SAIMA HABEEB

Ph.D (N) SCHOLAR

PROCEDURE - 1 ANTENATAL EXMINATION

INTRODUCTION
Antenatal examination is the assessment of the condition of a pregnant women and her growing
fetus.
AIM
The aim is to monitor the progress of pregnancy in order to support maternal health and normal
fetal development.

OBJECTIVE
The objective is to ensure a normal pregnancy delivery of a healthy baby from a healthy mother.

PURPOSE
1. To promote and maintain good physical health.
2. To detect high risk conditions of mother and fetus.
3. To supervise fetal growth and well being and to prevent compilations.
4. To teach mother regarding family planning, child care, nutrition, personal and
environmental hygiene.
5. To assess levels of health by taking a detailed history and to offer appropriate screening
test.

POINTS TO REMEMBER
a) Approach the women pleasantly to establish rapport.
b) Maintain privacy.
c) Make her comfortable while taking history to gain her cooperation.
d) Ask her to empty her bladder before conduction of abdominal palpation.
e) Notify if fetal heart rate is less than 120 and more than 160 beats/mt.
f) Fetal heart sound should not be confused with uterine soufflé.
g) Indicate her static weight as it is a sign of growth retardation of the fetus and poor health
of mother.
h) Report if there is sudden increase in weight as it indicates toxaemia in pregnancy.

ARTICLES

 Examination table/bed.
 B.P. apparatus, thermometer, Tape measure
  Fetoscope/stethoscope, weighing machine
 Urine testing articles for albumin and sugar
 Hand washing articles, Stool or chair for the women
 History sheet to write the history.

STEPS OF PROCEDURE

 Have all the articles ready in examination room.

 Greet the women and take her to the examination room.
 Make her comfortable.
 Take history : Identification data
 MEDICAL: Measles, malaria, Jaundice, hypertension, diabetes, tuberculosis or any other
major illness.
SURGICAL: Any operation, blood transfusion

MENSTRUAL: Cycle, duration, amount of blood

OBSTETRICAL: Previous pregnancies, labour, puerperium and condition of the baby.

FAMILY: Multiple pregnancies, mental Illness, diabetes, hypertension and any other
genetic condition.

 The above factors may indicate any manor illness affecting the fetus and general health of
the women.
 Ask the date of her last menstrual period to calculate the expected date of delivery.
 Estimate the expected date of delivery by adding nine calendar months and 7days to her
that menstrual date, as full term pregnancy is of 40 wks
 Take the weight of the women and compare it the previous weight, sudden increase will
indicate abnormality.
 Take weight and observe the gait of the women, of the women, to detect any gross
abnormality of the pelvis.
 Ask her to empty the bladder because pelvic examination finding will not be accurate
with a full bladder.
 Test urine for albumin and sugar.
 Ask the women to get her Hb%, blood group and Rh factor tested.

HEAD TO FOOT EXAMINATION/ASSESSMENT

 Make her comfortable on the examination table or bed.

 Maintain privacy by giving her a sheet to cover herself.
 Check her blood pressure to detect any toxaemia of pregnancy or hypertension for early
treatment.
 Check her temperature, pulse and respiration to detect any abnormality.
 Check her head for any gapping of sutures dandruff, cleanliness.
Check her lips, nose, ears for any discharge and abnormalities.
Check her gums, teeth, and tongue for any abnormality.
Check her skin conditions and any pigmentation.
Check her extremities for varicose veins, edema or any abnormalities.
Check genital area for any discharge and hygiene, anus for haemohoide.
 Examine the breast for size and contour, nipple, tubercle, secondary areola and
colostrums.
ABDOMINAL PALPATIONS

 Expose the abdomen from xiphoid sternum to Symphysis pubis and keep her legs straight
 Encourage her to relax her abdomen by taking deep breathing is necessary
 Worm your hands if cold. Cold hands will be uncomfortable and will not be able to relax
her abdomen.

