Cesarean Delivery
Defines the birth of a fetus via laparotomy and then hysterotomy.
Two general types of cesarean delivery
1) Primary: refers to a first-time hysterotomy
2) Secondary: denotes a uterus with one or more prior hysterotomy
incisions.
Neither definition includes removal of the fetus from the abdominal cavity
in the case of uterine rupture or with abdominal pregnancy.
Rarely, Hysterotomy is performed in a woman who has just died or in whom
death is expected soon postmortem or perimortem cesarean delivery
Most often because of emergent complications such as intractable hemorrhage,
Abdominal Hysterectomy is indicated following delivery.
When performed at the time of cesarean delivery, the operation is termed
Cesarean Hysterectomy.
If done within a short time after delivery, it is termed Postpartum
Hysterectomy.
Peripartum hysterectomy is a broader term that combines these two.
Hysterectomy is total, but Supracervical Hysterectomy is also an option.
Adnexa are not typically removed.
CESAREAN DELIVERY IN THE UNITED STATES
The reasons for the continued increase in the cesarean rates are the following:
1) Women are having fewer children, thus, a greater percentage of births are
among nulliparas, who are at increased risk for cesarean delivery.
2) The average maternal age is rising, and older women, especially nulliparas, are
at increased risk of cesarean delivery.
3) Use of electronic fetal monitoring is widespread.
This technique is associated with an increased cesarean delivery rate
compared with intermittent fetal heart rate auscultation
Cesarean delivery performed primarily for fetal distress comprises only a
minority of all such procedures.
Concern for an abnormal or non-reassuring fetal heart rate tracing
lowers the threshold for cesarean delivery.
4) Most fetuses presenting as breech are now delivered by cesarean.
Concern for fetal injury, as well as the infrequency with which a breech
presentation meets criteria for a labor trial, almost guarantee that most will
be delivered by cesarean.
5) Frequency of forceps and vacuum deliveries has decreased
6) Rates of labor induction continue to rise, and induced labor, especially among
nulliparas, increases the cesarean delivery rate
7) Prevalence of obesity has risen dramatically, and obesity increases the
cesarean delivery risk
8) Rates of cesarean delivery for women with preeclampsia have increased,
whereas labor induction rates for these patients have declined.
9) Vaginal birth after cesarean (VBAC) has decreased from a high of 28% in 1996
to 8% in 2007
10) Elective cesarean deliveries are increasingly being performed for a variety of
indications including concern for pelvic floor injury associated with vaginal birth,
medically indicated preterm birth, reduction of fetal injury risk, and for maternal
request.
11) Malpractice litigation related to fetal injury during spontaneous or operative
vaginal delivery continues to contribute significantly to the present cesarean
delivery rate.
CESAREAN DELIVERY INDICATIONS AND RISKS
More than 85% of these operations are performed for four reasons
1) Prior cesarean delivery
2) Dystocia
3) Fetal jeopardy
4) Abnormal fetal presentation
Maternal Mortality and Morbidity
To provide accurate informed consent, understanding both maternal and
neonatal risks and benefits with surgery is essential
Cesarean delivery has higher maternal surgical risks for the current and
subsequent pregnancies.
This is balanced against lower rates of perineal injury and short-term
pelvic floor disorders
For the neonate, cesarean delivery offers lower rates of birth trauma and
stillbirth.
Rates of initial respiratory difficulties are greater with cesarean delivery.
For the mother, death attributable solely to cesarean delivery is rare in the
United States.
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy
Numerous studies attest to increased mortality risks maternal mortality rates of
2.2 per 100,000 cesarean deliveries compared with 0.2 per 100,000 vaginal
births
Maternal mortality rate of 13 per 100,000 with elective repeat cesarean
delivery compared with 4 per 100,000 women undergoing a trial of labor
during VBAC attempt.
Similar to mortality rates, the frequency of some maternal complications is
increased with all cesarean compared with vaginal deliveries
Maternal morbidity rates increased twofold with cesarean compared with vaginal
delivery.
Principal among these are infection, hemorrhage, and thromboembolism
Anesthetic complications, which also rarely include death, have a greater
incidence with cesarean compared with vaginal delivery
Adjacent organs may be injured.
Bladder laceration rate is 1-3 per 1000 cesarean deliveries, ureteral injury
approximates 0.3 per 1000 cases
Bowel damage occurs in approximately 1 in 1000 cesarean deliveries
Women expressing a desire for elective primary cesarean delivery may be
counseled that surgery offers decreased risks for hemorrhage and
chorioamnionitis compared with planned primary vaginal birth.
Balanced against higher maternal rates of thromboembolism,
hysterectomy, and rehospitalization for infection or wound complications;
longer initial hospital stays; and greater rates of uterine rupture or
abnormal placental implantation in subsequent pregnancies
Women who undergo a cesarean delivery are much more likely to be delivered
by a repeat operation in subsequent pregnancies.
Women undergoing subsequent cesarean, the maternal risks just are
even greater
As an advantage, there is evidence that cesarean delivery is associated with
lower rates of urinary incontinence and pelvic organ prolapse
This protective advantage may persist to some degree over time, but
cesarean delivery is not wholly protective
Cesarean delivery is not protective long-term for fecal incontinence
Neonatal Morbidity
Cesarean delivery is associated with less risk of fetal trauma
Influences the choice of cesarean delivery despite the associated
maternal risks.
Fetal injury complicated 1% of cesarean deliveries.
Skin laceration was most common, but others included
Cephalohematoma
Clavicular Fracture
Brachial Plexopathy
Skull Fracture
Facial Nerve Palsy
Cesarean deliveries following a failed operative vaginal delivery attempt had the
highest injury rate
Page 1 of 12
 Lowest rate 0.5% occurred in the elective cesarean delivery group. 39 (p. 720), can be completed at this time.
Approximately a third of pregnant women who were delivered at Parkland Timing of Scheduled Cesarean Delivery
Hospital entered spontaneous labor at term,
96% of these delivered vaginally without adverse neonatal
Adverse neonatal sequelae from neonatal immaturity with elective
outcomes. delivery before 39 completed
Although physical injury risks are lower, cesarean delivery per se may have no weeks are appreciable (Clark, 2009; Tita, 2009a). To avoid these,
bearing on the neurodevelopmental prognosis of the infant. assurance of fetal maturity before
scheduled elective surgery is essential as outlined by the American
Patient Choice in Cesarean Delivery Academy of Pediatrics and the
Reasons for requested cesarean delivery include
Reduced risk of fetal injury
American College of Obstetricians and Gynecologists (2012) and
Avoidance of the uncertainty and pain of labor discussed in Chapter 31 (p. 615).
Protection of pelvic floor support To assist with this and other components of cesarean delivery
Convenience. planning, the American College of
Concept of informed free choice by the woman, and the autonomy of the Obstetricians and Gynecologists (2011a,c) has created Patient
physician in offering this choice. Safety Checklists to be completed
Data comparing planned cesarean and planned vaginal delivery were minimal
and thus should be interpreted cautiously.
before the planned surgery.
Cesarean delivery on maternal request should not be performed before 39 Perioperative CareIf cesarean delivery is scheduled, a sedative may
weeks gestation unless there is evidence of fetal lung maturity. be given at bedtime the night before surgery. In
It should be avoided in women desiring several children because of the general, no other sedatives, narcotics, or tranquilizers are
risk of placental implantation abnormalities and cesarean hysterectomy. administered until after the fetus is born.
