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Practical Obstetrics
AK Debdas
SECTION ONE: FORCEPS DELIVERY
1:
Outlet/Low Forceps
CONCLUSION
2:
Midcavity Forceps in Modern Obstetrics
INTRODUCTION
Definition of Midforceps Application
ACOG Classification of Forceps Application
Indications of Midforceps Application
Fetal Indications
Maternal Indications
Contraindication of Midforceps Delivery
Prerequisites of Midforceps Delivery
Documentation of the Procedure
Midforceps Application Technique (Fig. 2.1)
Instruments for Midforceps Delivery
Technique for Transverse Arrests
Technique for Occipitoposterior or Oblique Positions
Special Issues in Midforceps Application
Wandering
Correction of Deflexion and Asynclitism
Complications of Midforceps Deliveries
Failed Forceps vs Trial Forceps
Midforceps vs Vacuum Delivery
Midforceps Delivery vs Caesarean Section
ACOG Recommendation on Use of Midforceps
CONCLUSION
3:
Prophylactic Forceps
INTRODUCTION
History
Principle
Definition
Indications
Incidence
Instrumentation
Prerequisites for Application
Technique (Fig. 3.1)
Criteria for Perfect Application
Complications
Maternal
Fetal
Alternatives to Prophylactic Forceps
CONCLUSIONS
4:
Failed Forceps
CONCLUSION
SECTION TWO: VACUUM EXTRACTION
5:
Vacuum Extraction
INTRODUCTION AND HISTORY
Mandatory Prerequisites
Informed Consent
Prepared Physician
Prepared Patient
Acceptable Analgesia/Anaesthesia
Indications of Vacuum Extraction
Prolonged Second Stage of Labour
Shortening of the Second Stage of Labour
Presumed Fetal Jeopardy/ Fetal Distress
Trials of Instrumental Delivery
Contraindications of Vacuum Extraction
Types of Vacuum Extractors
Comparison of Instruments
Technique of Vacuum Extraction
Ghosting
Insertion and Fixing of the Cup
Traction
Complications and their Avoidence
What to Do when Vacuum Extraction Fails
Vacuum Extractor to Assist in Caesarean Delivery
Unique Advantages of Vacuum Extraction
Safeguards in Use of Vacuum Extraction
Complications
Neonatal Complications
Maternal Complications
Role of Vacuum in Modern Obstetrics
CONCLUSION
SECTION THREE: CAESAREAN SECTION
6:
Critical Review of Operative Techniques of Caesarean Section
INTRODUCTION
History (Young, 1944)
General Principles
Preoperative Patient Management
Maternal Position
Types of Abdominal Incision (Fig. 6.1)
Vertical Incision
Pfannensteil Incision
Modified Joel Cohen's Incision
May Lard's Incision
Cherney's Incision
Uterine Incision (Fig 6.2)
Lower Segment Transverse Incision
Lower Segment Vertical Incision
Classical Incision
Delivery of the Baby
Delivery of Placenta
Advisability about Exteriorisation of Uterus
Suturing of the Wound
Uterine Closure
Abdominal Closure
MISGAV-LADACH METHOD OF CAESAREAN SECTION
Future Research in the Technique
CONCLUSION
7:
Various Techniques of Delivery of Head by Hand at Caesarean Section
SPECIAL SOLUTIONS
Technique of Delivery of Head Stuck Deeply in the Pelvis
Technique of Delivery of Free Floating Head
Head Stuck at Abdominal Incision
The Need for Delivering the Head as Fast as Possible
CONCLUSION
8:
Technique of Application of Forceps for Delivering Head at Caesarean Section
DELIVERY BY USE OF DOUBLE FORCEPS BLADES
Forceps for Floating Head
Forceps for the Free Head at Brim or in Cavity
Forceps for the Deep Head
Choice of Instrument
CONCLUSION
9:
Technique of Delivery of Breech at Caesarean Section
