The ten years since the first edition of Operative Obstetrics have witnessed considerable changes in obstetric practice. There has been a continued increase in the rate of cesarean delivery, and the use of minimally-invasive surgery has rapidly gained popularity. Social changes affecting practice have also been significant, prompting a re-evaluation of the appropriateness of certain types of operations during pregnancy. This fully-updated edition includes chapters on cesarean delivery, birth injury, ectopic pregnancy, and common surgical complications. It features a new discussion of surgical procedures performed by non-physicians and an updated treatment of fetal surgery. The text also considers complicated and controversial subjects such as cervical insufficiency, pregnancy termination, instrumental delivery, and shoulder dystocia. Each of the four sections includes an in-depth analysis of the important ethical and legal issues underlying practice for the area in question. An expanded appendix reviews legal concepts pertinent to practitioners in the field of obstetrics.
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Over many years, various manipulations and specialized instruments were developed to expedite delivery of viable infants or to remove the fetus and the other products of conception from the uterus in case of fetal demise or incomplete delivery. A brief historical review of the origins of operative delivery techniques increases the appreciation of modern practitioners for the complex roots of the science and art that have led to modern practice. From the inception of the operation, controversy concerning the propriety of cesarean delivery has characterized the medical literature. It was recognized very early that postmortem operations on mothers dying in labor or late in pregnancy would rarely result in a normal and surviving child. The development of atraumatic delivery instruments is a complex and fascinating part of the history of obstetrics. An important development in the use of vacuum extraction has been major improvements in practitioner education.
The aim for genetic services is to provide a maximum of genetic diagnostic capabilities for any given pregnancy, with a minimum of fetal risk. This chapter focuses on the procedures and techniques currently available to clinicians to evaluate genetic disorders. Amniocentesis was first introduced in the 1880s as a treatment for hydramnios. Genetic amniocentesis usually is performed after 15 completed weeks of gestation. After ultrasonic study to confirm dates, fetal viability, fetal number, fetal anatomic survey and placentation, the patient is requested to empty her bladder. Prior to the attempt at transcervical biopsy (TC-CVS), an ultrasonic scan is performed to evaluate fetal viability, fetal number, placentation, and dating by crown-rump length (CRL) and gestational sac size. Complications associated with CVS include vaginal bleeding, amniotic fluid leakage, infection, fetalmaternal transfusion, teratogenic effects, and fetal loss. The future for prenatal genetics is clearly one of high technology and continue.
Alisa B. Modena, Perinatologist, Division of Maternal-Fetal Medicine Virtua Health Voorhees, New Jersey,
Aileen M. Gariepy, Clinical Instructor, Department of Obstetrics and Gynecology Thomas Jefferson University Philadelphia, Pennsylvania,
Stuart Weiner, Associate Professor, Department of Obstetrics and Gynecology Thomas Jefferson University Philadelphia, Pennsylvania
This chapter examines the use of ultrasound scanning in the intrapartum assessment of patients in labor and its invaluable utility to guide invasive procedures. It reviews several of these recent advances: cervical length evaluation as a predictor of preterm delivery and for the selection of appropriate induction of labor candidates; the evaluation of uterine bleeding; the monitoring of intrapartum fetal weight, and fetal well-being. Evaluation of fetal amniotic fluid quantity is an essential fetal assessment tool for the obstetrician. Fetal blood sampling is a practice used to gain access to the fetal blood for various indications; classically, obtaining a fetal blood sample can assist in the diagnosis of genetic disorders using a technique of rapid karyotyping, as well as to diagnose fetal infection and determine fetal blood type. Ultrasonography has proved to be helpful in the diagnosis of failed placental separation, allowing for expeditious surgical management prior to severe hemorrhage.
