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Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 7 of 12
a delayed-absorbable suture. In patients with a higher risk for difficult for women with anterior rectus fibrosis and peritoneal
infection, there may be theoretical adhesions (Bolze, 2013). Moreover,
value in selecting a monofilament suture here rather than braided long-term outcomes with these techniques, such as subsequent
material. uterine rupture, are unknown.
The subcutaneous tissue usually need not be closed if it is less than Classical Cesarean Incision
2 cm thick. With thicker layers, This incision is usually avoided because it encompasses the active
however, closure is recommended to minimize seroma and upper uterine segment and thus is
hematoma formation, which can lead to prone to rupture with subsequent pregnancies.
wound infection and/or disruption (Bohman, 1992; Chelmow, 2004). Indications. A classical incision is occasionally preferred for delivery.
Addition of a subcutaneousdrain does not prevent significant wound Some indications stem from
complications (Hellums, 2007; Ramsey, 2005). Skin is difficulty in exposing or safely entering the lower uterine segment. For
closed with a running subcuticular stitch using 4-0 delayed- example, a densely adhered
absorbable suture or with staples. In bladder from previous surgery is encountered; a leiomyoma occupies
comparison, final cosmetic results and infection rates appear similar, the lower uterine segment; the
skin suturing takes longer, but cervix has been invaded by cancer; or massive maternal obesity
wound separation rates are higher with staples (Basha, 2010; precludes safe access to the lower
Figueroa, 2013; Mackeen, 2012; Tuuli, uterine segment. A classical incision is also preferred in some cases
2011). of placenta previa with
Joel-Cohen and Misgav-Ladach Techniques anterior implantation, especially those complicated by placenta
The Pfannenstiel-Kerr technique just described has been used for accrete syndromes.
decades. More recently, the Joel- In other instances, fetal indications dictate the need. Transverse lie of
Cohen and Misgav-Ladach modifications have been described. a large fetus , especially if
These differ from traditional the membranes are ruptured and the shoulder is impacted in the birth
Pfannenstiel-Kerr entry mainly by their initial incision placement and canal, usually necessitates a
greater use of blunt dissection. classical incision. A fetus presenting as a back-down transverse lie is
The Joel-Cohen technique creates a straight 10-cm transverse skin particularly difficult to deliverthrough a transverse uterine incision. In
incision 3 cm below the level instances when the fetus is very small, especially if breech, a
of the anterior superior iliac spines. The subcutaneous tissue layer is classical incision may be preferable (Osmundson, 2013). In such
opened sharply 2 to 3 cm in the cases, the poorly developed lower
midline. This is carried down, without lateral extension, to the fascia. uterine segment provides inadequate space for the manipulations
A small transverse incision is required for breech delivery. Or,
made in the fascia, and a finger from each hand is hooked into the less commonly, the small fetal head may become entrapped by a
lateral angles of this fascial contracting uterine fundus following
incision. The incision is then stretched transversely. Once the fascia membrane rupture. Last, with multiple fetuses, a classical incision
is opened and rectus abdominis again may be needed to provide
muscle bellies identified, an index finger from each hand is inserted suitable room for extraction of fetuses that may be malpositioned or
between the bellies. One is preterm.
moved cranially and the other caudally, in opposition, to further Uterine Incision and Repair. A vertical uterine incision is initiated with
separate the bellies. Index finger a scalpel beginning as low
dissection is used to enter the peritoneum, and again, cranial and as possible and preferably within the lower uterine segment (Fig. 30-
caudad opposing stretch with index 11). If adhesions, insufficient
fingers will open this layer. All the layers of the abdominal wall are exposure, a tumor, or placenta percreta preclude development of a
then manually stretched laterally bladder flap, then the incision is
in opposition to further open the incision. The visceral peritoneum is made above the level of the bladder. Once the uterus is entered with
incised in the midline above the a scalpel, the incision is
bladder, and the bladder is bluntly reflected inferiorly to separate it extended cephalad with bandage scissors until it is long enough to
from the underlying lower uterine permit delivery of the fetus. With
segment. The myometrium is incised transversely in the midline and scissor use, the fingers of the nondominant hand are insinuated
then opened and extended between the myometrium and fetus to
laterally with one finger hooked into each corner of the hysterotomy prevent fetal laceration. As the incision is opened, numerous large
incision. Interrupted sutures are vessels that bleed profusely are
used for hysterotomy closure. Neither visceral nor parietal commonly encountered within the myometrium. The remainder of
peritoneum is closed. The Misgav-Ladach fetal and placental delivery mirrors
technique is similar and differs mainly in that myometrial incision that with a low transverse hysterotomy. For incision closure, one
closure is completed with a singlelayer method employs a layer of 0- or No. 1 chromic catgut with a
locking continuous suture (Hofmeyr, 2009; Holmgren, 1999). continuous
These techniques have been associated with shorter operative times stitch to approximate the deeper halves of the incision (Fig. 30-12).
