CESAREAN DELIVERY IN THE UNITED STATES
CESAREAN DELIVERY INDICATIONS AND RISKS
TECHNIQUE FOR CESAREAN DELIVERY
PERIPARTUM HYSTERECTOMY TECHNIQUE
Cesarean delivery defines the birth of a fetus via laparotomy and then hysterotomy. The origin of caesarean is uncertain and was reviewed in the 23rd edition of Williams Obstetrics (Cunningham, 2010). There are two general types of cesarean delivery—primary refers to a first-time hysterotomy and secondary denotes a uterus with one or more prior hysterotomy incisions. Neither definition includes removal of the fetus from the abdominal cavity in the case of uterine rupture or with abdominal pregnancy. Rarely, hysterotomy is performed in a woman who has just died or in whom death is expected soon—postmortem or perimortem cesarean delivery (Chap. 47, p. 956).
In some instances, and most often because of emergent complications such as intractable hemorrhage, abdominal hysterectomy is indicated following delivery. When performed at the time of cesarean delivery, the operation is termed cesarean hysterectomy. If done within a short time after delivery, it is termed postpartum hysterectomy. Peripartum hysterectomy is a broader term that combines these two. In most cases, hysterectomy is total, but supracervical hysterectomy is also an option. The adnexa are not typically removed.
CESAREAN DELIVERY IN THE UNITED STATES
From 1970 to 2010, the cesarean delivery rate in the United States rose from 4.5 percent of all deliveries to 32.8 percent. In 2010, this rate actually declined from a peak of 32.9 percent in 2009 (Martin, 2012). The other, albeit brief, decline was between 1989 and 1996 (Fig. 31-1, p. 610). This more profound decrease was largely due to a significantly increased rate of vaginal birth after cesarean (VBAC) and to a closely mirrored decrease in the primary rate. These trends were short lived, and in 2007, the primary cesarean delivery rate was above 30 percent, whereas VBAC rates had dropped to 8 percent (MacDorman, 2011).
The reasons for the continued increase in the cesarean rates are not completely understood, but some explanations include the following:
1. Women are having fewer children, thus, a greater percentage of births are among nulliparas, who are at increased risk for cesarean delivery.
2. The average maternal age is rising, and older women, especially nulliparas, are at increased risk of cesarean delivery.
3. The use of electronic fetal monitoring is widespread. This technique is associated with an increased cesarean delivery rate compared with intermittent fetal heart rate auscultation (Chap. 24, p. 496). Cesarean delivery performed primarily for “fetal distress” comprises only a minority of all such procedures. In many more cases, concern for an abnormal or “nonreassuring” fetal heart rate tracing lowers the threshold for cesarean delivery.
4. Most fetuses presenting as breech are now delivered by cesarean. As discussed in Chapter 28 (p. 561), concern for fetal injury, as well as the infrequency with which a breech presentation meets criteria for a labor trial, almost guarantee that most will be delivered by cesarean.
5. The frequency of forceps and vacuum deliveries has decreased (Chap. 29, p. 574).
6. Rates of labor induction continue to rise, and induced labor, especially among nulliparas, increases the cesarean delivery rate (Chap. 26, p. 523).
7. The prevalence of obesity has risen dramatically, and obesity increases the cesarean delivery risk (Chap. 48, p. 965).
8. Rates of cesarean delivery for women with preeclampsia have increased, whereas labor induction rates for these patients have declined.
9. Vaginal birth after cesarean—VBAC—has decreased from a high of 28 percent in 1996 to 8 percent in 2007 (Chap. 31, p. 610).
10. Elective cesarean deliveries are increasingly being performed for a variety of indications including concern for pelvic floor injury associated with vaginal birth, medically indicated preterm birth, reduction of fetal injury risk, and for maternal request.
11. Malpractice litigation related to fetal injury during spontaneous or operative vaginal delivery continues to contribute significantly to the present cesarean delivery rate.
CESAREAN DELIVERY INDICATIONS AND RISKS
Some indications for performing cesarean delivery are shown in Table 30-1. More than 85 percent of these operations are performed for four reasons—prior cesarean delivery, dystocia, fetal jeopardy, or abnormal fetal presentation.
TABLE 30-1. Some Indications for Cesarean Delivery
Prior cesarean delivery
Prior classical hysterotomy
Unknown uterine scar type
Uterine incision dehiscence
Prior full-thickness myomectomy
Genital tract obstructive mass
Invasive cervical cancer
Prior pelvic reconstructive surgery
HSV or HIV infection
Cardiac or pulmonary disease
Cerebral aneurysm or arteriovenous malformation
Pathology requiring concurrent intraabdominal surgery
Perimortem cesarean delivery
Failed operative vaginal delivery
Placenta previa or placental abruption
Nonreassuring fetal status
Abnormal umbilical cord Doppler study
Prior neonatal birth trauma
HIV = human immunodeficiency virus; HSV = herpes simplex virus.
Maternal Mortality and Morbidity
To provide accurate informed consent, understanding both maternal and neonatal risks and benefits with surgery is essential. As a broad overview, cesarean delivery has higher maternal surgical risks for the current and subsequent pregnancies. This is balanced against lower rates of perineal injury and short-term pelvic floor disorders, described in Chapter 27 (p. 536). For the neonate, cesarean delivery offers lower rates of birth trauma and stillbirth. Conversely, rates of initial respiratory difficulties are greater with cesarean delivery.
For the mother, death attributable solely to cesarean delivery is rare in the United States. Even so, numerous studies attest to increased mortality risks. Clark and colleagues (2008), in a review of nearly 1.5 million pregnancies, found maternal mortality rates of 2.2 per 100,000 cesarean deliveries compared with 0.2 per 100,000 vaginal births. In a metaanalysis of 203 studies, Guise and coworkers (2010) reported a maternal mortality rate of 13 per 100,000 with elective repeat cesarean delivery compared with 4 per 100,000 women undergoing a trial of labor during VBAC attempt.