METHODS

1. INSPECTION
A visual examination of the external surface of the abdomen, the size of the uterus is
assessed approximately by observation. A full bladder, distended color and obesity may give a
false impression of fetal size.

a)The shape of the uterus is longer than it is broad when the lie of fetus is longitudinal.
b)If the lie of the fetus is transverse, the uterus is low and broad.
c)The multiparous uterus may lack the ovoid shape of the primigravid uterus
d)If the fetus is in occipito posterior position a saucer like depression may be seen at or
below the umbilicus.
SKIN CHANGES
 Stretch marks from previous pregnancy, silvery and pink appearance in recent one (striae
gravidarum)
 Linea nigra-dark line of pigmentation running longitudinally in the entire of abdomen
below or sometimes above the umbilicus.
 Scar may indicate previous obstetrics or abdominal surgery

2. MEASUREMENTS
Estimate the height of the fundus with tape measurement from symphysis pubis to the actual
height of the uterus to correlate the height c dates this will determine the progress of fetal
growth check for abdominal girth at the highest point on the abdomen for detection of any
abnormality.

3. PALPATIONS:
The process of determining the outline of abdominal organs by lightly palpating the
abdominal wall with the fingers.
 a) FUNDAL PALPATIONS:This determines the pressure of the breech or the head this
information will help to diagnose the lie and presentation of the fetus. The examiner lays
both hands on the sides of the fundus, fingers held close together and covering around the
upper border of the uterus. Gentle yet deliberate pressure is applied using the palmar
surface of the fingers to determine the underlying part.
FINDINGS

 Broad, soft, irregular mass suggestive of buttocks, so lie is longitudinal and presentation
is vertex.
 Smooth, hard and globular mass suggestive of head so lie is longitudinal and presentation
is breech.

b) LATERAL PALPATIONS
This is used to locate the fetal back in order to determine position. It is done by placing
hands on the lateral or either flame sides of the abdominal level of umbilicus. ‘Walking’ the
fingertips of both hands over the abdomen from one side to the other is an excellent method
of locating the back. The fingers should be dipped into the abdominal wall deeply. To make
the back more prominent fundal pressure can be applied with one hand the other used to walk
over the abdomen.

FINDINGS

 Smooth, curved, continuous and resistant feel suggestive of back or spine.

 Comparatively empty small knob like irregular parts with empty spaces suggestive of
limbs.
 It shows the position of fetus either LOA or ROA in cephalic presentation and RSA and
LSA in breech presentation.

c) PELVIC PALPATIONS
 Ask the mother to bend her knees, face the legs.
 The sides of the uterus just below umbilical level are grasped snugly between the palms
of the hands the fingers held close together and pointing downwards and inward.
 This helps to locate the presentation and engagement by feeling the fetal part in the
lower pole of the uterus.
FINDINGS

 A hard mass a distinctive round, smooth surface will be felt suggestive of head as the
presenting part.
 If fingers converge-head is not yet engage,If fingers diverge-head is fixed/engaged.

d) PAWLIK’S MANOEUVRE
It is used to judge the size flexion and mobility of the head (engagement). The examiner
grasps the lower poll of the uterus between her fingers and thumb, which should be spread
wide enough apart to accommodate the fetal head. Ballot the fetal parts from one side to
other, to be sure of presentation. The head will be felt round, globular and hard, whereas
 breech will be soft and irregular. Observe the mother’s face to detect pain, if pain is present,
it denote engagement.

4. AUSCULTATION
Place the fetoscope/bell of pinards stethoscope on the abdomen and listen to the fetal
heart sound with your ear at the end of the fetoscope. Check the mother’s pulse
simultaneously to direct uterine souffle. It should be between 120-160 bets/mt.

AFTER CARE

 Cover the mother’s abdomen and make her comfortable.

 Wash your hands to prevent infection
 Complete record and advice for further visit diet, preparation of baby clothes, type of
clothes to be worn, exercises, rest, immunization, medication of prescribed and
preparation of labour.
 Instruct the women to report immediately in case of headache, epigastric pain, blurred
vision, vaginal bleeding, any leakage and increased or decreased fetal movements.
 Explain the supervisor and confirm your findings and advice.

