CESAREAN SECTIONWhen, Why and How

Matthew Snyder, DO, Maj, USAF, MCNellis 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)

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

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 1-Chromic)

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 baby’s 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.

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