and with lower rates of The outer depth of myometrium is
intraoperative blood loss and postoperative pain (Hofmeyr, 2008). then closed with similar suture and with a running stitch or figure-of-
They may, however, prove eight sutures. No unnecessary
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 8 of 12
needle tracks should be made lest myometrial vessels be perforated, adequate exposure is essential. Initially, placement of a self-retaining
leading to subsequenthemorrhage or hematomas. To achieve good retractor such as a Balfour is
approximation and to prevent the suture from tearing not necessary. Rather, satisfactory exposure is obtained with
through the myometrium, it is helpful to have an assistant compress cephalad traction on the uterus by an
the uterus on each side of the assistant, along with handheld retractors such as a Richardson or
wound toward the midline as each stitch is placed. PERIPARTUM Deaver. The bladder flap is
HYSTERECTOMY deflected downward to the level of the cervix if possible to permit
Indications total hysterectomy. In cases in
Hysterectomy is more commonly performed during or after cesarean which cesarean hysterectomy is planned or strongly suspected,
delivery but may be needed extended bladder flap dissection is
following vaginal birth. If all deliveries are considered, the rate ranges ideally completed before initial hysterotomy. Later attempts at bladder
from 0.4 to 2.5 per 1000 dissection may be obscured by
births and has risen significantly during the past few decades. During bleeding, or excess blood may be lost while this dissection is
a 25-year period, the rate of performed.
peripartum hysterectomy at Parkland Hospital was 1.7 per 1000 After cesarean delivery, the placenta is typically removed. In cases of
births (Hernandez, 2012). Most of placenta accrete syndromes,
this increase is attributed to the increasing rates of cesarean delivery in which hysterectomy is already planned, the placenta is usually left
and its associated complications undisturbed in situ. In either
in subsequent pregnancy (Bateman, 2012; Bodelon, 2009; Flood, situation, if the hysterotomy incision is bleeding appreciably, it can be
2009; Orbach, 2011). Of sutured or Pennington or
hysterectomies, approximately one half to two thirds are total, sponge forceps can be applied for hemostasis. If bleeding is minimal,
whereas the remaining cases are neither maneuver is necessary.
supracervical (Rossi, 2010; Shellhaas, 2009). The round ligaments are divided close to the uterus between Kocher
Cesarean hysterectomies are most commonly performed to arrest or clamps and doubly ligated
prevent hemorrhage from (Fig. 30-13). Either 0 or No. 1 suture can be used in either chromic
intractable uterine atony or abnormal placentation (Bateman, 2012; gut or delayed-absorbable
Hernandez, 2012; Owolabi, material. The incision in the vesicouterine serosa that was made to
2013). These as well as other less frequent indications are found in mobilize the bladder is extended
Table 30-3. For example, large laterally and upward through the anterior leaf of the broad ligament to
leiomyomas may preclude satisfactory hysterotomy closure and reach the incised round
necessitate hysterectomy. Or, ligaments. The posterior leaf of the broad ligament adjacent to the
postpartum infectious morbidity from an infected, necrotic uterus will uterus is perforated just beneath the
prompt uterine removal for fallopian tubes, uteroovarian ligaments, and ovarian vessels (Fig. 30-
recovery (Fig. 37-4, p. 688). Logically, risk factors for peripartum 14). These structures together
hysterectomy mirror the risks of are then doubly clamped close to the uterus and divided, and the
these indicated complications, which are described throughout the lateral pedicle is doubly ligated
text. Major complications of peripartum hysterectomy include (Fig. 30-15). The posterior leaf of the broad ligament is divided
increased blood loss and greater risk of toward the uterosacral ligaments
urinary tract damage. Blood loss is usually appreciable because (Fig. 30-16). Next, the bladder and attached peritoneal flap are
hysterectomy is being performed for further deflected and dissected as