PROCEDURE – 2 (EPISIOTOMY)

DEFINITION

A surgically planned incision on the perineum and the posterior vaginal wall during the second stage of
labour.
It is surgical procedure that enlarges the vaginal opening during labour by cutting perineum, the skin and
muscle between vulva and anus.

PURPOSES:
 To enlarge the vaginal introitus so as to facilitate easy and safe delivery of fetus.

 To minimize overstretching and rupture of perineal muscles

 To reduce the stress and strain on fetal head.

INDICATIONS:

 The baby is very large

 Breech delivery.

 Face to pubis delivery.

 Shoulder dystocia.
TYPES OF EPISIOTOMY

There are four main types:-

1) MEDIO-LATERAL

2) MEDIAN

3) LATERAL

4) J- SHAPED

STEPS OF MEDIOLATERAL EPISIOTOMY

There are 3 steps:-

STEP-1 (PRELIMINARIES)

 The perineum is thoroughly swabbed with antiseptic lotion and draped properly.

 Then local anesthesia 10 ml of 1% lignocaine is given in the perineum.

 This is also known as “INFILTRATION OF PERINEUM”.

STEP-2(INCISION)

 Two fingers are inserted in the vagina between the presenting part and posterior vaginal wall.

 The incision is made by a curved or straight, blunt pointed, sharp scissors, one blade of which is
placed inside in between the fingers and posterior vaginal wall and other on the skin.

 The incision should be made at the height of the uterine contraction when the tissues are
stretched.

 A single deliberate cut 4-5cm long is made diagonally in a straight line which is 2.5cm away from
anus.

 Birth of the head should follow immediately after episiotomy.

STEP-3(REPAIR)

 TIMING OF REPAIR:- The repair is done soon after the expulsion of placenta.

 The patient is placed in lithotomy position and good light source from behind is needed.

 The perineum including the wound area is cleansed with antiseptic solution.

 The patient is draped properly and repair should be done under strict aseptic techniques.

 The repair is done in three layers:-

i. Vaginal mucosa and submucosal tissues

ii. Perineal muscles , skin and subcutaneous tissue

POST OPERATIVE CARE

  DRESSING:-

 The wound is to be dressed each time following urination and defaecation.

 The dressing is done by swabbing with cotton swabs soaked in antiseptic solution followed by
application of antiseptic powder or ointment.

 COMFORT:-

 To relieve pain in the area, magnesium sulphate compress or application of infra red heat may be
used.

 Ice pack reduces swelling and pain also.

 Analgesics drugs may be given when required.

 AMBULANCE:-

 The patient is allowed to move out of the bed after 24 hrs.

 Prior to that, she is allowed to roll over on to her side or even to sit with thighs opposed.

 REMOVAL OF STITCHES:-

 Catgut or dexon sutures will be absorbed by itself.

 Nylon or silk sutures are to be cut on 6th day.

PROCEDURE -3 (LOWER SEGMENT CESARIAN SECTION)

It is an operative procedure whereby the fetuses after the end of 28th week are delivered through
an incision on the abdominal and uterine walls.

INSTRUMENTS USED IN LSCS:

 1 Sponge Holding Forceps 25cm 4 Green Armytage Forceps

 6 Artery Forceps curved 15cm 6 Artery Forceps St 15cm
 4 Allice Tissue Forceps Medium 15cm 4 Allice Tissue Forceps Large 15cm
 2 Bebcock Tissue Forceps 15cm 2 Toothed Forceps 15 cm
 2 Dissecting Forceps Toothed 15cm 2 Dissecting Forceps Non Toothed 15cm
 1 Needle Holder Mayo Heger 15 cm 4 Kell's Clamp 15cm
 1 Suction Tip 1 Tissue Cutting Scissors 17.5c
 2 B.P.Handle no4 4 Towel Clip Cross Action
 1 Bowl 20" 1 Doyen Retractor 5 cm
 1 Morr's Retractor 5cm 1 Self Retaining Retractor
 1 Dever's Retractor 5 cm 1 Instrument Bag
STEPS OF PROCEDURE

1) Preoperative preparation:

 Abdomen is scrubbed with soap and nonorganic iodine lotion.

