Cesarean Section Basics for FP Matthew Snyder DO

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 5000 g, GDM – 4500 g) �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 ◦ De. Bakey: 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: sub. Q 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 sub. Q incision

Cesarean Section: Incision to Fascia �Be ready with De. Bakey 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 counter-traction, 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 �Sub. Q 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 postop (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 sub. Q layer, debride wound daily with 1: 1 sterile saline/H 2 O 2 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 q 8 �Percocet 1 -2 tabs q 4 -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 710 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 Purulent drainage HA Serosanguinous drainage over half Vision changes RUQ/Epigastric pain Mastitis sx Increasing abd. pain Erythema/Induration/ increasing swelling around incision 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. 22 nd ed. , New York, 2005. �Gabbe, Steven, Niebyl, Jennifer, et al. Obstetrics: Normal and Problem Pregnancies. 4 th ed. , Nashville, 2001. �Gilstrap III, Larry, Cunningham, F. , et al. Operative Obstetrics. 2 nd ed. , New York, 2002. �www. uptodateonline. com