Samantha F. Butts, Assistant Professor, Department of Obstetrics and Gynecology Division of Infant and Reproductive Endocrinology University of Pennsylvania Medical School Philadelphia, Pennsylvania,
David B. Seifer, Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences Mount Sinai School of Medicine New York
This chapter provides a comprehensive discussion of the contemporary approach to ectopic pregnancy. It reviews the diagnosis and treatment options and the epidemiology and pathophysiology of ectopic pregnancy. Abnormalities of tubal function and ovum quality or an altered hormonal milieu may each contribute to the development of an ectopic pregnancy. Some of the most significant risk factors for the development of ectopic pregnancy include history of pelvic inflammatory disease (PID), prior fallopian tube surgery, increasing age, and a history of infertility. Prior tubal surgery results in an increased risk of ectopic implantation. Although surgery remains the mainstay of treatment for ectopic pregnancy, medical management is a widely used alternative. Methotrexate therapy for ectopic pregnancy is a widely used medical alternative to surgery. The use of proteomics to aid in the detection of early ectopic pregnancy is an active area of research.
Munir A. Nazir, Director Maternal-Fetal Medicine Assessment Laboratory, Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology Newark Beth Israel Medical Center Newark, New Jersey
This chapter reviews the problem of cervical change and cervical insufficiency as related to preterm delivery. Recommendations for surveillance and best practice are made, and the principal surgical procedures for cervical reinforcement (cerclage) are discussed and critiqued. Endovaginal sonography is the best method for the evaluation of women at risk for preterm delivery or cervical insufficiency during pregnancy. Late and uncommon complications of cerclage include fistula formation and, rarely, cervical stenosis. Cicatrix formation can result in cervical dystocia in labor or eventuate in deep cervical lacerations at delivery, which can extend into the broad ligament. Cervical cerclages are best classified based on their timing and the anatomic approach taken for the repair. In terms of timing, these procedures are considered as elective, urgent, or emergent. The current approach to the placement of cerclage is most often transvaginal, and most procedures are performed during pregnancy.
F. P. Bailey, Assistant Professor, Department of Obstetrics and Gynecology Tufts University School of Medicine Boston,
Heather Z. Sankey, Assistant Professor, Department of Obstetrics and Gynecology Tufts University School of Medicine Boston
This chapter reviews the history and epidemiology of modern pregnancy termination. In this review, the surgical and medical techniques appropriate for various gestational ages are presented, potential complications are considered, and the psychological issues surrounding abortion are discussed. Most women requesting termination of pregnancy are self-referred. Physicians who care for pregnant patients should assess the patient's attitudes toward the gestation at the time of the first prenatal visit. The initial assessment of gestational age is based on the last reported menstrual period and the physical examination. The method chosen for pregnancy termination depends on the period of gestation, the experience and preference of the operator, and the extent to which safe options are available that fit the patient's desires. The most common operative complication of pregnancy termination is uterine perforation. Failure to interrupt an intrauterine pregnancy occurs in less than 0.5 percent of suction-curettage patients.
Karen W. Green, Associate Professor Obstetrics and Gynecology, University of Massachusetts Medical Center Worcester, Massachusetts,
Matthew A. Esposito, Assistant Professor, Department of Obstetrics and Gynecology University of Massachusetts Medical Center Worcester, Massachusetts
Obstetric complications secondary to placental dysfunction can occur at any point in gestation. Improvements in perinatal diagnostic techniques such as focused ultrasound studies of fetal growth, placental blood flow, and fetal/placental anatomy now permit the identification of certain complications related to poor implantation or abnormal early development that can be linked to placental function. Confusion caused by the potential overlap in history and physical findings with the various placental abnormalities has led physicians in recent years to rely heavily on ultrasound scanning to help in identifying the cause of ante- and intrapartum hemorrhage. With the known association of placenta previa and prior cesarean delivery with placenta accreta, and an ever-increasing rate of cesarean delivery, there has been a recent focus on identifying ultrasound findings predictive of abnormal placenta adherence. Placental abnormalities can lead to maternal adverse outcomes such as hemorrhage requiring transfusion, more extensive surgery, emotional consequences, and even death.