TECHNIQUE OF DELIVERY OF THE FETUS
Delivery of the Buttocks and Trunk
Delivery of Shoulders and Arms
Delivery of Aftercoming Head
BM Technique
Causes of Failure of BM Technique
Forceps to the Aftercoming Head
Jaw Flexion and Shoulder Traction
Breech Delivery at CS after Internal Podalic Version
High Floating Head
Transverse or Oblique Lie
Timing of Giving Oxytocic Injection
CONCLUSION
10:
Technique of Caesarean Section in Transverse Lie and Shoulder Presentation
11:
Technique of Delivery of Twins at Caesarean Section
TECHNIQUE OF CAESAREAN SECTION IN TWINS
Anaesthesia3
Abdominal Incision
Uterine Incision
Technique of Actual Delivery4–6
Delivery in Cases with Vertex Presentation
Breech Presentation
Transverse Lie
Special Cases
Conjoint Twins7
Locked Twins
Preterm Twins
Likely Complications of Caesarean in Twin in Particular
CONCLUSION
12:
The Question of Peritoneal Closure (Visceral and Parietal) in CS and Review of Single Layer Uterine Closure
PERITONEAL CLOSURE
Current Evidence against Closure
REVIEW OF SINGLE LAYER UTERINE CLOSURE
CONCLUSION
13:
Increasing Rate of CS: What is Responsible? What is the Solution?
INTRODUCTION
The Causes of Increase of CS
Influence of Trend of Small Family Size
Progressively Increasing Age of Mothers
Changing Practice of Using Sophisticated Fetal Surveillance Techniques
Changed Trend in Management of Breech Presentation/Delivery
Changed Trend in the Management of Delay in Progress of Labour
Changed Socioeconomic and Demographic Factors
Fear of Litigation
Validation of Current Indication of CS
Repeat Caesarean Section
Fetal Distress
Failure to Progress/Dystocia
Morbidity of CS
Methods to Decrease Caesarean Deliveries
14:
Caesarean Section on Patient's Choice
SECTION FOUR: DESPERATE MAJOR OBSTETRIC OPERATIONS
15:
Internal Iliac Artery Ligation in Obstetrics
INTRODUCTION
Surgical Anatomy
Branches of Internal Iliac Artery
Anatomic Relations of Internal Iliac Artery (Fig. 15.1)
Collateral Circulation (Fig. 15.2)
Haemodynamic Consequence of Internal Iliac Ligation
Indications of Internal Iliac Ligation
Success Rate of Internal Iliac Artery Ligation
Technique
Site of Ligation
Approach
Surgical Steps
Efficacy
Complications
Recent Advances
CONCLUSION
16:
Scope and Technique of High Ligation of Uterine Artery for Intractable Postpartum Haemorrhage
CONCLUSION
17:
Scope and Technique of Uterine Packing for Intractable Postpartum Haemorrhage
INTRODUCTION
Place of Uterine Packing in Management of Uterine Bleeding
Technique of Uterine Packing
Proper Technique of Uterine Packing is Critical
Mechanism of Action of Pack
Indication (when and where)
Efficacy and Complications
18:
Surgery for Rupture Uterus
INTRODUCTION
Principles of Management
Rupture Uterus in Remote Areas: Plan of Management
Management of a Threatening Rupture
SURGICAL PROCEDURES
Repair of the Rent with or without Sterilisation
Indications
Key Points of Uterine Repair
Hysterectomy
Indications
Hysterectomy—Whether Subtotal or Total
Points to Remember about Abdominal Incision
Inspection of Uterus, Adnexa and Surrounding Structures
Steps of Hysterectomy
SPECIAL PROBLEMS ENCOUNTERED DURING SURGERY
Associated Vaginal Vault Injury (Colporrhexis)
Posterior Rupture2,3
Associated Bladder Injury
Spontaneous Injury
Iatrogenic Injury
Can Pregnancy Continue after a Rupture ?
