN 6

NEPAL
258
Chapter 38: Safe Motherhood, Epidemiology of Obstetrics

Table 38.6: Important causes of maternal deaths and main interventions. Causes
Hemorrhage: Mostly due to postpartum hemorrhage. Other causes are: (i) Antepartum hemorrhage (abruptio placentae, placenta previa),
(ii) Retained placenta, (iii) Abortion complications and ectopic pregnancy. Hemorrhage is more dangerous when the woman is anemic.

Infection is associated with labor and puerperium. Infections from premature rupture of membranes, prolonged and obstructed labor are still frequent in the developing world.
Hypertension during pregnancy pre-eclampsia, eclampsia
Unsafe abortion

Obstructed labor-due to cephalopelvic disproportion, abnormal lie or malpresentation.
Anemia is an indirect cause of death. About 50% of pregnant women worldwide suffer from anemia. Anemia is commonly due to dietary deficiency (nutrition, iron, folic acid, iodine and other micronutrients) or infections.
Other indirect causes: Viral hepatitis is endemic in India with high mortality. Death is mostly in the last trimester due to hepatic coma and coagulation failure and postpartum hemorrhage.

Percentage 20-25

15-20

12-15

10-13

15-20

5-10

Proven interventions
■ Treat anemia in pregnancy Skilled attendants at birth
•
■ Prevent/treat hemorrhage ■ Use oxytocics in time
•
Replace fluid loss
■ Transfusion of blood, if severe hemorrhage
■ Skilled attendants at birth
■ Clean practices (three cleans) during delivery ■ Antibiotics-if infection is evident
• Early detection ■ Appropriate referral
■ Antiseizure prophylaxis/treatment with MgSO4
■ Skilled attendant
a Access to family planning and safe abortion services
■ Antibiotics after evacuation ■ Postabortion care
• Use of partograph ■ Detection in time Refer for operative delivery
•
• Routine iron-folic acid supplementation ■ Treat hookworm, malaria, HIV, etc.
■ Admit when Hb 5,7 g/dl
■ Safe drinking water ■ Immunization
■ Appropriate referral and supportive care

80% of these deaths can be prevented through actions that are effective and affordable in developing country settings (WHO, UNICEF and
UNFPA-2001 ).

Viral hepatitis, when endemic, contributes significantly to maternal deaths.
■ Non-obstetric or fortuitous deaths: Accidents, typhoid and other infectious diseases.

FACTORS ASSOCIATED WITH MATERNAL MORTALITY
Age: In women aged 35 years or above, the risk is 3-4 times higher.
Parity: The risk is slightly more in primigravida but it is 3 times greater in para 5 or above where postpartum hemorrhage, malpresentations and ruptured uterus are more common. The risk is lowest in the second pregnancy.
Socioeconomic status: Mortality ratios are higher in women belonging to low socioeconomic strata.
Antenatal care: The women of lower socioeconomic status, are the high-risk women as often they do not avail the benefits of antenatal care.
Substandard care: When the care provided is below the generally accepted level, available at those circumstances. Shortage of resources (staff) or back up facilities (laboratory) is also included.
In the Low and Middle Income Countries (LMIC), avoidable social factors are palpably evident. These are related to: (a) Ignorance, teenage pregnancy or prejudice, (b) Unregulated fertility and unsafe abortion, (c) Poor socioeconomic condition, (d) Inadequate maternity

services, (e) Underutilization of the existing services, (f) Lack of communication and referral facilities. These are most often interrelated and are responsible for increased number of preventable deaths.
Important causes of maternal death (Fig. 38.2): Whereas in the organized sector (HIC)-hypertensive disorders, hemorrhage and pulmonary embolism are the main causes, in the LMIC-hemorrhage, sepsis and hypertensive disorders and unsafe abortion are the main causes (Table 38.6).
STEPS TO REDUCE MATERNAL MORTALITY
Actions may vary in respect of an individual country. The government must make maternal mortality a priority public health issue and periodically evaluate the programs in an effort to prevent or minimize maternal deaths. Specific actions are discussed under the following groups:
A. Health Sector Actions
■ Basic antenatal, intranatal and postnatal care (see RCH interventions). Risk assessment is a continued procedure throughout and is not once only.
■ A skilled birth attendant should be present at every birth. Functioning refel'ral system is essential for integration of domiciliary and institutional services.
■ Emergency Obstetric Care (EmOC) is to be provided at the First Referral Unit (FRU).
iJ Chapter 38: Safe Motherhood, Epidemiology of Obstetrics

