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“You’re going to suction what?!” Cesarean Section basics for FP. Matthew Snyder, DO Obstetrics Fellow. Overview. Indications Do’s & Don’ts of first-assisting Post-operative management Post-partum counseling. C/S Indications - Fetal. Fetal Macrosomia (over 5000g, GDM – 4500g)

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you re going to suction what cesarean section basics for fp

“You’re going to suction what?!”Cesarean Section basics for FP

Matthew Snyder, DO

Obstetrics Fellow

overview
Overview
  • Indications
  • Do’s & Don’ts of first-assisting
  • Post-operative management
  • Post-partum counseling
c s indications fetal
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 fetal4
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
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
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 fetal7
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)
surgical instruments
Surgical Instruments
  • Uses:
    • Adson: Skin
    • Bonney: Fascia
    • DeBakey: soft tissue, bleeders
    • Russians: uterus
surgical instruments10
Surgical Instruments
  • Uses:
    • Allis-Adair: tissue, uterus
    • Pennington: tissue, uterus
    • These are suitable for hemostasis use
surgical instruments11
Surgical Instruments
  • Uses:
    • Kocher clamp: fascia, thicker tissues
surgical instruments12
Surgical Instruments
  • Uses:
    • Richardson: general retractor
    • Goelet: subQ retractor
    • Fritsch bladder blade
surgical instruments13
Surgical Instruments
  • Uses:
    • Mayo, curved: fascia
    • Metzenbaum, curved: soft tissue
    • Bandage scissors: cord cutting, uterine extension
first assisting
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
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 uterus
Cesarean Section: Incision to Uterus
  • Provide traction/counter-traction to increase exposure during skin and subQ incision
cesarean section incision to uterus17
Cesarean Section: Incision to Uterus
  • Be ready with DeBakey forceps to grab bleeders – especially the Superficial Epigastric vessels
cesarean section incision to uterus18
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
cesarean section uterine incision to delivery
Cesarean Section: Uterine Incision to Delivery
  • With bladder blade inserted, use Richardson to retract superior tissue for optimum exposure
cesarean section uterine incision to delivery20
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 uterine incision to delivery21
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 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 closure
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
cesarean section closure23
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
post operative care
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 care25
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
Delayed Complications
  • Subsequent Pregnancies
    • Uterine rupture/dehiscence
    • Abnormal placental implantation (accreta, etc)
    • Repeat Cesarean section
  • Adhesions
  • Scaring/Keloids
wound dehiscence
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
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
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
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.
  • Most attendings will have pt f/u in office in about 2 wks for wound check
post partum counseling notify md do
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
Do’s & Don’ts of First-AssistingLast 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
Summary
  • Indications
  • Do’s & Don’ts of first-assisting
  • Post-operative management
  • Post-operative complications
  • Post-partum counseling
references
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