It should not be motivated by the unavailability of effective pain management.
Oral intake is stopped at least 8 hours before the procedure. The
woman scheduled for repeat
PATIENT PREPARATION cesarean delivery typically is admitted the day of surgery and
Delivery Availability evaluated by the obstetrical and
There is no nationally recognized standard of care that codifies an anesthesia teams. Recently performed hematocrit and indirect
acceptable time interval to begin Coombs test are reviewed, and if the
performance of a cesarean delivery. Previously, a 30-minute latter is positive, then availability of compatible blood must be
decision-to-incision interval was ensured.
recommended. In most instances, however, operative delivery is not As discussed in Chapter 25 (p. 509), regional analgesia is preferred
necessary within this 30-minute for cesarean delivery. An
time frame. Bloom and coworkers (2001) reported for the Maternal- antacid is given shortly before regional analgesia or induction with
Fetal Medicine Units Network general anesthesia. One example
that 69 percent of 7450 cesareans performed in labor commenced is Bicitra, 30 mL orally in a single dose. This minimizes the lung injury
more than 30 minutes after the risk from gastric acid
decision to operate. In a second study, Bloom and colleagues (2006) aspiration. Once the woman is supine, a wedge beneath the right hip
evaluated cesarean deliveries creates a left lateral tilt to aid
performed for emergency indications. They reported that failure to venous return and avoid hypotension. According to the American
achieve a cesarean delivery College of Obstetricians and
decision-to-incision time of less than 30 minutes was not associated Gynecologists (2010), there are insufficient data to determine the
with a negative neonatal value of fetal monitoring before
outcome. On the other hand, when faced with an acute, catastrophic scheduled cesarean delivery in women without risk factors. That said,
deterioration in fetal condition, fetal heart sounds should be
cesarean delivery usually is indicated as rapidly as possible, and documented in the operating room prior to surgery.
thus purposeful delays are For further preparation, if hair obscures the operative field it should
inappropriate. The American Academy of Pediatrics and the be removed the day of
American College of Obstetricians and surgery by clipping. This is associated with fewer surgical site
Gynecologists (2012) recommend that facilities giving obstetrical infections compared with shaving
care should have the ability to (Tanner, 2011). An indwelling bladder catheter is typically placed at
initiate cesarean delivery in a time frame that best incorporates Parkland Hospital to collapse
maternal and fetal risks and benefits. the bladder away from the hysterotomy incision, to avert urinary
Informed Consent retention secondary to regional
Obtaining informed consent is a process and not merely a medical analgesia, and to allow accurate postoperative urine measurement.
record document (American Small studies support the nonuse
College of Obstetricians and Gynecologists, 2012a). This of catheterization in hemodynamically stable women to minimize
conversation between a clinician and urinary infections (Li, 2011; Nasr,
patient should enhance a womans awareness of her diagnosis and 2009).
contain a discussion of medical The risk of thromboembolism is increased with pregnancy and almost
and surgical care alternatives, procedure goals and limitations, and doubled in those undergoing
surgical risks. For women with a cesarean delivery (James, 2006). For this reason, for all women not
prior cesarean delivery, the option of a trial of labor should be already receiving
included for suitable candidates. thromboprophylaxis, the American College of Obstetricians and
Also, in those desiring permanent sterilization, consenting for tubal Gynecologists (2011d) recommends
ligation, as described in Chapter
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 2 of 12
initiation of pneumatic compression hose before cesarean delivery. not (Reid, 2001; Starr, 2005; Yildirim, 2012). Vaginal cleansing is not
These are usually discontinued a part of preoperative
once the woman ambulates. In contrast, we favor the preparation at Parkland Hospital.
recommendations of American College of Chest Antibiotic prophylaxis against infective endocarditis is not
Physicians for early ambulation for women without risk factors who recommended for most with cardiac
are undergoing cesarean delivery conditionsexceptions are women with cyanotic heart disease,
(Bates, 2012). For women already receiving prophylaxis or those with prosthetic valves, or both (American
increasing risk factors, College of Obstetricians and Gynecologists, 2011b). Regimens
prophylaxis is escalated as discussed in Chapter 52 and shown in selected for routine cesarean infection
Table 52-8 (p. 1046). prophylaxis will also serve as appropriate endocarditis coverage
Some women scheduled for cesarean delivery have concurrent (Chap. 49, p. 991).
comorbidity that requires specific Surgical Safety
management in anticipation of surgery. Among others, these include The Joint Commission (2013) established a protocol to prevent
insulin-requiring or gestational surgical errors that encompasses
diabetes, coagulopathy or thrombophilia, chronic corticosteroid use, three components: (1) preprocedure verification of all relevant
and significant reactive airway documents, (2) marking the operative
disease. Preparations for surgery in these women are discussed in site, and (3) completion of a time out before procedure initiation.
the respective chapters covering The time out requires attention
these topics. of the entire team to confirm that the patient, site, and procedure are
Infection Prevention correct. Important discussions
Febrile morbidity is frequent after cesarean delivery. Numerous good- also include introduction of the patient-care team members,
quality trials have proved that verification of prophylactic antibiotics,
that a single dose of an antimicrobial agent given at the time of estimation of procedure length, and communication of anticipated
cesarean delivery significantly complications. Additionally,
decreases infection morbidity. Although more obvious for women requests for special instrumentation should be addressed
undergoing unscheduled cesarean preoperatively to prevent potential patient
delivery, this practice also significantly lowers the postoperative compromise and intraoperative delays.
infection rate in women undergoing An instrument, sponge, and needle count before and after surgery
elective surgery (American College of Obstetricians and and vaginal delivery is crucial to
Gynecologists, 2011b). Depending on drug surgical safety. If counts are not reconciled following abdominal or
allergies, most recommend a single intravenous dose of a -lactam vaginal examination, then
antimicrobialeither a radiographic imaging for retained foreign objects is obtained
cephalosporin or extended-spectrum penicillin derivative. A 1-g dose (American College of Obstetricians and
of cefazolin is an efficaciousand cost-effective choice. For obese Gynecologists, 2012b).
women, a 2-g dose usually provides adequate coverage, TECHNIQUE FOR CESAREAN DELIVERY
although Pevzner and associates (2011) showed this dose may be With minor variations, surgical performance of cesarean delivery is
inadequate for those with body comparable worldwide. Most
mass index > 40. In women with significant penicillin or steps are founded on evidence-based data, and these have been
cephalosporin allergy, a single 600-mg reviewed by Dahlke (2013) and
intravenous dose of clindamycin combined with a weight-based dose Hofmeyr (2009) and their associates. As with all surgery, a clear
of aminoglycoside is an understanding of relevant anatomy
alternative. A 900-mg clindamycin dose is used for obese patients. is essential, and this is described and illustrated in Chapter 2 (p. 16).
