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Cesarean Delivery and Peripartum Hysterectomy

Definition
Birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterectomy)

frequency

C/sec
Women are having fewer children. The average maternal age is rising. The use of electronic fetal monitoring is widespread. Breech presentation The incidence of midpelvic forceps and vacuum deliveries has decreased. Rates of labor induction continue to rise The prevalence of obesity has risen Concern for malpractice litigation Concern over pelvic floor injury assocated with vaginal birth

Indications

 Prior cesarean delivery Dystocia

Secondary arrest of dilatation Arrest of descent Cephalopelvic disproportion Failure to progress

 Fetal distress
Electronic monitor : 85% of labor in US (2002) C/sec rate 40% . Electronic monitor : cerebral palsy or perinatal death risk . c/sec 30min (AAP , ACOG 2002 guideline)

Breech presentation
Maternal, fetal morbidity & mortality .

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 dystocia only to women who meet strictly defined criteria

Maternal Mortality and Morbidity

Mortality risk
4 (1992-1998, north Carolina) Emergency : 9 / elective : 3 (1994-1996, UK, 2 million birth)

Source :
Pureperal infection, hemorrhage, thromboembolism

Obese women

Patient choice Cesarean Delivery

It has been argued that women should be able to choose to undergo elective cesarean delivery

Avoidance of
pelvic floor injury during vaginal birth Reduction in the risk of fetal injury

Convenience

Technique for Cesarean Delivery

Abdominal incisions
Midline vertical Suprapubic transverse

Vertical Incision
Infraumbilical midline vertical : quickest Level of ant. Rectal sheath, expose a strip of fascia in the midline about 2cm wide. Rectal sheath were incised by scalpel or scissor Rectus and pyramidalis m. are separated in the midline Peritoneum is incised superiorly to the upper pole of the incision and down ward to just above the peritoneal reflection over the bladder

Transverse Incisions
Modified Pfannenstiel incision Pubic hairline and extend beyond the lat. borders of the rectus m. Fascia is incised transversely the full length of the incision Separates the fascial sheath from the underlying rectus 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

Uterine incisions
Lower uterine segment transverse incision (by Kerr, 1926) : most often Low-segment vertical incision (classic incision) (by Kronig, 1912) Lower uterine segment transverse incsion
Easier to repair Rupture Adherence of bowel or omentum to the incisional line

Technique for Transverse Cesarean incision

Dextrorotated Thick meconium or infected amnionic fluid
> prefer to lay a moistened laparotomy pack in each lateral pertoneal gutter to absorb fluid and blood.

The loose vesicouterine serosa is grasped with the forceps. The hemostat tip points to the upper margin of the bladder

 The loose serosa above the upper margin of the bladder is elevated and incised laterally (2cm wide)

Dissection of bladder- bladder flap- off uterus to expose lower uterine segment In general, the separation of bladder should not exceed 5 cm in depth and usually less

 The uterus is opened through the lower uterine segment about 1 cm below the upper margin of the peritoneal reflection
After entering the uterine cavity, the incision is extended laterally with either fingers or bandage scissors Uterine incision large enough to allow delivery of the head and trunk of the fetus without either tearing into or having to cut into the uterine arteries and veins that course through the lateral margins of the uterus

Delivery of the Infant

In a cephalic presentation
Hand is slipped into the uterine cavity between the symphysis and fetal head Head is elevated gently with the fingers and palm 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

 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

 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

Repair of the Uterus

Exteriorization
Advantage
Relaxed, atonic uterus can be recognied quickly and massage applied Bleeding point are visualized more easily and repaired. Adnexal exposure is superior, and thus tubal sterilization is easier.

Disadvantage
Discomfort and vomiting under reginal analgesia Febrile morbidity, blood loss

 After placenta delivery, the uterine cavity is inspected and either suctioned or wiped 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 examined carefully for bleeding vessels The uterine incision is closed with one or two layers of continuous 1-0 absorbable suture. Traditionally, chromic suture was used.

 The initial suture is placed just beyond one angle of the incision.
A running-lock suture is then carried out, with each suture penetrating the full thickness of the 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 the uterus and bladder have been approximated with a continous 2-0 chromic catgut suture.