Similar to mortality rates, the frequency of some maternal complications is increased with all cesarean compared with vaginal deliveries (Table 30-2). Villar and associates (2007) reported that maternal morbidity rates increased twofold with cesarean compared with vaginal delivery. Principal among these are infection, hemorrhage, and thromboembolism. In addition, anesthetic complications, which also rarely include death, have a greater incidence with cesarean compared with vaginal delivery (Cheesman, 2009; Hawkins, 2011). Adjacent organs may be injured. The bladder laceration rate is 1 to 3 per 1000 cesarean deliveries, whereas that for ureteral injury approximates 0.3 per 1000 cases (Güngördük, 2010; Phipps, 2005; Rajasekar, 1997). Bowel damage occurs in approximately 1 in 1000 cesarean deliveries (Silver, 2006).
TABLE 30-2. Complications Associated with Low-Risk Planned Cesarean Deliverya Compared with Planned Vaginal Delivery among Healthy Women in Canada, 1991–2005
Women expressing a desire for elective primary cesarean delivery may be counseled that surgery offers decreased risks for hemorrhage and chorioamnionitis compared with planned primary vaginal birth. But this is again balanced against higher maternal rates of thromboembolism, hysterectomy, and rehospitalization for infection or wound complications; longer initial hospital stays; and greater rates of uterine rupture or abnormal placental implantation in subsequent pregnancies (Declercq, 2007; Geller, 2010; Liu, 2007).
Women who undergo a cesarean delivery are much more likely to be delivered by a repeat operation in subsequent pregnancies. For women undergoing subsequent cesarean, the maternal risks just described are even greater (Cahill, 2006; Marshall, 2011; Silver, 2006).
As an advantage, there is evidence that cesarean delivery is associated with lower rates of urinary incontinence and pelvic organ prolapse (Glazener, 2013; Gyhagen, 2013; Handa, 2011; Leijonhufvud, 2011; Rortveit, 2003). This protective advantage may persist to some degree over time, but cesarean delivery is not wholly protective (Dolan, 2010; MacArthur, 2011; Rortveit, 2001). Finally, cesarean delivery is not protective long-term for fecal incontinence (MacArthur, 2011, 2013; Nelson, 2010).
Cesarean delivery is associated with less risk of fetal trauma. And this in many instances influences the choice of cesarean delivery despite the associated maternal risks. Alexander and colleagues (2006) found that fetal injury complicated 1 percent of cesarean deliveries. Skin laceration was most common, but others included cephalohematoma, clavicular fracture, brachial plexopathy, skull fracture, and facial nerve palsy. Cesarean deliveries following a failed operative vaginal delivery attempt had the highest injury rate, whereas the lowest rate—0.5 percent—occurred in the elective cesarean delivery group. That said, Worley and colleagues (2009) found that approximately a third of pregnant women who were delivered at Parkland Hospital entered spontaneous labor at term, and 96 percent of these delivered vaginally without adverse neonatal outcomes.
Although physical injury risks are lower, cesarean delivery per se may have no bearing on the neurodevelopmental prognosis of the infant. Scheller and Nelson (1994) in a report from the National Institutes of Health and Lien and associates (1995) presented data specifically refuting any association between cesarean delivery and lower rates of either cerebral palsy or seizures. Moreover, as discussed in Chapter 33(p. 638), the incidences of neonatal seizures or cerebral palsy have not diminished as the rate of cesarean delivery has increased (Miller, 2008; Miller, 2013).
Patient Choice in Cesarean Delivery
As women have taken a more active role in their obstetrical care, some request elective cesarean delivery. Data regarding the true incidence of cesarean delivery on maternal request (CDMR) are limited, however, estimates are a 1- to 7-percent rate in the United States in 2003 (Gossman, 2006; Menacker, 2006).
Reasons for requested cesarean delivery include reduced risk of fetal injury, avoidance of the uncertainty and pain of labor, protection of pelvic floor support, and convenience. Thus, the debate surrounding CDMR includes its medical rationale from both a maternal and fetal-neonatal standpoint, the concept of informed free choice by the woman, and the autonomy of the physician in offering this choice.
To address this, the National Institutes of Health (2006) held a State-of-the-Science Conference on Cesarean Delivery on Maternal Request. A panel of experts critically reviewed available literature to form recommendations based on identified risks and benefits. It is noteworthy that most of the maternal and neonatal outcomes examined had insufficient data to permit such recommendations. Indeed, one of the main conclusions of the conference was that more high-quality research is needed to fully evaluate the issues. The American College of Obstetricians and Gynecologists (2013) concluded that data comparing planned cesarean and planned vaginal delivery were minimal and thus should be interpreted cautiously.
The panel was able to draw a few conclusions from existing information. Cesarean delivery on maternal request should not be performed before 39 weeks’ gestation unless there is evidence of fetal lung maturity. It should be avoided in women desiring several children because of the risk of placental implantation abnormalities and cesarean hysterectomy. Finally, it should not be motivated by the unavailability of effective pain management.
There is no nationally recognized standard of care that codifies an acceptable time interval to begin performance of a cesarean delivery. Previously, a 30-minute decision-to-incision interval was recommended. In most instances, however, operative delivery is not necessary within this 30-minute time frame. Bloom and coworkers (2001) reported for the Maternal-Fetal Medicine Units Network that 69 percent of 7450 cesareans performed in labor commenced more than 30 minutes after the decision to operate. In a second study, Bloom and colleagues (2006) evaluated cesarean deliveries performed for emergency indications. They reported that failure to achieve a cesarean delivery decision-to-incision time of less than 30 minutes was not associated with a negative neonatal outcome. On the other hand, when faced with an acute, catastrophic deterioration in fetal condition, cesarean delivery usually is indicated as rapidly as possible, and thus purposeful delays are inappropriate. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2012) recommend that facilities giving obstetrical care should have the ability to initiate cesarean delivery in a time frame that best incorporates maternal and fetal risks and benefits.
