Cesarean Delivery and Hysterectomy

7/28/2019 Cesarean Delivery and Hysterectomy

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Cesarean Delivery and

Per ipar tum Hysterectomy


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Defini t ion

Birth of a fetus through incisions in theabdominal wall (laparotomy) and the

uterine wall (hysterectomy)


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f requency


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C/sec

Women are having fewer children. The average maternal age is rising.

The use ofelectronic fetal monitoring is widespread.

Breech presentation

The incidence ofmidpelvic forceps and vacuumdeliveries has decreased.

Rates oflabor induction continue to rise

The prevalence ofobesity has risen Concern formalpractice litigation

Concern overpelvic floor injury assocated withvaginal birth


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Indicat ions


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Prior cesarean delivery Dystocia

Secondary arrest of dilatation

Arrest of descent Cephalopelvic disproportion

Failure to progress


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Fetal distress Electronic monitor : 85% of labor in US (2002)

C/sec rate 40%.

Electronic monitor : cerebral palsy or perinataldeath risk.

c/sec 30min(AAP ,

ACOG 2002 guideline)

Breech presentation

Maternal, fetal morbidity & mortality

.


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Methods to Decease Cesarean

Delivery Rates

Educating physicians, peer reviewing,encourage in a trial of labor after prior

transverse cesarean delivery, and

restricting cesarean deliveries for dystociaonly to women who meet strictly defined

criteria


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Maternal Mortal i ty and Morb idi ty

Mortality risk 4 (1992-1998, north Carolina)

Emergency : 9 / elective : 3 (1994-1996,UK, 2 million birth)

Source : Pureperal infection, hemorrhage,

thromboembolism

Obese women


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Patient cho ice Cesarean Delivery

It has been argued that women should beable to choose to undergo elective

cesarean delivery

Avoidance of

pelvic floor injury during vaginal birth

Reduction in the risk of fetal injury Convenience


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Techn ique for Cesarean Delivery

Abdominal incisions Midline vertical

Suprapubic transverse


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Vert ical Inc ision

Infraumbilical midline vertical : quickest

Level ofant. Rectal sheath, expose a stripof fascia in the midline about 2cm wide.

Rectal sheath were incised by scalpel orscissor

Rectus and pyramidalis m. are separatedin the midline

Peritoneum is incised superiorly to theupper pole of the incision and down wardto just above the peritoneal reflection over

the bladder


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Transverse Incis ions Modified Pfannenstiel incision

Pubic hairline and extend beyond the lat.borders of the rectus m.

Fascia is incised transversely the full length ofthe incision

Separates the fascial sheath from the underlyingrectus m. (umbilicus level)

Then peritoneum is opened as earlier.

Advantage Cosmetic advantage is apparent.

Stronger with less likelihood of dehiscence or hernia

Disadvatage

Exposure in some women is not as optimal


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Uter ine inc isions

Lower uterine segment transverse incision(by Kerr, 1926) : most often

Low-segment vertical incision (classicincision) (by Kronig, 1912)

Lower uterine segment transverseincsion Easier to repair

Rupture

Adherence of bowel or omentum to the

incisional line


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Techn ique fo r Transverse Cesarean

inc is ion

Dextrorotated

Thick meconium or infected amnionic fluid

> prefer to lay a moistened laparotomy packin each lateral pertoneal gutter to absorb fluidand blood.

The loose vesicouterine serosa is grasped

with the forceps. The hemostat tip points to the upper

margin of the bladder


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Delivery o f the In fan t

In a cephalic presentation Hand is slipped into the uterine cavity between

the symphysis and fetal head

Head is elevated gently with the fingers andpalm through the incision

Aided by modest transabdominal fundal pressure

After a long labor with CPD, the fetal head

may be tightly wedged in the birth canal

Upward pressure exerted by a hand in the

vagina by an assistant will help to dislodge the

head and allow its delivery above the symphysis


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The shoulders then are

delivered using gentle

traction plus fundal

pressure

And oxytocin infusion

(10-20IU/L at 10ml/min)Until the uterus

contracts satisfactorily


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The cord is clamped,

After infant is given to the team member

Uterus incision is observed for any

vigorously bleeding sites

Promptly clamped with Pennington or ring

forceps, or similar instruments

Placental buging through the uterine

incision as the uterus contracts.

Fundal massage

Reduces bleeding

Hastens placental delivery


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After placenta delivery, the uterine cavity is

inspected and either suctioned orwiped out

with a gauze pack to remove avulsed

membranes, vernix, clots, and others.

The upper and lower cut edges and each

angle of the uterine incision are examinedcarefully for bleeding vessels

The uterine incision is closed with one or twolayers of continuous 1-0 absorbable suture.

Traditionally, chromic suture was used.


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The initial suture is placed just beyond oneangle of the incision.

A running-lock suture is then carried out, witheach suture penetrating the full thickness ofthe myometrium If lower segment is thin, one layer of suture can be

obtained. Individual bleeding sites can be secured with

figure-of-eight or mattress sutures.

Traditionally, serosal edges overlying theuterus and bladderhave been approximatedwith a continous 2-0 chromic catgut suture.


