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Youre going to suction what?!Cesarean Section
basics for FP

• Matthew Snyder, DO
• Obstetrics Fellow

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Overview

• Indications
• Dos Donts of first-assisting
• Post-operative management
• Post-partum counseling

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C/S Indications - Fetal

• Fetal Macrosomia (over 5000g, GDM 4500g)
• Multiple Gestations
• Fetal Intolerance to Labor
• Malpresentation / Unstable Lie Breech or
  Transverse presentation

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C/S Indications - Fetal

• Non-reassuring Fetal Heart Tracing
• Repetitive Variable Decelerations
• Repetitive Late Decelerations
• Fetal Bradycardia
• Fetal Tachycardia
• Cord Prolapse

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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

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C/S Indications Maternal/Fetal

• Abnormal Placentation
• Placenta previa
• Vasa previa
• Placental abruption
• Conjoined Twins
• Perimortem
• Failed Induction / Trial of Labor

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C/S Indications Maternal/Fetal

• Arrest Disorders
• Arrest of Descent (no change in station after 2
  hours, lt10 cm dilated)
• Arrest of Dilation (lt 1.2 cm/hr nullip lt 1.5
  cm/hr multip)
• Failure of Descent (no change in station after 2
  hours, fully dilated)

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C/S Indications Maternal/Fetal
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Surgical Instruments

• Uses
• Adson Skin
• Bonney Fascia
• DeBakey soft tissue, bleeders
• Russians uterus

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Surgical Instruments

• Uses
• Allis-Adair tissue, uterus
• Pennington tissue, uterus
• These are suitable for hemostasis use

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Surgical Instruments

• Uses
• Kocher clamp fascia, thicker tissues

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Surgical Instruments

• Uses
• Richardson general retractor
• Goelet subQ retractor
• Fritsch bladder blade

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Surgical Instruments

• Uses
• Mayo, curved fascia
• Metzenbaum, curved soft tissue
• Bandage scissors cord cutting, uterine extension

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First-assisting

• General principles
• Ensure proper exposure of the working field
• Anticipate next move and be proactive
• Listen carefully to surgeons instructions
• If unsure of surgeons preferences ASK!!
• Have good situational awareness

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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, dont make primary surgeon wait on
  you
• Assist draping pt., connecting suction bovie

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Cesarean Section Incision to Uterus

• Provide traction/counter-traction to increase
  exposure during skin and subQ incision

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Cesarean Section Incision to Uterus

• Be ready with DeBakey forceps to grab bleeders
  especially the Superficial Epigastric vessels

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Cesarean Section Incision to Uterus

• 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
  counter-traction, ensure adequate lighting

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Cesarean Section Uterine Incision to Delivery

• With bladder blade inserted, use Richardson to
  retract superior tissue for optimum exposure

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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

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Cesarean Section Uterine Incision to Delivery

• After incision is made, give adequate retraction
  if uterine extension is needed and prepare for
  fundal pressure
• Be ready for bladder blade removal on surgeons
  command before head delivery
• Once infant is delivered, either bulb suction
  infant or clamp/cut cord
• Hand infant off to waiting NRP staff

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Cesarean Section 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

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Cesarean Section 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

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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

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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

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Delayed Complications

• Subsequent Pregnancies
• Uterine rupture/dehiscence
• Abnormal placental implantation (accreta, etc)
• Repeat Cesarean section
• Adhesions
• Scaring/Keloids

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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 11 sterile saline/H2O2 mixture and
  pack with gauze
• May use prophylactic abx Keflex, Bactrim,
  Clinda
• KEY Close f/u and wound exploration

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Post-partum counselingPharm

• Continue PNV
• Colace
• Motrin 800 mg q8
• Percocet 1-2 tabs q4-6 for breakthrough
• OCP (start 4-6 wks post-partum)

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Post-partum counselingActivity

• No lifting objects over babys wt.
• Continue ambulation
• No strenuous activity
• NOTHING by vagina (sex, tampons, douches,
  bathtubs, hot tubs) for 6 wks!!

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Post-partum counselingIncision 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.
• Most attendings will have pt f/u in office in
  about 2 wks for wound check

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Post-partum counselingNotify 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

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Dos Donts of First-AssistingLast Thoughts

• Remember, Exposure is the key!
• Listen carefully to the surgeon
• Have good situational awareness
• Dont overlook post-op fever
• Have a low threshold for consulting surgeon if
  indications warrant

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Summary

• Indications
• Dos Donts of first-assisting
• Post-operative management
• Post-operative complications
• Post-partum counseling

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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