Ch 18-Cesarean
-22% of live births in US are C-section, primaries account for 14.5%
-ACOG goals: FTP/CPD 2-4%, repeat 2-6%, breech/malpresentation 1.3-3.5%, 
fetal distress 1.5-3%, bleeding 1%
-c/s rate incr w/ age likely d/t incr dystocia and medical problems
-no reduction in rate of CP despite incr in c/s rate
-rates in teaching hospital 20% vs. 24.7% in others
-mat mortality 6-22:100,000 births; 1/3-1/2 directly result of c/s

Indications
Fetal-sig nonremediable & nonreassuring FHR, breech, cord prolapse, VLBW 
fetus, active herpes
Mat-Fetal-previa, abruption, dystocia
Mat-lg obstructing tumor, lg condylomata, perm abd cerclage

Incisions
-midline, Pfannenstiel, Maylard
	-vertical allow rapid access
	-transverse cosmetically better, less painful, lower risk herniation
-apply traction perpendicular to incision to make curvilinear
-Maylard-transverse incision of rectus muscles
	-less dissection & retraction, repeat easier
	-need to ligate inf epigastrics
-enter fascia by scissors or scalpel
-avoid incision on underside of pannicula d/t incr risk infection
-obese have wound infection 29%, nonobese 4%
	-subq closure if >2 cm fat to decr wound disruption
Uterus
-low transverse: less risk entering upper uterine segment, ease of entry, 
decr blood loss, less repair, easier reperitonealization, less adhesions, 
allows for VBAC
-low vertical: use for poorly dev lower uterine segment, preterm breech or 
transverse lie
-classic: rapid entry to uterus, but incr adhesions, incr risk uterine 
rupture
-incise vesicouterine serosa and extend bilat bluntly
-incise uterus 1-2 cm above upper border bladder
-may extend sl upward to lat margins either sharply or bluntly, want to 
avoid vessels
-if ant placenta: dissect through, separate from lower uterine segment or 
use classical incision

Delivery
-elevate and flex head thru incision, then fundal pressure
-preterm fetus: 50% will require classic or low vertical for malpresentation 
or poorly dev segment
	-undev segment does not allow for wide enough transverse incision
	-more common injury to bladder, broad ligament laceration & uterine artery 
laceration regardless of incision
Breech: grasp feet and pull thru incision, min hyperextension of head
-give pit following delivery
-placenta: manual removal has incr blood loss & infection (23 vs. 3%)

Closing Up
+/- exteriorization of uterus, clean w/ lap sponge
-reapprox in 1 or 2 layers w/ 0 or 00 chromic of Vicryl
+/- locking sutures: better hemostasis, but incr risk tissue ischemia
-incr rate of rupture w/ one layer
-closure of classic often requires 2-3 layers
-most don’t close bladder flap & peritoneum
	-decr pain & quicker rtn bowel function
+/- repair of rectus
-no chromic in fascia d/t fast breakdown
-Vicryl or Maxon if concerned about poor healing (DM, steroid use)
-reapprox subq if obese

Intraop Complications
-uterine lac from extension of incision
	-watch for ureter injury if lat extension
-bladder injury more common w/ repeat, may also occur @ time of hysterectomy 
in 4-5%
	-repair w/ 2 or 3-0 chromic
	-leave catheter for 7-10 days
-ureteral injury in 1:1000, usually during efforts to control bleeding
-bowel injury 1:1300
	-prior abd surgery incr risk
	-small serosal defects closed w/ int silk
	-full thickness running or int 3-0 absorbable in 2-3 layers
	-consider gen surg c/s if sigmoid, lg intestine or lg defect
	-consider colostomy if fecal contaminant
	-broad abx coverage
-atony: oxytocin, methergine, hemabate
-placenta accreta: if focal may excise & oversew bleeding areas w/ figure of 
8
	-o/w consider hyst
-postmortem c/s should be initiated in 4-5 min of arrest
	-incr survival: viable age, delivery w/in 10 min, avail staff & equip for 
neonatal resuscitation
	-outcome often poor
-fluids should be 100-125 ml/hr in labor to account for fluid losses
-intraop 500-1000 ml/hr to max 3 L in 4 hrs

