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Before the procedure:

Pt informed consent signed

Indications: breech, cephalopelvic disproportion (CPD), failure to progress, nonreassuring FHT
Risks: infection, bleeding, injury to bowel/bladder which would require more surgery, death
Anesthesia options: General, SPINAL MOST COMMON IN SALINA, epidural (usually SVD)

Prepping the patient:

Check FHT until patient draped
Tilt patient with sandbag to get pressure off IVC so put a wedge on patient's right side
Ensure adequate fluids are running with anesthesia
Foley placement
Prep with betadine for sterilization --- stand on left side of patient so right hand can be used to
apply betadine

Steps to procedure:
1. Check for anesthesia with allis clamp --- 4 quadrant testing to ensure adequate block
2. Plan the incision: pfannensteil incision is 2 fingerbreaths above the pubic symphysis in midline and
laterally to 2 fingerbreaths in from the ASIS. Use marking pen to draw line for incision
3. Surgeon has left hand above incision and assistant has left hand below incision to tense the skin.
Using the scalpel, cut superficially at lateral edges towards yourself. You can clamp and cauterize
any bleeding veins encountered in this step. (Promontory veins???)
4. Incise the subcutaneous fat down to fascia with scalpel
5. Nick the fascia with scalpel
6. Carry incision of the fat/fascia laterally with Mayo's by tunneling under the fascia, then cutting
(separates rectus muscle from fascia) to edge
7. Oschner clamps - clamp below superior border of rectus fascia, tunnel with fingers, then cut with
mayos pointing DOWN midline about 3 inches (Don't button hole fascia!!!)
8. Repeat above step with inferior border
9. Divide rectus muscles --- bluntly dissect with fingers (superior high), tunnel and cut with mayo's
down towards bladder - tent muscle up to avoid the bladder (WATCH BLADDER!)
10. Divide peritoneum - bluntly dissect with finger down through peritoneal fat to peritoneum. TENT
and clamp with Kelleys, pinch area with fingers to check for bowel
11. Use knife to enter the perioteneal cavity. Extend incision cephalad/caudal with METZ
12. Inferiorly slide finger down, and stop when tissue thickens b/c this is bladder
13. Hook fingers in peritoneal incision and pull
14. Call for bladder blade and place appropriately
15. Feel lower segment of uterus for rotation
16. Identify vesico-uterine fold over lower uterine segment
17. Russian/smooth forceps used to pick up the peritoneum
18. METZ - incise peritoneum and tunnel and cut to left and right. Assistant swings bladder blade to
left and right
19. Forceps pick up lower edge of peritoneum and bluntly dissect with finger down 3- cm to protect
bladder if uterine incision extension occurs
20. Replace bladder blade under the peritoneum
21. Using scalpel, (assistant with suction), incise 2cm transversely through lower uterine segment just
below where vesicouterine peritoneum cut --- one cell layer at a time
22. Once through the wall, pull the incision apart with 2 index fingers
23. Right hand placed below baby's head --- dont use lower segment as fulcrum to get baby's head
24. Deliver head (push from below, suction/forceps, T uterus if necessary)
25. Assistant with fundal pressure, deliver the shoulders, clamp and cut cord
26. Manually deliver placenta then add pitocin to IVF and open up IV
27. Uterus then externalized and held up with wet lab on abdomen by assistant
28. Dry lap to wipe endometrial cavity for placental fragments
29. Place bladder blade again for protection
30. Ring forceps at corner of uterine incisions and on lower uterine segment in middle for hemostasis
31. Look now for extension of incision towards cervix or vagina
32. Repair extensions 1st with running LOCKING stitch beyond apex with 1-0 chromic (round or taper
33. Closing uterine segment ---> left hand behind broad ligament at edge of uterus in order to identify
uterine vessels. Take 1cm of uterine tissue outside --> inside --> outside and tie 3 (chromic) and 4
(vicryl) square knots. Tag this end.
34. Close 1st layer running, LOCKING stitches incorporating lower 2/3 of muscle using Russian to reset
35. End incision with left hand again behind broad ligament watching uterine vessels. Tag this end.
36. 2nd layer uterine closure - started on left side again ---> especially if pt is ever gonna do TOLAC
37. 2 bite stitch over tagged end that's tied to tagged end
38. Running horizontal mattress over the 1st layer (so it's buried)
39. Check for hemostasis of uterine incision, place any needed Figure of 8's especially at the lateral
margins to obtain hemostasis.
40. Run the vesicouterine fold with 2-0 or 3-0 chromic or vicryl --- optional step
41. Examine ovaries and tubes --- check uterine anatomy
42. Place uterus back in abdominal cavity and check abdominal cavity --- can suction and irrigate
43. Richardson retractor to left to check left gutter for blood clots, repeat on right side, and then
recheck the uterine incision
44. Grasp peritoneum with 2 kellies at middle and 1 at lower end of incision. Use 0 or 2-0 vicryl to
close this with running stitch. May use malleable retractor and smooth picks PRN. ***Take very
small bites at inferior border of peritoneum close b/c close proximity to bladder!***
45. Rectus muscle closure with 2-3 interrupted stitches (Parriott doesn't do this)
46. Replace Oschner's to check bleeding on rectus muscle --- cauterize any bleeders
47. Fascia closure with 0-vicryl getting both layers (army-navy retractors) and picks with teeth. Run to
midline and tie.
48. Subcutaneous fat reapproximation if >2cm thick with interrupted sutures. 3-0 vicryl appropriate --
- looking for scarpa's fascia (fine white line) in the subQ fat
49. Skin closure --- subcutaneous staples are common choice. Can use adson pickups to help evert
skin edges to get staples placed appropriately
50. Pressure dressing and can place steri strips over incision after clean area.
51. Put in post-op C/S orders and dictate procedure