Antimicrobial administration before surgical incision has been shown Abdominal Incision
to lower postoperative In obstetrics, usually a midline vertical or a suprapubic transverse
infection rates without adverse neonatal effects compared with drug incision is chosen for laparotomy.
administration after umbilical Transverse abdominal entry is by either Pfannenstiel or Maylard
cord clamping (Sullivan, 2007; Tita, 2009b; Witt, 2011). For this incisions. Of these, the Pfannenstiel
reason, the American College of incision is selected most frequently for cesarean delivery. Transverse
Obstetricians and Gynecologists (2011b) recommends that incisions follow Langer lines
prophylaxis be administered within the 60 of skin tension, and superior cosmetic results compared with vertical
minutes prior to the start of planned cesarean delivery. For emergent incisions can be achieved.
delivery, prophylaxis should be Additionally, decreased rates of postoperative pain, fascial wound
given as soon as feasible. dehiscence, and incisional hernia
Preoperative preparation of the abdominal wall skin is effective to compared with vertical entry are benefits. Use of the Pfannenstiel
prevent wound infection. incision, however, is often
Either chlorhexidine or povidone-iodine solutions can be used. In discouraged for cases in which a large operating space is essential
addition, to prevent postoperative or in which access to the upper
metritis following cesarean delivery, preoperative vaginal cleansing abdomen may be needed. Because of the layers created during
with a povidone-iodine scrub incision of the internal and external
has been evaluated in small randomized trials (Haas, 2013). Some oblique aponeuroses with transverse incisions, purulent fluid can
show benefit, whereas others do collect between these. Therefore,
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 3 of 12
cases with high infection risks may favor a midline incision. Last, required, extension of the fascial incision further laterally may cut
neurovascular structures, which these vessels. Therefore, if lateral
include the ilioinguinal and iliohypogastric nerves and superficial and extension is needed, these vessels should be identified and
inferior epigastric vessels, are coagulated or ligated to prevent bleeding
often encountered with transverse incisions. Logically, bleeding, and vessel retraction.
wound hematoma, and neurological Once the fascia is incised, the inferior fascial edge is grasped with
disruption may more frequently complicate these incisions compared suitable clamps and elevated
with vertical incision. With by the assistant as the operator separates the fascial sheath from the
repeat cesarean delivery, reentry through a Pfannenstiel incision underlying rectus muscles either
usually is more time consuming and bluntly or sharply until the superior border of the symphysis pubis is
difficult because of scarring. reached. Any blood vessels
The Maylard incision differs mainly from the Pfannenstiel in that the coursing between the sheath and muscles are clamped, cut, and
bellies of the rectus ligated, or they are coagulated with an
abdominis muscles are transected horizontally to widen the operating electrosurgery blade. Next, the superior fascial edge is grasped and
space. It is technically more again, separation of fascia from
difficult due to its required isolation and ligation of the inferior the rectus muscles is completed. Meticulous hemostasis is
epigastric arteries, which lie lateral imperative to lower rates of infection and
to these muscle bellies. bleeding. The fascial separation is carried near enough to the
Vertical infraumbilical incisions provide quick entry to shorten umbilicus to permit an adequate midline
incision-to-delivery time (Wylie, longitudinal incision of the peritoneum. The rectus abdominis and
2010). Moreover, this incision has minimal blood loss, superior pyramidalis muscles are then
access to the upper abdomen, separated in the midline by sharp and blunt dissection to expose the
generous operating room, and the flexibility for easy wound transversalis fascia and
extension if greater space or access is peritoneum.
needed. No important neurovascular structures traverse this incision, The transversalis fascia and preperitoneal fat are dissected carefully
and aponeuroses at the linea to reach the underlying
alba are fused. Main disadvantages are poorer cosmetic results, peritoneum. The peritoneum near the upper end of the incision is
higher fascial dehiscence or opened carefully, either bluntly or
incisional hernia rates, and greater postoperative pain. For morbidly by elevating it with two hemostats placed approximately 2 cm apart.
obese patients, a vertical The tented fold of peritoneum
incision that extends up and around the umbilicus may be preferable between the clamps is examined and palpated to ensure that
to avoid cutting through a large omentum, bowel, or bladder is not
pannus (Fig. 48-7, p. 968). adjacent. The peritoneum is then incised. The incision is extended
Transverse Incisions superiorly to the upper pole of the
With the Pfannenstiel incision, the skin and subcutaneous tissue are incision and downward to just above the peritoneal reflection over the
incised using a low, transverse, bladder. Importantly, in
slightly curvilinear incision. This is made at the level of the pubic women who have had previous intraabdominal surgery, including
hairline, which is typically 3 cm cesarean delivery, omentum or
above the superior border of the symphysis pubis. The incision is bowel may be adhered to the undersurface of the peritoneum.
extended somewhat beyond the Moreover, in women with obstructed
lateral borders of the rectus abdominis muscles. It should be of labor, the bladder may be pushed cephalad almost to the level of the
adequate width to accommodate umbilicus.
delivery12 to 15 cm is typical. Vertical Incision
Sharp dissection is continued through the subcutaneous layer to the An infraumbilical midline vertical incision begins 2 to 3 cm above the
fascia. The superficial superior margin of the
epigastric vessels can usually be identified halfway between the skin symphysis and should be of sufficient length to allow fetal delivery
and fascia, several centimeters without difficulty. Therefore, its
from the midline, and coagulated. If lacerated, these may be suture length should correspond with the estimated fetal size, and 12 to 15
ligated with 3-0 plain gut suture or cm is typical. Sharp or
coagulated with an electrosurgical blade. electrosurgical dissection is performed to the level of the anterior
The fascia is then incised sharply at the midline. The anterior rectus sheath. A small opening is
abdominal fascia is typically made sharply with scalpel in the upper half of the linea alba.
composed of two visible layers, the aponeurosis from the external Placement here avoids potential
oblique muscle and a fused layer cystotomy. Index and middle fingers are placed beneath the fascia,
containing aponeuroses of the internal oblique and transverse and the fascial incision is extended
abdominis muscles. Ideally, the two superiorly and inferiorly with scissors or scalpel. Midline separation of
layers are individually incised during lateral extension of the fascial the rectus muscles and
incision. The inferior epigastricvessels typically lie outside the lateral pyramidalis muscles and peritoneal entry are then similar to those
border of the rectus abdominis muscle and beneath the fused with the Pfannenstiel incision.
aponeuroses of the internal oblique and transverse abdominis Hysterotomy
muscles. Thus, although infrequently
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 4 of 12
Most often, the lower uterine segment is incised transversely as
described by Kerr in 1921.
Occasionally, a low-segment vertical incision as described by Krnig
in 1912 may be used. The
classical incision is a vertical incision into the body of the uterus
above the lower uterine segment
and reaches the uterine fundus. In practice, however, the classical
incision is similar to the lowvertical
incision, which is typically extended cephalad only to the extent
required for fetal delivery.
For most cesarean deliveries, the transverse incision is preferred.
Compared with a classical
incision, it is easier to repair, is located in the inactive segment and
thus least likely to rupture duringa subsequent pregnancy, causes
less incision-site bleeding, and promotes less bowel or omentum
adherence to the myometrial incision.
Low Transverse Cesarean Incision
Before any hysterotomy, the surgeon should palpate the fundus and
adnexa to identify degrees of
uterine rotation. The uterus may be dextrorotated so that the left
round ligament is more anterior and
closer to the midline. In such cases, hysterotomy placement is
modified to keep the incision centered
within the lower segment. This avoids extension into and laceration of
the left uterine artery. With
thick meconium or infected amnionic fluid, some surgeons prefer to
put a moistened laparotomy
sponge in each lateral peritoneal gutter to absorb fluid and blood that
escape from the opened uterus.
