JF Institute of Health Sciences/LACHS
Affiliated to TU/IOM
Hattiban, Lalitpur
Lesson Plan on “Obstructed labor”
Submitted To: Submitted by:
Respected Madam Sabina Dahal
Mrs. Sita Kumari Rai Koirala Roll no: 20
Co-ordinator Bsc. Nursing 4th year,7th Batch
Lesson Plan:
Subject: Midwifery Nursing II
Topic: Operative delivery
Date: 2077-8-
Time:
Venues: Janamaitri Foundation Institute of Health Science
Duration: 1 hour
No. of participants: 28
Level of participants: Bsc. Nursing 3rd year
Language: English+ Nepali
Name of the student: Sabina Dahal
Name of supervisor: Respected Madam Sita Kumari Rai Koirala
General Objective:
At the end of the teaching session, participants will be able to explain about
operative delivery.
S. Specific objectives Contents Time Teaching Teaching Evaluation
N learning learning
method media
At the beginning of -Self introduction Have you ever
session -Attendance 2 min Brainstorming Power point heard about
-Topic introduction operative delivery?
-Objective
-Pre-test
At the end of the
session, participants
will be able to: -What do you
mean by operative
1. define operative Definition of delivery?
delivery. operative delivery.
Power point
2. state the types of Stating the types of -Can you say the
operative delivery. operative delivery. types of operative
Power point delivery?
3. Define caesarean Definition of
section caesarean section What do you mean
Power point by caesarean
illustrate the Illustrating the section?
4. indications of indications of
caesarean section. caesarean section. -What are the
Power point indications of
caesarean section?
5. state types of Stating the types of
caesarean section. caesarean section. Power point What are the types
of caesarean
section?
6. Enlist the Enlisting the Power point
contraindications of contraindications of What are the
caesarean section caesarean section contraindications
7. of caesarean
Power point section?
explain the pre- Explanation of the
8. operative and post- pre-operative and How do you
operative post-operative Power point manage caesarean
management of management of section pre-
9. caesarean section caesarean section. operatively and
post-operatively?
state the Stating the What are the
complications of complications of complications of
caesarean section caesarean section. caesarean section?
define destructive Definition of
operation destructive
operation
Enlist types of Enlisting types of
destructive operation destructive
operation
Introduce Introduction of
craniotomy craniotomy
State indications of Stating the
craniotomy indications of
craniotomy
Describe pre-
requisites for Description of the
craniotomy pre-requisites for
craniotomy
Enlist the
contraindications of Enlisting the
craniotomy contraindications of
craniotomy
explain about the
complications of Explanation about
craniotomy. the complications
of craniotomy.
define evisceration Definition of
evisceration
enlist the indications Enlisting the
of evisceration indications of
evisceration
explain cleidotomy Explanation of
cleidotomy
describe decapitation Description of
decapitation
state the indications Stating the
of decapitation indications of
decapitation
explain the nursing Explanation of the
care for the patient nursing care for the
undergoing patient undergoing
destructive destructive
operations. operations
Operative Delivery
Introduction
Operative delivery refers to an obstetrical procedure in which active measures are taken to
accompolish delivery.
Such operations were performed in the past to deliver a obstructed labor in threatened uterine
rupture , when the baby was dead or dying or grossly malformed when survival was doubtful.
Operative delivery can be performed through
caesarean sections and
destructive operations.
Caesarean Section
Caesarean section is an operative procedure whereby the fetus after end of 28th weeks are
delivered through an incision on the abdominal and uterine walls .
Indications
1. Absolute indications
Placenta Previa
Cephalopelvic disproportion
Carcinoma of cervix
Vaginal Obstruction ( Atresia, stenosis)
2. Relative indications
Previous Caesarean delivery
Fetal distress
Dystocia
Antepartum Hemorrhage
Malpresentation
Recurrent fetal wastage
Hypertensive disorder
Medical Gynecological Disorders: Diabetes, pelvic tumors
3. Fetal indication
Fetal distress
Umbilical cord prolapse
Multiple pregnancy
Types
On the basis of timing;
i. Elective Caesarean Section : When the operation is at a prearranged time during
pregnancy to ensure the best quality of obstetrics, anesthesia, neonatal resuscitation and
nursing services.
ii. Emergency Caesarean Section: When the operation is performed due to unforeseen or
acute obstetric emergencies .
On the basis of incision site;
i. Lower segment Caesarean section (LSCS)
ii. Classical or upper segment Caesarean section
i. Lower segment Caesarean section: In this operation the extraction of the baby is done
through an incision made in the lower segment through a transperitoneal approach.
ii. Classical or upper segment Caesarean section: In this operation baby is extracted
through an incision made in the upper segment of the uterus.
Contraindications
In the absence of maternal interest
Appropriate manpower, skill and facility is not available
Pyogenic infection of the abdominal wall
Baby is too premature to survive ex-utero
Dead fetus
Preoperative Management
Physical preparation : The abdomen , back , private parts and upper part of thigh are
shaved.
