Special Surgical Procedures II
LESSON 2: Procedures in Gynecological and Obstetrical Surgery
2-44
2-44. CESAREAN SECTION
a. General.
(1) This operation involves the delivery of an infant through an incision made in the abdominal and uterine walls. This procedure is indicated in instances of previous section, primary and secondary uterine dystocia, cephalopelvic disproportion, placenta previa, abruptio placentas, toxemia, fetal distress (prolapsed cord), diabetes, Rh sensitization, tumors, previous vaginal surgery, abnormal presentation, and many others. In some instances, the cesarean section may be scheduled according to the estimated date of confinement, estimated fetal weight, and definite auscultation of fetal heartbeat at or before 20 weeks from the last menstrual period. At other times, Cesarean section may be performed on an emergency basis.
(2) Several methods for abdominal delivery are accepted: classic cesarean section, low or cervical cesarean section, extraperitoneal operation, and cesarean hysterectomy. The low segment section is today considered standard; however, the classic method may be chosen in some circumstances.
b. Patient Preparation.
(1) The extent of preoperative planning and preparation will depend on the urgency of the delivery and should be paced accordingly. Whole blood should be available. When the patient arrives in surgery, she may or may not be in labor. The circulator should auscultate the fetal heart tone with a fetuscope. The patient is positioned supinely on the table, and restraints are applied; the patient is never left unattended. A Foley retention catheter is inserted and connected to gravity drainage. Choice of anesthetic agent is made by the anesthesiologist after reviewing the condition of the mother and fetus.
(2) Adequate personnel should be available to individually care for the mother and child, since simultaneous urgent needs may arise.
c. Operative Procedure (Low Cervical Method).
(1) A 12- to 15-cm long skin incision is made from below the umbilicus to above the symphysis. As the incision is continued through the fascia and rectus muscles to expose the lower portion of the cervix, blood vessels may be clamped with Crile forceps and ligated with plain gut suture number 3-0.
(2) The exposed peritoneum is incised transversely with a scalpel and Metzenbaum scissors between the two round ligaments. By blunt dissection, the bladder is freed and retracted with the universal DeLee retractor to expose the lower segment of the uterus.
(3) Using a new scalpel blade and bandage scissors, the uterus may be opened either transversely in the manner of Kerr or longitudinally in the manner of Kronig. Using the Kerr
technique, a lunar incision is made through the myometrium extending to within one inch of each uterine artery.
(4) The membranes are ruptured and suction immediately applied.
(5) The fetal head is delivered by inserting a hand between the head and the symphysis, rotating the face posteriorly, and exerting upward traction. With the Kronig technique, the face is rotated anteriorly.
(6) The fetal body is delivered. The cord is double cross clamped with Rochester-Pean forceps and cut with bandage scissors. The baby is given to the assistant (pediatrician) for resuscitation and care.
(7) The placenta and all membranes are manually removed from the uterus.
(8) The uterine edges are grasped with Pennington clamps and a layered closure begun. A continuous suture of chromic gut number 0 or number 2-0 is placed through the deep myometrium (and possibly endometrium). A second layer of similar sutures is placed in the superior myometrium and serosa. A sponge count is taken as the uterine cavity is closed.
(9) A tubal ligation may be done at this time.
(10) The bladder flap of peritoneum is sutured to the visceral layer with a continuous chromic gut suture number 2-0 swaged to a taper-point needle.
(11) The fascia and skin are closed as for laparotomy. A pressure dressing is applied to the abdomen and a pad to the perineum.