A moist sponge may also be used to pack protruding bowel away
from the operative field.
The reflection of peritoneum above the upper margin of the bladder
and overlying the anterior
lower uterine segmenttermed the bladder flapis grasped in the
midline with forceps and incised
transversely with scissors (Fig. 30-1). Bladder flap creation effectively
moves the bladder away
fr o m the planned hysterotomy site and prevents bladder laceration if
an unintended inferior
hysterotomy extension occurs during fetal delivery. Following this
initial incision, scissors are inserted between the vesicouterine
serosa and
myometrium of the lower uterine segment. The scissors are pushed
laterally from the midline on each
side to further open the visceral peritoneum and expose the
myometrium. This transverse peritoneal
incision extends almost the full length of the lower uterine segment.
As the lateral margin on each side
is approached, the scissors are directed somewhat more cephalad
(Fig. 30-2). The lower edge of
peritoneum is elevated, and the bladder is gently separated from the
underlying myometrium with
blunt or sharp dissection within this vesicouterine space (Fig. 30-3).
In general, this caudad separation of bladder does not exceed 5 cm
and usually is less. It is
possible, especially with an effaced, dilated cervix, to dissect
downward so caudally as to
inadvertently expose and then enter the underlying vagina rather
than the lower uterine segment.
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy
However, in instances in which cesarean hysterectomy is planned or
anticipated, extended caudad
bladder dissection is recommended to aid total hysterectomy and
decrease the risk of cystotomy.
Some surgeons do not create a bladder flap. The main advantage is
a shorter skin incision-todelivery
time, however, data supporting this practice are limited
(Hohlagschwandtner, 2001; Tuuli,
2012).
The uterus is entered through the lower uterine segment
approximately 1 cm below the upper
margin of the peritoneal reflection. It is important to place the uterine
incision relatively higher in
women with advanced or complete cervical dilatation. Failure to
adjust increases the risk of lateral
extension of the incision into the uterine arteries. It may also lead to
incision of the cervix or vagina
rather than the lower uterine segment. Such incisions into the cervix
can create significant
postoperative distortion of cervical anatomy. Correct placement uses
the vesicouterine serosal
reflection as a guide. Uterine Incision. The uterus can be incised by a
variety of techniques. Each is initiated by using a
scalpel to transversely incise the exposed lower uterine segment for
1 to 2 cm in the midline (Fig. 30-
4). This must be done carefully to avoid fetal laceration. Careful blunt
entry using hemostats or
fingertip to split the muscle may be helpful. Once the uterus is
opened, the incision can be extended
by simply spreading the incision, using lateral and slightly upward
pressure applied with each index
finger (Fig. 30-5). Alternatively, if the lower uterine segment is thick,
then cutting laterally and then
slightly upward with bandage scissors will extend the incision.
Importantly, when scissors are used,
the index and midline fingers of the nondominant hand should be
insinuated beneath the myometrium
and above fetal parts to prevent fetal laceration. Comparing blunt and
sharp extensions of the initial
uterine incision, sharp extension is associated with an increased
estimated blood loss, but
postoperative hematocrit changes, need for transfusion, and infection
rates are not different (Xu,
2013). The uterine incision should be made large enough to allow
delivery of the head and trunk of the
fetus without either tearing into or having to cut into the uterine
vessels that course along the lateral
uterine margins. If the placenta is encountered in the incision line, it
must be either detached or
incised. When the placenta is incised, fetal hemorrhage may be
severe. Thus, delivery and cord
clamping should be performed as soon as possible.
At times, a low-transverse hysterotomy is selected but provides
inadequate room for delivery. In
such instances, one corner of the hysterotomy incision is extended
cephalad into the contractile
portion of the myometriuma J incision. If this is completed
bilaterally, a U incision is formed. Last, some prefer to extend in the
midlinea T incision. As expected, these have been linked with
higher intraoperative blood loss (Boyle, 1996; Patterson, 2002).
Moreover, as these extend into the
Page 5 of 12
contractile portion, a trial of labor and vaginal delivery are more likely
contraindicated in future
pregnancies.
Delivery of the Fetus. In a cephalic presentation, a hand is slipped
into the uterine cavity between
the symphysis and fetal head. The head is elevated gently with the
fingers and palm through the
incision. Once the head enters the incision, delivery may be aided by
modest transabdominal fundal
pressure (Fig. 30-6). After a long labor with cephalopelvic
disproportion, the fetal head may be tightly wedged in the
birth canal. This situation can have disastrous results, and there are
three considerations for delivery.
First, a push method may be used. With this, 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. Relief of such
head impaction increases the risk of hysterotomy extension and
associated blood loss as well as fetal
skull fracture. As an alternative, a pull method is used in which the
fetal legs are grasped and
delivered through the hysterotomy opening. The fetus is then
delivered by traction as one would
complete a breech extraction. Support for this latter approach comes
only from small randomizedtrials and case series (Bastani, 2012;
Shazly, 2013; Veisi, 2012). Last, a low vertical hysterotomy
incision, which will give more room for the pull technique, may be
selected. If a low transverse
incision has already been made, then this can be extended to a J-,
U-, or T-incision for room.
Conversely, in women without labor, the fetal head may be unmolded
and without a leading
cephalic point. The round head may be difficult to lift through the
uterine incision in a relatively thick
lower segment that is unattenuated by labor. In such instances, either
forceps or a vacuum device may
be used to deliver the fetal head as shown in Figure 30-7. After head
delivery, a finger should be passed across the fetal neck to determine
whether it is
encircled by one or more umbilical cord loops. If an umbilical cord
coil is felt, it should be slipped
over the head. The head is rotated to an occiput transverse position,
which aligns the fetal
bisacromial diameter vertically. The sides of the head are grasped
with two hands, and gentle
downward traction is applied until the anterior shoulder enters the
hysterotomy incision (Fig. 30-8).
Next, by upward movement, the posterior shoulder is delivered.
During delivery, abrupt or powerful
force is avoided to avert brachial plexus injury. With steady outward
traction, the rest of the body
then readily follows. Gentle fundal pressure may aid this. With some
exceptions, current American Heart Association neonatal
resuscitation
recommendations eschew suctioning immediately following birth,
even with meconium present
(Kattwinkel, 2010). A fuller discussion of this and the timing of
umbilical cord clamping as it relates
to neonatal outcome are found in Chapter 27 (p. 539). The umbilical
cord is clamped, and the
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy
newborn is given to the team member who will conduct resuscitative
efforts as needed (Chap. 32, p.
625).
The American Academy of Pediatrics and the American College of
Obstetricians and
Gynecologists (2012) recommend that a qualified person who is
skilled in neonatal resuscitation
should be in the delivery room, with all equipment needed for
neonatal resuscitation, to care for the
neonate. Jacob and Phenninger (1997) compared 834 cesarean
deliveries with 834 low-risk vaginal
deliveries. They found that with regional analgesia, there is rarely a
need for infant resuscitation after
elective repeat cesarean delivery or cesarean delivery for dystocia
without fetal heart rate
abnormalities and that a pediatrician may not be necessary at such
deliveries. At Parkland Hospital,
pediatric nurse practitioners attend uncomplicated, scheduled
cesarean deliveries.