Obtaining informed consent is a process and not merely a medical record document (American College of Obstetricians and Gynecologists, 2012a). This conversation between a clinician and patient should enhance a woman’s awareness of her diagnosis and contain a discussion of medical and surgical care alternatives, procedure goals and limitations, and surgical risks. For women with a prior cesarean delivery, the option of a trial of labor should be included for suitable candidates. Also, in those desiring permanent sterilization, consenting for tubal ligation, as described in Chapter 39 (p. 720), can be completed at this time.
Timing of Scheduled Cesarean Delivery
Adverse neonatal sequelae from neonatal immaturity with elective delivery before 39 completed weeks are appreciable (Clark, 2009; Tita, 2009a). To avoid these, assurance of fetal maturity before scheduled elective surgery is essential as outlined by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2012) and discussed in Chapter 31 (p. 615). To assist with this and other components of cesarean delivery planning, the American College of Obstetricians and Gynecologists (2011a,c) has created Patient Safety Checklists to be completed before the planned surgery.
If cesarean delivery is scheduled, a sedative may be given at bedtime the night before surgery. In general, no other sedatives, narcotics, or tranquilizers are administered until after the fetus is born. Oral intake is stopped at least 8 hours before the procedure. The woman scheduled for repeat cesarean delivery typically is admitted the day of surgery and evaluated by the obstetrical and anesthesia teams. Recently performed hematocrit and indirect Coombs test are reviewed, and if the latter is positive, then availability of compatible blood must be ensured.
As discussed in Chapter 25 (p. 509), regional analgesia is preferred for cesarean delivery. An antacid is given shortly before regional analgesia or induction with general anesthesia. One example is Bicitra, 30 mL orally in a single dose. This minimizes the lung injury risk from gastric acid aspiration. Once the woman is supine, a wedge beneath the right hip creates a left lateral tilt to aid venous return and avoid hypotension. According to the American College of Obstetricians and Gynecologists (2010), there are insufficient data to determine the value of fetal monitoring before scheduled cesarean delivery in women without risk factors. That said, fetal heart sounds should be documented in the operating room prior to surgery.
For further preparation, if hair obscures the operative field it should be removed the day of surgery by clipping. This is associated with fewer surgical site infections compared with shaving (Tanner, 2011). An indwelling bladder catheter is typically placed at Parkland Hospital to collapse the bladder away from the hysterotomy incision, to avert urinary retention secondary to regional analgesia, and to allow accurate postoperative urine measurement. Small studies support the nonuse of catheterization in hemodynamically stable women to minimize urinary infections (Li, 2011; Nasr, 2009).
The risk of thromboembolism is increased with pregnancy and almost doubled in those undergoing cesarean delivery (James, 2006). For this reason, for all women not already receiving thromboprophylaxis, the American College of Obstetricians and Gynecologists (2011d) recommends initiation of pneumatic compression hose before cesarean delivery. These are usually discontinued once the woman ambulates. In contrast, we favor the recommendations of American College of Chest Physicians for early ambulation for women without risk factors who are undergoing cesarean delivery (Bates, 2012). For women already receiving prophylaxis or those with increasing risk factors, prophylaxis is escalated as discussed in Chapter 52 and shown in Table 52-8 (p. 1046).
Some women scheduled for cesarean delivery have concurrent comorbidity that requires specific management in anticipation of surgery. Among others, these include insulin-requiring or gestational diabetes, coagulopathy or thrombophilia, chronic corticosteroid use, and significant reactive airway disease. Preparations for surgery in these women are discussed in the respective chapters covering these topics.
Febrile morbidity is frequent after cesarean delivery. Numerous good-quality trials have proved that that a single dose of an antimicrobial agent given at the time of cesarean delivery significantly decreases infection morbidity. Although more obvious for women undergoing unscheduled cesarean delivery, this practice also significantly lowers the postoperative infection rate in women undergoing elective surgery (American College of Obstetricians and Gynecologists, 2011b). Depending on drug allergies, most recommend a single intravenous dose of a β-lactam antimicrobial—either a cephalosporin or extended-spectrum penicillin derivative. A 1-g dose of cefazolin is an efficacious and cost-effective choice. For obese women, a 2-g dose usually provides adequate coverage, although Pevzner and associates (2011) showed this dose may be inadequate for those with body mass index > 40. In women with significant penicillin or cephalosporin allergy, a single 600-mg intravenous dose of clindamycin combined with a weight-based dose of aminoglycoside is an alternative. A 900-mg clindamycin dose is used for obese patients.
Antimicrobial administration before surgical incision has been shown to lower postoperative infection rates without adverse neonatal effects compared with drug administration after umbilical cord clamping (Sullivan, 2007; Tita, 2009b; Witt, 2011). For this reason, the American College of Obstetricians and Gynecologists (2011b) recommends that prophylaxis be administered within the 60 minutes prior to the start of planned cesarean delivery. For emergent delivery, prophylaxis should be given as soon as feasible.
Preoperative preparation of the abdominal wall skin is effective to prevent wound infection. Either chlorhexidine or povidone-iodine solutions can be used. In addition, to prevent postoperative metritis following cesarean delivery, preoperative vaginal cleansing with a povidone-iodine scrub has been evaluated in small randomized trials (Haas, 2013). Some show benefit, whereas others do not (Reid, 2001; Starr, 2005; Yildirim, 2012). Vaginal cleansing is not a part of preoperative preparation at Parkland Hospital.
Antibiotic prophylaxis against infective endocarditis is not recommended for most with cardiac conditions—exceptions are women with cyanotic heart disease, prosthetic valves, or both (American College of Obstetricians and Gynecologists, 2011b). Regimens selected for routine cesarean infection prophylaxis will also serve as appropriate endocarditis coverage (Chap. 49, p. 991).
The Joint Commission (2013) established a protocol to prevent surgical errors that encompasses three components: (1) preprocedure verification of all relevant documents, (2) marking the operative site, and (3) completion of a “time out” before procedure initiation. The “time out” requires attention of the entire team to confirm that the patient, site, and procedure are correct. Important discussions also include introduction of the patient-care team members, verification of prophylactic antibiotics, estimation of procedure length, and communication of anticipated complications. Additionally, requests for special instrumentation should be addressed preoperatively to prevent potential patient compromise and intraoperative delays.
