Transcript Cesarean for FP

Cesarean Section Basics for FP
Matthew Snyder, DO
Family Medicine/Obstetrics
Overview
Indications
 Do’s & Don’ts of first-assisting
 Post-operative management
 Post-partum counseling

Objectives

List 3 maternal and fetal indications for
performing a C/S

Identify the primary surgical instruments
used in C/S

List 5 potential complications associated
with C/S
C/S Indications - Fetal
Fetal Macrosomia (over 5000g, GDM –
4500g)
 Multiple Gestations
 Fetal Intolerance to Labor
 Malpresentation / Unstable Lie – Breech
or Transverse presentation

C/S Indications - Fetal

Non-reassuring Fetal Heart Tracing
◦
◦
◦
◦
◦
Repetitive Variable Decelerations
Repetitive Late Decelerations
Fetal Bradycardia
Fetal Tachycardia
Cord Prolapse
C/S Indications - Maternal
Elective Repeat C/S
 Maternal infection (active HSV, HIV)
 Cervical Cancer/Obstructive Tumor
 Abdominal Cerclage
 Contracted Pelvis

◦ Congenital, Fracture

Medical Conditions
◦ Cardiac, Pulmonary, Thrombocytopenia
C/S Indications – Maternal/Fetal

Abnormal Placentation
◦ Placenta previa
◦ Vasa previa
◦ Placental abruption
Conjoined Twins
 Perimortem
 Failed Induction / Trial of Labor

C/S Indications – Maternal/Fetal

Arrest Disorders
◦ Arrest of Descent (no change in station after
2 hours, <10 cm dilated)
◦ Arrest of Dilation (< 1.2 cm/hr nullip; < 1.5
cm/hr multip)
◦ Failure of Descent (no change in station after
2 hours, fully dilated)
C/S Indications – Maternal/Fetal
Surgical Instruments

Uses:
◦ Adson: Skin
◦ Bonney: Fascia
◦ DeBakey: soft tissue,
bleeders
◦ Russians:
uterus/muscle
Surgical Instruments

Uses:
◦ Allis-Adair: tissue,
uterus
◦ Pennington: tissue,
uterus
◦ These are suitable for
hemostasis use
Surgical Instruments

Uses:
◦ Kocher clamp: fascia,
thicker tissues
Surgical Instruments

Uses:
◦ Richardson: general
retractor
◦ Goelet: subQ retractor
◦ Fritsch bladder blade
Surgical Instruments

Uses:
◦ Mayo, curved: fascia
◦ Metzenbaum, curved: soft
tissue
◦ Bandage scissors: cord
cutting, uterine extension
First-assisting

General principles:
◦
◦
◦
◦
◦
Ensure proper exposure of the working field
Anticipate next move and be proactive
Listen carefully to surgeon’s instructions
If unsure of surgeon’s preferences – ASK!!
Have good situational awareness
Cesarean Section

Preparation phase:
◦ Ensure pt is moved to OR in timely fashion –
strong, respectful encouragement to staff may
be necessary
◦ Ensure good FHT before prepping!!
◦ If possible, don’t make primary surgeon wait
on you
◦ Assist draping pt., connecting suction & bovie
Cesarean Section:
Incision to Fascia

Provide traction/counter-traction to increase
exposure during skin and subQ incision
Cesarean Section:
Incision to Fascia

Be ready with DeBakey forceps to grab bleeders –
especially the Superficial Epigastric vessels
Cesarean Section:
Fascial Incision to Peritoneum
Use Richardson retractors in superior/lateral fashion
to assist in incising rectus fascia
 Assist with elevating superior and inferior edges of
rectus fascia with Kocher clamps, provide countertraction, ensure adequate lighting

Cesarean Section:
Peritoneal Incision/Bladder Flap Creation

With bladder blade inserted, use Richardson to
retract superior tissue for optimum exposure
Cesarean Section:
Uterine Incision to Delivery

With pressure applied to suction tip, suction uterine
incision during passes of scalpel to ensure adequate
visualization and prevent fetal injury
Cesarean Section:
Delivery of Infant
After incision is made, give adequate
retraction if uterine extension is needed
and prepare for fundal pressure
 Be ready for bladder blade removal on
surgeon’s command before head delivery
 Once infant is delivered, either bulb
suction infant or clamp/cut cord
 Hand infant off to waiting NRP staff