Scientific advancements have had a profound impact on preconception risk assessment, prenatal diagnostic capabilities, and early intervention. Increased use of sophisticated ultrasound scans and laboratory technology, including the application of recent developments in gene mapping and prenatal blood, tissue, amniotic fluid testing, has resulted in dramatic advancements in antepartum testing. Legal events indicate that the failure to timely utilize technology appropriately to establish the diagnosis of a fetal problem earlier when treatment or termination may have avoided the outcome, is a sufficient and legal recognizable injury for the parents. A physician considering a diagnosis of ectopic pregnancy must be careful to elicit both positive and negative historic data that might support an increased risk of ectopic pregnancy. Conducting advanced scanning procedures is potentially hazardous from a legal point of view when the personnel involved have limited expertise or limited exposure to high-risk conditions.
This chapter begins with a discussion on the pharmacology of both new and accepted drugs in obstetric anesthesia management. Drugs administered to the parturient to provide analgesia or anesthesia for childbirth can affect not only maternal physiology but also fetal condition and neonatal well-being. Therapeutic strategies must be formulated with consideration for these effects, as well as the compounding influences of obstetric agents and illicitly consumed substances. Operative anesthesia must be appropriately adapted to the special requirements of surgery during pregnancy but is rarely a legitimate alternative for analgesic management. An obstetric anesthesia service requires a director with interest and skill in management; clinical, educational, or research success is not a substitute. Challenges include provision for appropriate staffing and equipment and fostering effective communication among professional staff from multiple disciplines whose timely, coordinated input is essential to safe, high-quality outcomes.
Paul C. Youngstrom, Staff Anesthesiologist, The Cleveland Clinic Foundation Cleveland, Ohio,
Margaret Sedensky, Professor, Department of Anesthesiology and Department of Genetics University Hospitals of Cleveland Case Western Reserve University School of Medicine Cleveland, Ohio,
Daniel F. Grum, Associate Professor, Department of Anesthesiology The University of Tennessee School of Medicine Chief Department of Anesthesiology Director Resident Education Department of Anesthesiology The University of Tennessee Health Science Center Memphis, Tennessee
Obstetric labor management begins when the woman is first admitted. Many obstetricians or midwives are comfortable using ultrasound in the labor and delivery suite to verify the clinical examination. In the active phase of labor, the rate of progress in terms of cervical dilatation is a function of parity. This chapter discusses active management of labor. Progress in labor is commonly evaluated by plotting cervical dilatation and the descent of the presenting part against time. If marked cranial deflection is accompanied by abnormal labor progression, disproportion is likely, and cesarean delivery is normally the best management choice. Lesser degrees of deflection are common in many ultimately successful labors, especially in posterior and transverse presentations. Appropriate management protocols for oxytocin and epidural anesthetic use, makes it possible to provide adequate analgesia for a large percentage of labors and permit nearly normal labor progression with a low level of intervention.
The process of placental delivery and the subsequent involution of the uterus during the puerperium are often described as the third and fourth stages of labor. This chapter presents a brief historical review concerning third- and fourth-stage events, followed by a discussion of the physiology of placental separation and uterine involution. The diagnosis and treatment of retained placenta and membranes (secundines), uterine inversion, postpartum hemorrhage and atony, and hematomas are considered. Important cultural and historical events in world history have been directly influenced by complications of involving the third stage of labor. Active management of the third stage of labor consists of the immediate administration of oxytocin after delivery of the infant, early cord clamping, and gentle traction on the cord, combined with gentle uterine massage to prompt placental separation. Periurethral lacerations, which often bleed freely, appear in the thin tissues on either side of the clitoris or urethra.
This chapter reviews the fundamentals of the techniques for breech delivery and the evaluative process required for appropriate management. Also reviewed are external cephalic version (ECV) and internal podalic version (IPV) and the special needs of the premature breech fetus at delivery. These concepts and approaches are applicable in all breech presentations, independent of the route of delivery. Techniques for delivering the breech fetus are assisted breech delivery, delivering the aftercoming head, and breech extraction. Piper forceps (or alternatively, Simpson or Keilland forceps) can be used for delivering the aftercoming head at the clinician's discretion. The risk that the breech fetus might become acidotic during labor and delivery is marginally greater than for its cephalic counterpart. Once a breech presentation has been diagnosed, the patient and her family can be counseled and instructed about the potential problems that might be encountered.