 Premedicative sedative must be given.
 Antacid is given to neutralize the existing gastric acid.
 The stomach should be emptied.
 Bladder should be emptied by a foley catheter.
2) Anaesthesia: Usually done in spinal anaesthesia , sometimes under GA like in the cases of
Eclampsia. The patient is tilted 10 to 15 degrees to her left using a wedge or blanket. This is
done to avoid vena caval compression by her uterus (supine hypotensive syndrome)
3) Cleansing and Draping: The skin should be cleansed preferably with Povidone-iodine 7.5%
in order to prevent surgical site infection.

4) Abdominal incision: A transverse skin incision is associated with reduced postoperative pain
and is more esthetically acceptable to patients compared with a vertical incision (classic). The
fannenstiel incision is slightly curved and made 2 to 3 cm above the symphysis pubis. The
incision should allow for at least 15 cm of exposure. The skin and subcutaneous fat is incised
with electrocautery.

5) Uterine incision: The anterior rectus sheath is incised transversely. The rectus muscles are
separated in the midline. The parietal peritoneum is opened. The loose peritoneum over the lower
uterine segment is held and incised transversely, for about 10 cm in a semilunar fashion with its
edges directed upwards. The bladder is dissected downward and is retained behind a Doyen's
retractor placed over the symphysis. Membranes are ruptured by toothed or Kocher’s forceps.

6) Delivery of the infant & removal of placenta and membranes: The head is delivered by
introducing the right hand gently below it and lifting it up helped by fundal pressure done by the
assistant, using one blade of the forceps or, using Wrigley’s forceps. If the head is deep in the
pelvis it can be pushed up vaginally by an assistant. The Doyen’s retractor is removed after the
hand or forceps blade is applied and before head extraction. Suction for the foetus is carried out
before delivery of the head. In breech or transverse lie the foetus is extracted as breech. Once the
umbilical cord is clamped and cut, it is time to deliver the placenta via spontaneous extraction.
Gentle traction is placed on the cord and oxytocin is used to enhance uterine contractions. The
placenta is checked to make sure it is complete and the uterus is explored with one hand to
remove any remaining membranes or placental tissue. The uterus is than massaged to promote
contraction. Oxytocin is given to promote uterine contraction and involution.

7) Suture of uterine wound: Closure of the uterine incision is done in 3 layers. The first is a
continuous locking suture taking most of the myometrium but not passing through the decidua to
guard against endometriosis and weakness of the scar. The second is a continuous or interrupted
one inverting the first layer. The third is a continuous or interrupted layer to close the visceral
peritoneum of the uterus. Similarly, the rectus muscles are not surgically reapproximated. The
fascial tissue is carefully closed to provide good wound strength and the skin is closed with a
subcuticular suture.

8)Concluding part: The mops placed inside are removed and number verified.peritoneal
toileting is done and the blood clots are removed. Abdomen is closed in layers. The vagina is
cleansed of blood clots and sterile vulval pad is placed.

PROCEDURE – 4 (INDUCTION OF LABOR):

Induction of labor is the stimulation of uterine contractions before the onset of spontaneous
labor. The procedure is more likely to be successful when the cervix is ripe, i.e. it has undergone
structural changes to produce softening, dilatation and effacement.

Indications for induction:

Maternal indications:-

 Prolonged or post-term pregnancy

 Previous history of unexplained intrauterine death
 Medical problems, renal, respiratory, or cardiac disease
 Intrauterine death of fetus
 Chronic polyhydramnios
 Congenital malformation of fetus

Fetal indications:-

 Chronic placental insufficiency

 Rh isoimmunisation
 Unstable lie
 Diabetes mellitus
 Post maturity

Methods of induction:

1. Medical
2. Surgical
3. Combined
4. Mechanical

MEDICAL INDUCTION:-

In medical induction maturation of cervix is achieved by use of drugs, mainly the

  Prostaglandin (PGE2, PGE1),
 Oxytocin,
 Mifepristone.