• Good quality obstetric services at the referral centers are to be ensured. Facilities for blood transfusion, laparotomy and cesarean section must be available at the FRU level.
■ Prevention of unwanted pregnancy and unsafe abortion. All couples and individuals should have access to effective, client-oriented and confidential family planning services.
■ Frequent joint consultation among specialists in the management of medical disorders in pregnancy, particularly anemia, viral hepatitis, and hypertension.
• Maternal mortality conferences and audit to evaluate the cause of death and the avoidable factors.
■ Periodic refresher courses for continuing education of obstetricians, general practitioners, midwives and ancillary staff and to highlight the preventable factors.
B. Community, Society and Family Actions: Wide range of groups (women's groups), healthcare professionals, religious leaders can help the woman to obtain the essential obstetric care.
C. National Health Mission (NHM) Action Plan is to: ■ Strengthen all First Referred Units (FRUs).
11 Provide basic and comprehensive Emergency Obstetric Care (EmOc) and essential newborn care (see below).
■ Janani Shishu Suraksha Karyakram (JSSK) under the umbrella of NHM is to implement the interventions in all the states and Union Territories (UTs) with a special focus on Low-Performing States (LPS) that they have low institutional deliveries (Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Odisha, Jammu and Kashmir). The remaining states have been named as high performing states.
D. Skilled birth attendant
Skilled Birth Attendant (SBA) is defined as an accredited health professional (doctor, midwife or nurse) who has been educated and trained to achieve proficiency in the skills, needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period and in the identification, management and referral of complications in women and newborns. Besides doctors, SBAs include Auxiliary Nurse Midwives (ANMs), Lady Health Visitors (LHVs) and Staff Nurse (SNs), SBAs are trained and made competent to take certain life-saving measures.
E. Accredited Social Health Activist (ASHA)
ASHA is a female (preferably a daughter-in-law) accre dited social health worker of 25-45 years age. She is to work in a village with population >1,000 under the NRHM scheme. She is trained over a period of 3-4 weeks for the work.

11 She acts as a link person among the beneficiary at the village level with the ANMs, LHVs, doctors at the FRU (Government).
■ She arranges escort to the pregnant woman, sick child and provide DOTs, ORS, IFA tablets for the needful.
11 She works along with Anganwadi Workers (AWWs) and TRBAs to provide service under JSSYK.
F. 1. Empowered Action Group (including Assam). 2. Other states:
EAGA states-Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Rajasthan, Odisha and Assam.
EAGA states in India currently is the location of over 60% of maternal deaths. These EAGA states and the rural and tribal areas need special strategies and intervention to improve the maternal deaths and to react the national goal and SDG.
Conclusion:
11 EAGA states and the rural and tribal areas are the regions for majority of maternal deaths (60%). These areas need special strategies and specific intervention.
11 Educational programs and motivation for women about the benefits of planned delivery at health facilities.
11 All the EAGA states need continuing reliable estimation of maternal deaths for review. This is needed for any strategic change and appropriate intervention.
11 Prioritizing specific improvement in maternal health outcomes in EAGA states are needed.
11 It is expected that each state in India achieves the 2030 goals with prioritization and need specific intervention.
Most deaths: Occurring in EAGA states (63%) and among women aged between 20 and 29 years (58%).

MATERNAL HEALTH BEYOND 2030 I NATIONAL HEALTH POLICY (GOl-2017)
The National Health Policy 2017, aims the attainment of highest possible level of health and wellbeing for all at all ages through preventive and primitive healthcare system.
The policy principles are:
1. Professionalism, Integrity and Ethics: NHP demands high professional standard. Integrity and ethics are to be maintained.
2. Equity: Inequity to be reduced. This is to reduce disparity on the ground of gender, poverty, caste, disability or other forms of social and geographical barriers.
3. Affordability: The costs of care should be made affordable for all.
4. Universality: Prevention of exclusions on social, economic or on any other grounds.
Chapter 38: Safe Motherhood, Epidemiology of Obstetrics ml

