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Cesarean Section

Matthew Snyder, DO, Maj, USAF, MC Nellis AFB, NV. When, Why and How. Cesarean Section. Indications Instruments Procedure Post-operative management Post-partum counseling. Overview. Fetal Macrosomia (over 5000g, GDM – 4500g) Multiple Gestations Fetal Intolerance to Labor

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Cesarean Section

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  1. Matthew Snyder, DO, Maj, USAF, MC Nellis AFB, NV When, Why and How Cesarean Section

  2. Indications Instruments Procedure Post-operative management Post-partum counseling Overview

  3. Fetal Macrosomia (over 5000g, GDM – 4500g) Multiple Gestations Fetal Intolerance to Labor Malpresentation / Unstable Lie – Breech or Transverse presentation C/S Indications - Fetal

  4. Non-reassuring Fetal Heart Tracing • Repetitive Variable Decelerations • Repetitive Late Decelerations • Fetal Bradycardia • Fetal Tachycardia • Cord Prolapse C/S Indications - Fetal

  5. 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

  6. Abnormal Placentation • Placenta previa • Vasa previa • Placental abruption • Conjoined Twins • Perimortem • Failed Induction / Trial of Labor C/S Indications – Maternal/Fetal

  7. 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

  8. C/S Indications – Maternal/Fetal

  9. Surgical Instruments • Uses: • Adson: Skin • Bonney: Fascia • DeBakey: soft tissue, bleeders • Russians: uterus

  10. Surgical Instruments • Uses: • Allis-Adair: tissue, uterus • Pennington: tissue, uterus • These are suitable for hemostasis use

  11. Surgical Instruments • Uses: • Kocher clamp: fascia, thicker tissues

  12. Surgical Instruments • Uses: • Richardson: general retractor • Goelet: subQ retractor • Fritsch bladder blade

  13. Surgical Instruments • Uses: • Mayo, curved: fascia • Metzenbaum, curved: soft tissue • Bandage scissors: cord cutting, uterine extension

  14. 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

  15. Cesarean Section: Incision to Uterus • Determined by previous mode of delivery/hx and body habitus – Pfannenstiel most common – 3 cm (2 fingerbreadths) above symphysis

  16. Cesarean Section: Incision to Uterus • Be cautious of the Superficial Epigastric vessels

  17. 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.

  18. 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: Incision to Uterus

  19. Cesarean Section: Uterine Incision to Delivery • Vesicoperitoneum reflexion entered with Metz and extended bil. for bladder flap

  20. 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.

  21. 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

  22. 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 1-Chromic) • Perform imbricating stitch

  23. 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

  24. 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

  25. 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 post-op), 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 Post-Operative Care

  26. Subsequent Pregnancies • Uterine rupture/dehiscence • Abnormal placental implantation (accreta, etc) • Repeat Cesarean section • Adhesions • Scaring/Keloids Delayed Complications

  27. Wound Dehiscence • 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

  28. 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)

  29. 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!!

  30. 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

  31. Fever (100.4)/Chills HA Vision changes RUQ/Epigastric pain Mastitis sx Increasing abd. pain Erythema/Induration/ increasing swelling around incision 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 Post-partum counseling:Notify MD/DO

  32. Indications Surgical Technique Post-operative management Post-operative Complications Post-partum counseling Summary

  33. 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. • www.uptodateonline.com References

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