After birth, an intravenous infusion containing two ampules or 20
units of oxytocin per liter of
crystalloid is infused at 10 mL/min. Some prefer higher infusion
dosages, however, bolus doses are
avoided because of associated hypotension (Roach, 2013). Once the
uterus contracts satisfactorily, the rate can be reduced. An alternative
is carbetocina longer-acting oxytocin derivative that is not
available in the United Statesthat provides suitable, albeit more
expensive, hemorrhage
prophylaxis (Su, 2012). Second-tier agents are ergot-alkaloids, which
carry hypertensive side effects,
and misoprostol, which provides inferior postpartum hemorrhage
protection compared with oxytocin.
Last, the use of tranexamic acid (Cyklokapron) has recently been
described in a few small studies to
lower blood loss during cesarean delivery (Abdel-Aleem, 2013;
Gngrdk, 2011). Its
antifibrinolytic action and effects on thromboembolism rates in
pregnant surgical patients are unclear,
and larger trials are needed before widespread use. Additional
discussions of all these agents are
found in Chapters 27 (p. 547) and 41 (p. 785).
Placental Delivery. The uterine incision is observed for any vigorously
bleeding sites. These should
be promptly clamped with Pennington or ring forceps. The placenta is
then delivered unless it has
already done so spontaneously. Many surgeons prefer manual
removal, but spontaneous delivery, as
shown in Fig. 30-9, along with some cord traction may reduce the
risk of operative blood loss and
infection (Anorlu, 2008; Baksu, 2005). Fundal massage may begin as
soon as the fetus is delivered to
hasten placental separation and delivery. Immediately after delivery
and gross inspection of the placenta, the uterine cavity is suctioned
and
wiped out with a gauze sponge to remove avulsed membranes,
vernix, and clots. Previously, doublegloved
fingers or ring forceps placed through the hysterotomy incision were
used to dilate an
ostensibly closed cervix. This practice does not improve infection
rates from potential hematometra
and is not recommended (Gngrdk, 2009; Liabsuetrakul, 2011).
Page 6 of 12
Uterine Repair. After placental delivery, the uterus is lifted through the sterilization is to be performed, it is now done as described in
incision onto the draped Chapter 39 (p. 720).
abdominal wall, and the fundus is covered with a moistened Adhesions
laparotomy sponge. Although some Following cesarean delivery, adhesions commonly form within the
clinicians prefer to avoid such uterine exteriorization, it often has vesicouterine space or between
benefits that outweigh its the anterior abdominal wall and uterus. And with each successive
disadvantages. For example, the relaxed, atonic uterus can be pregnancy, the percentage of
recognized quickly and massage affected women and adhesion severity increases (Morales, 2007;
applied. The incision and bleeding points are more easily visualized Tulandi, 2009). Adhesions can
and repaired, especially if there significantly lengthen incision-to-delivery times and total operative
have been extensions. Adnexal exposure is superior, and thus, tubal time (Rossouw, 2013; Sikirica,
sterilization is easier. The 2012). Although occurring infrequently, rates of cystotomy and bowel
principal disadvantage is discomfort and vomiting caused by traction injury are also increased
in cesarean deliveries (Rahman, 2009; Silver, 2006).
performed under regional analgesia. Importantly, rates of febrile Intuitively, scarring can be reduced by handling tissues delicately,
morbidity or blood loss do not achieving hemostasis, and
appear to be increased with uterine exteriorization (Coutinho, 2008; minimizing tissue ischemia, infection, and foreign-body reaction. Data
Walsh, 2009). are conflicting regarding
Before hysterotomy closure, previously clamped large vessels may closure of the bladder flap (visceral peritoneum) or of the abdominal
be ligated separately or cavity (parietal peritoneum) and
incorporated within the running incision closure. One angle of the its effect on subsequent adhesions. Some note benefit from closure
uterine incision is grasped to of one, but not the other, or neither
stabilize and maneuver the incision. The uterine incision is then (CAESAR study collaborative group, 2010; Cheong, 2009;
closed with one or two layers of Kapustian, 2012; Lyell, 2005, 2012).
continuous 0- or No. 1 absorbable suture (Fig. 30-10). Chromic Benefit from placement of an adhesion barrier at the repaired
suture is used by many, but some hysterotomy site is limited to only
prefer synthetic delayed-absorbable sutures. Single-layer closure is two nonrandomized studies (Chapa, 2011; Fushiki, 2005). Currently,
typically faster and is not there is an ongoing multicenter
associated with higher rates of infection or transfusion (CAESAR randomized trial to evaluate use of the barrier Seprafilm at the time of
study collaborative group, 2010; cesarean delivery (National
Dodd, 2008; Hauth, 1992). Moreover, most studies observed that the Institutes of Health, 2012).
type of uterine closure does not Abdominal Closure
significantly affect complications in the next pregnancy (Chapman, Any laparotomy sponges are removed, and the paracolic gutters and
1997; Durnwald, 2003; Roberge, cul-de-sac are gently suctioned
2011). At Parkland Hospital, we favor the one-layer uterine closure. of blood and amnionic fluid. Some surgeons irrigate the gutters and
The initial suture is placed just cul-de-sac, especially in the
beyond one angle of the uterine incision. A running-lock suture for presence of infection or meconium. Routine irrigation in low-risk
hemostasis is then performed, with women, however, leads to greater
each suture penetrating the full thickness of the myometrium. intraoperative nausea and without lower postoperative infection rates
Concern has been expressed by some (Harrigill, 2003; Viney, 2012).
clinicians that sutures through the decidua may lead to endometriosis After sponge and instrument counts are found to be correct, the
or adenomyosis in the abdominal incision is closed in
hysterotomy scar, but this is rare. It is important to carefully select the layers. Many surgeons omit the parietal peritoneal closure. In
site of each stitch and to avoid addition to ambiguity regarding
withdrawing the needle once it penetrates the myometrium. This adhesion prevention, data are also conflicting as to whether
minimizes perforation of unligated nonclosure of parietal peritoneum
vessels and subsequent bleeding. The running-lock suture is decreases postoperative discomfort and analgesia requirements
continued just beyond the opposite (Chanrachakul, 2002; Lyell, 2005;
incision angle. If approximation is not satisfactory after a single-layer Rafique, 2002). However, if there is distended bowel in the incision
continuous closure or if site, we find that peritoneal
bleeding sites persist, then more sutures are required. Either another closure may help to protect the bowel when fascial sutures are
layer of running suture is placed placed.
to achieve approximation and hemostasis, or individual bleeding sites As each layer is closed, bleeding sites are located, clamped, and
can be secured with figure-ofeight or mattress sutures. ligated or coagulated with an
Traditionally, serosal edges overlying the uterus and bladder have electrosurgical blade. The rectus abdominis muscles are allowed to
been approximated with a fall into place. With significant
continuous 2-0 chromic catgut suture. Multiple randomized trials diastasis, the rectus muscles may be approximated with one or two
suggest that omission of this step figure-of-eight sutures of 0 or No.
causes no postoperative complications (Grundsell, 1998; Irion, 1996; 1 chromic gut suture. The overlying rectus fascia is closed by a
Nagele, 1996). If tubal continuous, nonlocking technique with

Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 7 of 12
a delayed-absorbable suture. In patients with a higher risk for
infection, there may be theoretical
value in selecting a monofilament suture here rather than braided
material.
