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Cesarean Delivery and Peripartum Hysterectomy. 부산백병원 산부인과 조인호. Definition. Birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterectomy). frequency. C/sec 이 증가한 이유. Women are having fewer children . The average maternal age is rising.

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cesarean delivery and peripartum hysterectomy

Cesarean Delivery and Peripartum Hysterectomy

부산백병원 산부인과


  • Birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterectomy)
c sec
C/sec이 증가한 이유
  • Women are having fewer children.
  • The average maternal age is rising.
  • The use of electronic fetal monitoring is widespread.
  • Breech presentation
  • The incidence of midpelvic forceps and vacuum deliveries has decreased.
  • Rates of labor induction continue to rise
  • The prevalence of obesity has risen
  • Concern for malpractice litigation
  • Concern over pelvic floor injury assocated with vaginal birth
Prior cesarean delivery
  • Dystocia
    • Secondary arrest of dilatation
    • Arrest of descent
    • Cephalopelvic disproportion
    • Failure to pregress
Fetal distress
    • Electronic monitor : 85% of labor in US (2002)
    • C/sec rate를 40%까지 높임.
    • Electronic monitor : cerebral palsy or perinatal death의 risk를 감소시키지 못함.
    • c/sec결정 후 30min이내 시행해야 함(AAP , ACOG 2002 guideline)
  • Breech presentation
    • Maternal, fetal morbidity & mortality가 유의 있게 증가함.
methods to decease cesarean delivery rates
Methods to Decease Cesarean Delivery Rates
  • Educating physicians, peer reviewing, encourage in a trial of labor after prior transverse cesarean delivery, and restricting cesarean deliveries for dystocia only to women who meet strictly defined criteria
maternal mortality and morbidity
Maternal Mortality and Morbidity
  • Mortality risk
    • 4배 (1992-1998, north Carolina)
    • Emergency : 9배 / elective : 3배 (1994-1996, UK, 2 million birth)
    • Source :
      • Pureperal infection, hemorrhage, thromboembolism
    • Obese women
patient choice cesarean delivery
Patient choice Cesarean Delivery
  • It has been argued that women should be able to choose to undergo elective cesarean delivery
  • Avoidance of
    • pelvic floor injury during vaginal birth
    • Reduction in the risk of fetal injury
  • Convenience
technique for cesarean delivery
Technique for Cesarean Delivery
  • Abdominal incisions
    • Midline vertical
    • Suprapubic transverse
vertical incision
Vertical Incision
  • Infraumbilical midline vertical : quickest
  • Level of ant. Rectal sheath, expose a strip of fascia in the midline about 2cm wide.
  • Rectal sheath were incised by scalpel or scissor
  • Rectus and pyramidalis m. are separated in the midline
  • Peritoneum is incised superiorly to the upper pole of the incision and down ward to just above the peritoneal reflection over the bladder
transverse incisions
Transverse Incisions
  • Modified Pfannenstiel incision
  • Pubic hairline and extend beyond the lat. borders of the rectus m.
  • Fascia is incised transversely the full length of the incision
  • Separates the fascial sheath from the underlying rectus m. (umbilicus level까지)
  • Then peritoneum is opened as earlier.
  • Advantage
    • Cosmetic advantage is apparent.
    • Stronger with less likelihood of dehiscence or hernia
  • Disadvatage
    • Exposure in some women is not as optimal
uterine incisions
Uterine incisions
  • Lower uterine segment transverse incision (by Kerr, 1926) : most often
  • Low-segment vertical incision (classic incision) (by Kronig, 1912)
  • Lower uterine segment transverse incsion의 장점
    • Easier to repair
    • 다음 임신 중 Rupture의 위험성 감소
    • Adherence of bowel or omentum to the incisional line의 감소
technique for transverse cesarean incision
Technique for Transverse Cesarean incision
  • Dextrorotated
  • Thick meconium or infected amnionic fluid
    • > prefer to lay a moistened laparotomy pack in each lateral pertoneal gutter to absorb fluid and blood.
  • The loose vesicouterine serosa is grasped with the forceps.