Indications for medical induction are:

I. Intrauterine fetal death

II. Premature rupture of membranes
III. In combination with surgical induction (ARM)
IV. In case of failure of surgical induction

Oxytocin induction: Oxytocin is effective for induction of labor when the cervix is ripe. It is
less effective as a cervical ripening agent. It acts by:

 Receptor mediation
 Voltage mediated calcium channels, and
 Prostaglandin production

STEPS OF INDUCTION WITH OXYTOCIN:

 The syntocin is dissolved in isotonic solution e.g. normal saline.

 The infusion is controlled through a pump to enable accurate assessment of volume and
rate.
 Manual counting of the drops per minute is followed carefully.
 The rate of infuse on is maintained as per the progress of the labor.
 Uterine contractions are maintained at an interval of 3 minutes, lasting for 45-50
seconds.
 Infusion rat is expressed in terms of milliunits per minute.

The aim of oxytocin administration is to initiate effective contractions, and to maintain the
normal pattern of uterine activity until delivery and at least 30-60 minutes beyond that.

Prostaglandins induction:

Prostaglandin is most commonly administered by the intravaginal route. Prostaglandin E2

preparations are available in gel and pessary form and are inserted close to the cervix. It acts
locally on the contiguous cells. PGE2 and PGF2a both cause myometrial contraction. PGE2 is
Important for cervical ripening whereas PGFa for myometrial contractions.

STEPS OF INDUCTION WITH PROSTAGLANDIN:

 Keep mother in recumbent position.

 Insert prostaglandin close to the cervix i.e. posterior fornix of the vagina.
 Mother should remain in rest for an hour.
  Monitor FHR and uterine contractions continuously for 30-60 minutes.
 Usual dose is 1-3mg, repeated after 6-8 hours, if needed.

Misoprostol (PGE1) induction:

It is currently being used either transvaginally or orally for induction of labor. Oral use of
misoprostol is less effective than vaginal administration. It is used for cervical ripening and labor
induction and reduces the risks of uterine hyper stimulation, meconium stained liquor and fetal
heart irregularities. It is contraindicated in women with previous caesarean birth.

STEPS FOR INTRAVAGINAL APPLICATION OF MISOPROSTOL:

 Place one fourth of a misoprostol intravaginally, without the use of any gel (gel may
prevent the tablet from dissolving).
 The mother should remain recumbent for 30 minutes.
 FHR and uterine activity is to be monitored for at least 3 hours after misoprostol
application before the patient is allowed to ambulate.

When oxytocin augmentation is required, a minimum interval of three hours is required after the
last misoprostol dose.

SURGICAL INDUCTION:

Surgical induction of labor is achieved by two methods:

1. Artificial rupture of membranes (ARMs)

2. Stripping of the membranes

Artificial ruptures of membranes or amniotomy:

Amniotomy is performed to induce labor when the cervix is favourable or during labor to
augment contractions. Amniotomy allows the presenting part to decent with improved
application to the cervical os.

STEPS INVOLVED IN AMNIOTOMY:

 The mother is in lithotomy position.

 Full surgical asepsis is to be taken.
 Two fingers are introduced into the vagina smeared with antiseptic ointment.
 Index finger is passed through the cervical canal beyond the internal os.
 The membranes are swept free from the lower segment as far as reached by the finger.
 With one or two fingers still in the cervical canal with the palmer surface upwards, a long
Kocher’s forceps with the blades closed or an amnion hook is introduced along the
palmer aspect of the fingers up to the membranes.
  The blades are opened to seize the membranes and are torn by twisting movements.
Amnihook is used to scratch over the membranes. This is followed by visible escape of
amniotic fluid.
 After the amniotomy, the following are to be assessed;
I. colour of the amniotic fluid
II. status of the cervix
III. station of the head
IV. detection of cord prolapse
V. quality of FHR

A sterile vulval pad is placed. Prophylactic antibiotic may be prescribed.