An instrument, sponge, and needle count before and after surgery and vaginal delivery is crucial to surgical safety. If counts are not reconciled following abdominal or vaginal examination, then radiographic imaging for retained foreign objects is obtained (American College of Obstetricians and Gynecologists, 2012b).
TECHNIQUE FOR CESAREAN DELIVERY
With minor variations, surgical performance of cesarean delivery is comparable worldwide. Most steps are founded on evidence-based data, and these have been reviewed by Dahlke (2013) and Hofmeyr (2009) and their associates. As with all surgery, a clear understanding of relevant anatomy is essential, and this is described and illustrated in Chapter 2 (p. 16).
In obstetrics, usually a midline vertical or a suprapubic transverse incision is chosen for laparotomy. Transverse abdominal entry is by either Pfannenstiel or Maylard incisions. Of these, the Pfannenstiel incision is selected most frequently for cesarean delivery. Transverse incisions follow Langer lines of skin tension, and superior cosmetic results compared with vertical incisions can be achieved. Additionally, decreased rates of postoperative pain, fascial wound dehiscence, and incisional hernia compared with vertical entry are benefits. Use of the Pfannenstiel incision, however, is often discouraged for cases in which a large operating space is essential or in which access to the upper abdomen may be needed. Because of the layers created during incision of the internal and external oblique aponeuroses with transverse incisions, purulent fluid can collect between these. Therefore, cases with high infection risks may favor a midline incision. Last, neurovascular structures, which include the ilioinguinal and iliohypogastric nerves and superficial and inferior epigastric vessels, are often encountered with transverse incisions. Logically, bleeding, wound hematoma, and neurological disruption may more frequently complicate these incisions compared with vertical incision. With repeat cesarean delivery, reentry through a Pfannenstiel incision usually is more time consuming and difficult because of scarring.
The Maylard incision differs mainly from the Pfannenstiel in that the bellies of the rectus abdominis muscles are transected horizontally to widen the operating space. It is technically more difficult due to its required isolation and ligation of the inferior epigastric arteries, which lie lateral to these muscle bellies.
Vertical infraumbilical incisions provide quick entry to shorten incision-to-delivery time (Wylie, 2010). Moreover, this incision has minimal blood loss, superior access to the upper abdomen, generous operating room, and the flexibility for easy wound extension if greater space or access is needed. No important neurovascular structures traverse this incision, and aponeuroses at the linea alba are fused. Main disadvantages are poorer cosmetic results, higher fascial dehiscence or incisional hernia rates, and greater postoperative pain. For morbidly obese patients, a vertical incision that extends up and around the umbilicus may be preferable to avoid cutting through a large pannus (Fig. 48-7, p. 968).
With the Pfannenstiel incision, the skin and subcutaneous tissue are incised using a low, transverse, slightly curvilinear incision. This is made at the level of the pubic hairline, which is typically 3 cm above the superior border of the symphysis pubis. The incision is extended somewhat beyond the lateral borders of the rectus abdominis muscles. It should be of adequate width to accommodate delivery—12 to 15 cm is typical.
Sharp dissection is continued through the subcutaneous layer to the fascia. The superficial epigastric vessels can usually be identified halfway between the skin and fascia, several centimeters from the midline, and coagulated. If lacerated, these may be suture ligated with 3-0 plain gut suture or coagulated with an electrosurgical blade.
The fascia is then incised sharply at the midline. The anterior abdominal fascia is typically composed of two visible layers, the aponeurosis from the external oblique muscle and a fused layer containing aponeuroses of the internal oblique and transverse abdominis muscles. Ideally, the two layers are individually incised during lateral extension of the fascial incision. The inferior epigastric vessels typically lie outside the lateral border of the rectus abdominis muscle and beneath the fused aponeuroses of the internal oblique and transverse abdominis muscles. Thus, although infrequently required, extension of the fascial incision further laterally may cut these vessels. Therefore, if lateral extension is needed, these vessels should be identified and coagulated or ligated to prevent bleeding and vessel retraction.
Once the fascia is incised, the inferior fascial edge is grasped with suitable clamps and elevated by the assistant as the operator separates the fascial sheath from the underlying rectus muscles either bluntly or sharply until the superior border of the symphysis pubis is reached. Any blood vessels coursing between the sheath and muscles are clamped, cut, and ligated, or they are coagulated with an electrosurgery blade. Next, the superior fascial edge is grasped and again, separation of fascia from the rectus muscles is completed. Meticulous hemostasis is imperative to lower rates of infection and bleeding. The fascial separation is carried near enough to the umbilicus to permit an adequate midline longitudinal incision of the peritoneum. The rectus abdominis and pyramidalis muscles are then separated in the midline by sharp and blunt dissection to expose the transversalis fascia and peritoneum.
The transversalis fascia and preperitoneal fat are dissected carefully to reach the underlying peritoneum. The peritoneum near the upper end of the incision is opened carefully, either bluntly or by elevating it with two hemostats placed approximately 2 cm apart. The tented fold of peritoneum between the clamps is examined and palpated to ensure that omentum, bowel, or bladder is not adjacent. The peritoneum is then incised. The incision is extended superiorly to the upper pole of the incision and downward to just above the peritoneal reflection over the bladder. Importantly, in women who have had previous intraabdominal surgery, including cesarean delivery, omentum or bowel may be adhered to the undersurface of the peritoneum. Moreover, in women with obstructed labor, the bladder may be pushed cephalad almost to the level of the umbilicus.
