Transcript Cesarean Section Primary

CESAREAN SECTION
When, Why and How
Matthew Snyder, DO, Maj, USAF, MC
Nellis AFB, NV
OVERVIEW
Indications
 Instruments
 Procedure
 Post-operative management
 Post-partum counseling

C/S INDICATIONS - FETAL
Fetal Macrosomia (over 5000g, GDM – 4500g)
 Multiple Gestations
 Fetal Intolerance to Labor
 Malpresentation / Unstable Lie – Breech or
Transverse presentation

C/S INDICATIONS - FETAL

Non-reassuring Fetal Heart Tracing
 Repetitive
Variable Decelerations
 Repetitive Late Decelerations
 Fetal Bradycardia
 Fetal Tachycardia
 Cord Prolapse
C/S INDICATIONS - MATERNAL
Elective Repeat C/S
 Maternal infection (active HSV, HIV)
 Cervical Cancer/Obstructive Tumor
 Abdominal Cerclage
 Contracted Pelvis

 Congenital,

Fracture
Medical Conditions
 Cardiac,
Pulmonary, Thrombocytopenia
C/S INDICATIONS – MATERNAL/FETAL

Abnormal Placentation
 Placenta
previa
 Vasa previa
 Placental abruption
Conjoined Twins
 Perimortem
 Failed Induction / Trial of Labor

C/S INDICATIONS – MATERNAL/FETAL

Arrest Disorders
 Arrest
of Descent (no change in station after 2
hours, <10 cm dilated)
 Arrest
of Dilation (< 1.2 cm/hr nullip; < 1.5 cm/hr
multip)
 Failure
of Descent (no change in station after 2
hours, fully dilated)
C/S INDICATIONS – MATERNAL/FETAL
SURGICAL INSTRUMENTS

Uses:
 Adson:
Skin
 Bonney: Fascia
 DeBakey: soft tissue,
bleeders
 Russians: uterus
SURGICAL INSTRUMENTS

Uses:
 Allis-Adair:
tissue,
uterus
 Pennington: tissue,
uterus
 These
are suitable
for hemostasis use
SURGICAL INSTRUMENTS

Uses:
 Kocher
clamp:
fascia, thicker
tissues
SURGICAL INSTRUMENTS

Uses:
 Richardson:
general
retractor
 Goelet: subQ
retractor
 Fritsch bladder blade
SURGICAL INSTRUMENTS

Uses:
 Mayo,
curved: fascia
 Metzenbaum, curved:
soft tissue
 Bandage scissors: cord
cutting, uterine
extension
CESAREAN SECTION:
INCISION TO UTERUS

Preparation:
 Ensure
SCDs applied
 Setup bovie and suction
 Test pt by pinching on either side of incision and
around navel with Allis clamp
 Lap sponge in other hand
CESAREAN SECTION:
INCISION TO UTERUS

Determined by previous mode of delivery/hx and body
habitus – Pfannenstiel most common – 3 cm (2
fingerbreadths) above symphysis
CESAREAN SECTION:
INCISION TO UTERUS

Be cautious of the Superficial Epigastric vessels
CESAREAN SECTION:
INCISION TO UTERUS


Rectus fascia incised in midline and extended bil.
with Mayo scissors/scalpel
Elevate superior and inferior edges of rectus fascia
with Kocher clamps, dissect muscle from fascia at
linea alba.
CESAREAN SECTION:
INCISION TO UTERUS

Separate rectus fascia to enter peritoneum
 Bluntly
with finger
 Using two hemostats to elevate peritoneum and
incise with Metzenbaum scissors
**Be careful of adhesions!!! – transilluminate at all
times!!!**
CESAREAN SECTION:
UTERINE INCISION TO DELIVERY

Vesicoperitoneum reflexion entered with
Metz and extended bil. for bladder flap
CESAREAN SECTION:
UTERINE INCISION TO DELIVERY

Score lower uterine segment with scalpel and
continue in midline to avoid uterine aa. Extend
bluntly or with bandage scissors.
CESAREAN SECTION:
UTERINE INCISION TO DELIVERY
Once delivering hand inserted, bladder blade
removed
 Bring head up to incision by flexing fetal head,
without flexing wrist to avoid uterine incision
extensions
 Once infant delivered, collect cord gases if
desired and cord blood sample
 Deliver placenta manually or with uterine
massage