Abdominal Closure
Sponge and instrument counts are found to be correct, the abdominal incisionis closed in layers. 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

 Subcutaneous tissure
Less than 2cm : need not to close More than 2cm : should be closed

Skin
Vertical mattress sutres of 3-0, 4-0 silk or equivalent sutre Running 4-0 subcuticular stitch using semipermanent suture Skin clips.

Technique for Classical Cesarean Incision

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

Uterine Incision (Classic)

Beginning as low as possible with a scalpel Above the level of the bladder Incision is extended cephalad with bandage scissior Until is is sufficiently long to permit delivery of the fetus

Uterine repair (Classic)

Approximate the deeper halves of the incision by continuous suture with chromic 0 or 1-0 Then outer halves were closed with similar suture Assistant compress the uterus on each side of the wound Uterine serosa are approximated with continuous 2-0 chromic catcut.

Peripartum Hysterectomy
Life saving if there is severe obstetrical hemorrhage 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)

Peripartum Hysterectomy Indication

Uterine atony (most common)
Kastner, 2002 Shellhaas, 2001

Laceration of major Uterine vessels Placenta accreta Large myomas Severe cervical dysplasia, CIS

Peripartum Hysterectomy complication

Peripartum Hysterectomy Technique

Following delivery, the major bleeding vessels are clamped and ligated quickly The placenta is removed The uterine incision can be approximated with a continuous suture.
If bleeding is minimal, closure is not necessary

 The round ligaments close to the uterus are divided and doubly ligated The incision in the vesicouterine serosa is extended laterally and upward through the anterior leaf of the broad ligament to reach the incised round

 The posterior leaf of the broad ligament adjacent 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

 The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligaments

 The bladder is further dissected from the lower uterine 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 Cm below the lowest margin of the cervix to expose the uppermost part of the vagina

 The ascending uterine artery and veins on either side are identified and near their origin are doubly clamped immediately adjacent to the uterus and divided The vascular pedicle is doubly suture ligated

 The cardinal and uterosacral ligaments and many 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

 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

 Each of the angles of the lateral vaginal fornix are secured to the cardinal and uterosacral ligaments

 A running-lock stitch is placed through the edge of the vaginal mucosa Some clinicians choose reperitonealization of the pelvis.

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 catherter is placed

Peripartum Management Intravenous Fluids

Hct of 30 or more and a normally expanded blood volume and extracellular fluid volume most often tolerates blood loss up to 1500 mL without difficulty Blood loss averages about 1 L, but is quite variable Lactated Ringer solution or a similar solution with 5 % dextrose, 1 to 2 L are infused during and immediately after the operation

Peripartum Management Prevention of postop. infection

Febrile morbidity is frequent after cesarean delivery Ruptured membranes-> single 2g dose of a B-lactam drug, cephalosporin or an extended-spectrum penicillin Up to 20% of women develops fever despite peripartum prophylactic antibiotics. (Goepfert, 2001)

Peripartum Management Recovery Suite

Must be monitored closely
BP, urine flow ( > at least 30mL/hr ) amount of bleeding 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 Subsequent Care

Analgesia
Meperidine 75~100 mg or morphine sulfate 10~15 mg, IM every 3~4 hours as needed for discomfort

Vital Signs
BP, pulse, urine flow, amount of bleeding, and status of the uterine fundus evaluated at least hourly for 4 hours at the minimum Thereafter, for the first 24 hours, these are checked at interval of 4 hours

 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 If urine output falls below 30mL/hr, then the woman should be reevaluated promptly The cause of the oliguria may range from unrecognized blood loss to an antidiuretic effect from infused oxytocin

 Bladder and Bowel Function

The bladder catheter most often can be removed by 12 hours after operation In uncomplicated cases, solid food may be offered within 8 hours of surgery adynamic ileus is of short duration
Symptoms
abdominal distention and gas pains, an inability to pass flatus or stool

Treatment :
nasogastric decompression, intravenous fluid, electrolyte supplementation, 10-mg bisacodyl rectal suppository

 Ambulation
At least the day after surgery, 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 shower is not harmful

 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 that supports the breasts without marked compression will usually minimize discomfort

Discharge from the Hospital

Generally discharged on the third or fourth postpartum day