An infraumbilical midline vertical incision begins 2 to 3 cm above the superior margin of the symphysis and should be of sufficient length to allow fetal delivery without difficulty. Therefore, its length should correspond with the estimated fetal size, and 12 to 15 cm is typical. Sharp or electrosurgical dissection is performed to the level of the anterior rectus sheath. A small opening is made sharply with scalpel in the upper half of the linea alba. Placement here avoids potential cystotomy. Index and middle fingers are placed beneath the fascia, and the fascial incision is extended superiorly and inferiorly with scissors or scalpel. Midline separation of the rectus muscles and pyramidalis muscles and peritoneal entry are then similar to those with the Pfannenstiel incision.
Most often, the lower uterine segment is incised transversely as described by Kerr in 1921. Occasionally, a low-segment vertical incision as described by Krönig in 1912 may be used. The classical incision is a vertical incision into the body of the uterus above the lower uterine segment and reaches the uterine fundus. In practice, however, the classical incision is similar to the low-vertical incision, which is typically extended cephalad only to the extent required for fetal delivery. For most cesarean deliveries, the transverse incision is preferred. Compared with a classical incision, it is easier to repair, is located in the inactive segment and thus least likely to rupture during a subsequent pregnancy, causes less incision-site bleeding, and promotes less bowel or omentum adherence to the myometrial incision.
Low Transverse Cesarean Incision
Before any hysterotomy, the surgeon should palpate the fundus and adnexa to identify degrees of uterine rotation. The uterus may be dextrorotated so that the left round ligament is more anterior and closer to the midline. In such cases, hysterotomy placement is modified to keep the incision centered within the lower segment. This avoids extension into and laceration of the left uterine artery. With thick meconium or infected amnionic fluid, some surgeons prefer to put a moistened laparotomy sponge in each lateral peritoneal gutter to absorb fluid and blood that escape from the opened uterus. A moist sponge may also be used to pack protruding bowel away from the operative field.
The reflection of peritoneum above the upper margin of the bladder and overlying the anterior lower uterine segment—termed the bladder flap—is grasped in the midline with forceps and incised transversely with scissors (Fig. 30-1). Bladder flap creation effectively moves the bladder away from the planned hysterotomy site and prevents bladder laceration if an unintended inferior hysterotomy extension occurs during fetal delivery.
FIGURE 30-1 The loose vesicouterine serosa above the bladder reflection is grasped with forceps and incised with Metzenbaum scissors.
Following this initial incision, scissors are inserted between the vesicouterine serosa and myometrium of the lower uterine segment. The scissors are pushed laterally from the midline on each side to further open the visceral peritoneum and expose the myometrium. This transverse peritoneal incision extends almost the full length of the lower uterine segment. As the lateral margin on each side is approached, the scissors are directed somewhat more cephalad (Fig. 30-2). The lower edge of peritoneum is elevated, and the bladder is gently separated from the underlying myometrium with blunt or sharp dissection within this vesicouterine space (Fig. 30-3).
FIGURE 30-2 The loose serosa above the upper margin of the bladder is elevated and incised laterally.
FIGURE 30-3 Cross section shows blunt dissection of the bladder off the uterus to expose the lower uterine segment.
In general, this caudad separation of bladder does not exceed 5 cm and usually is less. It is possible, especially with an effaced, dilated cervix, to dissect downward so caudally as to inadvertently expose and then enter the underlying vagina rather than the lower uterine segment. However, in instances in which cesarean hysterectomy is planned or anticipated, extended caudad bladder dissection is recommended to aid total hysterectomy and decrease the risk of cystotomy.
Some surgeons do not create a bladder flap. The main advantage is a shorter skin incision-to-delivery time, however, data supporting this practice are limited (Hohlagschwandtner, 2001; Tuuli, 2012).
The uterus is entered through the lower uterine segment approximately 1 cm below the upper margin of the peritoneal reflection. It is important to place the uterine incision relatively higher in women with advanced or complete cervical dilatation. Failure to adjust increases the risk of lateral extension of the incision into the uterine arteries. It may also lead to incision of the cervix or vagina rather than the lower uterine segment. Such incisions into the cervix can create significant postoperative distortion of cervical anatomy. Correct placement uses the vesicouterine serosal reflection as a guide.
Uterine Incision. The uterus can be incised by a variety of techniques. Each is initiated by using a scalpel to transversely incise the exposed lower uterine segment for 1 to 2 cm in the midline (Fig. 30-4). This must be done carefully to avoid fetal laceration. Careful blunt entry using hemostats or fingertip to split the muscle may be helpful. Once the uterus is opened, the incision can be extended by simply spreading the incision, using lateral and slightly upward pressure applied with each index finger (Fig. 30-5). Alternatively, if the lower uterine segment is thick, then cutting laterally and then slightly upward with bandage scissors will extend the incision. Importantly, when scissors are used, the index and midline fingers of the nondominant hand should be insinuated beneath the myometrium and above fetal parts to prevent fetal laceration. Comparing blunt and sharp extensions of the initial uterine incision, sharp extension is associated with an increased estimated blood loss, but postoperative hematocrit changes, need for transfusion, and infection rates are not different (Xu, 2013).
FIGURE 30-4 The myometrium is carefully incised to avoid cutting the fetal head.
FIGURE 30-5 After entering the uterine cavity, the incision is extended laterally with fingers or with bandage scissors (inset).
The uterine incision should be made large enough to allow delivery of the head and trunk of the fetus without either tearing into or having to cut into the uterine vessels that course along the lateral uterine margins. If the placenta is encountered in the incision line, it must be either detached or incised. When the placenta is incised, fetal hemorrhage may be severe. Thus, delivery and cord clamping should be performed as soon as possible.
At times, a low-transverse hysterotomy is selected but provides inadequate room for delivery. In such instances, one corner of the hysterotomy incision is extended cephalad into the contractile portion of the myometrium—a J incision. If this is completed bilaterally, a U incision is formed. Last, some prefer to extend in the midline—a T incision. As expected, these have been linked with higher intraoperative blood loss (Boyle, 1996; Patterson, 2002). Moreover, as these extend into the contractile portion, a trial of labor and vaginal delivery are more likely contraindicated in future pregnancies.
