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)

of Dilation (< 1.2 cm/hr nullip; < 1.5 cm/hr multip) of Descent (no change in station after 2 hours, fully dilated)

Arrest

Failure

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

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

DELAYED COMPLICATIONS

Subsequent Pregnancies
Uterine

rupture/dehiscence Abnormal placental implantation (accreta, etc) Repeat Cesarean section

Adhesions Scaring/Keloids

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

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 babys 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

POST-PARTUM COUNSELING: NOTIFY MD/DO

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

SUMMARY
Indications Surgical Technique Post-operative management Post-operative Complications Post-partum counseling

REFERENCES

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