C Section

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the Pfannenstiel

is a transverse skin

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incision

that has made to finger

Bret's

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above the pubic bone approximately the

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width from an
outstretched index finger

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to

the thumb another method for
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estimating the proper width of a
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Pfannenstiel incision is to measure the
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length from an end of an ALICE clamp to
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the hinge on each side of the midline
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the skin incision should be made

using
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the full length of the blade not

just
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the tip and should go all the way

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through the skin to the subcutaneous

fat
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incising the skin too deeply causes
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unnecessary bleeding carry the incision
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down in the midline all the way to

the
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fascia avoiding the subcutaneous tissue
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on each side through which travel the
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superficial epigastric vessels once the
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natasha is reached it is nicked on each
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side of the Linea Alba the subcutaneous
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tissue is then stretched to expose the
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underlying fascia the fascial incision
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is then extended using Mayo scissors
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it's important that the Mayo scissors
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are curved upwards towards the patient's
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head rather than downward towards their
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feet the tips of the Mayo should be up
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against the fashio so that you can

be
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sure not to capture underlying

rectus
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muscle during the dissection once the
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fascia is incised it is grasped with
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Kocher clamps and elevated securely and
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separated from the underlying rectus
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muscles the fashio is attached to the
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midline and therefore must be dissected
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from the midline in order to elevate it
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up properly this is accomplished

using
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Mayo scissors the inferior aspect of the
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fascia is also grass with Kocher clamps
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and similarly dissected finally the
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rectus muscles are separated in the
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midline and taken down to the

peritoneum
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which is entered bluntly by poking

a
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finger superiorly and then once it is
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entered bluntly dissected on each side
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to offer exposure to the uterus
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occasionally there are peritoneal bands
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and peritoneal adhesions that must be
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taken down sharply using Metzenbaum
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scissors to facilitate entry as best as
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possible this is best accomplished in a
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delta shape to avoid injuring the
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urinary bladder a bladder retractor

is
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then placed to prevent bladder injury

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it's important to dissect the bladder
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from the uterus this is best
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accomplished by first incising the
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vesicle uterine serosa and then

placing
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a retractor between the two we call the
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separated serosa a bladder flap
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when this is incised it should

not be
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more than four or five centimeters

in
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total width smooth pickups are used to
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separate the serosa from the uterus

and
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then it is bluntly separated down to the
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level of the bladder pushing against the
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uterus not against the bladder the
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bladder retractor is then placed within
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this fold
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next is the uterine incision and a
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patient who is labored this lower
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uterine segment is extremely thin and it
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is easy to injure the fetus for this
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reason the last stages of uterine entry
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are usually accomplished by blunt
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dissection the amnion is ruptured

using
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an ALICE and the fetal head is to live
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during elevation of the fetal head do
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not break that is bend your wrist or you
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may cause an extension of the uterine

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incision down into the cervix vagina or
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bladder here's an example of a difficult
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delivery because this patient had not
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labored the lower uterine segment was
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not developed and a bandage scissors is
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necessary to extend the incision
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additionally the fetal head cannot be
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delivered spontaneously in a vacuum

it
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is necessary it is placed on the fetal

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occiput and then the fetal head is
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delivered in the usual manner
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once the head is delivered the

shoulders
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must be delivered with gentle upward and
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downward traction similar to that which
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is performed in a spontaneous vaginal
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delivery the mouth should be

suctioned
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first followed by the nose
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here's an example of a bridge

delivery
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again entry into the uterus occurs

with
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care not to cut the fetal presenting
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part so at the final stages blunt
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dissection is used with the finger once
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the finger goes into the cavity the
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uterus is extended laterally with
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traction
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notice that the amnion was spontaneously

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entered following this for breech
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delivery the fetal feet are identified
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and they are pulled through the incision
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and the baby follows to the level of

the
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shoulder blades the baby is wrapped in a
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towel and rotated sacrum anterior or
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back facing straight up the arms are
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delivered by rotating the baby in

the
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direction of the arm that needs to be
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removed and then using the Pinard
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maneuver to remove the arms the Pinard
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maneuver places a finger along the long
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axis of a bone in order to prevent
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breakage by going parallel to the bone
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the bone is splinted the

most difficult
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part of any breech delivery is delivery
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of the head the head must be flexed this