Delivery of the Fetus. In a cephalic presentation, a hand is slipped into the uterine cavity between the symphysis and fetal head. The head is elevated gently with the fingers and palm through the incision. Once the head enters the incision, delivery may be aided by modest transabdominal fundal pressure (Fig. 30-6).
FIGURE 30-6 Delivery of the fetal head.
After a long labor with cephalopelvic disproportion, the fetal head may be tightly wedged in the birth canal. This situation can have disastrous results, and there are three considerations for delivery. First, a “push” method may be used. With this, upward pressure exerted by a hand in the vagina by an assistant will help to dislodge the head and allow its delivery above the symphysis. Relief of such head impaction increases the risk of hysterotomy extension and associated blood loss as well as fetal skull fracture. As an alternative, a “pull” method is used in which the fetal legs are grasped and delivered through the hysterotomy opening. The fetus is then delivered by traction as one would complete a breech extraction. Support for this latter approach comes only from small randomized trials and case series (Bastani, 2012; Shazly, 2013; Veisi, 2012). Last, a low vertical hysterotomy incision, which will give more room for the “pull” technique, may be selected. If a low transverse incision has already been made, then this can be extended to a J-, U-, or T-incision for room.
Conversely, in women without labor, the fetal head may be unmolded and without a leading cephalic point. The round head may be difficult to lift through the uterine incision in a relatively thick lower segment that is unattenuated by labor. In such instances, either forceps or a vacuum device may be used to deliver the fetal head as shown in Figure 30-7.
FIGURE 30-7 A. The first cesarean forceps blade is placed. B. Slight upward and outward traction is used to lift the head through the incision.
After head delivery, a finger should be passed across the fetal neck to determine whether it is encircled by one or more umbilical cord loops. If an umbilical cord coil is felt, it should be slipped over the head. The head is rotated to an occiput transverse position, which aligns the fetal bisacromial diameter vertically. The sides of the head are grasped with two hands, and gentle downward traction is applied until the anterior shoulder enters the hysterotomy incision (Fig. 30-8). Next, by upward movement, the posterior shoulder is delivered. During delivery, abrupt or powerful force is avoided to avert brachial plexus injury. With steady outward traction, the rest of the body then readily follows. Gentle fundal pressure may aid this.
FIGURE 30-8 The anterior (A) and then the posterior (B) shoulder are delivered.
With some exceptions, current American Heart Association neonatal resuscitation recommendations eschew suctioning immediately following birth, even with meconium present (Kattwinkel, 2010). A fuller discussion of this and the timing of umbilical cord clamping as it relates to neonatal outcome are found in Chapter 27 (p. 539). The umbilical cord is clamped, and the newborn is given to the team member who will conduct resuscitative efforts as needed (Chap. 32, p. 625).
The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2012) recommend that “a qualified person who is skilled in neonatal resuscitation should be in the delivery room, with all equipment needed for neonatal resuscitation, to care for the neonate.” Jacob and Phenninger (1997) compared 834 cesarean deliveries with 834 low-risk vaginal deliveries. They found that with regional analgesia, there is rarely a need for infant resuscitation after elective repeat cesarean delivery or cesarean delivery for dystocia without fetal heart rate abnormalities and that a pediatrician may not be necessary at such deliveries. At Parkland Hospital, pediatric nurse practitioners attend uncomplicated, scheduled cesarean deliveries.
After birth, an intravenous infusion containing two ampules or 20 units of oxytocin per liter of crystalloid is infused at 10 mL/min. Some prefer higher infusion dosages, however, bolus doses are avoided because of associated hypotension (Roach, 2013). Once the uterus contracts satisfactorily, the rate can be reduced. An alternative is carbetocin—a longer-acting oxytocin derivative that is not available in the United States—that provides suitable, albeit more expensive, hemorrhage prophylaxis (Su, 2012). Second-tier agents are ergot-alkaloids, which carry hypertensive side effects, and misoprostol, which provides inferior postpartum hemorrhage protection compared with oxytocin. Last, the use of tranexamic acid (Cyklokapron) has recently been described in a few small studies to lower blood loss during cesarean delivery (Abdel-Aleem, 2013; Güngördük, 2011). Its antifibrinolytic action and effects on thromboembolism rates in pregnant surgical patients are unclear, and larger trials are needed before widespread use. Additional discussions of all these agents are found in Chapters 27 (p. 547) and 41 (p. 785).
Placental Delivery. The uterine incision is observed for any vigorously bleeding sites. These should be promptly clamped with Pennington or ring forceps. The placenta is then delivered unless it has already done so spontaneously. Many surgeons prefer manual removal, but spontaneous delivery, as shown in Fig. 30-9, along with some cord traction may reduce the risk of operative blood loss and infection (Anorlu, 2008; Baksu, 2005). Fundal massage may begin as soon as the fetus is delivered to hasten placental separation and delivery.
FIGURE 30-9 Placenta bulging through the uterine incision as the uterus contracts. A hand gently massages the fundus to help aid placental separation.
Immediately after delivery and gross inspection of the placenta, the uterine cavity is suctioned and wiped out with a gauze sponge to remove avulsed membranes, vernix, and clots. Previously, double-gloved fingers or ring forceps placed through the hysterotomy incision were used to dilate an ostensibly closed cervix. This practice does not improve infection rates from potential hematometra and is not recommended (Güngördük, 2009; Liabsuetrakul, 2011).
Uterine Repair. After placental delivery, the uterus is lifted through the incision onto the draped abdominal wall, and the fundus is covered with a moistened laparotomy sponge. Although some clinicians prefer to avoid such uterine exteriorization, it often has benefits that outweigh its disadvantages. For example, the relaxed, atonic uterus can be recognized quickly and massage applied. The incision and bleeding points are more easily visualized and repaired, especially if there have been extensions. Adnexal exposure is superior, and thus, tubal sterilization is easier. The principal disadvantage is discomfort and vomiting caused by traction in cesarean deliveries performed under regional analgesia. Importantly, rates of febrile morbidity or blood loss do not appear to be increased with uterine exteriorization (Coutinho, 2008; Walsh, 2009).
