CESAREAN Most common major surgical procedure in the UNITED STATES:1/3 of births - PowerPoint Presentation

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CESAREAN

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Most common major surgical procedure in the UNITED STATES:1/3 of births

70% Of cesarean deliveries in the UNITED STATES are primary cesareans;three common indication are:

1.Failure to progress during labor (35%)

2.Non_reasurring fetal status (24%)

3.Fetal malpresentation(19%)

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Williams:

1.Maternal

Prior cesarean delivery

Abnormal placentation

Maternal request

Prior classical hysterotomy

Unknown uterine scar type

Uterine incision dehisence

Prior full thickness myomectomy

Genital tract obstructive mass

Invasive cervical cancer

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Prmannet

cercelage

Prior

pelvc reconstructive sugery

Prior

significan perineal trauma

PELVIC DEFORMITY

Hsv OR HIV infection

CARDIAC OR PULMONARY DISease

Cerebral aneurysm or arteriovenous mlformation perimortem cesarean delivery

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Maternal Fetal

Cephalopelvic disproportion

Failed operative vaginal delivery

Placenta previa or placental abruption

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FETAL

Non reasusuring fetal status

Malpresentation

Macrosomia

Congenital anomaly

Abnormal umbilical cord duppler study

Thrombocytopenia

Prior neonatal birth trauma

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Preoperative

Planned term cesarean delivery at 39 or 40 w of

gestation

Sedative may be given at bed time the night before surgery

Solid food intake stopped at least 6 – 8 hours before surgery (uncomplicated patients moderate amount of clear liquid up to 2 hours before surgery)

Admit the day of surgery

Antacid is given shortly before the analgesia (

Bicitra

, 30ml, orally in a single dose)

Left lateral tilt

Five minute tracing of fetus. Minimum fetal heart rate sound.

Electrosurgical pad on the lateral thigh.

Intra operative

normothermia

lowes

wound infection rate

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Preoperative

Anesthesia

consultation

Baseline

Hb (one month), blood

type,antibody

screen indirect coombs

AB Prophylaxis:without AB 5-20 Fold greater greater risk of infection compared with vaginal birth/Narrow sperctrum AB within 60 min before incision such as cefazolin or ampicillin

Women<120 kg=CEFAZOLIN 2 gr (Williams 1 gr)

WOMEN>=120 kg= CEFAZOLIN 3 gr

Half life CEFAZOLIN>AMPICILLIN/Extra doses

(excessive blood loss,duration of sugery >two half lives of thec drug

CEFAZOLIN+AZITHRIMYCIN 500 mg IV=IN labor or ROM FOR AT LEAST 4 H

ALLERGY:CLINDAMYCIN 900mg+Gentamycin 5mg/kg IV

Thrombo

phylaxy

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Fetal presentation and placental location

Bladder catheterizationHair removal

Skin preparation

Vaginal preparation

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Skin

incision

Choice

of incision — 

transverse skin

incision:

a better cosmetic appearance and possibly less postoperative pain and hernia formation .

we rarely perform a vertical midline incision, we often select this approach when:

The

incision-to-delivery time is critical

A

transverse incision may not provide adequate exposure

The

patient has a bleeding diathesis and thus is at increased risk of subcutaneous or subfascial hematoma

formation

Patients with high infection risk

Neurovascular structures (

ilioinguinal

and

iliohypogastric

nerves and superficial and inferior epigastric vessels)

Obese patients

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Transverse incision

Pfannenstiel

:

common

JOEL –Cohen

Maylard

incision (rectus

andominies

transected) (inferior epigastric

arterie

)

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Pfannenstiel

Level of pubic hair line (3 cm about superior border of symphysis pubis)

12-15 cm

Sharp dissection through the subcutaneous to the fascia (superficial epigastric vessel)

Anterior abdominal

fascial

= aponeurosis external oblique muscle fused layer transverse

abdominies

+ internal oblique

Fascial

separation

cephalad

8 cm

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vertical midline incision

2 to 3 cm above the superior margin of the symphysis

12 to 15 cm

Sharp dissection through the subcutaneous layer

Extended first superiorly then inferiorly

Other stages are similar

to

Pfannenstiel

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Subcutaneous tissue

layerFascial layer

 

Rectus muscle

layer

Opening the peritoneum

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Hysterotomy

Transverse

incision

Monro Kerr or Kerr

incision

Low uterine segment vertical

 (Kronig, DeLee, or Cornell

)

classical incisions

Fundal or posterior incision (placental accrete)

The generally accepted indications for considering a vertical uterine incision are:

●Poorly developed lower uterine segment when more than normal intrauterine manipulation is anticipated (eg, extremely preterm breech presentation, back down transverse lie).

●Lower uterine segment pathology that precludes a transverse incision (eg, large leiomyoma, anterior placenta previa or accreta).

●Densely adherent bladder.

●Postmortem delivery.

●Delivery of a very large fetus (eg, anomalous, extreme macrosomia) when there is high risk of extension of a transverse incision into uterine vessels or a T or J extension may be required to extract the fetus

.

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Kerr

Easier to repair

Less incision-site bleeding

Promote less bowel or

omentum

adherence to

myometrial

incision

Less likely to rupture during subsequent pregnancy

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Palpate the fundus to identify uterine rotation

Moist sponge

to pack protruding bowel

Peritoneal edge is elevated and incised laterally

Bladder flap shorter skin incision to delivery time

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Uterine incision

Digital palpation to find the physiological border between firmer upper segment and more flexible lower segment.

Advanced cervical dilation

hysterotomy

is higher

1 to 2 cm

Comparing blunt and sharp expansion: blunt associated with fewer unintended incision extension, shorter operative time and less blood loss.

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Delivery of the fetus

Push (dislodge)

Pull

Fetal pillow

Round head (difficult)

Encircled umbilical cord

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20 units of oxytocin per liter (10 ml/min)

Delivery of the placenta

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Uterine repair

Uterus is lifted

One or two layers of continues 0 no. 1 absorbable suture: chromic catgut

/

Vicryl

Single layer is faster

Individual bleeding site: figure of 8 or mattress

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Scaring can be reduced by handling tissues delicately achieving hemostasis and minimizing tissue ischemia infection foreign body reaction

No benefit to peritoneal closure

No benefit of adhesion barrier

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Abdominal closure

Irrigation (greater intra operative nausea)

Muscle approximated by 0 or no. 1 Chromic figure of 8 gut

sucure

.

Overlying rectus fascia: continues nonlocking with delayed absorbable suture

Subcutaneous tissues if less than 2 cm thick need not be closed

Skin closed with 4-0 delayed

bsorbable

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Joel-Cohen and Misgav

ladach techniques

Differ from Kerr by their initial incision and greater use of blunt dissection

Joel-Cohen Technique: Straight 10 cm transverse skin incision 3 cm below the level of anterior superior iliac spine. Subcutaneous tissue is opened sharply.

Misgav

ladach

technique defers in that peritoneum is interred bluntly

Shorter operative time, less blood loss and post operative pain

Difficult

in women with adhesion or fibrosis

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Uncomplicated cesarean delivery of fetus in cephalic presentation

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UTERINE CLOSURE

Exteriorizing the uterus