COMBINED METHOD:

The combined medical and surgical methods are commonly used to increase the efficacy of
induction by reducing the induction-delivery interval. The oxytocin infusion is started either
prior to or following rupture of membranes depending mainly upon the state of the cervix and
head-brim relation. With the head engaged, it is preferable to induce with prostaglandin gel or to
start oxytocin infusion followed by ARM.

MECHANICAL (BALLOON DILATORS) METHOD:

This type of induction is carried out by the use of catheters..

STEPS OF MECHANICAL INDUCTION:

 The catheter is introduced into the endocervix by direct visualization or blindly by

locating the cervix with the examining fingers and guiding the catheter over the hand and
fingers through the endocervix and into the potential space between the amniotic
membrane and the lower uterine segment.
 The balloon reservoir is inflated with 30-50ml of normal saline.
 The balloon is retracted so that it rests on the internal os.
 Apply pressure by adding weights to the catheter end.
 Constant pressure: attach 1 L of intravenous fluids to the catheter end and
suspend it from the end of the bed.
 Intermittent pressure: gently tug on the catheter end two to four times per hour.
 Saline infusion—Inflate catheter with 40ml of sterile water or saline.
 Infuse sterile saline at a rate of 40ml /hour using an infusion pump.
 Remove six hours later or at the time of spontaneous expulsion or rupture of membranes
(whichever occurs first).
 Prostaglandin E2 infusion.
PROCEDURE -5 (ARTIFICIAL RUPTURE OF MEMRANES)

Also known as amniotomy is the procedure by which the amniotic sac is deliberately ruptured so
as to cause the release of amniotic fluid. Amniotomy is usually performed for the purpose of
inducing or expediting labor or in anticipation of the placement of internal monitors (uterine
pressure catheters or fetal scalp electrodes). It is typically done at the bedside in the labor and
delivery suite.

EQUIPMENT USED:

 Amniotomy hook or amniotomy glove or amniotic needle

 Sterile gloves and lubricant.
 Absorbent pads and towels to be placed under the patient.
 Fetal monitor.
 Tocolytic should be available, especially if labor is being augmented.
STEPS OF PROCEDURE
1) Place the patient in lithotomy position, drap the area and put the sterile cloth or towel under
the perineal area.

2) If an amniotic hook is used, the handle of the device is held with one hand outside the vagina
while 2 fingers of the opposite hand are placed in the vagina to guide the tip. Care should be
taken to protect maternal tissues from the point. .

3) Once the hook reaches the amniotic sac, the tip is pushed up against the sac with the index or
middle finger of the internal hand to pierce the membranes

.4) The hook is then pulled through the membranes with the external hand holding the handle to
create a hole in the sac. If an amniotic finger cot is being used, the pointed tip is dragged through
the membranes with the finger to create the amniotomy.

5) The examining hand should remain in place to confirm that there has been no prolapse of the
umbilical cord during the amniotomy.
6) The hand is then removed from the vagina ,the nature of the amniotic fluid (ie, clear, bloody,
meconium-stained, or purulent) is documented, and the fetal heart rate should be monitored for
several minutes after the procedure.

PROCEDURE – 6 (PLACENTAL EXAMINATION)

DEFINITION

A thorough inspection and examination of the placenta and membranes, soon after explusion,for
its completeness and normalcy.

PURPOSES

1. To ensure that the entire placenta and membranes have been expelled and no part has
been retained.
2. To make sure that placenta is of normal size, shape, consistency and weight.
3. To detect abnormalities such as infarctions, calcifications or additional lobes.
4. To ascertain the length of the cord, number of blood vessels and site of insertion of
the cord.
5. To prevent PPH and infection.

