CESAREAN SECTIO (C/S)

Surgical technique

  • Low transverse incision through the skin
  • Small transverse incision strictly in the midline throuigh the subcutaneous tissue and fascia
  • Split the fascia by sliding a pair of slightly opened scissors transversely to the right and left.
  • That will spare the subcutaneous vessels avoiding unnecessary bleeding
  • Stretch the wound manually in a vertical direction
  • Open the peritoneum bluntly with your fingers
  • Stretch the wound further by manual traction in a transverse direction
  • Place a retractor distally in the wound
  • Apply downward traction to the retractor by assistant
  • Small transverse incision in the upper part of the lower segment of the uterus
  • Maintain a safe distance away from the bladder.
  • The more the lower segment is stretched, the higher the incision should be
  • 3 to 5 fingers above the bladder.
  • Do not incise the bladder peritoneum and push down the bladder to make the incision low in the lower segment as described in many textbooks. That’s a recipe for troublesome vaginal tears.
  • Stretch the uterine incision manually in a transverse direction
  • Apply fundal pressure by assistant
  • Lift out the presenting part with
    • One hand
    • Sellheim’s Obstetrical Lever
    • One blade of pair of ordinary obstetrical forceps  
  • Deliver the baby
  • Clamp and cut the umbilical cord
  • Lift out uterus from the abdominal cavity
  • Squeeze out placenta by fundal pressure
  • Or remove it by hand from the uterine cavity
  • Close the incision in the lower segment with a continuous inverting suture from one corner of the incision to the other.
  • Use resorbable suture such as Chromic Catgut or Polyglycolic Acid.
  • One layer is enough.
  • Remove blood from the abdominal cavity
  •  Return uterus into the abdomen
  • Close the fascia with a continuous suture
  • Close the skin
Cesarean Sectio

CHALLENGES WITH CESAREAN SECTIO

FULL BLADDER

Empty bladder by suprapubic puncture

Full Bladder in C/S

DEEPLY IMPACTED HEAD

There are two options:

  1. Have an assistant push the head from below with a hand in vagina
Pushing Impacted Head from Below

2) Perform internal version and extraction on a foot through the uterine incision

C/S with Internal Version

LATERAL TEARS OF THE UTERINE INCISION

  • Close the wound with two continuous sutures
  • Start suturing separately in each corner
  • Tie the sutures together in the midline

BLEEDING FROM UTERINE ARTERY

  • Clamp the artery above and below the bleeding point
  • Apply suture-ligation
Bleeding from Uterine Artery

MYOMA

  • Make the uterine incision in a convenient place
  • Avoid the myoma(s) in the incision
  • Do not try to shell out or remove the myoma(s)
  • It may cause torrential and fatal bleeding.
Myoma in C/S

HIV POSITIVE PATIENT:

  • Use protection
  • Give prophylactic medication before surgery

ABDOMINAL PACK

  • Be sure to remove all abdominal packs before wound closure
  • Suspect retained pack in septic complications

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