The subcutaneous tissue usually need not be closed if it is less than
2 cm thick. With thicker layers,
however, closure is recommended to minimize seroma and
hematoma formation, which can lead to
wound infection and/or disruption (Bohman, 1992; Chelmow, 2004).
Addition of a subcutaneousdrain does not prevent significant wound
complications (Hellums, 2007; Ramsey, 2005). Skin is
closed with a running subcuticular stitch using 4-0 delayed-
absorbable suture or with staples. In
comparison, final cosmetic results and infection rates appear similar,
skin suturing takes longer, but
wound separation rates are higher with staples (Basha, 2010;
Figueroa, 2013; Mackeen, 2012; Tuuli,
2011).
Joel-Cohen and Misgav-Ladach Techniques
The Pfannenstiel-Kerr technique just described has been used for
decades. More recently, the Joel-
Cohen and Misgav-Ladach modifications have been described.
These differ from traditional
Pfannenstiel-Kerr entry mainly by their initial incision placement and
greater use of blunt dissection.
The Joel-Cohen technique creates a straight 10-cm transverse skin
incision 3 cm below the level
of the anterior superior iliac spines. The subcutaneous tissue layer is
opened sharply 2 to 3 cm in the
midline. This is carried down, without lateral extension, to the fascia.
A small transverse incision is
made in the fascia, and a finger from each hand is hooked into the
lateral angles of this fascial
incision. The incision is then stretched transversely. Once the fascia
is opened and rectus abdominis
muscle bellies identified, an index finger from each hand is inserted
between the bellies. One is
moved cranially and the other caudally, in opposition, to further
separate the bellies. Index finger
dissection is used to enter the peritoneum, and again, cranial and
caudad opposing stretch with index
fingers will open this layer. All the layers of the abdominal wall are
then manually stretched laterally
in opposition to further open the incision. The visceral peritoneum is
incised in the midline above the
bladder, and the bladder is bluntly reflected inferiorly to separate it
from the underlying lower uterine
segment. The myometrium is incised transversely in the midline and
then opened and extended
laterally with one finger hooked into each corner of the hysterotomy
incision. Interrupted sutures are
used for hysterotomy closure. Neither visceral nor parietal
peritoneum is closed. The Misgav-Ladach
technique is similar and differs mainly in that myometrial incision
closure is completed with a singlelayer
locking continuous suture (Hofmeyr, 2009; Holmgren, 1999).
These techniques have been associated with shorter operative times
and with lower rates of
intraoperative blood loss and postoperative pain (Hofmeyr, 2008).
They may, however, prove
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy
difficult for women with anterior rectus fibrosis and peritoneal
adhesions (Bolze, 2013). Moreover,
long-term outcomes with these techniques, such as subsequent
uterine rupture, are unknown.
Classical Cesarean Incision
This incision is usually avoided because it encompasses the active
upper uterine segment and thus is
prone to rupture with subsequent pregnancies.
Indications. A classical incision is occasionally preferred for delivery.
Some indications stem from
difficulty in exposing or safely entering the lower uterine segment. For
example, a densely adhered
bladder from previous surgery is encountered; a leiomyoma occupies
the lower uterine segment; the
cervix has been invaded by cancer; or massive maternal obesity
precludes safe access to the lower
uterine segment. A classical incision is also preferred in some cases
of placenta previa with
anterior implantation, especially those complicated by placenta
accrete syndromes.
In other instances, fetal indications dictate the need. Transverse lie of
a large fetus , especially if
the membranes are ruptured and the shoulder is impacted in the birth
canal, usually necessitates a
classical incision. A fetus presenting as a back-down transverse lie is
particularly difficult to deliverthrough a transverse uterine incision. In
instances when the fetus is very small, especially if breech, a
classical incision may be preferable (Osmundson, 2013). In such
cases, the poorly developed lower
uterine segment provides inadequate space for the manipulations
required for breech delivery. Or,
less commonly, the small fetal head may become entrapped by a
contracting uterine fundus following
membrane rupture. Last, with multiple fetuses, a classical incision
again may be needed to provide
suitable room for extraction of fetuses that may be malpositioned or
preterm.
Uterine Incision and Repair. A vertical uterine incision is initiated with
a scalpel beginning as low
as possible and preferably within the lower uterine segment (Fig. 30-
11). If adhesions, insufficient
exposure, a tumor, or placenta percreta preclude development of a
bladder flap, then the incision is
made above the level of the bladder. Once the uterus is entered with
a scalpel, the incision is
extended cephalad with bandage scissors until it is long enough to
permit delivery of the fetus. With
scissor use, the fingers of the nondominant hand are insinuated
between the myometrium and fetus to
prevent fetal laceration. As the incision is opened, numerous large
vessels that bleed profusely are
commonly encountered within the myometrium. The remainder of
fetal and placental delivery mirrors
that with a low transverse hysterotomy. For incision closure, one
method employs a layer of 0- or No. 1 chromic catgut with a
continuous
stitch to approximate the deeper halves of the incision (Fig. 30-12).
The outer depth of myometrium is
then closed with similar suture and with a running stitch or figure-of-
eight sutures. No unnecessary
Page 8 of 12
needle tracks should be made lest myometrial vessels be perforated,
leading to subsequenthemorrhage or hematomas. To achieve good
approximation and to prevent the suture from tearing
through the myometrium, it is helpful to have an assistant compress
the uterus on each side of the
wound toward the midline as each stitch is placed. PERIPARTUM
HYSTERECTOMY
Indications
Hysterectomy is more commonly performed during or after cesarean
delivery but may be needed
following vaginal birth. If all deliveries are considered, the rate ranges
from 0.4 to 2.5 per 1000
births and has risen significantly during the past few decades. During
a 25-year period, the rate of
peripartum hysterectomy at Parkland Hospital was 1.7 per 1000
births (Hernandez, 2012). Most of
this increase is attributed to the increasing rates of cesarean delivery
and its associated complications
in subsequent pregnancy (Bateman, 2012; Bodelon, 2009; Flood,
2009; Orbach, 2011). Of
hysterectomies, approximately one half to two thirds are total,
whereas the remaining cases are
supracervical (Rossi, 2010; Shellhaas, 2009).
Cesarean hysterectomies are most commonly performed to arrest or
prevent hemorrhage from
intractable uterine atony or abnormal placentation (Bateman, 2012;
Hernandez, 2012; Owolabi,
2013). These as well as other less frequent indications are found in
Table 30-3. For example, large
leiomyomas may preclude satisfactory hysterotomy closure and
necessitate hysterectomy. Or,
postpartum infectious morbidity from an infected, necrotic uterus will
prompt uterine removal for
recovery (Fig. 37-4, p. 688). Logically, risk factors for peripartum
hysterectomy mirror the risks of
these indicated complications, which are described throughout the
text. Major complications of peripartum hysterectomy include
increased blood loss and greater risk of
urinary tract damage. Blood loss is usually appreciable because
hysterectomy is being performed for
hemorrhage that frequently is torrential, and the procedure itself is
associated with substantial bloodloss. Although many cases with
such hemorrhage cannot be anticipated, those with abnormal
implantation can often be identified antepartum. Preoperative
preparations for placenta accreta are
discussed in Chapter 41 (p. 807) and have also been outlined by the
Society for Maternal-Fetal
Medicine (2010) and American College of Obstetricians and
Gynecologists (2012c).
