Cesarea

C H A P T E R 20
Cesarean Section
PART 2
Michael S. Baggish
Cesarean section is one of the most commonly performed the uterine arteries should be ascertained to avoid inadvertent
n
operations in the United States. A transverse or vertical entry extension of the incision through them. The membranes are
SECT ION 5
laparotomy is performed. A transverse incision is selected more opened, and amniotic fluid is suctioned as it pours out into the
frequently (by a ratio of 10:1). The uterus may be left in situ wound.
within the abdominal cavity, or it may be exteriorized. The head of the infant (cephalic presentation) appears
The technique of low transverse cesarean section is per- beneath the incision (Fig. 20.10). It is grasped beneath the chin
formed as follows. The bladder is emptied by the insertion of and occiput and is gently delivered. It is rotated to facilitate
a Foley catheter. First, a bladder blade is inserted anteriorly delivery of the shoulders, and this is followed by delivery of the
(Fig. 20.1). The small and large intestines are packed away with breech. The umbilical cord is clamped (doubly) and cut. The
moistened abdominal (laparotomy) pads, which should be care- placenta is now seen in the depths of the wound (Fig. 20.11).
fully counted and tagged. The round ligaments should be iden- It is separated and extracted. The uterine cavity is manually
tified so that the degree and direction of uterine rotation can explored, and clots are evacuated. The edges of the incision are
be determined. Identification of enlarged or aberrant vessels grasped with Babcock clamps. A 10-mm Hegar dilator is passed
should be documented. through the cervix. Alternatively, a 36-French Pratt dilator may
The reflection of peritoneum from the bladder dome to the be passed through the cervix to facilitate lochial drainage. The
uterus is grasped with a Kelly clamp (Fig. 20.2). The peritoneal incision is inspected for any extensions. The uterine vessels and
reflection is elevated. With a Metzenbaum scissors, the bladder bladder are checked for any injuries.
peritoneal reflection is sharply divided and is extended trans- The incision is closed in layers. The deep muscle is approxi-
versely for the length of the proposed uterine incision, typically mated with interrupted figure-of-8 suture ligatures of 0 Vicryl
8 to 10 cm (Figs. 20.3 and 20.4). The bladder is gently pushed (Figs. 20.12 and 20.13A). The superficial muscle and the uterine
inferiorly away from the lower uterine segment. This not serosa are closed by a running 0 Vicryl (see Fig. 20.13A, Inset, and
uncommonly results in small-vessel disruption and light bleed- 20.13B). The bladder flap peritoneum is sutured over the inci-
ing (Fig. 20.5). sion with running 3-0 Vicryl or PDS suture.
A trace incision is made into the uterus above the bladder The uterus is massaged and replaced into the abdominal cav-
reflection (Fig. 20.6). With the use of a scalpel, a deeper central ity. Retractors and packs are removed and carefully counted to
cut, approximately 4 cm in length, is carried down to the amni- ensure that each and every implement has been accounted for.
otic sac, which bulges through the wound (Fig. 20.7A and B). A low vertical section may be performed by incising verti-
Alternatively, the sharp incision is stopped just short of entry cally through the lower uterine segment. Care must be taken
into the uterine cavity. At this point, the muscle may be spread to avoid extension of this incision into the bladder. The only
with the surgeon’s index fingers and the cavity entered bluntly advantage of this incision is that it permits further extension
(Fig. 20.8A and B). superiorly into the active portion of the uterus to gain greater
In either case, once the bulging membranes have been iden- space to manipulate the fetus (e.g., in the delivery of a transverse
tified, the incision may be extended to right and left by using presentation).
scissors or by spreading with fingers (Fig. 20.9). The location of
311
Descargado para Daniela Moncada (daniela-escobar@juanncorpas.edu.co) en University Foundation Juan N Corpas de ClinicalKey.es por Elsevier en marzo 26,
2024. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
312 PART 2 n SECTION 5 n Abdominal Surgery During Pregnancy
FIG. 20.1 Full-term pregnant uterus exposed and exteriorized. A bladder FIG. 20.2 The peritoneal reflection between the bladder and the uterus is
retractor is seen in the foreground. The edges of the entry incision are beneath elevated.
the obstetrician’s hands.
FIG. 20.3 The bladder peritoneum is incised sharply in an avascular plane. FIG. 20.4 The dissection is completed along the length of the anticipated
Vascularization of this peritoneum may be seen in cases of placenta previa or deeper uterine incision.
accreta.
CHAPTER 20 Cesarean Section 313
Round
ligament
PART 2
Uterus
n
SECT ION 5
Bladder
Separation of
bladder from
uterus
FIG. 20.5 The operator gently pushes the bladder inferiorly, detaching it from the lower uterine segment.
FIG. 20.6 The lower uterine segment is now exposed. The uterine arteries
are palpated to determine the lateral extreme of the uterine incision.
4 cm
Trace incision
Cut deeper to
amniotic sac
B
FIG. 20.7 A. A small (3- to 4-cm) trace incision is made, then is extended deeper through the myometrium. B. At this point, bleeding is brisk, and suctioning is
essential to detect when the uterine cavity has been entered.
PART 2
n
SECT ION 5
Bulging
amnion
Bluntly revealing
membranes with
index fingers
B
FIG. 20.8 A. Alternatively, the cavity may be entered bluntly by spreading the index fingers through the last thin layer of myometrium. B. The appearance of
bulging membranes signals entry into the endometrial space.
Uterine
vessels
Uterine
vessels
Increasing
incision
width
FIG. 20.9 With the membranes intact, the small entry incision may be
widened laterally.
FIG. 20.10 The membranes are now ruptured and widely opened. The infant’s
head comes into view, and delivery is implemented.
PART 2
n
SECT ION 5
FIG. 20.11 The placental location is observed and recorded. Next, the
placenta is manually removed. The uterine cavity is explored and cleared of
any adherent membranes.
FIG. 20.12 The deeper muscle is closed with interrupted 0 Vicryl figure-of-8
sutures.
Serosal closure
Peritoneal
closure
Figure-of-8
deep closure
B
FIG. 20.13 A. The superficial muscle and uterine serosa are closed with running or running lock sutures of 0 Vicryl. B. After the serosa is closed, the bladder
peritoneum is sutured to the uterus at the upper margin of the incision.

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C H A P T E R 20

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