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Abdom inal Closure

Sponge and instrument counts are found tobe correct, the abdominal incisionis closed inlayers.

Peritoneal closure will help to pretect the

bowel when fascial sutures are placed.As each layer is closed, bleeding sites are

located, clamped, and ligated.

Fascial closure

Interrupted 0 Nonabsorbable suture Continuous, nonlocking suture of a long-lasting

absorbable or permanents type


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Techn ique fo r Classical Cesarean

Incis ion

Indication Difficulty in exposing or safely entering the

lower Ut. segment Bladder is densely adherent from prev. surgery

Myoma occupies the lower Ut. seg. Cx. has been invaded by cancer

T-lie

Placenta previa with ant. Implantation,

especially placenta percreta Fetus is very small, breech, low. Ut. Seg is not

thinned out

Massive maternal obesity


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Peripartum Hysterectomy

Life saving if there is severe obstetricalhemorrhage

1 in every 200 c/sec (29,000 c/sec) (Shellhaas,

2001)

1 in every 950 deliveries

1 in 135 c/sec (26,700 c/sec)/ 1 in 1850 delivery

-> 1 in every 500 deliveries (129,000 deliveries)(9years, Parkland Hospital, 2002)


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P i t H t t


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Following delivery, the major bleedingvessels are clamped and ligated quickly

The placenta is removed

The uterine incision can be approximatedwith a continuous suture.

If bleeding is minimal, closure is notnecessary

Peripartum Hysterectomy

Technique


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The round ligaments close to the uterusare divided and doubly ligated

The incision in the vesicouterine serosa isextended laterally and upward through the

anterior leaf of the broad ligament to reach

the incised round


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The posterior leaf of the broad ligamentadjacent to the uterus is perforated just

beneath the fallopian tube, utero-ovarian

ligaments and ovarian vessels

Then, these are doubly clamped close to

the uterus


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The posterior leaf of the broad ligament isdivided inferiorly toward the uterosacral

ligaments


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The bladder is further dissected from the loweruterine segment by blunt dissection with

pressure directed towards the lower segment

and not bladder.

Sharp dissection may be necessary

The bladder is dissected free for about 2 Cmbelow the lowest margin of the cervix to expose

the uppermost part of the vagina


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The cardinal and uterosacral ligaments andmany large vessels the ligaments contain are

doubly clamped systematically with Heaney

curved clamps and incised and suture ligated

These steps are repeated until the level of the

lateral vaginal fornix is reached

In this way, the descending branches of the

uterine vessels are clamped, cut, and ligated


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Immediately below the level of the cervix,a curved clamp is swung in across the

lateral vaginal fornix, and the tissue is

incised medially to the clamp


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Each of the angles of the lateral vaginalfornix are secured to the cardinal and

uterosacral ligaments


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A running-lock stitch is placed through theedge of the vaginal mucosa

Some clinicians choose reperitonealizationof the pelvis.


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Peripartum Management


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Preoperative Care

Hematocrit should be rechecked

Oral intake is stopped at least 8 hours

before surgery Antacid given shortly before the induction

minimizes the risk of lung injury from

gastric acid Indwelling bladder catherteris placed



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In travenous Fluids

Hct of 30 or more and a normallyexpanded blood volume and extracellularfluid volume most often tolerates bloodloss up to 1500 mL without difficulty

Blood loss averages about 1 L, but is quitevariable

Lactated Ringer solution or a similar

solution with 5 % dextrose, 1 to 2 L areinfused during and immediately after theoperation


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Recovery Suite

Must be monitored closely BP, urine flow ( > at least 30mL/hr )

amount ofbleeding from the vagina

uterine fundus contraction

Effective analgesics Meperidine 75~100 mg or morphine 10~15

mg, IM or IV

Encouraging deep breathing and coughing



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Subsequen t Care

Analgesia Meperidine 75~100 mg ormorphine sulfate

10~15 mg, IM every 3~4 hours as needed fordiscomfort

Vital Signs BP, pulse, urine flow, amount of bleeding, and

status of the uterine fundus evaluated at leasthourly for 4 hours at the minimum

Thereafter, for the first 24 hours, these arechecked at interval of4 hours


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Fluid Therapy and Diet Rarely develops fluid sequestration in the

third space after normal cesarean delivery

3L of fluid should prove adequate during the

first 24 hours after surgery

Ifurine output falls below 30mL/hr, then the

woman should be reevaluated promptly

The cause of the oliguria may range fromunrecognized blood loss to an antidiuretic

effect from infused oxytocin


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Ambulation At least the day aftersurgery, with assistance, should

get out of bed

With early ambulation, venous thrombosis and

pulmonary embolism are uncommon Wound care

Inspected each day

The skin sutures are removed on the fourth day after

surgery By the third postpartum day, bathing by showeris not

harmful


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Laboratory Hct is routinely measured

Breast care Breast feeding can be initiated by the day

after surgery

If not to breast feed, a breast binder thatsupports the breasts without markedcompression will usually minimize discomfort

Discharge from the Hospital

Generally discharged on the third or fourthpostpartum day

Cesarean Delivery and Hysterectomy

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