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can be accomplished by placing
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suprapubic or abdominal pressure and by
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pulling down on the fetal chin and malar
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eminences in a maneuver called
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thimerosal smell evite maneuver

notice
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that the mouth is bulb suction first the
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cord is in clamped and cut
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blood gas and cord for baby blood type
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must be obtained before delivery of the
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placenta if this is not

possible a cord
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segment measuring 12 centimeters should
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be clamped and set aside for collection
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within 30 minutes once the cord blood is
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obtained the cord is clamped above the
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level of the initial stick and this
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placenta is delivered spontaneously

if
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possible through uterine massage if not

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possible a cleavage plane must be found
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between the placenta and the uterus and
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manual extraction
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the placenta is performed as seen

here
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the plane is not easy to find

because
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the membranes often get in the way

but
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once the plane is identified the
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placenta comes out easily the placenta
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must be inspected afterwards to make
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sure that it's intact
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once the placenta is delivered

the
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uterus is then delivered through

the
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incision it is wrapped in a moist
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laparotomy sponge and a dry laparotomy
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sponge is used to clear the inside of
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the uterus of all clots and debris both
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in the fundus and also in the lower

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you'd lower uterine segment

especially
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in cases in which a patient is

labored
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once the cavity is cleared the incision
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is closed using a running locking
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technique it starts at the apex with
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care taken to avoid damaging the uterine
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vessels if the uterine vessels are
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damaged a large hematoma can form in the
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broad ligament that makes it very
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difficult to control bleeding
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each incision is placed between the
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endometrium and the myometrium and

then
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comes out between the myometrium and the
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serosa do not go through the serosa
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or annoying bleeding we'll follow you to
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the end of the case
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at the end of the closure continue to

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take care not to damage the uterine
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vessel on the opposite side once

the
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suture is closed an imitating stitch can
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be performed if hemostasis is not
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assured if the incision is hemostatic
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and indicating stitch is optional now
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for some Anatomy here's the round
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ligament here's the ovary hiding behind
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the uterine vein and fallopian tube
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there's the fallopian tube and then

the
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uterine vein is this large structure
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about the size of a garden hose and

now
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back to the implicating suture in order
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to perform an imbricate enclosure

you
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can either do a vertical or horizontal
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closure this is a vertical

closure
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approximately one centimeter of tissue

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is grasped with a needle both above and
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below the incision and pull together
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it's important that the needle go in

at
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a 90 degree angle to the tissue

to
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capture deep tissue and then come out
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below the serosa ledge this is a

running
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non-locking stitch occasionally it's
200
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important to place a device underneath
201
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the suture line to facilitate closure
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this technique is not easy to learn at
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first but once you have it down it is

a
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true joy to practice
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once the uterus is closed the front is
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packed against the bladder retractor and
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then the posterior cul-de-sac is it
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usually irrigated although it's not
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absolutely necessary to do this if

there
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is a lot of blood and a lot of clots

or
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if the patient is labored a long time is
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probably wise finally the uterus is
213
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inspected and if the incision is still
214
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hemostatic it's returned to the
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abdominal cavity rotating it slightly

so
216
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that the it neck so are not torqued the
217
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fascia is closed by placing the suture

218
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approximately one centimeter from the
219
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fascial edge and then placing additional
220
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sutures in a non-locking manner
221
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approximately one centimeter away from
222
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the previous it's important that the
223
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suture not go through fat because fat
224
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contains nerves and especially at the
225
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apex you can cause a nerve entrapment
226
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they can persist and linger for weeks or

227
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months or even longer after the

delivery
228
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an ALICE clamp can be used to grasp the
229
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apex if it's difficult to visualize once
230
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the apex is secured a running
231
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non-locking suture may be carried half
232
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way or all the way across if it's taken
233
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to half way the center should be tagged
234
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to facilitate closure of the other half
235
00:11:17,120 --> 00:11:20,130

make sure to use your
assistance during
236
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this part of the operation so that they
237
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can retract the fat without causing the
238
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fashio to be distorted from your view a
239
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good assistant will also keep suture
240
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material out of the way so that it does
241
00:11:32,760 --> 00:11:35,070
not get tangled with the area

in which
242
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you're working
243
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when you reach the midline and leave a

