Cesarean Delivery and Peripartum Hysterectomy

1. Cesarean Delivery and Peripartum Hysterectomy 부산백병원 산부인과 조인호

2. Definition • Birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterectomy)

3. frequency

4. C/sec이 증가한 이유 • Women are having fewer children. • The average maternal age is rising. • The use of electronic fetal monitoring is widespread. • Breech presentation • The incidence of midpelvic forceps and vacuum deliveries has decreased. • Rates of labor induction continue to rise • The prevalence of obesity has risen • Concern for malpractice litigation • Concern over pelvic floor injury assocated with vaginal birth

5. Indications

6. Prior cesarean delivery • Dystocia • Secondary arrest of dilatation • Arrest of descent • Cephalopelvic disproportion • Failure to pregress

7. Fetal distress • Electronic monitor : 85% of labor in US (2002) • C/sec rate를 40%까지 높임. • Electronic monitor : cerebral palsy or perinatal death의 risk를 감소시키지 못함. • c/sec결정 후 30min이내 시행해야 함(AAP , ACOG 2002 guideline) • Breech presentation • Maternal, fetal morbidity & mortality가 유의 있게 증가함.

8. 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 dystocia only to women who meet strictly defined criteria

9. Maternal Mortality and Morbidity • Mortality risk • 4배 (1992-1998, north Carolina) • Emergency : 9배 / elective : 3배 (1994-1996, UK, 2 million birth) • Source : • Pureperal infection, hemorrhage, thromboembolism • Obese women

11. Patient choice Cesarean Delivery • It has been argued that women should be able to choose to undergo elective cesarean delivery • Avoidance of • pelvic floor injury during vaginal birth • Reduction in the risk of fetal injury • Convenience

12. Technique for Cesarean Delivery • Abdominal incisions • Midline vertical • Suprapubic transverse

13. Vertical Incision • Infraumbilical midline vertical : quickest • Level of ant. Rectal sheath, expose a strip of fascia in the midline about 2cm wide. • Rectal sheath were incised by scalpel or scissor • Rectus and pyramidalis m. are separated in the midline • Peritoneum is incised superiorly to the upper pole of the incision and down ward to just above the peritoneal reflection over the bladder

14. Transverse Incisions • Modified Pfannenstiel incision • Pubic hairline and extend beyond the lat. borders of the rectus m. • Fascia is incised transversely the full length of the incision • Separates the fascial sheath from the underlying rectus m. (umbilicus level까지) • 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

15. Uterine incisions • Lower uterine segment transverse incision (by Kerr, 1926) : most often • Low-segment vertical incision (classic incision) (by Kronig, 1912) • Lower uterine segment transverse incsion의 장점 • Easier to repair • 다음 임신 중 Rupture의 위험성 감소 • Adherence of bowel or omentum to the incisional line의 감소

16. Technique for Transverse Cesarean incision • Dextrorotated • Thick meconium or infected amnionic fluid • > prefer to lay a moistened laparotomy pack in each lateral pertoneal gutter to absorb fluid and blood. • The loose vesicouterine serosa is grasped with the forceps. • The hemostat tip points to the upper margin of the bladder

18. The loose serosa above the upper margin of the bladder is elevated and incised laterally (2cm wide) • Dissection of bladder- bladder flap- off uterus to expose lower uterine segment • In general, the separation of bladder should not exceed 5 cm in depth and usually less

21. The uterus is opened through the lower uterine segment about 1 cm below the upper margin of the peritoneal reflection • After entering the uterine cavity, the incision is extended laterally with either fingers or bandage scissors • Uterine incision large enough to allow delivery of the head and trunk of the fetus without either tearing into or having to cut into the uterine arteries and veins that course through the lateral margins of the uterus

24. Delivery of the Infant • In a cephalic presentation • Hand is slipped into the uterine cavity between the symphysis and fetal head • Head is elevated gently with the fingers and palm 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

26. 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

27. 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

29. Repair of the Uterus • Exteriorization • Advantage • Relaxed, atonic uterus can be recognied quickly and massage applied • Bleeding point are visualized more easily and repaired. • Adnexal exposure is superior, and thus tubal sterilization is easier. • Disadvantage • Discomfort and vomiting under reginal analgesia • Febrile morbidity, blood loss의 증가

30. After placenta delivery, the uterine cavity is inspected and either suctioned or wiped 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 examined carefully for bleeding vessels • The uterine incision is closed with one or two layers of continuous 1-0 absorbable suture. Traditionally, chromic suture was used.

32. The initial suture is placed just beyond one angle of the incision. • A running-lock suture is then carried out, with each suture penetrating the full thickness of the 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 the uterus and bladder have been approximated with a continous 2-0 chromic catgut suture.

33. Abdominal Closure • Sponge and instrument counts are found to be correct, the abdominal incisionis closed in layers. • 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

34. Subcutaneous tissure • Less than 2cm : need not to close • More than 2cm : should be closed • Skin • Vertical mattress sutres of 3-0, 4-0 silk or equivalent sutre • Running 4-0 subcuticular stitch using semipermanent suture • Skin clips.

35. Technique for Classical Cesarean Incision • 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

36. Uterine Incision (Classic) • Beginning as low as possible with a scalpel • Above the level of the bladder • Incision is extended cephalad with bandage scissior • Until is is sufficiently long to permit delivery of the fetus

37. Uterine repair (Classic) • Approximate the deeper halves of the incision by continuous suture with chromic 0 or 1-0 • Then outer halves were closed with similar suture • Assistant compress the uterus on each side of the wound • Uterine serosa are approximated with continuous 2-0 chromic catcut.

38. Peripartum Hysterectomy • Life saving if there is severe obstetrical hemorrhage • 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)

39. Peripartum HysterectomyIndication • Uterine atony (most common) • Kastner, 2002 • Shellhaas, 2001 • Laceration of major Uterine vessels • Placenta accreta • Large myomas • Severe cervical dysplasia, CIS

40. Peripartum Hysterectomycomplication

41. Peripartum HysterectomyTechnique • Following delivery, the major bleeding vessels are clamped and ligated quickly • The placenta is removed • The uterine incision can be approximated with a continuous suture. • If bleeding is minimal, closure is not necessary

42. The round ligaments close to the uterus are divided and doubly ligated • The incision in the vesicouterine serosa is extended laterally and upward through the anterior leaf of the broad ligament to reach the incised round

44. The posterior leaf of the broad ligament adjacent 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

46. The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligaments

48. The bladder is further dissected from the lower uterine 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 Cm below the lowest margin of the cervix to expose the uppermost part of the vagina

50. The ascending uterine artery and veins on either side are identified and near their origin are doubly clamped immediately adjacent to the uterus and divided • The vascular pedicle is doubly suture ligated