Prepare the mother psychologically by providing assurance and explaining the
indication , procedure and need of caesarean section .
Antacid therapy: sodium citrate 30ml is given to neutralize the existing gastric acid.
Ranitidine (H2 blocker) 150 mg iks given orally night before and it is repeated 50 mg IM
or IV one hour before the surgery.
Metoclopramide 10mg is given through IV to increase tone of the lower esophageal
sphincter as well as to reduce gastric contents.
Bladder should be emptied by foleys catheter,
Fetal Heart Sound should be checked.
Blood grouping and cross match for emergency requirements.
Preliminary preparation of the skin of abdomen , back and private area with antiseptic
solution.
Postoperative Management
For first 24 hours
Observation for first 6-8 [Link] check up of pulse ,BP amount of vaginal
bleeding and behavior of the uterus is done and recorded.
Fluid: Sodium Chloride (0.9%) or Ringer’s lactate drip is continued until at least 2-
2,5litres of the solution are infused.
Blood transfusion is done in anemic condition and more than blood loss of 0.5 to 1 litre.
Oxytocics: Injection Oxytocin 5 units IM or IV or methargin 0.2 mg .
Prophylactic antibiotics( cephaosporins, metronidazole) is given ,
Analgesics: Pethidine Hydrochloride 75-100 mg is administered .
Ambulation: She is encouraged to breathe deeply and move her legs.
Baby is put into breasts for feeding after 3-4 hours when mother is stable .
Day 1 : Oral feeding in the form of plain water or black tea . Active bowel sounds are observed
at the end of the day.
Day 2: Light solid diet of the patients choice, bowel care, 3/4 teaspoons of lactulose is given at
bed time if bowel don’t move spontaneously.
Day 5 or 6: Abdominal skin stitches are to be removed .
Complications
Intra-operative complications
Extension of uterine incision
Uterine laceration
Bladder and ureteral injury
GI tract injury
Hemorrhage
Post-operative Complications
Immediate
Postpartum hemorrhage
Shock
Anesthetic hazards: hypotension , spinal headache
Infections
Intestinal obstructions
Deep vein thrombosis
Wound complications
Remote
Backache
Incisional hernia
Intestinal obstructions
Destructive operations
Destructive operations are designed to diminish the bulk of the fetus so as to facilitate easy
delivery through the birth canal .
The different types are:
Craniotomy
Evisceration/Embryotomy
Decapitation
Cleidotomy
Craniotomy
It is an operation to make a perforation on the fetal head , to evacute the contents followed by
extraction of the fetus.
Indications
Cephalic presentation producing obstructed labor with dead fetus
Hydrocephalus
Interlocking head of twins
Pre requisites condition for craniotomy
Cervix must be fully dilated.
Baby must be dead ( hydrocephalus being excluded)
Consent should be taken.
Uterus must be intact and not ruptured.
Contraindications
Rupture of the uterus.
Pelvic tumor obstructing labor
Placenta previa : major degrees
Usual sites preferred for perforation of Cranium
- Anterior fontannel or parietal bone is perforated in vertex presentation
- If it is face,orbit is perforated
- If it is brow , frontal bone is perforated.
Complications
Rupture of the uterus
Injury to the cervix ,bladder, vagina, rectum , sacral promontory and pelvic floor
Traumatic post partum hemorrhage
Shock
Sepsis
Evisceration
It consists of removal of thoracic and abdominal contents through an opening on the thoracic or
abdominal cavity at the most accessible site.
If difficulty arises the spine have to be divided with embryotomy scissors.
Indications
Neglected shoulder presentation with dead fetus.
Fetal malformations such as fetal ascites or hugely distended bladder or monsters.
Thoracic or abdominal tumors
Cleidotomy
The operation consists of reduction in the bulk of the shoulder girdle by division of one or both
the clavicles .
It is done in dead fetus with shoulder dystocia .
The clavicles are divided by the embryotomy scissors under the guidance of left two fingers
places inside the vagina.
Decapitation
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 vagina.
Indications
Neglected shoulder presentation with dead fetus where neck is easily accessible
Interlocking head of twins
Reduce the width of the shoulder in large fetus that cannot be delivered vaginally.
Monster fetus with double head.
Nursing care
Exploration of the utero-vaginal canal must be done to exclude rupture of the uterus or
laceration on the vagina or any genital injury.
An indwelling catheter is put inside specially following craniotomy for a period of 3-5
days or until bladder tone is regained.
Dextrose saline drip is to be continued till dehydration is corrected .
Blood transfusion may be done if required.
Antibiotics should be given 6 hourly either orally or parenterally.
Provide emotional support to woman and family/
References
Dutta D.C. Textbook of obstetrics. Jaypee brothers medical publishers (p) Ltd Pg. no .( 586-597
[Link] and D. Roberta. Maternal and Newborn Nursing .Health science publishers [Link] ( 276-
279)
Tuitui.R and Suwal.S.N. Manual of midwifery II Vidhyarthi Pustak Bhandar Pg no.(343-354)
