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INTRODUCTION
Section 2 of 10
Section 3 of 10
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Fetal indications
Fetal indications for cesarean delivery include those in which neonatal morbidity
and mortality could be decreased by the prevention of trauma, infection, and
prolonged acidemia.
Section 4 of 10
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with severe pulmonary disease) such that an operation may jeopardize maternal
survival. In such difficult situations, a care plan outlining when and if to intervene
should be made with the family in the setting of a multidisciplinary meeting.
Furthermore, a cesarean delivery may not be recommended if the fetus has a
known karyotypic abnormality (trisomy 13 or 18) or known congenital anomaly
that may lead to death (anencephaly).
WORKUP
Section 5 of 10
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Lab Studies:
When patients are admitted for labor and delivery, most have blood for a
CBC count and type and screen drawn when an intravenous line is started
(a basic requirement for patients when they are admitted to the labor floor).
If a patient has a hemoglobin level within the reference range, has had an
uncomplicated pregnancy, and is anticipated to have a vaginal delivery, the
use of having blood submitted to the lab for a routine CBC count and type
and screen currently is being scrutinized from a cost-benefit standpoint. In
many centers, blood is drawn and simply held in case the patient's course
changes. Namely, if the decision is made to perform a cesarean delivery for
an abnormal labor course, nonreassuring fetal testing, or abnormal
bleeding, then the blood work is submitted.
The following are several situations in which a CBC count and type and
screen always will be submitted upon admission to labor and delivery:
o
A grand multipara
hemorrhage.
TREATMENT
Section 6 of 10
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Repair of the uterus can be facilitated by manual delivery of the uterine fundus
through the abdominal incision. Externalizing the uterine fundus facilitates uterine
massage, the ability to assess whether the uterus is atonic, and the examination
of the adnexa.
The uterine cavity usually is wiped clean of all membranes with a dry laparotomy
sponge, and the cervix can be dilated with an instrument, such as a Kelly clamp, if
the patient underwent delivery with a previously undilated cervix. Typically, an Allis
clamp is placed at the angles of the uterine incision. The incision is inspected for
other bleeding vessels, and any extensions of the incision are evaluated. Inspect
the bladder and lower segment inferior to the incision.
Repair of a low transverse uterine incision can be performed in either a 1-layer or
2-layer fashion with zero or double-zero chromic or Vicryl suture. The first layer
should include stitches placed lateral to each angle, with prior palpation of the
location of the lateral uterine vessels. Most physicians use a continuous locking
stitch. If the first layer is hemostatic, a second layer (Lembert stitch), which is used
to imbricate the incision, does not need to be placed. A large prospective study
has shown no increase in postoperative complications with a 1-layer versus 2layer closure. Although the risk of uterine rupture with subsequent trials of labor
appears to not be increased with a 1-layer closure, the authors await follow-up
data from this trial.
Closure of a vertical incision usually requires several layers because the incision
is through a thicker portion of the uterus. Again, a heavy suture material is used,
and usually the first layer closes the inner half of the incision, with a second and
possible third layer used to close the outer half and serosal edges. Again, note the
extent of a vertical uterine incision because it impacts how a patient should be
counseled regarding future pregnancies.
When the uterus is closed, attention must be paid to its overall tone. An atonic
uterus can be encountered in a patient with a multiple gestation, polyhydramnios,
or a failed attempt at a vaginal delivery in which the patient was on Pitocin
augmentation for a prolonged period. If the uterus does not feel firm and
contracted with massage and intravenous oxytocin, consider intramuscular
injections of prostaglandin (15-methyl-prostaglandin, Hemabate) or
methylergonovine and repeat as appropriate.
Continued closure
If the uterine incision is hemostatic, the uterine fundus is replaced into the
abdominal cavity (unless a concurrent tubal ligation is to be performed). The
incision is reinspected for hemostasis, and the bladder flap also is inspected. The
paracolic gutters are visualized, and any blood clots are removed with dry
laparotomy sponges. The vesicouterine peritoneum and parietal peritoneum can
be reapproximated with a running chromic stitch. Many physicians prefer to not
close the peritoneum because these surfaces reapproximate within 24-48 hours
and can heal without scar formation. Furthermore, the rectus muscles to do not
need to be reapproximated.
The subfascial tissue is inspected for bleeding, and, if hemostatic, the fascia is
closed. The fascia can be closed with a running stitch, and synthetic braided
sutures are preferred over chromic sutures. Chromic sutures do not maintain their
tensile strength as long or as predictably as synthetic braided material. If the
patient is at risk for poor wound healing (eg, those with chronic steroid use), then
a delayed absorbable or permanent suture can be used. Place stitches at
approximately 1-cm intervals and more than 1 cm away from the incision line.
The subcutaneous tissue should be inspected for hemostasis and can be irrigated
according to physician preference. The subcutaneous tissue does not have to be
reapproximated, but in patients who are obese (subcutaneous depth >2 cm), a
drain may be placed and connected to an external bulb suction apparatus. The
skin edges can be closed either with a subcuticular stitch or with staples (removed
3 or 4 d postoperatively).