5. Patient centered and quality of care: Gender sensitive, effective, safe, and convenient healthcare services to be provided with dignity and confidentiality.
6. Accountability: Financial and performance account ability, transparency in decision making, and elimination of corruption in healthcare systems are essential. It is applicable both in public and private care.
I MATERNAL NEAR MISS
A woman who experienced a severe !]
complication and she nearly died, but she ■- ' • ,cj survived the severe health condition during pregnancy, childbirth or postpartum is !J considered as maternal near miss or Severe Acute Maternal Morbidity (SAMM). Maternal near miss is defined as: 'A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy' (WHO). MNM incidence ratio (MNMIR) refers to the number of maternal near miss cases per 1000 live births (MNMIR = MNM/1000 LB).

Potentially life-threatening conditions commonly seen in obstetrics are:
II Hypertensive disorders: Sever pre-eclampsia, eclampsia.
■ Hemorrhagic disorders: Placenta previa, placental abruption and postpartum hemorrhage.
■ Other systemic disorders: Septic shock and others. Specific defining criteria for MNM (SAMM) are:
■ Clinical criteria: • Acute cyanosis • Loss of Consciousness (LC) lasting >12 hours, gasping • LC and absence of pulse/heart beat • Respiratory rate >40 breaths/min or <6/min stroke • Disseminated Intravascular Coagulation (DIC).
■ Laboratory-based criteria: • Oxygen saturation <90%
for >60 minutes • PaOz1FiO2 <200 mm Hg • Serum
creatinine 3.5 mg/dL • Serum bilirubin 6.0 mg/dL • pH <7.1 • Lactate >5 • Acute thrombocytopenia (<50,000 platelets/ cu mm).
■ Interventions-based criteria: • Use of vasoactive drugs (dopamine, epinephrine), • Hysterectomy following infection/hemorrhage • Transfusion >5 units blood • Dialysis for acute renal failure • Cardiopulmona1y resuscitation.
OR: Any single criteria that signifies cardiorespiratory collapse indicated with heart ( •) symbol is accepted.
Read more Dutta's Clinics in Obstetrics, Ch. 16.
I MATERNAL MORBIDITY
It has been estimated that for one maternal death at least 15 more suffer from severe morbidities.
Definition: Obstetric morbidity originates from any
cause related to pregnancy or its management any time

during antepartum, intrapartum and postpartum period usually up to 42 days after confinement. The parameters of maternal morbidity are:
1. Fever more than 100.4°F or 38°C and continuing more than 24 hours.
2. Blood pressure more than 140/90 mm of Hg. 3. Recurrent vaginal bleeding.
4. Hb% less than 10.5 g irrespective of gestational period. 5. Asymptomatic bacteriuria of pregnancy.

Classifications
I. Direct obstetric morbidity:
• Temporary • Permanent (chronic) II. Indirect obstetric morbidity
Direct-Temporary: Antepartum Hemorrhage (APH), Postpartum Hemorrhage (PPH), eclampsia, obstructed labor, rupture uterus, sepsis, ectopic pregnancy, molar pregnancy, etc.
Chronic: Vesicovaginal Fistula (VVF), Rectovaginal Fistula (RVF), dyspareunia, Current Procedural Termino logy (CPT), prolapse, secondary infertility, obstetric palsy, Sheehan's syndrome, etc.
Indirect: These conditions are only expressions of aggravated previous existing diseases like malaria, hepatitis, tuberculosis, anemia, etc., by the changes in the various systems during pregnancy.
Reproductive morbidity is used in a broader sense to include-(a) Obstetric morbidity, (b) Gynecological morbidity, and (c) Contraceptive morbidity.
I PERINATAL MORTALITY
Perinatal mortality is defined as deaths among fetuses weighing 1000 g or more at birth (28 weeks of gestation) who die before or during delivery or within the first 7 days of delivery. The perinatal mortality rate is expressed in terms of such deaths per 1000 total births. The perinatal mortality rate closely reflects both the standards of medical care and effectiveness of social and public health measures. According to the WHO, the limit of viability is brought down to a fetus weighing 500 g (gestational age 22 weeks) or body length (25 cm crown-heel) or more. However, for international comparisons, only deaths of fetuses or infants weighing 1000 g at birth should be included as in the Low and Middle Income Countries (LMIC) many such deaths are under-reported.
Perinatal deaths could be reduced by at least 50% worldwide if key interventions are applied for the newborn. The perinatal mortality is less than 10 per 1000 total births in the developed countries while it is much higher in the developing countries (26/1000 in India). The major health problem in the LMIC arises from the synergistic effect of infection and preterm birth combined with non-utilization of obstetric care.
ED Chapter 38: Safe Motherhood, Epidemiology of Obstetrics