V. Ravishankar, Clinical Assistant Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences State University of New York at Stony Brook Stony Brook University School of Medicine Stony Brook, New York,
J. Gerald Quirk, Professor and Chair, Department of Obstetrics, Gynecology, and Reproductive Medicine State University of New York at Stony Brook
This chapter explores the maternal and fetal complications, advances in prenatal diagnosis, and management of complications unique to multiple gestations. Tidal volume and oxygen consumption in multiple gestations are increased, as is the normal alkalosis seen in singleton pregnancy. Hypertensive disorders increase by at least twofold in twin gestations. Hemorrhagic complications occur more frequently with twins. Growth of singletons and twins is comparable until 27 weeks gestation. The uterus accommodates the larger volume imposed by twins by overdistension, and beyond a certain limit, premature labor can result. Preterm deliveries (less than 37 weeks' gestation) occurred in 10.6% of singleton pregnancies against a phenomenal rate of 61.2% of live births in multiple gestations. Diagnosis of multiple gestations, establishing chorionicity, identifying anomalies, foreseeing possible maternal and fetal complications, prevention and treatment of preterm labor, and management of growth restriction are some of the areas of medicolegal concerns in multiple gestations.
This chapter reviews and examines the best evidence available about the nature and scope of shoulder dystocia, including reasonable management options and the challenging ethical and legal aspects surrounding this common obstetric emergency. The range of injuries to the newborn following a shoulder dystocia typically include trauma to the brachial plexus or phrenic nerve, fractures of the clavicle or humerus, neonatal asphyxia, and even death. From a medicolegal perspective, any reasonable method to resolve the impacted anterior shoulder conforms to the level of care expected of the average competent physician. If the physician can articulate a reasonable basis for the clinical judgment, and that information is documented in the medical record, then the physician has the best defense against a medicolegal entanglement. Acute management of dystocia remains a major problem. Some practitioners, on encountering a shoulder dystocia, fail to approach the problem systematically and sometimes panic.
Pregnancy, labor, and delivery are associated with major physiologic changes that can decrease maternal reserves. Consequently, various techniques of analgesia and anesthesia can have profound effects on maternal physiology. Furthermore, obstetric pain management and operative obstetric anesthesia are recognized as secondary causes of neonatal respiratory depression. Improper management of labor is the common claim in obstetrical malpractice cases. Malpresentation and/or dystocia are some of the most fertile areas for medical negligence lawsuits. The clinician must be fully aware of the general predisposing factors to complications in the third stage of labor. Common postpartum complications include urinary tract problems, such as infections, urine retention, or incontinence. Obstetricians have long recognized the excessive perinatal morbidity and mortality associated with the breech-presenting fetus. Multiple gestations often pose intrapartum management problems. Emphasizing the shoulder dystocia was a true obstetric emergency, and greater emphasis was placed on team approach, including neonatal resuscitation.
This chapter considers selected aspects of surgical technique, complications, and the management of some surgical problems that develop in association with pregnancy. The signs and symptoms of various surgical conditions are modified by the anatomic and physiologic changes that accompany pregnancy, paradoxically often resulting in their exacerbation, an apparent reduction in intensity, or a change in the location of the expected physical signs. Impaired healing and wound infections are among the most common complications of surgery, in pregnant as in nonpregnant patients. During abdominal surgery, iatrogenic injuries commonly involve the gastrointestinal and urinary tracts. Surgical complications involve gallbladder disease and appendicitis. The chapter discusses a series of neoplastic disorders encountered at varying degrees of frequency during pregnancy, and outlines their clinical management. In areas of developing surgical techniques, the most significant area of legal exposure falls in the lag between actual practice and the establishment of accepted safeguards.