Cesarean Section:
Hysterotomy Closure
Use a moist lap sponge to wrap uterus and
retract once placenta is delivered
 Facilitate closure of the uterine incision by
ensuring locking of suture by flipping suture
loop over needle

Cesarean Section:
Rectus Fascia closure & Subcut/skin closure
Assist with maintaining hemostasis,
irrigating rectouterine pouch and gutters
and closure of fascia/skin
 Fascia closed with non-locking suture –
do not want to strangulate vessels
 SubQ space closed if over 2 cm depth
 If needed, clear lower uterine segment
and vagina of clots once skin is closed and
dressed

Post-Operative Care
Pt. must urinate within four hours of
Foley removal, otherwise replace Foley
for another 12 hours
 Any fever post-op MUST be investigated

◦
◦
◦
◦
Wind: Atelectasis, pneumonia
Water: UTI
Walking: DVT, PE, Pelvic thromboembolism
Wounded: Incisional infection,
endomyometritis, septic shock
Post-Operative Care





In the first 12-24 hours, the dressing may become
soaked with serosanguinous fluid – if saturated,
replace dressing otherwise no action needed
After Foley is removed (usually within 12 hours
post-op), encourage ambulation of halls, not just
room
Dressing may be removed in 24-48 hours post-op
(attending specific), use maxipad
Ensure pt. is tolerating PO intake, urinating well and
has flatus before discharge
Watch for post-op ileus
Delayed Complications

Subsequent Pregnancies
◦ Uterine rupture/dehiscence
◦ Abnormal placental implantation (accreta, etc)
◦ Repeat Cesarean section
Adhesions
 Scaring/Keloids

Wound Dehiscence





Noted by separation of wound usually during staple
removal or within 1-2 weeks post-op
Must explore entire wound to determine depth of
dehiscence (open up incision if needed) – if through
rectus fascia, back to the OR
If dehiscence only in subQ layer, debride wound daily
with 1:1 sterile saline/H2O2 mixture and pack with
gauze
May use prophylactic abx – Keflex, Bactrim, Clinda
KEY: Close f/u and wound exploration
Post-partum counseling:
Pharm
Continue PNV
 Colace
 Motrin 800 mg q8
 Percocet 1-2 tabs q4-6 for breakthrough
 OCP (start 4-6 wks post-partum)

Post-partum counseling:
Activity
No lifting objects over baby’s wt.
 Continue ambulation
 No strenuous activity
 NOTHING by vagina (sex, tampons,
douches, bathtubs, hot tubs) for 6 wks!!

Post-partum counseling:
Incision Care
Only showers – light washing
 If pt has steristrips, should fall off in 7-10
days, otherwise use warm, wet washcloth
to remove
 If pt has staples – removal in 3-7 days
outpt.
 F/u in office in about 2 wks for wound
check

Post-partum counseling:
Notify MD/DO







Fever (100.4)/Chills
HA
Vision changes
RUQ/Epigastric pain
Mastitis sx
Increasing abd. pain
Erythema/Induration/
increasing swelling
around incision






Purulent drainage
Serosanguinous drainage
over half dollar size on
pad
Wound separation
Purulent vaginal
discharge
Vaginal bleeding over 1
pad/hr or golf ball size
clots
Calf tenderness
Do’s & Don’ts of First-Assisting
Last Thoughts





Remember, Exposure is the key!
Listen carefully to the surgeon
Have good situational awareness
Don’t overlook post-op fever
Have a low threshold for consulting surgeon if
indications warrant
Summary
Indications
 Do’s & Don’ts of first-assisting
 Post-operative management
 Post-operative complications
 Post-partum counseling

References
Cunningham, F., Leveno, Keith, et al.
Williams Obstetrics. 22nd ed., New York,
2005.
 Gabbe, Steven, Niebyl, Jennifer, et al.
Obstetrics: Normal and Problem
Pregnancies. 4th ed., Nashville, 2001.
 Gilstrap III, Larry, Cunningham, F., et al.
Operative Obstetrics. 2nd ed., New York,
2002.
 www.uptodateonline.com