Majority of fetal deaths (70-90%) occur before the onset of labor. The important causes of antepartum deaths are: (a) Chronic hypoxia (30%), (b) Pregnancy complications (30%), (c) Congenital malformations (15%), (d) Infection (5%), and (e) Unexplained (20%).
PREDISPOSING FACTORS OF PERINATAL MORTALITY
Many factors influence the perinatal survival and these are briefly discussed below (Table 38.7):
■ Epidemiological: Age-elderly (>35 years), teenagers, parity above 5, low socioeconomic condition, poor maternal nutritional status-all adversely affect the pregnancy outcome.
■ Medical disorders: Anemia (Hb <8 g/dL),
hypertensive disorders, diabetes mellitus, acute fever (malaria) and infection (HIV) are often associated. Perinatal deaths increase due to hypoxia, hypothermia, IUGR, prematurity, infections and congenital malformations.
■ Obstetric complications: (a) Antepartum hemor rhage particularly abruptio placentae is responsible for about 10% of perinatal deaths due to severe hypoxia, (b) Pre-eclampsia-eclampsia is associated with high perinatal loss either due to placental insufficiency or preterm delivery (c) Rh isoimmunization, (d) Preterm labor, (e) Cervical incompetence premature effacement and dilatation of cervix <34 weeks is responsible for significant perinatal deaths from prematurity.
■ Complications of labor: Dystocia from disproportion, malpresentation, abnormal uterine action, premature rupture of membranes may result in asphyxia, amnionitis and birth injuries contributing to perinatal deaths.
■ Fetoplacentalfactors:
• Multiple pregnancy most often leads to preterm delivery and the related complications.
• Intrauterine growth restriction and low-birth weight babies: Low weight babies are more vulnerable to biochemical, neurological and respiratory complications resulting in high perinatal deaths.

• Preterm labor and preterm rupture of the mem branes are the known leading causes of prematurity.
• Congenital malformation and chromosomal abnormalities are responsible for 15% of perinatal deaths, the lethal malformations are mostly related to nervous, cardiovascular or gastrointestinal system. With prenatal diagnosis, it is reduced significantly.
■ Unexplained: About 20% of stillbirths have no obvious fetal, placental, maternal or obstetric causes.
PREVENTION: As every mother has the right to con clude her pregnancy safely so also has the baby got a right to be born alive safe and healthy. As such, utilization of obstetric service only around delivery, may not minimize perinatal deaths appreciably. Simultaneous demographic and social changes are essential. The following measures are helpful in reducing the perinatal mortality.
■ Prepregnancy health care and counseling.
■ Ge1ietic counseling in high-risk cases and prenatal diagnosis to detect genetic, chromosomal or structural abnormalities are essential.
■ Regular antenatal care, with advice regarding health, diet and rest.
■ Detection and management of medical disorders in pregnancy: Anemia, diabetes, infections and pre eclampsia-eclampsia. Immunization against tetanus should be done as a routine.
■ Screening of high-risk patients as with high parity, extremes of age, and twins, etc. and their mandatory hospital delivery. Risk approach to RCH care is essential.
■ Careful monitoring in labor to detect hypoxia early and avoidance of traumatic vaginal delivery.
■ Skilled birth attendant-to minimize sepsis, at least three cleans are to be maintained.
■ Provision of referral neonatal service, especially to look after the preterm and LBW babies.
■ Healthcare education of the mother about the care of the newborn. Early and exclusive breastfeeding, prevention of hypothermia.