An important factor affecting the cesarean hysterectomy complication
rate is whether the operation
is performed electively or emergently (Briery, 2007). After anticipated
or planned cesarean
hysterectomy, there are lower rates of blood loss, less need for blood
transfusions, and fewer urinary
tract complications compared with emergent procedures (Briery,
2007; Glaze, 2008; Sakse, 2007).
Peripartum Hysterectomy Technique
Supracervical or total hysterectomy is performed using standard
operative techniques. For this,
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy
adequate exposure is essential. Initially, placement of a self-retaining
retractor such as a Balfour is
not necessary. Rather, satisfactory exposure is obtained with
cephalad traction on the uterus by an
assistant, along with handheld retractors such as a Richardson or
Deaver. The bladder flap is
deflected downward to the level of the cervix if possible to permit
total hysterectomy. In cases in
which cesarean hysterectomy is planned or strongly suspected,
extended bladder flap dissection is
ideally completed before initial hysterotomy. Later attempts at bladder
dissection may be obscured by
bleeding, or excess blood may be lost while this dissection is
performed.
After cesarean delivery, the placenta is typically removed. In cases of
placenta accrete syndromes,
in which hysterectomy is already planned, the placenta is usually left
undisturbed in situ. In either
situation, if the hysterotomy incision is bleeding appreciably, it can be
sutured or Pennington or
sponge forceps can be applied for hemostasis. If bleeding is minimal,
neither maneuver is necessary.
The round ligaments are divided close to the uterus between Kocher
clamps and doubly ligated
(Fig. 30-13). Either 0 or No. 1 suture can be used in either chromic
gut or delayed-absorbable
material. The incision in the vesicouterine serosa that was made to
mobilize the bladder is extended
laterally and upward through the anterior leaf of the broad ligament to
reach the incised round
ligaments. The posterior leaf of the broad ligament adjacent to the
uterus is perforated just beneath the
fallopian tubes, uteroovarian ligaments, and ovarian vessels (Fig. 30-
14). These structures together
are then doubly clamped close to the uterus and divided, and the
lateral pedicle is doubly ligated
(Fig. 30-15). The posterior leaf of the broad ligament is divided
toward the uterosacral ligaments
(Fig. 30-16). Next, the bladder and attached peritoneal flap are
further deflected and dissected as
needed from the lower uterine segment and retracted out of the
operative field. If the bladder flap is
unusually adhered, as it may be after previous hysterotomy incisions,
careful sharp dissection may be
necessary (Fig. 30-17). Special care is required from this point on to
avoid injury to the ureters, which pass beneath the
uterine arteries. To help accomplish this, an assistant places constant
traction to pull the uterus in the
direction away from the side on which the uterine vessels are being
ligated. The ascending uterine
artery and veins on either side are identified near their origin. These
pedicles are then doubly
clamped immediately adjacent to the uterus, divided, and doubly
suture ligated. As shown in Figure
30-18, we prefer to use three heavy clampsHeaney or Ballantine
to incise the tissue between the
most medial clamps, and then ligate the pedicle in the clamps lateral
to the uterus. With cesarean hysterectomy, it may be more
advantageous in cases of profuse hemorrhage to
rapidly double clamp and divide all of the vascular pedicles between
clamps to gain hemostasis. The
Page 9 of 12
operator can then return to ligate all of the pedicles.
Total Hysterectomy
Even if total hysterectomy is planned, we find it in many cases
technically easier to finish the operation after amputating the uterine
fundus and placing Ochsner or Kocher clamps on the cervical
stump for traction and hemostasis. Self-retaining retractors also may
be placed at this time. To
remove the cervix, the bladder is mobilized further if needed. This
carries the ureters caudad as the
bladder is retracted beneath the symphysis and will prevent
laceration or suturing of the bladder
during cervical excision and vaginal cuff closure.
If the cervix is effaced and dilated considerably, its softness may
obscure palpable identification
of the cervicovaginal junction. The junction location can be
ascertained through a vertical uterine
incision made anteriorly in the midline, either through the open
hysterotomy incision or through an
incision created at the level of the ligated uterine vessels. A finger is
directed inferiorly through the
incision to identify the free margin of the dilated, effaced cervix and
the anterior vaginal fornix. The
contaminated glove is replaced. Another useful method to identify the
cervical margins is to
transvaginally place four metal skin clips or brightly colored sutures
at 12, 3, 6, and 9 oclock it is more common with
positions on the cervical edges in cases of planned hysterectomy.
The cardinal ligaments, the uterosacral ligaments, and the many
large vessels these ligaments
contain are clamped systematically with Heaney-type curved or
straight clamps (Fig. 30-19). The
clamps are placed as close to the cervix as possible, taking care not
to include excessive tissue in
each clamp. The tissue between the pair of clamps is incised, and
the lateral pedicle is suture ligated.
These steps are repeated caudally 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 as the cervix is dissected
from the cardinal ligaments. Immediately below the level of the
cervix, a curved clamp is placed across the lateral vaginal
fornix, and the tissue is incised above the clamp (Fig. 30-20). The
excised lateral vaginal fornix can
be simultaneously doubly ligated and sutured to the stump of the
cardinal ligament. The cervix is
inspected to ensure that it has been completely removed, and the
vagina is then repaired. Each of the
angles of the lateral vaginal fornix is secured to the cardinal and
uterosacral ligaments to mitigate
later vaginal prolapse (Fig. 30-21). Following this step, some
surgeons prefer to close the vagina
using figure-of-eight sutures. Others achieve hemostasis by using a
running-lock stitch placed through
the mucosa and adjacent endopelvic fascia around the
circumference of the vaginal cuff (Fig. 30-22). If a self-retaining
retractor has not already been placed, some clinicians choose to
insert one at
this point. The bowel is then packed out of the field, and all sites are
examined carefully for bleeding.
One technique is to perform a systematic bilateral survey from the
fallopian tube and ovarian ligament
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy
pedicles to the vaginal vault and bladder flap. Bleeding sites are
ligated with care to avoid the
ureters. The abdominal wall normally is closed in layers, as
previously described for cesarean
delivery (p. 597).
Supracervical Hysterectomy
To perform a subtotal hysterectomy, the uterine body is amputated
immediately above the level of
uterine artery ligation. The cervical stump may be closed with
continuous or interrupted chromic
catgut sutures of 0 or No. 1 gauge. Subtotal hysterectomy is often all
that is necessary to stop
hemorrhage. It may be preferred for women who would benefit from
a shorter surgery or for those
with extensive adhesions that threaten significant urinary tract injury.
Salpingo-OophorectomyBecause of the large adnexal vessels and
their close proximity to the uterus, it may be necessary to
remove one or both adnexa to obtain hemostasis. Briery and
colleagues (2007) reported unilateral or
bilateral oophorectomy in a fourth of cases. Preoperative counseling
should include this possibility.
Cystotomy
Rarely, and usually in women who have had a previous cesarean
delivery, the bladder may be
lacerated. This complication may occur during cesarean delivery, but
cesarean hysterectomy, especially if there is abnormal placental
implantation.
