“You’re going to suction what?!” Cesarean Section basics for FP

1. “You’re going to suction what?!”Cesarean Section basics for FP Matthew Snyder, DO Obstetrics Fellow

2. Overview • Indications • Do’s & Don’ts of first-assisting • Post-operative management • Post-partum counseling

3. C/S Indications - Fetal • Fetal Macrosomia (over 5000g, GDM – 4500g) • Multiple Gestations • Fetal Intolerance to Labor • Malpresentation / Unstable Lie – Breech or Transverse presentation

4. C/S Indications - Fetal • Non-reassuring Fetal Heart Tracing • Repetitive Variable Decelerations • Repetitive Late Decelerations • Fetal Bradycardia • Fetal Tachycardia • Cord Prolapse

5. 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

6. C/S Indications – Maternal/Fetal • Abnormal Placentation • Placenta previa • Vasa previa • Placental abruption • Conjoined Twins • Perimortem • Failed Induction / Trial of Labor

7. 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)

8. C/S Indications – Maternal/Fetal

9. Surgical Instruments • Uses: • Adson: Skin • Bonney: Fascia • DeBakey: soft tissue, bleeders • Russians: uterus

10. Surgical Instruments • Uses: • Allis-Adair: tissue, uterus • Pennington: tissue, uterus • These are suitable for hemostasis use

11. Surgical Instruments • Uses: • Kocher clamp: fascia, thicker tissues

12. Surgical Instruments • Uses: • Richardson: general retractor • Goelet: subQ retractor • Fritsch bladder blade

13. Surgical Instruments • Uses: • Mayo, curved: fascia • Metzenbaum, curved: soft tissue • Bandage scissors: cord cutting, uterine extension

14. 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

15. 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

16. Cesarean Section: Incision to Uterus • Provide traction/counter-traction to increase exposure during skin and subQ incision

17. Cesarean Section: Incision to Uterus • Be ready with DeBakey forceps to grab bleeders – especially the Superficial Epigastric vessels

18. Cesarean Section: Incision to Uterus • 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

19. Cesarean Section: Uterine Incision to Delivery • With bladder blade inserted, use Richardson to retract superior tissue for optimum exposure

20. 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

21. Cesarean Section: Uterine Incision to Delivery • 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

22. Cesarean Section: 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

23. Cesarean Section: 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 • SubQ space closed if over 2 cm depth • If needed, clear lower uterine segment and vagina of clots once skin is closed and dressed

24. 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

25. 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 post-op (attending specific), use maxipad • Ensure pt. is tolerating PO intake, urinating well and has flatus before discharge • Watch for post-op ileus

26. Delayed Complications • Subsequent Pregnancies • Uterine rupture/dehiscence • Abnormal placental implantation (accreta, etc) • Repeat Cesarean section • Adhesions • Scaring/Keloids

27. 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 subQ layer, debride wound daily with 1:1 sterile saline/H2O2 mixture and pack with gauze • May use prophylactic abx – Keflex, Bactrim, Clinda • KEY: Close f/u and wound exploration

28. Post-partum counseling:Pharm • Continue PNV • Colace • Motrin 800 mg q8 • Percocet 1-2 tabs q4-6 for breakthrough • OCP (start 4-6 wks post-partum)

29. 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!!

30. Post-partum counseling:Incision Care • Only showers – light washing • If pt has steristrips, should fall off in 7-10 days, otherwise use warm, wet washcloth to remove • If pt has staples – removal in 3-7 days outpt. • Most attendings will have pt f/u in office in about 2 wks for wound check

31. Post-partum counseling:Notify MD/DO • Fever (100.4)/Chills • HA • Vision changes • RUQ/Epigastric pain • Mastitis sx • Increasing abd. pain • Erythema/Induration/ increasing swelling around incision • Purulent drainage • Serosanguinous drainage over half dollar size on pad • Wound separation • Purulent vaginal discharge • Vaginal bleeding over 1 pad/hr or golf ball size clots • Calf tenderness

32. Do’s & Don’ts of First-AssistingLast 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

33. Summary • Indications • Do’s & Don’ts of first-assisting • Post-operative management • Post-operative complications • Post-partum counseling

34. References • Cunningham, F., Leveno, Keith, et al. Williams Obstetrics. 22nd ed., New York, 2005. • Gabbe, Steven, Niebyl, Jennifer, et al. Obstetrics: Normal and Problem Pregnancies. 4th ed., Nashville, 2001. • Gilstrap III, Larry, Cunningham, F., et al. Operative Obstetrics. 2nd ed., New York, 2002. • www.uptodateonline.com