Complications of Surgery
Recognition of Rupture after Delivery of Child
Prevention of Uterine Rupture
EPILOGUE
19:
Postpartum Hysterectomy
CONCLUSION
20:
Management of Acute Inversion of Uterus
INTRODUCTION
History
Definition
Types
Incidence
Aetiology
Pathology
Effects
Diagnosis
Symptoms
Signs
Initial Management
Manual Replacement
Techniques for Reduction
Operative Management
Post-reposition Management
Complications
Prevention
Unusual Scenarios
Fertility Following Inversion
CONCLUSION
SECTION FIVE: TECHNIQUE OF VAGINAL DELIVERY OF BREECH
21:
Assisted Breech Delivery
CONCLUSION
22:
Breech Extraction
PRACTICAL PROCEDURE OF BREECH EXTRACTION
Bringing out Buttocks and Legs
Management of Cases of with Extended Legs
Technique of Groin Traction
Technique of Conversion of Frank Breech to Footling Breech
Management of Cases of Breech with Flexed Legs—
Delivery upto Lower Half of the Scapula
Manoeuvring the Shoulder Girdle and Delivery of Superior Extremities
Delivery of Head
CONCLUSION
SECTION SIX: ASSISTED MULTIPLE BIRTH
23:
Procedure of Vaginal Delivery of Twins and Triplets
CONCLUSION
PROCEDURE OF DELIVERY OF TRIPLETS
SECTION SEVEN: SHOULDER DYSTOCIA
24:
Management of Shoulder Dystocia
CONCLUSION
SECTION EIGHT: CURRENT TECHNIQUE OF CLINICAL ASSESSMENT OF FETAL GROWTH
25:
Growth Tape
INTRODUCTION
Method Used Conventionally to Assess Fetal Growth Clinically
Findings of Literature Review on Guess-estimation/3 Landmark Methods of Assessment of Fetal Growth
Attempt towards Standardisation of Clinical Method of Assessment of Fetal Growth
Successively Measuring Fundal Height by Centimeter (cm) Tape
Advantage of the Method
Disadvantage of the Method
Use of ‘Gravidogram’
Disadvantage
Use of ‘Growth Tape’
Advantages of Growth Tape
Procedure of Taking Symphyseal-fundal Height (SFH) Measurement by Growth Tape
The procedure
How to Avoid Bias in Taking Tape Reading
1. Use the Tape in Reverse Manner (This is the Recommended Method)
2. Take Measurement without the Knowledge of the Gestational Age
3. Place the Tape Face Down on the Abdomen
How to Delineate the Fundus
The Reality about Engaged Head and ‘Lightening’ and the Question of Compensation of SFH Measurement for the Engaged Head
Scientific Corroboration of the Reliability of SFH Measurement
CONCLUSION
SECTION NINE: GADGETARY FETAL MONITORING TECHNIQUES IN PRACTICE
26:
Technique and Scope of Antenatal (External) Cardiotocography
TECHNIQUE OF ANTENATAL FHR MONITORING (by External CTG)
Method of FH Pick-up
Structure and Types of US Transducer Used to Pick-up FHR
How FHR is Computed from Echo Signal
Materials Required for Pick-up of FHR Abdominally
Practical Technique of Doing Antenatal CTG
Some Operational Problems and their Solutions
Erratic Digital Display
Intermittent Dotty Tracing
Questionable Heart Rate
Doubling and Halving Defect
Mechanism of ‘Doubling’
Mechanism of Halving
Special Advantages of the External Monitoring
Antenatal Monitoring of Twins by CTG
Drawbacks of Fetal Monitoring Done Abdominally (Externally)
TECHNIQUE OF ANTENATAL UA MONITORING
Practical Procedure of Doing External Tocography
Fixing the Transducer
Baseline Setting
Reading
Information that can be Obtained by External Tocography
Drawbacks of External Tocography
Some Examples of Antenatal CTG Tracing and Interpretation
Reactive Non-stress Test (NST)
Flat CTG
Late Deceleration with Braxton Hicks Contraction/Labour Contraction
Sinusoidal Pattern
Clinical Correlation of Sinusoidal Pattern
Subtypes of Sinusoidal Pattern
27:
Technique and Scope of Intranatal (Internal) Cardiotocography
CONCLUSION
28:
Management of Non-reassuring Cardio-tocographic (CTG) Tracing
CONCLUSION
29:
Fetal Vibroacoustic Stimulation Test (VAST)
PLACE OF VAST FOR INTRAPARTUM FETAL MONITORING
VAST as an ‘Admission Test’
VAST as an Alternative to FBS
Uses and Advantages of VAST as a Method for Fetal Surveillance.