Before hysterotomy closure, previously clamped large vessels may be ligated separately or incorporated within the running incision closure. One angle of the uterine incision is grasped to stabilize and maneuver the incision. The uterine incision is then closed with one or two layers of continuous 0- or No. 1 absorbable suture (Fig. 30-10). Chromic suture is used by many, but some prefer synthetic delayed-absorbable sutures. Single-layer closure is typically faster and is not associated with higher rates of infection or transfusion (CAESAR study collaborative group, 2010; Dodd, 2008; Hauth, 1992). Moreover, most studies observed that the type of uterine closure does not significantly affect complications in the next pregnancy (Chapman, 1997; Durnwald, 2003; Roberge, 2011).
FIGURE 30-10 The cut edges of the uterine incision are approximated with a running-lock suture anchored at either angle of the incision.
At Parkland Hospital, we favor the one-layer uterine closure. The initial suture is placed just beyond one angle of the uterine incision. A running-lock suture for hemostasis is then performed, with each suture penetrating the full thickness of the myometrium. Concern has been expressed by some clinicians that sutures through the decidua may lead to endometriosis or adenomyosis in the hysterotomy scar, but this is rare. It is important to carefully select the site of each stitch and to avoid withdrawing the needle once it penetrates the myometrium. This minimizes perforation of unligated vessels and subsequent bleeding. The running-lock suture is continued just beyond the opposite incision angle. If approximation is not satisfactory after a single-layer continuous closure or if bleeding sites persist, then more sutures are required. Either another layer of running suture is placed to achieve approximation and hemostasis, or individual bleeding sites can be secured with figure-of-eight or mattress sutures.
Traditionally, serosal edges overlying the uterus and bladder have been approximated with a continuous 2-0 chromic catgut suture. Multiple randomized trials suggest that omission of this step causes no postoperative complications (Grundsell, 1998; Irion, 1996; Nagele, 1996). If tubal sterilization is to be performed, it is now done as described in Chapter 39 (p. 720).
Following cesarean delivery, adhesions commonly form within the vesicouterine space or between the anterior abdominal wall and uterus. And with each successive pregnancy, the percentage of affected women and adhesion severity increases (Morales, 2007; Tulandi, 2009). Adhesions can significantly lengthen incision-to-delivery times and total operative time (Rossouw, 2013; Sikirica, 2012). Although occurring infrequently, rates of cystotomy and bowel injury are also increased (Rahman, 2009; Silver, 2006).
Intuitively, scarring can be reduced by handling tissues delicately, achieving hemostasis, and minimizing tissue ischemia, infection, and foreign-body reaction. Data are conflicting regarding closure of the bladder flap (visceral peritoneum) or of the abdominal cavity (parietal peritoneum) and its effect on subsequent adhesions. Some note benefit from closure of one, but not the other, or neither (CAESAR study collaborative group, 2010; Cheong, 2009; Kapustian, 2012; Lyell, 2005, 2012).
Benefit from placement of an adhesion barrier at the repaired hysterotomy site is limited to only two nonrandomized studies (Chapa, 2011; Fushiki, 2005). Currently, there is an ongoing multicenter randomized trial to evaluate use of the barrier Seprafilm at the time of cesarean delivery (National Institutes of Health, 2012).
Any laparotomy sponges are removed, and the paracolic gutters and cul-de-sac are gently suctioned of blood and amnionic fluid. Some surgeons irrigate the gutters and cul-de-sac, especially in the presence of infection or meconium. Routine irrigation in low-risk women, however, leads to greater intraoperative nausea and without lower postoperative infection rates (Harrigill, 2003; Viney, 2012).
After sponge and instrument counts are found to be correct, the abdominal incision is closed in layers. Many surgeons omit the parietal peritoneal closure. In addition to ambiguity regarding adhesion prevention, data are also conflicting as to whether nonclosure of parietal peritoneum decreases postoperative discomfort and analgesia requirements (Chanrachakul, 2002; Lyell, 2005; Rafique, 2002). However, if there is distended bowel in the incision site, we find that peritoneal closure may help to protect the bowel when fascial sutures are placed.
As each layer is closed, bleeding sites are located, clamped, and ligated or coagulated with an electrosurgical blade. The rectus abdominis muscles are allowed to fall into place. With significant diastasis, the rectus muscles may be approximated with one or two figure-of-eight sutures of 0 or No. 1 chromic gut suture. The overlying rectus fascia is closed by a continuous, nonlocking technique with a delayed-absorbable suture. In patients with a higher risk for infection, there may be theoretical value in selecting a monofilament suture here rather than braided material.
The subcutaneous tissue usually need not be closed if it is less than 2 cm thick. With thicker layers, however, closure is recommended to minimize seroma and hematoma formation, which can lead to wound infection and/or disruption (Bohman, 1992; Chelmow, 2004). Addition of a subcutaneous drain does not prevent significant wound complications (Hellums, 2007; Ramsey, 2005). Skin is closed with a running subcuticular stitch using 4-0 delayed-absorbable suture or with staples. In comparison, final cosmetic results and infection rates appear similar, skin suturing takes longer, but wound separation rates are higher with staples (Basha, 2010; Figueroa, 2013; Mackeen, 2012; Tuuli, 2011).
Joel-Cohen and Misgav-Ladach Techniques
The Pfannenstiel-Kerr technique just described has been used for decades. More recently, the Joel-Cohen and Misgav-Ladach modifications have been described. These differ from traditional Pfannenstiel-Kerr entry mainly by their initial incision placement and greater use of blunt dissection.