CESAREAN SECTION:
UTERINE CLOSURE
If exteriorized, use a
moist lap sponge to
wrap uterus and
retract once placenta
is delivered
 Close uterine incision
with locking suture
(usually 0-Vicryl or 1Chromic)
 Perform imbricating
stitch

CESAREAN SECTION:
CLOSURE
Examine adnexa, irrigate rectouterine pouch
and/or gutters and re-examine uterine incision
 Ensure hemostasis of rectus then close fascia
with non-locking suture to avoid vessel
strangulation
 Close subcut. space if over 2 cm, then skin
 If needed, clear lower uterine segment and
vagina of clots once skin is closed and dressed

POST-OPERATIVE CARE
Pt. must urinate within four hours of Foley
removal, otherwise replace Foley for another 12
hours
 Any fever post-op MUST be investigated

 Wind:
Atelectasis, pneumonia
 Water: UTI
 Walking: DVT, PE, Pelvic thromboembolism
 Wounded: Incisional infection, endomyometritis,
septic shock
POST-OPERATIVE CARE
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In the first 12-24 hours, the dressing may become
soaked with serosanguinous fluid – if saturated,
replace dressing otherwise no action needed
After Foley is removed (usually within 12 hours postop), encourage ambulation of halls, not just room
Dressing may be removed in 24-48 hours post-op
(attending specific), use maxipad
Ensure pt. is tolerating PO intake, urinating well and
has flatus before discharge
Watch for post-op ileus
DELAYED COMPLICATIONS

Subsequent Pregnancies
 Uterine
rupture/dehiscence
 Abnormal placental implantation (accreta, etc)
 Repeat Cesarean section
Adhesions
 Scaring/Keloids

WOUND DEHISCENCE
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Noted by separation of wound usually during staple
removal or within 1-2 weeks post-op
Must explore entire wound to determine depth of
dehiscence (open up incision if needed) – if
through rectus fascia, back to the OR
If dehiscence only in subQ layer, debride wound
daily with 1:1 sterile saline/H2O2 mixture and pack
with gauze
May use prophylactic abx – Keflex, Bactrim, Clinda
KEY: Close f/u and wound exploration
POST-PARTUM COUNSELING:
PHARM
Continue PNV
 Colace
 Motrin 800 mg q8
 Percocet 1-2 tabs q4-6 for breakthrough
 OCP (start 4-6 wks post-partum)

POST-PARTUM COUNSELING:
ACTIVITY
No lifting objects over baby’s wt.
 Continue ambulation
 No strenuous activity
 NOTHING by vagina (sex, tampons, douches,
bathtubs, hot tubs) for 6 wks!!

POST-PARTUM COUNSELING:
INCISION CARE
Only showers – light washing
 If pt has steristrips, should fall off in 7-10 days,
otherwise use warm, wet washcloth to remove
 If pt has staples – removal in 3-7 days outpt.
 Most attendings will have pt f/u in office in
about 2 wks for wound check
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POST-PARTUM COUNSELING:
NOTIFY MD/DO
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Fever (100.4)/Chills
HA
Vision changes
RUQ/Epigastric pain
Mastitis sx
Increasing abd. pain
Erythema/Induration/
increasing swelling around
incision
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Purulent drainage
Serosanguinous drainage
over half dollar size on pad
Wound separation
Purulent vaginal discharge
Vaginal bleeding over 1
pad/hr or golf ball size clots
Calf tenderness
SUMMARY
Indications
 Surgical Technique
 Post-operative management
 Post-operative Complications
 Post-partum counseling

REFERENCES
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Cunningham, F., Leveno, Keith, et al. Williams
Obstetrics. 22nd ed., New York, 2005.
Gabbe, Steven, Niebyl, Jennifer, et al.
Obstetrics: Normal and Problem Pregnancies.
4th ed., Nashville, 2001.
Gilstrap III, Larry, Cunningham, F., et al.
Operative Obstetrics. 2nd ed., New York, 2002.
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