  • The hemostat tip points to the upper margin of the bladder
The loose serosa above the upper margin of the bladder is elevated and incised laterally (2cm wide)
  • Dissection of bladder- bladder flap- off uterus to expose lower uterine segment
  • In general, the separation of bladder should not exceed 5 cm in depth and usually less
The uterus is opened through the lower uterine segment about 1 cm below the upper margin of the peritoneal reflection
  • After entering the uterine cavity, the incision is extended laterally with either fingers or bandage scissors
  • Uterine incision large enough to allow delivery of the head and trunk of the fetus without either tearing into or having to cut into the uterine arteries and veins that course through the lateral margins of the uterus
delivery of the infant
Delivery of the Infant
  • In a cephalic presentation
    • Hand is slipped into the uterine cavity between the symphysis and fetal head
    • Head is elevated gently with the fingers and palm through the incision
    • Aided by modest transabdominal fundal pressure
  • After a long labor with CPD, the fetal head may be tightly wedged in the birth canal
    • Upward pressure exerted by a hand in the vagina by an assistant will help to dislodge the head and allow its delivery above the symphysis
The shoulders then are delivered using gentle traction plus fundal pressure
  • And oxytocin infusion (10-20IU/L at 10ml/min) Until the uterus contracts satisfactorily
The cord is clamped,
  • After infant is given to the team member
  • Uterus incision is observed for any vigorously bleeding sites
  • Promptly clamped with Pennington or ring forceps, or similar instruments
  • Placental buging through the uterine incision as the uterus contracts.
  • Fundal massage
    • Reduces bleeding
    • Hastens placental delivery
repair of the uterus
Repair of the Uterus
  • Exteriorization
    • Advantage
      • Relaxed, atonic uterus can be recognied quickly and massage applied
      • Bleeding point are visualized more easily and repaired.
      • Adnexal exposure is superior, and thus tubal sterilization is easier.
    • Disadvantage
      • Discomfort and vomiting under reginal analgesia
      • Febrile morbidity, blood loss의 증가
After placenta delivery, the uterine cavity is inspected and either suctioned or wiped out with a gauze pack to remove avulsed membranes, vernix, clots, and others.
  • The upper and lower cut edges and each angle of the uterine incision are examined carefully for bleeding vessels
  • The uterine incision is closed with one or two layers of continuous 1-0 absorbable suture. Traditionally, chromic suture was used.
The initial suture is placed just beyond one angle of the incision.
  • A running-lock suture is then carried out, with each suture penetrating the full thickness of the myometrium
    • If lower segment is thin, one layer of suture can be obtained.
    • Individual bleeding sites can be secured with figure-of-eight or mattress sutures.
  • Traditionally, serosal edges overlying the uterus and bladder have been approximated with a continous 2-0 chromic catgut suture.
abdominal closure
Abdominal Closure
  • Sponge and instrument counts are found to be correct, the abdominal incisionis closed in layers.
  • Peritoneal closure will help to pretect the bowel when fascial sutures are placed.
  • As each layer is closed, bleeding sites are located, clamped, and ligated.
  • Fascial closure
    • Interrupted 0 Nonabsorbable suture
    • Continuous, nonlocking suture of a long-lasting absorbable or permanents type
Subcutaneous tissure
    • Less than 2cm : need not to close
    • More than 2cm : should be closed
  • Skin
    • Vertical mattress sutres of 3-0, 4-0 silk or equivalent sutre
    • Running 4-0 subcuticular stitch using semipermanent suture
    • Skin clips.
technique for classical cesarean incision
Technique for Classical Cesarean Incision
  • Indication
    • Difficulty in exposing or safely entering the lower Ut. segment
      • Bladder is densely adherent from prev. surgery
      • Myoma occupies the lower Ut. seg.
      • Cx. has been invaded by cancer
    • T-lie
    • Placenta previa with ant. Implantation, especially placenta percreta
    • Fetus is very small, breech, low. Ut. Seg is not thinned out
    • Massive maternal obesity
uterine incision classic
Uterine Incision (Classic)
  • Beginning as low as possible with a scalpel
  • Above the level of the bladder
  • Incision is extended cephalad with bandage scissior
  • Until is is sufficiently long to permit delivery of the fetus
uterine repair classic
Uterine repair (Classic)
  • Approximate the deeper halves of the incision by continuous suture with chromic 0 or 1-0
  • Then outer halves were closed with similar suture
  • Assistant compress the uterus on each side of the wound
  • Uterine serosa are approximated with continuous 2-0 chromic catcut.
peripartum hysterectomy
Peripartum Hysterectomy
  • Life saving if there is severe obstetrical hemorrhage
  • 1 in every 200 c/sec (29,000 c/sec) (Shellhaas, 2001)
  • 1 in every 950 deliveries
  • 1 in 135 c/sec (26,700 c/sec)/ 1 in 1850 delivery -> 1 in every 500 deliveries (129,000 deliveries) (9years, Parkland Hospital, 2002)
peripartum hysterectomy indication
Peripartum HysterectomyIndication
  • Uterine atony (most common)
    • Kastner, 2002
    • Shellhaas, 2001
  • Laceration of major Uterine vessels
  • Placenta accreta
  • Large myomas
  • Severe cervical dysplasia, CIS
peripartum hysterectomy technique
Peripartum HysterectomyTechnique
  • Following delivery, the major bleeding vessels are clamped and ligated quickly
  • The placenta is removed
  • The uterine incision can be approximated with a continuous suture.