hemorrhage that frequently is torrential, and the procedure itself is needed from the lower uterine segment and retracted out of the
associated with substantial bloodloss. Although many cases with operative field. If the bladder flap is
such hemorrhage cannot be anticipated, those with abnormal unusually adhered, as it may be after previous hysterotomy incisions,
implantation can often be identified antepartum. Preoperative careful sharp dissection may be
preparations for placenta accreta are necessary (Fig. 30-17). Special care is required from this point on to
discussed in Chapter 41 (p. 807) and have also been outlined by the avoid injury to the ureters, which pass beneath the
Society for Maternal-Fetal uterine arteries. To help accomplish this, an assistant places constant
Medicine (2010) and American College of Obstetricians and traction to pull the uterus in the
Gynecologists (2012c). direction away from the side on which the uterine vessels are being
An important factor affecting the cesarean hysterectomy complication ligated. The ascending uterine
rate is whether the operation artery and veins on either side are identified near their origin. These
is performed electively or emergently (Briery, 2007). After anticipated pedicles are then doubly
or planned cesarean clamped immediately adjacent to the uterus, divided, and doubly
hysterectomy, there are lower rates of blood loss, less need for blood suture ligated. As shown in Figure
transfusions, and fewer urinary 30-18, we prefer to use three heavy clampsHeaney or Ballantine
tract complications compared with emergent procedures (Briery, to incise the tissue between the
2007; Glaze, 2008; Sakse, 2007). most medial clamps, and then ligate the pedicle in the clamps lateral
Peripartum Hysterectomy Technique to the uterus. With cesarean hysterectomy, it may be more
Supracervical or total hysterectomy is performed using standard advantageous in cases of profuse hemorrhage to
operative techniques. For this, rapidly double clamp and divide all of the vascular pedicles between
clamps to gain hemostasis. The
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 9 of 12
operator can then return to ligate all of the pedicles. pedicles to the vaginal vault and bladder flap. Bleeding sites are
Total Hysterectomy ligated with care to avoid the
Even if total hysterectomy is planned, we find it in many cases ureters. The abdominal wall normally is closed in layers, as
technically easier to finish the operation after amputating the uterine previously described for cesarean
fundus and placing Ochsner or Kocher clamps on the cervical delivery (p. 597).
stump for traction and hemostasis. Self-retaining retractors also may Supracervical Hysterectomy
be placed at this time. To To perform a subtotal hysterectomy, the uterine body is amputated
remove the cervix, the bladder is mobilized further if needed. This immediately above the level of
carries the ureters caudad as the uterine artery ligation. The cervical stump may be closed with
bladder is retracted beneath the symphysis and will prevent continuous or interrupted chromic
laceration or suturing of the bladder catgut sutures of 0 or No. 1 gauge. Subtotal hysterectomy is often all
during cervical excision and vaginal cuff closure. that is necessary to stop
If the cervix is effaced and dilated considerably, its softness may hemorrhage. It may be preferred for women who would benefit from
obscure palpable identification a shorter surgery or for those
of the cervicovaginal junction. The junction location can be with extensive adhesions that threaten significant urinary tract injury.
ascertained through a vertical uterine Salpingo-OophorectomyBecause of the large adnexal vessels and
incision made anteriorly in the midline, either through the open their close proximity to the uterus, it may be necessary to
hysterotomy incision or through an remove one or both adnexa to obtain hemostasis. Briery and
incision created at the level of the ligated uterine vessels. A finger is colleagues (2007) reported unilateral or
directed inferiorly through the bilateral oophorectomy in a fourth of cases. Preoperative counseling
incision to identify the free margin of the dilated, effaced cervix and should include this possibility.