Table 38.7: Important causes of neonatal mortality and the main interventions.
Causes Percentage Proven interventions

Prematurity and low birth weight 48.1 Birth asphyxia and birth trauma 12.9

Neonatal pneumonia 12.0 Other noncommunicable disease 7.1
Sepsis 5.4 Congenital malformation 4.0 Others 10.5

♦ Maternal immunization against tetanus ♦ Warmth
♦ Screening for infections

♦ Skilled attendants at birth ♦ Warmth
♦ Prevention of obstetric complications and management
♦ Infection control
♦ Breastfeeding

+ Clean delivery (three cleans)
♦ Early and exclusive breastfeeding
♦ Early recognition and management of infections
♦ Detection and management of obstetric complications

+ Warmth
♦ Referral to special care unit

CLASSIFICATION OF PRETERM NEWBORN
♦ Extremely preterm: <28 weeks
♦ Very early preterm: 28 to 31 weeks ♦ Early preterm: 32 to 33617 weeks
♦ Late preterm: 34 to 36617 weeks

CLASSIFICATION OF TERM NEWBORN ♦ Early term: 37°17 weeks through
38617 weeks
♦ Full term: 39°17 weeks through 40617weeks
°
♦ Late term: 41 17 weeks through 4 617 weeks
1
♦ Post-term: 42°17 weeks and beyond

Conception

o 2 12
t

1st
Conception trimester

Chapter 38: Safe Motherhood, Epidemiology of Obstetrics ED Birth

500 1000 2500 3250 4000 Weight of the fetus (g)
•

I I
I
I
0 1
l
3 4
..--------.--.',.._ Weeks after
birth

20 22 28 37 40 42 44 Weeks of
t gestation
2nd trimester 3rd trimester Birth

Fig. 38.4: Perinatal nomenclature.

IMPORTANT CAUSES OF PERINATAL MORTALITY AND MAIN INTERVENTIONS
■ Educating the community to utilize the available maternity and child healthcare services. Family plan ning services can prevent unwanted pregnancies.
■ Autopsy studies of all perinatal deaths.
■ Continued study of perinatal mortality problems by demographic studies, regular clinically allied interdepartmental meetings and pathological research.
Perinatal morbidity: It implies major illness of the neonate from birth to first 4 weeks of life. Important causes of morbidity are due to: (a) Prematurity and low birth weight, (b) Birth asphyxia and birth trauma, (c) Congenital malformations.
I STILLBIRTHS
A stillbirth is the birth of a newborn after 28th com pleted week ( weighing 1000 g or more) when the baby does not breathe or show any sign of life after delivery (Fig. 38.4). Such deaths include antepartum deaths (macerated) and intrapartum deaths (fresh stillbirths). Stillbirths rate is the number of such deaths per 1000 total births (live and stillbirth) (Table 38.7 and 38.8). I NEONATAL DEATHS
Neonatal death is the death of the infant within 28 days after birth. Neonatal mortality rate is the number of

such deaths per 1000 live births. Majority of the deaths occur within 48 hours of birth.
Causes: The causes of death within 7 days are almost always obstetrically related (Table 38.7) and as such stillbirths and neonatal deaths within 7 days are grouped together as perinatal deaths. About two-thirds of the neonatal deaths are related to prematurity.
HEALTH PROGRAMS IN MATERNAL AND CHILD HEALTH CARE (Government of India)
1. Reproductive and Child Health (RCH)
2. Janani Sishu Suraksha Karyakaram (JSSK) 2011. 3. LaQShya: Labor room quality
4. Anemia Mukt Bharat to reduce anemia to <32% (NIPl-2018).
Improvement in initiative:To ensure Respectful Maternity Care (RMC)-2017.

NATIONAL DIGITAL HEALTH MISSION (NDHM)
Objective: It is to create a digital echo system that supports universal health coverage with the use of a national health ID for every citizen.There are six building blocks to it-(a) Health data (personal health records) with the use of NDHM registry, (b) Health ID, (c) Health registries-to provide information about doctors, nurses, ASHAs and others, (d) Health claims (through e-claim form), (e) Health Data Analytics for health information providers, (f) Use ofTelemedicine and e-Pharmacy Network.
Aims of the Care
1. To reduce maternal and newborn mortality and morbidity.

Table 38.8:_ Important causes of stillbirths and min' 1nte_rventions: .. ' . . .

Causes
Birth asphyxia and trauma
Pregnancy complications (placental abruption, hypertension, diabetes mellitus)
Fetal congenital malformations and chromosomal anomalies Infections
Causes unknown

Proven interventions
Skilled attendants at birth. Effective management of obstetric complications Prepregnancy care, effective management of pregnancy complications.

