Z. Lavasani M.D. Amiralmomenin Hospital. Overview Definition Indication and Contraindication...
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Transcript of Z. Lavasani M.D. Amiralmomenin Hospital. Overview Definition Indication and Contraindication...
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Z. Lavasani M.D.Amiralmomenin Hospital
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Overview•Definition•Indication and Contraindication•Preoperaive management•Intraoperative management•Postoperative management•Complication
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Cesarean section
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DefinitionOperative procedure performed to deliver the fetus through an incision in abdominal wall (laparotomy) and uterine wall (hysterotomy)
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Common indicationsRepeat cesarean sectionDystocia or failure to progressBreech presentationFetal distress
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Accepted IndicationsFailed inductionCPDFetal distressPlacental
abruptionPlacental previaUmbilical cord
prolapse
Active genital herpes infection
Abdominal cerclageConjoined twinAnomaly of pelvic
boneTransverse lie and
persistent mentoposterior
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Controversial indicationsBreech presentationRepeat cesarean
section or prior uterine scar
Immune thrombocytopenia
Severe Rh immunization
Prior vaginal surgeryLarge vulvar
condylomata
hyperextended headTwinsSevere preeclampsiaHigh risk for fetal
distressAssisted
reproductive technology
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Contraindications /Motherc/sDeath fetus in uteroFetal anomaly
NVDPlacenta PreviaClassic IncisionMyomectomy
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Contraindications /FetusVasa PreviaFetal DistressPlacenta PreviaCord PresentationMyelomenangocelVellamentous Placenta
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Intraoperative ComplicationsFetal injuryUterine and genital injuryUterine atony bleedingUrinary tract injuryGastrointestinal tract injuryAnaesthetic complication
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Postoperative complicationsEarly complication
Paralytic ileus Endomyometritis Wound infection Urinary tract infection Intraabdominal and pelvic infection Intraabdominal bleeding Respiratory tract infection Thromboembolic disease
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Postoperative complicationsLate complication
Intestinal infectionDehiscence of uterine incisionPlacenta accreta
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AnatomySkinSubcutaneous tissueAnterior rectus sheetRectus musclesPreperitoneal fatPeritoneumVesicouterine membrane (serosa)Urinary bladderUterus
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Arterial supply of abdominal wall
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Preoperative managementPatient education and Inform consent
NPO at least 8 hrsIV fluidPre-operative lab
Hct ,Hb level Blood is typed and screen
PRC 1-2 unit
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Preoperative management• Urinary catheterization• IV Line• Preparation of the abdomen and
genitalia• Prophylactic ATB• Personnel trained in neonatal
resuscitation should be available
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Intraoperative managementPosition
Left lateral tiltAnesthesia
General anesthesiaSpinal blockEpidural block
Skin preparationAntiseptic solution (povidone-iodine scrub)DryingPaint iodine solution
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Intraoperative managementSkin Incision
Vertical midline incisionTransverse incision
Pfannenstiel incisionMaylad incisionCherney incision
Subcutaneous tissue incisionAnterior rectus fascia incision & dissection
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Midline vertical
Maylard incision
Pfannenstiel incision
Skin incision
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Intraoperative managementSeparation of rectus muscle Peritoneal incisionVesicouterine reflection identification & incisionUterine incision
Low transverse incision Low vertical incisionClassical incision J-shaped incisionT-shaped incision
Fetal deliveryPlacental delivery
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Indication of Classical Incision
Anterior Placenta PreviaTransverse (Low Back)Shoulder PresentationSmall FetusMyomaCervical Cancer
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Divided rectus muscle
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Vesicouterine reflection identification and incision
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AP and lateral vesicouterine space
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Classical uterine incision
Lower uterine incision
other uterine incision
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Low vertical uterine incision
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Extension of low transverse uterine incision
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Fundal pressure and manual head delivery
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Manual head delivery
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Neonatal delivery
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Deep engage and manual head delivery
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Forceps head delivery
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Short hale forceps delivery
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Vectis forceps delivery
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Manual removal placenta
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Intraoperative managementMyometrial wound closure
Two-layer running-locking sutureSingle-layer running suture
Vesicouterine closureCheck bleeding & remove blood clotAdnexa examination
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Closure of uterine incision
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Closure of low transverse uterine incision
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Repair classical incision
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Abdominal wall closure
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Smead Jones suture
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Intraoperative managementAbdominal wall closure Parietal peritoneum Rectus sheet Subcutaneous tissue Skin closure
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Postoperative managementAnalgesic Vital signsUrinationFeedingAmbulation
Wound careLab
investigation
Breast feedingDischarge
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On Request On Requestسزارين انتخابی اولّي�ه )سزارين انتخابی اولّي�ه )CesareanCesarean))
افزايش سن ازدواج
پاريتی کمتر
ترس از اختالالت آناتومی لگن ودرد زايمان
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TOL (Trail of labor)TOL (Trail of labor)يا زايمان طبّيعی پس از سزارين يا زايمان طبّيعی پس از سزارين
((VBACVBACقبلی )قبلی )60 درصد موارد با موفقّيت انجام می شود80 تا
کاهش یافته است2007آمار انجام آن از سال
مادر بايد از عوارضTOL با خبر باشد و به انتخابخودش آن را انتخاب کند
پارگي رحم از خطرناک ترين عوارضTOL .است
18بّين پارگي رحم تا خروج جنّين در يک فاصله دقّيقه اي جنّين دچا ر عوارض جدي مثل
انسفالوپاتي هايپوکسّيک مي شود.