Post op complications
-endomyometritis: 35-40% if no abx, 5% if ppx abx
-wound infection 2.5-16.1%, if chorio approx 20%
	-E. coli, P. mirabilis, Bacteroides & GBS
	-decr risk: hair removal @ incision (not pubic), skin prep, sterile 
technique, wound hemostasis, ppx abx, avoidance of plain gut sutures and 
unnecessary suture material, closed system drainage, skin closure w/ suture 
and delayed closure if gross contaminated w/ stool
-if infected, open wound for drainage and debride margins
	-pack w/ wet to dry tid until good granulation
	-consider 2ndary intention vs. closure once controlled
-dehiscence 5% of infections
	-must be closed in OR under sterile conditions
-if persistent fever on abx consider imaging to determine source
-UTIs 2-16% after c/s
-common for nausea or distention 24 hr post d/t anesthesia and narcs
-ileus if prolonged n/v, absence of BS or no flatus
	-NPO, adequate fluids, if persists NG tube
-mechanical obstruction: high pitched BS, n/v w/ distention
	-try conservative tx as above
	-if fails consider exp lap
-DVT 0.24% all deliveries; 3-5x higher w/ c/s
-risk: obesity, incr age, incr parity, inability to ambulate
-if untx 15-25% will get PE, 15% fatal
-if tx 4.5% w/ PE, 0.7% death
-unilat swelling, pain & tenderness, >2cm circ difference, edema, palp cord, 
change in leg color
-PE: tachypnea (90%), dyspnea (80%), pleuritic chest pain (>70%), 
apprehension (60%), tachycardia (40%) & cough (>50%)
	-Dopplers 90% for prox, 50% for calf
	-check ABG, CXR, EKG, PT/PTT, give O2
	-start heparin w/ dx
-septic pelvic thrombophlebtis 0.5-2% of pts w/ wound infection
	-mainly dx of exclusion, usually on R side
	-fever and unilat pain
-provide adequate analgesia to prevent atelectasis
-early ambulation-improves lung function, rtn of bowel & bladder
-sit up at 8-12 hrs, ambulate 1st day, shower 2nd day
-diet clinician dependent
-Foley out 12-24 hrs unless complications
-cover incision 1st day w/ light dressing
-expect Hct to decr 2-3% during 48 hrs after surgery
-to home usually day 2-5
-limit activity to care of newborn 1st week
-nl activity by 3-4 weeks

Strategies to Decr C/S Rate
-active management of labor
-strict def of dystocia
-offer VBAC-TOL
-careful interpretation of FHR
-VBAC successful in 60-80%
	-must have surgical team immed avail
->2 prior c/s have definite incr rate of rupture
-careful w/ prostaglandins
-greater success if non-recurring indication or previous VD (82-86%)
-dystocia 67% success rate
-+/- macrosomic infants less successful (>4000g)
-no assoc of extent of dilation w/ future success
-limited data on low vertical incision
-classic w/ 12% uterine rupture
	-deliver when fetal lung maturity
-better success if early response to oxytocin
-oxytocin may incr rate of rupture if used in latent phase or dysfunctional 
labor
-miso assoc w/ incr rate rupture, PGE gel ok
-may see fetal distress or lack of pressure w/ IUPC
-no routine uterine exploration after del
-asx dehiscence in <2% prior to c/s
-no diff in fetal mortality btw elective repeat and VBAC if discount IUFD, 
VLBW, congenital anomalies
-risks of fetal morbidity low w/ rupture if monitored
-inability to determine type of incision should not prevent TOLAC
-repeat when >39 wks or documented lung maturity
-if BTL needed, decr morbidity PP vs. @ time of c/s

Informed Consent
Professional Approach: customary practice in community
-usually discuss hemorrhage, infection & anesthesia cx
-not usually injury to nearby organs
-if d/t malpresentation discuss fetal benefits
-consider risk for hyst and transfusion if repeat
Pt Viewpoint: what reasonable pt would want
-discuss all risks even if rare if has serious consequences
? signed vs. just documentation of discussion

Peripartum Hysterectomy
-usually unplanned to control bleeding after conservative measures fail
-incr risk if previous c/s d/t abnl placenta and rupture
-most common cause accrete or percreta (64%), atony (21%)
-uterine rupture 0.2-0.8%
-occ “nonemergency” for large fibroids, malignancy
-emergency more often subtotal
-23% w/ hyst for atony have no RF
-mortality rate 3.2/100,000
Technique
-early adequate displacement of bladder from lower uterine segment & cervix
-overlapping sutures for vascular pedicles
-selective placement of clamps & sutures to control bleeding
-periodic inspection of bladder for injury
-localization of ureter if lat extension
-avoid excessive removal of vag length
-blood loss 500-1000 ml greater than in nonpregnant hyst
-perform usual c/s w/ more extended bladder flap laterally
-may reapproximate uterine incision
-exteriorize uterus
-mobilize bladder if not already done
-clamp round ligaments, then cut and ligate
-place utero-ovarian clamps & tie ovarian end
-clamp & cut utero-ovarian ligament & fallopian
-some then incise broad ligament & isolate uterine veins
-2-3x clamp asc uterine vessels, avoiding ureter
Subtotal
-if difficult or excessive bleeding may be quicker
-cut at level above pedicles
-close stump w/ figure of 8
-some ligate uterine vessels @ angle of cx to decr bleeding
Total
-if more stable, perform as above, then…
-separate cx from cardinal and uterosacral ligament & vagina
-clamp & cut cardinal & uterosacral ligaments 1-2x
-lower segment well dev may need >1 pedicle fro cardinal ligaments
-incise cx from vag w/ scalpel, avoid leaving cx or taking excessive vag 
length
-use Mayo’s to remove circumferentially
-clamp vag cuff
-secure angles to cardinal ligament & uterosacral ligament
0may leave cuff open to allow blood or serous material to drain
-if closed use 1-2 layers if pelvis dry w/ int figure of 8 or continuous
-may leave open by running locked circ suture @ margin to min bleeding
-may reperitonealize w/ cont suture reapproximate med & lat leaves of broad 
ligament
-then approx ant vesicouterine peritoneum over vag vault to cul de sac 
peritoneum