244
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tag do not tie a surgeon's knot in this
245
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particular throw the two strands

on the
246
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one side will be adequate enough

to
247
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cause friction within the knot to
248
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prevent slippage and a surgeon's knot
249
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can just weaken the knot
250
00:12:07,270 --> 00:12:10,000
on this side I want you to notice a

few
251
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things that are being done well

first
252
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the spacing is correct
253
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approximately a centimeter of fascist
254
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being grasped and the spacing is
255
00:12:18,820 --> 00:12:22,240
approximately a centimeter second there
256
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is some retraction that occurs from that
257
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center suture and that allows

the fashio
258
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to come up and be easily accessible

and
259
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finally when this stitch is placed is
260
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placed parallel to the patient's body

261
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from the head down to the feet when you
262
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go with the direct axis of the body

it
263
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prevents a dog ear from occurring in
264
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sutures that are placed like this once
265
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the final suture is placed and the

final
266
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knot is tied both of these are cut to
267
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approximately one centimeter and

then
268
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the subcutaneous tissue is first

269
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irrigated and then closed if the depth
270
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of this incision were greater than two
271
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finger breaths deep then a subcutaneous
272
00:13:11,200 --> 00:13:13,420
stitch would be placed prior to

closure
273
00:13:13,420 --> 00:13:16,740
of the skin that is not the case
right
274
00:13:16,740 --> 00:13:21,130
here and so it will not be placed before
275
00:13:21,130 --> 00:13:24,070
the skin is closed all subcutaneous
276
00:13:24,070 --> 00:13:26,620
capillary bleeding is rendered
277
00:13:26,620 --> 00:13:28,620
hemostatic using an electric cautery
278
00:13:28,620 --> 00:13:31,630
this is helpful to prevent a seroma from
279
00:13:31,630 --> 00:13:35,430
later forming always use a clean towel
280
00:13:35,430 --> 00:13:38,110
we frequently give the patient an option
281
00:13:38,110 --> 00:13:40,510
of closure with either staples or a sub
282
00:13:40,510 --> 00:13:43,960
ticular stitch as you see here the
283
00:13:43,960 --> 00:13:46,930
difference is that staples often can

be
284
00:13:46,930 --> 00:13:48,790
placed quicker so in the middle of the
285
00:13:48,790 --> 00:13:52,090
night that's often our choice however

286
00:13:52,090 --> 00:13:54,850
the staples must be removed after three
287
00:13:54,850 --> 00:13:56,950
days and if a patient leaves after
288
00:13:56,950 --> 00:13:59,890
post-op day two they have to return so
289
00:13:59,890 --> 00:14:01,660
patients that live far away

should
290
00:14:01,660 --> 00:14:04,090
probably have a sub particular stitch
291
00:14:04,090 --> 00:14:07,180
placed the subcuticular stitch can also
292
00:14:07,180 --> 00:14:09,640
cause some inflammation and irritation
293
00:14:09,640 --> 00:14:12,090
and people that react to it and
294
00:14:12,090 --> 00:14:14,910

potentially aggravate keloid formation
295
00:14:14,910 --> 00:14:18,540
so patients that tend to react to

things
296
00:14:18,540 --> 00:14:22,139
may do better with staple
297
00:14:22,139 --> 00:14:26,410
once the incision is closed the
298
00:14:26,410 --> 00:14:31,920
surrounding drape is peeled back and
299
00:14:31,920 --> 00:14:36,999
tincture of benzoin is placed in order
300
00:14:36,999 --> 00:14:39,220
to clean the area and caused traction
301
00:14:39,220 --> 00:14:41,709
from steri-strips and in steri-strips
302
00:14:41,709 --> 00:14:43,029
are place over the dry
303
00:14:43,029 --> 00:14:45,720
benzoin
304
00:14:52,570 --> 00:14:54,780
once the steri-strips have been
305
00:14:54,780 --> 00:14:58,380
placed a dry dressing is placed over