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::TOLTOLموارد منع انجام موارد منع انجام اسکار کالسیک یا اسکار عمودی در ناحیه سگمان تحتانی رحم 1(
که به قسمت فوقانی کشیده شده باشد.
T-Invertاسکار 2(
پارگی قبلی رحم3(
بّيش از يک بار اسکار روی رحم4(
جنّين بسّيار درشت5(
ناهنجاری مولرين6(
لگن تنگ7(
عوارض طبی يا مامایی منع زايمان واژينال8(
عدم تمايل بّيمار9(
عدم دسترسی به انجام شرايط اورژانس سزارین مثل نبود 10(جراح يا متخصص بی هوشی و پرسنل آموزش ديده برای
مراقبت از نوزاد
(Postdateحاملگی پس از موعد )11(
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::TOLTOLشرايط انجام شرايط انجام فقط یک بار سزارین قبلی
لگن مناسب
نداشتن سابقه پارگی رحم
رضایت بّيمار
امکان سزارين اورژانس با حضور جراح، بی هوشی وپرسنل آموزش دیده
نداشتن موارد منع زايمان طبّيعی
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::TOLTOLاقدامات الزم برای اقدامات الزم برای IV Lineهنگام پذیرش بّيمار
CBC، BG/Rh
رزرو خون
مانّيتورينگ مداوم قلب جنّين
معاينه مک�رر
حضور پرسنل مامایی، بی هوشی و نوزادان
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م در م در نکات مّه� ::TOLTOLنکات مّه�.زايمان خود به خود بايد انجام شود
به هّيچ وجه نبايد از مواد القا کننده زايمان استفادهشود.
.تسکّين اپی دورال منعی ندارد
.زايمان طبیعی قبلی، باالترين موفقّيت را دارد
سابقه سزارين به دلّيل تنگی لگن، پايّين ترينموفقیت را دارد.
بّيشترين محل پارگی رحم اسکار قبلی و سگمانتحتانی رحم است.
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عاليم پارگی رحم:عاليم پارگی رحم:افت قلب یا الگوی غّيرطبّيعی قلب جنّين
احساس درد يا احساس پاره شدن در ناحّيه برش قبلی
کاهش شدت و دفعات انقباضات رحم
خونريزی واژينال
عاليم شوک: اضطراب، بی قراری، ضعف، سرگّيجه و دردشانه
عضو نمايش به سمت باال رفته يا لمس نمی شود
در صورت شک به پارگی رحم، سزارين در صورت شک به پارگی رحم، سزارين اورژانس اورژانس
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سزارین پس از فوت مادر
* بسیار نادر است.و الکتروانسppفالوگرافی توسppط مppادر مppرگ بایppد *
الکتروکاردیوگرافی اثبات شود.* فاصpله زمpانی مpرگ مpادر تpا خpروج جpنین سpالم مشpخص
نیست.* شpکم ورحم بایpد بpدون ضpد عفpونی کpردن و بpه سpرعت بpاز
شود.منتقpل شود. NICU* جpنین بایpد بpه سpرعت خpارج شpود و بpه
از کمpتر جpنین خpروج تpا مpادر مpرگ فاصpله دقیقpه 10* پروگنوز بّهتر.
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هیسترکتومی به دنبال سزاریناورژانس
پارگی رحم•خونریزی غیرقابل کنترل از قبیل:•
آتpونی رحم، سpینوزویید محpل جفت، اختالل انعقادی
چسبندگی جفت•عفونت رحم•
غیراورژانسکارسینوم•لیومیوم•
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