Postoperative details: In the recovery room, vital signs are taken every 15
minutes for the first 1-2 hours, and urine output is monitored on an hourly basis. In
addition to routine assessment, palpate the fundus to ensure that it feels firm.
Attention needs to be paid to the amount of vaginal bleeding.
If the patient had regional anesthesia, they usually receive a long-acting analgesic
with the regional anesthetic. Therefore, pain control usually is not an issue in the
first 24 hours. If a patient did not receive a long-acting analgesic or had general
anesthesia, narcotics can be administered either intramuscularly or intravenously
(on schedule or with a basal rate supplemented with patient-controlled boluses).
When the patient is tolerating liquids, narcotics can be administered orally as
needed.
When patients recover sensation after a regional anesthetic and vital signs have
been stable with minimal vaginal bleeding, they can be taken to their room. The
patient should have vital signs taken every hour for at least the first 4 hours and,
again, attention should be paid to urine output.
Overall, a patient should receive approximately 3-4 L of intravenous fluid from
initiation of the intravenous line through the first 24 hours. The patient can be
started on clear liquids 12-24 hours after an uncomplicated procedure, and diet
can be advanced accordingly. When the patient is able to tolerate good oral
intake, the intravenous fluids can be stopped.
The bladder catheter can be removed 12-24 hours postoperatively. If the patient is
unable to void in 6 hours, consider replacing the Foley for an additional 12-24
hours.
On the first postoperative day, encourage the patient to ambulate. Increase
ambulation every day as tolerated by the patient. The dressing can be removed
12-24 hours after surgery and can be left open after that time. Typically, the blood
count is checked 12-24 hours after surgery, or sooner if a greater than average
blood loss has occurred.
If a patient plans to breastfeed, this can be initiated within a few hours after
delivery. If a patient plans to bottle feed, a tight bra or breast binder should be
used in the postoperative period.
If the patient has recovered well postoperatively, she can be discharged safely 3-4
days after surgery. If staples were used to approximate the skin, remove them
prior to discharge. If the patient has had a vertical skin incision or is at risk for poor
healing (eg, diabetes or long-term steroid use), the physician may elect to keep
the staples in for 2-3 extra days and have the patient return to the office at that
time.
Prior to discharge, a discussion about contraception should take place. Stress that
even if a mother is breastfeeding, she still can conceive. Ask patients to refrain
from intercourse for 4-6 weeks postpartum.
Follow-up care: After a cesarean delivery, the patient can be observed as a
patient who delivered vaginally. The normal recommendation is to have the patient
make a follow-up appointment 4-6 weeks after delivery. If bleeding has stopped, a
repeat Papanicolaou test is customary. During this visit, review any notable
findings from the surgery and discuss delivery options for future pregnancies.
For excellent patient education resources, visit eMedicine's Pregnancy and
Reproduction Center. Also, see eMedicine's patient education articles Labor Signs
and Cesarean Childbirth.
COMPLICATIONS
Section 7 of 10
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Postoperative complications
Section 8 of 10
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Outcome And Prognosis Future And Controversies Bibliography
Patients who undergo cesarean delivery usually take slightly longer to fully
recover than those who have a vaginal delivery. However, the overall long-term
condition of the patient is not adversely affected. Occasionally, some patients can
experience pelvic pain associated with intra-abdominal adhesions, a situation that
can be aggravated in those who have multiple procedures.
The most important things for patients to know about their cesarean delivery are
why they had one and what kind of incision was performed on the uterus.
If a patient had a cesarean delivery for presumed cephalopelvic disproportion,
then attempting a vaginal birth with the next pregnancy is associated with a
decreased risk of success. Overall, patients attempting a vaginal birth after a prior
cesarean delivery can expect success approximately 70% of the time. If the
cesarean delivery was performed because of an abnormal fetal heart pattern or
for a malpresentation, then expectations for a successful vaginal birth can be
higher than 70%. If the uterine incision was vertical, the risk of uterine rupture is
increased above the approximate 1% risk associated with a low transverse
incision. If the incision was confined to the lower segment, many physicians allow
patients to attempt a vaginal birth in subsequent pregnancies. However, if the
incision extended into the upper contractile portion, the risk of uterine rupture can
approach 10%, with 50% of these occurring prior to the onset of labor.
A previous cesarean delivery can increase the risk of developing placenta accreta
if placenta previa is present in any subsequent pregnancies. The risk of placenta
accreta in a patient with previa is approximately 4% with no prior cesarean
deliveries; the risk increases to approximately 25% with 1 prior cesarean delivery
and to 40% with 2 prior cesarean deliveries.
FUTURE AND CONTROVERSIES
Section 9 of 10
Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications
Outcome And Prognosis Future And Controversies Bibliography