Safety of VAST
30:
The Technique and Scope of Computerised Fetal Heart Rate Analysis
31:
Fetal ECG Analysis and Detection of Intrapartum Hypoxia
32:
Technique and Place of Fetal Pulse Oximetry during Labour
INTRODUCTION
Technique (Fig. 32.1)
Clinical Use
CONCLUSION
33:
Technique of Fetal Blood Sampling and Scope of Use of Lactate Card for Confirming the Diagnosis of Fetal Distress
INTRODUCTION
Fetal Energy Production—Why Lactate Assay ?
Fetal Scalp Blood Sampling—Technique
Equipment Needed
The Actual Technique (Fig. 33.3)
Contraindications for FBS
Fineries of Blood Lactate Testing
Normal Lactate Values in Fetal Scalp Blood
Fetal Scalp Blood Lactate Analysis
Clinical Application
Lactaemic but not Acidaemic—Explanation
Future Perspective
34:
Technique and Scope of Internal Tocography
UTERINE ACTIVITY—NORMAL AND ABNORMAL
Frequency
Normal
Abnormality
Management
Duration
Normal
Abnormality
Amplitude
Normal
Abnormality
Management
Basal Tone
Shape of the Contraction Curve
Units of Measurement of Uterine Power
Montevideo Unit
Alexandria Unit
Relation of Uterine Contraction with the Position of the Patient
Supine Position
Lateral Position
Erect Position
Difference in Character of Contraction between Spontaneous and Induced or Augmented Labour
Drawbacks of Internal Tocometry
Place of Internal Tocometry
Practical Approach to Tocometry in Labour (Debdas, 1998)
SECTION TEN: OPERATIONS FOR DELIVERY OF RETAINED PLACENTA
35:
Management of Retained Placenta
CONCLUSION
36:
Management of Morbidly Adherent Placenta (MAP)
UTERUS CONSERVING OPERATIONS
UTERUS SACRIFICING PROCEDURES
Recent Advances
CONCLUSION
SECTION ELEVEN: FETAL REDUCTION BY DESTRUCTIVE OPERATION
37:
A New Safe and Instant Technique of Craniotomy
INTRODUCTION
Reasons for Not Practicing Craniotomy
More Reasons for Opting for CS
Difficulties and Dangers of Currently Practiced Standard Method of Craniotomy
THE NEW PROPOSED SAFE AND INSTANT TECHNIQUE OF CRANIOTOMY
Instruments Required
Features of Debdas’ Drill Perforator (Fig. 37.3)
Description of the ‘Placer Tube’
Skull Tractor
Practical Procedure of the New Instant Craniotomy
Advantages of the Proposed New Method
Contraindication of Craniotomy by the Proposed Drill and Suction Method
An Alternative Method for Perforation of Head
CONCLUSION
38:
Scope and Technique of Evisceration
CONCLUSION
SECTION TWELVE: PERMANENT AUGMENTATION OF PELVIC CAPACITY
39:
Scope and Technique of Symphysiotomy
CONCLUSION
SECTION THIRTEEN: TECHNIQUE OF REPAIR OF LOWER GENITAL TRACT INJURY
40:
Technique of Repair of Cervical Lacerations
41:
Repair of Fresh Third/Fourth Degree Perineal Tear (Complete Perineal Tear)
DEFINITION
Incidence and Risk Factors
Relation of Episiotomy to CPT
Anatomy of Perineal Muscles and Anal Sphincter
Steps of Repair of Complete Perineal Tear
Primary prerequisites
CONCLUSION
42:
Management of Vulvo-Vaginal Haematoma
INDEX
TOC
Index
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