Bladder injury is typically identified at the time of surgery, and initially,
a gush of clear fluid into
the operating field may be seen. If cystotomy is suspected, it may be
confirmed with retrograde
instillation of sterile infant formula through a Foley catheter into the
bladder. Leakage of opaque milk
aids in laceration identification and delineation of its borders. In some
cases, cystoscopy may be
indicated to further define bladder injury. Primary repair is preferred
and lowers the risk of
postoperative vesicovaginal fistula formation. Once ureteral patency
is confirmed, the bladder may
be closed with a two- or three-layer running closure using a 3-0
absorbable or delayed-absorbable
suture (Fig. 30-23). The first layer inverts the mucosa into the
bladder, and subsequent layers
reapproximate bladder muscularis. Postoperative care requires
continuous bladder drainage for 7 to
10 days.
PERIPARTUM MANAGEMENT
Intravenous Fluids
During and after cesarean delivery, requirements for intravenous
fluids can vary considerably.
Intravenously administered fluids consist of either lactated Ringer
solution or a similar crystalloid
solution with 5-percent dextrose. Typically, at least 2 to 3 L is infused
during surgery. Blood loss
with uncomplicated cesarean delivery approximates 1000 mL. The
average-sized woman with a hematocrit of 30 percent or more and
with a normally expanded blood and extracellular fluid volume
most often will tolerate blood loss up to 2000 mL without difficulty.
Unappreciated bleeding through
Page 10 of 12
the vagina during the procedure, bleeding concealed in the uterus sequestration in the bowel wall and lumen does not occur, unless
after its closure, or both commonly perhaps it was necessary to pack
lead to underestimation. the bowel away from the operative field. Thus, the woman who
Blood loss averages 1500 mL with elective cesarean hysterectomy, undergoes routine cesarean delivery
although this is variable rarely develops fluid sequestration in the extracellular space. On the
(Pritchard, 1965). Most peripartum hysterectomies are unscheduled, contrary, she normally begins
and blood loss in these cases is surgery with a physiologically enlarged extravascular volume
correspondingly greater. Thus, in addition to close monitoring of vital acquired during pregnancy that she
signs and urine output, the mobilizes and excretes after delivery. As a generalization, 3 L of fluid
hematocrit should be determined intra- or postoperatively as should prove adequate during
indicated (Chap. 41, p. 781). the first 24 hours after surgery. If urine output falls below 30 mL/hr,
Recovery Suite however, the woman should be
Close monitoring of the amount of vaginal bleeding is necessary for reevaluated promptly. The cause of the oliguria may range from
at least an hour in the immediate unrecognized blood loss to an
postoperative period. The uterine fundus is also identified frequently antidiuretic effect from infused oxytocin.
by palpation to ensure that the Women undergoing unscheduled cesarean delivery may have
uterus remains firmly contracted. Unfortunately, as conduction pathological retention or constriction
analgesia fades or the woman awakens of the extracellular fluid compartment caused by severe
from general anesthesia, abdominal palpation is likely to produce preeclampsia, sepsis syndrome, vomiting,
pain. An analgesic given by prolonged labor without adequate fluid intake, and increased blood
intermittent intravenous injection can be effective (Table 30-4). A loss.
sterile thin abdominal wound Bladder and Bowel Function
dressing is sufficient, and indeed, a thick, heavily taped padded The Foley catheter most often can be removed by 12 hours
dressing will interfere with fundal postoperatively, or more conveniently, the
palpation and massage. Deep breathing and coughing are morning after surgery. The prevalence of urinary retention following
encouraged. Once regional analgesia begins cesarean delivery approximates
to fade or the woman becomes fully awake following general 3 to 7 percent. Regional analgesia and failure to progress in labor are
anesthesia, criteria for transfer to the identified risks (Chai, 2008;
postpartum ward include minimal bleeding, stable vital signs, and Liang, 2007). Thus, surveillance for bladder overdistention should be
adequate urine output. implemented as with vaginal
delivery.
Hospital Care until Discharge In uncomplicated cases, solid food may be offered within 8 hours of
Analgesia, Vital Signs, Intravenous Fluids surgery (Bar, 2008; Orji,
A number of schemes are suitable for postoperative pain control. 2009). Although some degree of adynamic ileus follows virtually
Some basic regimens are shown in every abdominal operation, in most
Table 30-4. In a trial at Parkland Hospital, Yost and associates (2004) cases of cesarean delivery, it is negligible. Symptoms include
found that morphine provided abdominal distention, gas pains, and an
superior pain relief to meperidine and was associated with inability to pass flatus or stool. The pathophysiology of postoperative
significantly higher rates of breast feeding ileus is complex and involves
and continuation of infant rooming in. Breast feeding can be initiated inflammatory and neural factors that are incompletely understood
the day of surgery. If the mother elects not to breast feed, a binder (van Bree, 2012). If associated with
that supports the breasts without marked compression usually will otherwise unexplained fever, an unrecognized bowel injury may be
minimize discomfort (Chap. 36, p. 675). responsible. Treatment for ileus
After transfer to her room, the woman is assessed at least hourly for has changed little during the past several decades and involves
4 hours, and thereafter at intravenous fluid and electrolyte
intervals of 4 hours. Vital signs, uterine tone, urine output, and supplementation. If severe, nasogastric decompression is necessary.
bleeding are evaluated. The hematocrit Ambulation and Wound Care
is routinely measured the morning after surgery. It is checked sooner As discussed on page 590, women undergoing cesarean delivery
if there was unusual blood loss have an increased risk of venous
or if there is hypotension, tachycardia, oliguria, or other evidence to thromboembolism compared with those delivering vaginally.
suggest hypovolemia. If the Additional risks include age > 35;
hematocrit is decreased significantly from the preoperative level, the obesity; parity > 3; emergency cesarean; cesarean hysterectomy;
measurement is repeated and a concurrent infection, major illness,
search is instituted to identify the cause. If the hematocrit stabilizes, preeclampsia, or gross varicosities; recent immobility; and prior
the mother can be allowed to deep-vein thrombosis or
ambulate, and if there is little likelihood of further blood loss, iron thrombophilia (Marik, 2008). Postoperative thromboprophylaxis is
therapy is preferred to transfusion. discussed in Chapter 52 (p. 1045). Early ambulation lowers the risk
As described in Chapter 36 (p. 671), the puerperium is characterized of venous thromboembolism. In most instances, by the day
by excretion of fluid that was after surgery, a woman should get briefly out of bed with assistance
retained during pregnancy. At least with elective cesarean delivery, at least twice to walk.
significant extracellular fluid
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 11 of 12
Ambulation can be timed so that a recently administered analgesic
will minimize discomfort. By the
second day, she may walk without assistance.
The incision is inspected each day, and skin sutures or clips often
can be removed on the fourth
postoperative day. If there is concern, however, for superficial wound
separationfor example, in
obese patientsthe suture or clips should remain in place for 7 to 10
days. By the third postpartum
day, showering is not harmful to the incision.
Hospital Discharge
Unless there are complications during the puerperium, the mother
generally is discharged on the third
or fourth postpartum day (Buie, 2010). Data from small studies
suggest that earlier discharge may be
feasible for properly selected and motivated women (Strong, 1993;
Tan, 2012). Activities during the
first week should be restricted to self-care and newborn care with
assistance. Driving can be
resumed when pain does not limit the ability to brake quickly and
when narcotic medications are not
in use. Return to work is variable. Six weeks is commonly cited,
although many women use the
Family and Medical Leave Act to allow up to 12 weeks for recovery
and newborn bonding.

Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 12 of 12