Preconceptional genetic counseling, prenatal diagnosis Effective care during pregnancy and labor. Clean delivery.
(Ch. 22, Box 22.4)
&I Chapter 38: Safe Motherhood, Epidemiology of Obstetrics

2. To improve quality of care:
(a) Intrapartum care; (b) Postpartum care; (c) Timely referral; (d) Improve communication
3. National rural health message (NRHM 2005-12). Read more Dutta's Bedside Clinics and Viva-Voce in Obstetrics and Gynecology (p. 348)
4. National Digital Health Mission (NDHM)
Training for skill development in obstetrics
The special areas that need development of skill for improving the outcomes in obstetrics are:
1. Operative vaginal delivery: Instrumental deliveries (forceps/ventouse) (p. 530)

2. Assisted vaginal breech delive1y (p. 361) 3. Shoulder dystocia-management (p. 383)
4. Internal podalic version and breech extraction (p. 542) 5. Cesarean delivery (p. 542)
6. Communication skill (p. 592) 7. Breaking the bad news (p. 593)
Method of skill development:
A. Use of simulations-in the form of mannequins or computer generated programmes are of help.
B. Different training programs and courses are available for this purpose in many medical institutions/ organizations including ICOG, FOGSI, in India.

> Safe motherhood is a global effort to achieve the SDG target of MMR 70 per 100,000 live births, by 2030.
> Lifetime risk of dying from pregnancy related complications for a woman of UC regions is 1 in 150, compared to 1 in 4,900 in the developed regions in India, presently, it is 0.3%.
> The 2030 agenda comprises 17 Sustainable Development Goals (SDGs). It integrates all three main dimensions of developments (economic, social and environmental).
> National sociodemographic goals for 2015 and international commitment are to improve maternal and newborn health. RCH care is an integrated and composite care to improve the health of the women and children in India.
> Maternal death is expressed (MMR) per 100,000 live births. Maternal deaths are classified into-(a) Direct, (b) Indirect and (c) Fortuitous deaths. In India, MMR presently is 130 per 100,000 live births (2014-2016).
> Important causes of maternal deaths are: (i) Hemorrhage (20-25%), (ii) Hypertension (15-20%), (iii) Infection (11%), (iv) Unsafe abortion (8%), (v) Obstructed labor (9%), (vi) Anemia (15-20%), and (vii) Other indirect (viral hepatitis) causes (5-10%) (p. 556).
> Maternal Near Miss is a condition when a woman who nearly died but survived from a severe health condition, during pregnancy, childbirth or within 6 weeks of puerperium. For diagnosis, patient should meet 3 criteria-(1) Clinical (symptoms/signs); (2) Investigation; (3) Intervention.
> There are several proved interventions that can prevent maternal deaths. Steps to reduce maternal mortality are a coordinated long term effort (Table 38.6).
> Maternal morbidity (obstetric morbidity) develops from any cause related to pregnancy, childbirth or puerperium. Nearly 15 more women suffer from severe morbidity, when there is one maternal death.
> Perinatal mortality is expressed per 1000 total births. Important causes of PNM are: (i) Infection (33%), (ii) Birth asphyxia and trauma (28%), (iii) Preterm birth and/or LBW (24%), and (iv) Congenital malformation (15%).
> Important causes of stillbirths are: Birth asphyxia and trauma (30%), pregnancy complications (30%) and others.
> The SDGs '2030 agenda proposed to reduce maternal mortality to <70/100,000 LB and to reduce neonatal mortality to 12/1000 LB. No country should have an MMR higher than 140 deaths per 100,000 live births (twice the global target).
> The key strategies towards Ending Preventable Maternal Mortality (EPMM) by 2030 (WHO 2015) are: to address inequalities, to ensure universal and comprehensive health care, to ensure accountability and the others.
> Specific interventions to prevent maternal deaths are: Preventing and managing the complications of pregnancy, to end poverty and inequalities and the others.

Special Topics in Obstetrics

CHAPTER OUTLINE
❖ lntrapartum Fetal Evaluation ► Methods of Fetal Evaluation
❖ Nonreassuring Fetal Status
(NRFS)
► Management
❖ Shock in Obstetrics
► Classification
► Pathophysiology ► General Changes

► Hypovolemic Shock ► Endotoxic Shock