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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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Peripartum Management
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
Peripartum Management
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Peripartum Management
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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Peripartum Management
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Peripartum Management
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
Peripartum Management
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Peripartum Management
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
Recommended