Reinaldo Figueroa, Clinical Associate Professor, Department of Obstetrics, Gynecology and Reproductive Medicine State University of New York at Stony Brook,
J. Gerald Quirk, Professor and Chair, Department of Obstetrics, Gynecology, and Reproductive Medicine State University of New York at Stony Brook
This chapter discusses instrument design, technique of application, and the risks and benefits of assisted delivery. The principal controversies concerning instrumental delivery by both forceps and the vacuum extractor are reviewed, and recommendations are made about the use of these instruments. The focus of this presentation remains the desirability and safety of instrumental delivery and a critical analysis of what constitute the best modern practice. Delivery instruments are conveniently classified into eight types: five of forceps, two of vacuum extractors, and one for miscellaneous instruments. The most important contraindications to vaginal delivery operations are operator inexperience and the inability to achieve a proper application. Educating clinicians in the appropriate use of force in instrumental deliveries is a difficult task. Instrument application involves forceps operation, and vacuum extraction. Maternal perineal lacerations are common complications of all operative vaginal deliveries; most are associated with episiotomy.
This chapter discusses the current practice of cesarean delivery, the indications for the operation, the performance of the surgery, and its potential complications. After forceps and vacuum extraction procedures, symphysiotomy is the principal alternative to the cesarean operation. Epidurals do prolong the second stage of labor and increase the use of oxytocin to maintain progress. As the morbidity associated with cesarean delivery remains low, and the risks associated with elective operations are better appreciated, indications for cesarean operations have progressively increased. The chapter reviews the operative technique for cesarean delivery, cesarean hysterectomy, and the surgical management of acute obstetric hemorrhage. Possible immediate post-operative complications of surgical sterilization include infection, bleeding, intraoperative bowel or bladder injury, thromboembolism, and rarely, death. Sterilization failures are often the result of either mistaken identification of some other intraabdominal structure for the fallopian tube, or of incomplete occlusion of the tubal lumina.
Richard J. Scotti, Clinical Professor, University of Southern California Keck School of Medicine Los Angeles,
Janice N. Young, Medical Director, Woman to Woman Gynecology of Naples Naples, Florida,
Mat H. Ho, Associate Professor, Department of Obstetrics and Gynecology School of Medicine, Texas
This chapter reviews conditions occurring in the urinary tract during pregnancy that place the mother, and often the fetus, at risk. Conditions discussed in the chapter that might require surgery during pregnancy include urolithiasis, urinary tract obstruction, accidental and iatrogenic lower urinary tract injury, urethral diverticula, genitourinary fistulas, complications of previous urologic surgery, and urinary tract carcinoma. The normal homeostatic changes involving the urinary tract are frequently responsible for the gravid woman's urinary complaints. The treatment of choice for distal ureteral calculi in pregnant patients who require intervention is cystoscopic examination, followed by either passage of a ureteral stent to relieve obstruction, or ureteroscopy with calculus manipulation. During labor and delivery, the bladder is vulnerable to trauma and injury. Mucosal congestion, submucosal hemorrhage, and capillary oozing around the trigone have been observed cystoscopically after delivery.
This chapter provides an overview of the principles of modern operative fetal intervention. In practice, maternal safety has remained the highest priority in fetal surgery. Some have suggested that pregnant women are a particularly vulnerable group of patients who might have a low threshold to consent to highly invasive fetal therapies, even if the benefits to their unborn children could be small. Preoperative preparation for fetoscopic surgery is done in a fashion similar to that used in open fetal surgery. Fetoscopy offers several distinct advantages when compared with open fetal surgery. The chapter talks about twin-twin transfusion syndrome, airway obstruction, thoracic anomalies, and sacrococcygeal teratoma, congenital diaphragmatic hernia, myelomeningocele, and aortic stenosis. Although most prenatally diagnosed anomalies are best managed after birth, several disorders have predictable, irreversible, and devastating consequences under expectant prenatal management.
Most surgical conditions that occur in the nonpregnant patient also occur in pregnancy. For a surgical problem that arises during pregnancy, the urgency of surgical treatment must be balanced against the risk that such treatment poses to the mother and the fetus. Current obstetric literature and legal case reports reveal that obstetric forceps and the vacuum extractor are coming back into the mainstream of obstetric practice. Cesarean delivery has been a major tool to assist the obstetrician in improving pregnancy outcome. Urologic injuries occurring during the course of pregnancy or more commonly during surgical or instrumental delivery, can result in serious and potentially life-threatening complications to both the mother and the unborn infant. Most urologic injuries from vaginal or abdominal surgical procedures on pregnant women involve some form of direct mechanical injury or compromise to the bladder or ureters.