the anterior vaginal fornix. The Cystotomy
contaminated glove is replaced. Another useful method to identify the Rarely, and usually in women who have had a previous cesarean
cervical margins is to delivery, the bladder may be
transvaginally place four metal skin clips or brightly colored sutures lacerated. This complication may occur during cesarean delivery, but
at 12, 3, 6, and 9 oclock it is more common with
positions on the cervical edges in cases of planned hysterectomy. cesarean hysterectomy, especially if there is abnormal placental
The cardinal ligaments, the uterosacral ligaments, and the many implantation.
large vessels these ligaments Bladder injury is typically identified at the time of surgery, and initially,
contain are clamped systematically with Heaney-type curved or a gush of clear fluid into
straight clamps (Fig. 30-19). The the operating field may be seen. If cystotomy is suspected, it may be
clamps are placed as close to the cervix as possible, taking care not confirmed with retrograde
to include excessive tissue in instillation of sterile infant formula through a Foley catheter into the
each clamp. The tissue between the pair of clamps is incised, and bladder. Leakage of opaque milk
the lateral pedicle is suture ligated. aids in laceration identification and delineation of its borders. In some
These steps are repeated caudally until the level of the lateral vaginal cases, cystoscopy may be
fornix is reached. In this way, indicated to further define bladder injury. Primary repair is preferred
the descending branches of the uterine vessels are clamped, cut, and lowers the risk of
and ligated as the cervix is dissected postoperative vesicovaginal fistula formation. Once ureteral patency
from the cardinal ligaments. Immediately below the level of the is confirmed, the bladder may
cervix, a curved clamp is placed across the lateral vaginal be closed with a two- or three-layer running closure using a 3-0
fornix, and the tissue is incised above the clamp (Fig. 30-20). The absorbable or delayed-absorbable
excised lateral vaginal fornix can suture (Fig. 30-23). The first layer inverts the mucosa into the
be simultaneously doubly ligated and sutured to the stump of the bladder, and subsequent layers
cardinal ligament. The cervix is reapproximate bladder muscularis. Postoperative care requires
inspected to ensure that it has been completely removed, and the continuous bladder drainage for 7 to
vagina is then repaired. Each of the 10 days.
angles of the lateral vaginal fornix is secured to the cardinal and
uterosacral ligaments to mitigate PERIPARTUM MANAGEMENT
later vaginal prolapse (Fig. 30-21). Following this step, some Intravenous Fluids
surgeons prefer to close the vagina During and after cesarean delivery, requirements for intravenous
using figure-of-eight sutures. Others achieve hemostasis by using a fluids can vary considerably.
running-lock stitch placed through Intravenously administered fluids consist of either lactated Ringer
the mucosa and adjacent endopelvic fascia around the solution or a similar crystalloid
circumference of the vaginal cuff (Fig. 30-22). If a self-retaining solution with 5-percent dextrose. Typically, at least 2 to 3 L is infused
retractor has not already been placed, some clinicians choose to during surgery. Blood loss
insert one at with uncomplicated cesarean delivery approximates 1000 mL. The
this point. The bowel is then packed out of the field, and all sites are average-sized woman with a hematocrit of 30 percent or more and
examined carefully for bleeding. with a normally expanded blood and extracellular fluid volume
One technique is to perform a systematic bilateral survey from the most often will tolerate blood loss up to 2000 mL without difficulty.
fallopian tube and ovarian ligament Unappreciated bleeding through
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy 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 or fourth postpartum day (Buie, 2010). Data from small studies
will minimize discomfort. By the suggest that earlier discharge may be
second day, she may walk without assistance. feasible for properly selected and motivated women (Strong, 1993;
The incision is inspected each day, and skin sutures or clips often Tan, 2012). Activities during the
can be removed on the fourth first week should be restricted to self-care and newborn care with
postoperative day. If there is concern, however, for superficial wound assistance. Driving can be
separationfor example, in resumed when pain does not limit the ability to brake quickly and
obese patientsthe suture or clips should remain in place for 7 to 10 when narcotic medications are not
days. By the third postpartum in use. Return to work is variable. Six weeks is commonly cited,
day, showering is not harmful to the incision. although many women use the
Hospital Discharge Family and Medical Leave Act to allow up to 12 weeks for recovery
Unless there are complications during the puerperium, the mother and newborn bonding.
generally is discharged on the third
Rem Alfelor Chapter 30: Cesarean Delivery and Peripartum Hysterectomy Page 12 of 12