EQUIPMENTS

 Placenta in a bowl.
 A washable surface to lay the placenta.
 A weighing machine.
 Measuring tape.
 Kidney tray.
 Pair of gloves.

PROCEDURE

1. Double gloves to protect from contamination.

2. Using gloved hands hold the placenta by the cord allowing the membranes to hang (Twisting
the cord twice around the fingers will provide a firm, because hanging membranes will provide a
better view to check its completeness.
3. Identify the hole through which the baby was delivered.
4. Insert hand through the hole and spread out the fingers to view the membranes and the blood
vessels.
5. Remove the hand from inside the membranes and lay the placenta on a flat surface with the
fetal surface up. Identify the site of cord insertion.
6. Examine the two membranes, amnion and chorion for completeness and presence of abnormal
vessels indicating succenturiate lobe.
7. Invert the placenta, expose the maternal surface and remove any clots present.
8. Examine the maternal surface by spreading it in the palms of your two hands and placing the
cotyledons in close approximation (any broken fragment must be replaced before accurate
assessment is made)
9. Assess for presence of abnormalities such as infarctions, calcifications or Succenturiate
lobes.
10. Inspect the cut end of the umbilical cord for presence of three umbilical vessels.
11. Measure the length of the umbilical cord by holding it extended against a graduated
surface/side of the weighing scale (the length of the cord on the baby may be added to get the
total length where applicable).
12. Weigh the placenta by placing it on the weighing scale meant for the purpose. A full term
placenta will be about 7inches in diameter and about 1 ½ inches thick.
13. Place the placenta in the bin for proper disposal.
14. Clean the area used for examination of the placenta and membranes, the weighing Scale and
the bowl.
15. Remove gloves and wash hands
16. Record in the patient’s chart, the findings of placental examination and weight of the
Placenta, length of the cord and any special observations made.
PROCEDURE – 7 (TUBAL LIGATION)

TUBECTOMY: It is an operation where resection of a segment of both the fallopian tubes is

done to achieve permanent sterilization. The approach may be abdominal or vaginal.

STEPS FOR ABDOMINAL TUBECTOMY:

1. Anaesthesia: - The operation is done under general common spinal or local anaesthesia.

2. Incision: - Incision is made two fingers breadth above the symphysis pubis. The incision may
be either midline or Para median or transverse. The abdomen is open by the usual procedure.

3. Delivery of the tube: - The index finger is introduced through the incision. The finger is
passed across the posterior surface and then to the posterior leaf of the broad ligament from
where the tube is hooked out. The tube is identified by the fimbriae end and mesosalpinx
containing utero-ovarian anastomotic vessel.

Techniques: - Pomeroy’s:

 A loop is made by holding the tube by an Allis forceps in such a way that the major part
of the loop consists mainly of isthmus and part of the ampulla part of the tube (at the
junction of proximal and middle third).
 Through an avascular area in the mesosalpinx, a needle threaded with no. 0 chromic
catgut is passed and both the limbs of the loop are firmly tied together.
 About 1 – 1.5 cm of the segment of the loop distal to the ligature is excised.
 The tube is so excised as to leave behind about 1.5 cm of intact tube adjacent to uterus.
 Segment of the loop removed is to be inspected to be sure that the wall has not been
partially resected.
 Send the excised segment for histology.

The same procedure is repeated on the other side because of the absorption of the absorbable
ligature, the cut ends become independently sealed off and arte separated after a few weeks.

Advantages:

It is easy, safe and very effective and simple technique. The failure rate is 0.1-0.5 per cent.
BIBLIOGRAPHY:

1. Dutta DC. Textbook of Gynecology, 6th edn, Kolkata; New Central Book Agency; Page
No 563-608.
2. Manual of Midwifery and Gynecological Nursing, 2nd edn, Jaypee Brothers Medical
Publishers, Page No; 451 – 455.
3. Jacob Annamma. Textbook of Midwifery and Gynecological Nursing, 4th edn, Jaypee
Brothers Medical Publishers, Page No; 658-651