    • If bleeding is minimal, closure is not necessary
The round ligaments close to the uterus are divided and doubly ligated
  • The incision in the vesicouterine serosa is extended laterally and upward through the anterior leaf of the broad ligament to reach the incised round
The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tube, utero-ovarian ligaments and ovarian vessels
  • Then, these are doubly clamped close to the uterus
The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligaments
The bladder is further dissected from the lower uterine segment by blunt dissection with pressure directed towards the lower segment and not bladder.
  • Sharp dissection may be necessary
  • The bladder is dissected free for about 2 Cm below the lowest margin of the cervix to expose the uppermost part of the vagina
The ascending uterine artery and veins on either side are identified and near their origin are doubly clamped immediately adjacent to the uterus and divided
  • The vascular pedicle is doubly suture ligated
The cardinal and uterosacral ligaments and many large vessels the ligaments contain are doubly clamped systematically with Heaney curved clamps and incised and suture ligated
  • These steps are repeated until the level of the lateral vaginal fornix is reached
  • In this way, the descending branches of the uterine vessels are clamped, cut, and ligated
Immediately below the level of the cervix, a curved clamp is swung in across the lateral vaginal fornix, and the tissue is incised medially to the clamp
Each of the angles of the lateral vaginal fornix are secured to the cardinal and uterosacral ligaments
A running-lock stitch is placed through the edge of the vaginal mucosa
  • Some clinicians choose reperitonealization of the pelvis.
peripartum management preoperative care
Peripartum Management Preoperative Care
  • Hematocrit should be rechecked
  • Oral intake is stopped at least 8 hours before surgery
  • Antacid given shortly before the induction minimizes the risk of lung injury from gastric acid
  • Indwelling bladder catherter is placed
peripartum management intravenous fluids
Peripartum ManagementIntravenous Fluids
  • Hct of 30 or more and a normally expanded blood volume and extracellular fluid volume most often tolerates blood loss up to 1500 mL without difficulty
  • Blood loss averages about 1 L, but is quite variable
  • Lactated Ringer solution or a similar solution with 5 % dextrose, 1 to 2 L are infused during and immediately after the operation
peripartum management prevention of postop infection
Peripartum ManagementPrevention of postop. infection
  • Febrile morbidity is frequent after cesarean delivery
  • Ruptured membranes-> single 2g dose of a B-lactam drug, cephalosporin or an extended-spectrum penicillin
  • Up to 20% of women develops fever despite peripartum prophylactic antibiotics. (Goepfert, 2001)
peripartum management recovery suite
Peripartum ManagementRecovery Suite
  • Must be monitored closely
    • BP, urine flow ( > at least 30mL/hr )
    • amount of bleeding from the vagina
    • uterine fundus contraction
  • Effective analgesics
    • Meperidine 75~100 mg or morphine 10~15 mg, IM or IV
  • Encouraging deep breathing and coughing
peripartum management subsequent care
Peripartum ManagementSubsequent Care
  • Analgesia
    • Meperidine 75~100 mg or morphine sulfate 10~15 mg, IM every 3~4 hours as needed for discomfort
  • Vital Signs
    • BP, pulse, urine flow, amount of bleeding, and status of the uterine fundus evaluated at least hourly for 4 hours at the minimum
    • Thereafter, for the first 24 hours, these are checked at interval of 4 hours
Fluid Therapy and Diet
    • Rarely develops fluid sequestration in the third space after normal cesarean delivery
    • 3L of fluid should prove adequate during the first 24 hours after surgery
    • If urine output falls below 30mL/hr, then the woman should be reevaluated promptly
    • The cause of the oliguria may range from unrecognized blood loss to an antidiuretic effect from infused oxytocin
Bladder and Bowel Function
    • The bladder catheter most often can be removed by 12 hours after operation
    • In uncomplicated cases, solid food may be offered within 8 hours of surgery
    • adynamic ileus is of short duration
      • Symptoms
        • abdominal distention and gas pains,
        • an inability to pass flatus or stool
      • Treatment :
        • nasogastric decompression,
        • intravenous fluid,
        • electrolyte supplementation,
        • 10-mg bisacodyl rectal suppository
    • At least the day after surgery, with assistance, should get out of bed
    • With early ambulation, venous thrombosis and pulmonary embolism are uncommon
  • Wound care
    • Inspected each day
    • The skin sutures are removed on the fourth day after surgery
    • By the third postpartum day, bathing by shower is not harmful
    • Hct is routinely measured
  • Breast care
    • Breast feeding can be initiated by the day after surgery
    • If not to breast feed, a breast binder that supports the breasts without marked compression will usually minimize discomfort
  • Discharge from the Hospital
    • Generally discharged on the third or fourth postpartum day