the
306
00:14:58,380 --> 00:15:01,250
steri-strips and the drapes are removed
307
00:15:01,250 --> 00:15:05,960
finally the uterus is pushed with some
308
00:15:05,960 --> 00:15:08,670
fundal pressure to get all the clots and
309
00:15:08,670 --> 00:15:11,930
degrees out and the vagina is

irrigated
310
00:15:11,930 --> 00:15:14,430
and the patient is sent to the recovery
311
00:15:14,430 --> 00:00:00,000
room

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1

00:00:06,649 --> 00:00:08,480

that has made to finger

00:00:08,480 --> 00:00:11,360

above the pubic bone approximately the

00:00:11,360 --> 00:00:13,849

width from an<font color="#E5E5E5">

outstretched index finger

00:00:13,849 --> 00:00:16,910

the thumb another</font><font color="#E5E5E5"> method for</font>

00:00:16,910 --> 00:00:18,650

<font color="#E5E5E5">estimating the proper width of a</font>

00:00:18,650 --> 00:00:21,199

Pfannenstiel incision<font color="#E5E5E5"> is to measure the</font>

00:00:21,199 --> 00:00:23,180

<font color="#E5E5E5">length from an end of an ALICE clamp to</font>

00:00:23,180 --> 00:00:27,760

<font color="#E5E5E5">the hinge on each side of the midline</font>

00:00:29,530 --> 00:00:32,000

the skin<font color="#CCCCCC"> incision should</font><font color="#E5E5E5"> be made

00:00:32,000 --> 00:00:33,950

<font color="#E5E5E5">the full length of the blade</font><font color="#CCCCCC"> not

00:00:33,950 --> 00:00:35,360

the tip and should go all the way

00:00:35,360 --> 00:00:37,430

<font color="#E5E5E5">through the skin</font><font color="#CCCCCC"> to the subcutaneous

00:00:37,430 --> 00:00:39,530

incising the skin<font color="#CCCCCC"> too deeply causes</font>

00:00:39,530 --> 00:00:41,630

unnecessary bleeding carry the incision

00:00:41,630 --> 00:00:43,550

down in the midline<font color="#CCCCCC"> all the way</font><font color="#E5E5E5"> to

00:00:43,550 --> 00:00:45,470

fascia<font color="#E5E5E5"> avoiding the subcutaneous tissue</font>

00:00:45,470 --> 00:00:47,690

<font color="#E5E5E5">on each side through which travel the</font>

00:00:47,690 --> 00:00:50,510

superficial<font color="#E5E5E5"> epigastric vessels once the</font>

00:00:50,510 --> 00:00:53,630

<font color="#CCCCCC">natasha</font><font color="#E5E5E5"> is reached</font><font

00:00:53,630 --> 00:00:55,910

00:00:55,910 --> 00:00:58,940

tissue is then stretched to expose the

00:00:58,940 --> 00:01:03,440

underlying fascia the fascial incision

00:01:03,440 --> 00:01:05,440

is then<font color="#E5E5E5"> extended using Mayo scissors</font>

00:01:05,440 --> 00:01:08,390

it's important that the Mayo scissors

00:01:08,390 --> 00:01:10,910

are curved upwards towards<font color="#CCCCCC"> the patient's</font>

00:01:10,910 --> 00:01:14,030

head rather than downward towards their

00:01:14,030 --> 00:01:17,150

feet<font color="#E5E5E5"> the tips of the Mayo should be up</font>

00:01:17,150 --> 00:01:19,340

against the<font color="#CCCCCC"> fashio</font><font color="#E5E5E5"> so that you can

sure<font color="#CCCCCC"> not to capture</font><font color="#E5E5E5"> underlying

00:01:21,649 --> 00:01:24,350

muscle<font color="#E5E5E5"> during the dissection once the</font>

00:01:24,350 --> 00:01:26,869

fascia is incised<font color="#CCCCCC"> it is grasped with</font>

00:01:26,869 --> 00:01:29,440