The Joel-Cohen technique creates a straight 10-cm transverse skin incision 3 cm below the level of the anterior superior iliac spines. The subcutaneous tissue layer is opened sharply 2 to 3 cm in the midline. This is carried down, without lateral extension, to the fascia. A small transverse incision is made in the fascia, and a finger from each hand is hooked into the lateral angles of this fascial incision. The incision is then stretched transversely. Once the fascia is opened and rectus abdominis muscle bellies identified, an index finger from each hand is inserted between the bellies. One is moved cranially and the other caudally, in opposition, to further separate the bellies. Index finger dissection is used to enter the peritoneum, and again, cranial and caudad opposing stretch with index fingers will open this layer. All the layers of the abdominal wall are then manually stretched laterally in opposition to further open the incision. The visceral peritoneum is incised in the midline above the bladder, and the bladder is bluntly reflected inferiorly to separate it from the underlying lower uterine segment. The myometrium is incised transversely in the midline and then opened and extended laterally with one finger hooked into each corner of the hysterotomy incision. Interrupted sutures are used for hysterotomy closure. Neither visceral nor parietal peritoneum is closed. The Misgav-Ladach technique is similar and differs mainly in that myometrial incision closure is completed with a single-layer locking continuous suture (Hofmeyr, 2009; Holmgren, 1999).
These techniques have been associated with shorter operative times and with lower rates of intraoperative blood loss and postoperative pain (Hofmeyr, 2008). They may, however, prove difficult for women with anterior rectus fibrosis and peritoneal adhesions (Bolze, 2013). Moreover, long-term outcomes with these techniques, such as subsequent uterine rupture, are unknown.
Classical Cesarean Incision
This incision is usually avoided because it encompasses the active upper uterine segment and thus is prone to rupture with subsequent pregnancies.
Indications. A classical incision is occasionally preferred for delivery. Some indications stem from difficulty in exposing or safely entering the lower uterine segment. For example, a densely adhered bladderfrom previous surgery is encountered; a leiomyoma occupies the lower uterine segment; the cervix has been invaded by cancer; or massive maternal obesity precludes safe access to the lower uterine segment. A classical incision is also preferred in some cases of placenta previa with anterior implantation, especially those complicated by placenta accrete syndromes.
In other instances, fetal indications dictate the need. Transverse lie of a large fetus, especially if the membranes are ruptured and the shoulder is impacted in the birth canal, usually necessitates a classical incision. A fetus presenting as a back-down transverse lie is particularly difficult to deliver through a transverse uterine incision. In instances when the fetus is very small, especially if breech, a classical incision may be preferable (Osmundson, 2013). In such cases, the poorly developed lower uterine segment provides inadequate space for the manipulations required for breech delivery. Or, less commonly, the small fetal head may become entrapped by a contracting uterine fundus following membrane rupture. Last, with multiple fetuses, a classical incision again may be needed to provide suitable room for extraction of fetuses that may be malpositioned or preterm.
Uterine Incision and Repair. A vertical uterine incision is initiated with a scalpel beginning as low as possible and preferably within the lower uterine segment (Fig. 30-11). If adhesions, insufficient exposure, a tumor, or placenta percreta preclude development of a bladder flap, then the incision is made above the level of the bladder. Once the uterus is entered with a scalpel, the incision is extended cephalad with bandage scissors until it is long enough to permit delivery of the fetus. With scissor use, the fingers of the nondominant hand are insinuated between the myometrium and fetus to prevent fetal laceration. As the incision is opened, numerous large vessels that bleed profusely are commonly encountered within the myometrium. The remainder of fetal and placental delivery mirrors that with a low transverse hysterotomy.
FIGURE 30-11 An initial small vertical hysterotomy incision is made in the lower uterine segment. Fingers are insinuated between the myometrium and fetus to avoid fetal laceration. Scissors extend the incision cephalad as needed for delivery.
For incision closure, one method employs a layer of 0- or No. 1 chromic catgut with a continuous stitch to approximate the deeper halves of the incision (Fig. 30-12). The outer depth of myometrium is then closed with similar suture and with a running stitch or figure-of-eight sutures. No unnecessary needle tracks should be made lest myometrial vessels be perforated, leading to subsequent hemorrhage or hematomas. To achieve good approximation and to prevent the suture from tearing through the myometrium, it is helpful to have an assistant compress the uterus on each side of the wound toward the midline as each stitch is placed.
FIGURE 30-12 Classical incision closure. The deeper half (A) and superficial half (B) of the incision are closed in a running fashion.
Hysterectomy is more commonly performed during or after cesarean delivery but may be needed following vaginal birth. If all deliveries are considered, the rate ranges from 0.4 to 2.5 per 1000 births and has risen significantly during the past few decades. During a 25-year period, the rate of peripartum hysterectomy at Parkland Hospital was 1.7 per 1000 births (Hernandez, 2012). Most of this increase is attributed to the increasing rates of cesarean delivery and its associated complications in subsequent pregnancy (Bateman, 2012; Bodelon, 2009; Flood, 2009; Orbach, 2011). Of hysterectomies, approximately one half to two thirds are total, whereas the remaining cases are supracervical (Rossi, 2010; Shellhaas, 2009).
Cesarean hysterectomies are most commonly performed to arrest or prevent hemorrhage from intractable uterine atony or abnormal placentation (Bateman, 2012; Hernandez, 2012; Owolabi, 2013). These as well as other less frequent indications are found in Table 30-3. For example, large leiomyomas may preclude satisfactory hysterotomy closure and necessitate hysterectomy. Or, postpartum infectious morbidity from an infected, necrotic uterus will prompt uterine removal for recovery (Fig. 37-4, p. 688). Logically, risk factors for peripartum hysterectomy mirror the risks of these indicated complications, which are described throughout the text.
TABLE 30-3. Some Indications for Peripartum Hysterectomy
Postpartum uterine infection
Invasive cervical cancer
Major complications of peripartum hysterectomy include increased blood loss and greater risk of urinary tract damage. Blood loss is usually appreciable because hysterectomy is being performed for hemorrhage that frequently is torrential, and the procedure itself is associated with substantial blood loss. Although many cases with such hemorrhage cannot be anticipated, those with abnormal implantation can often be identified antepartum. Preoperative preparations for placenta accreta are discussed in Chapter 41 (p. 807) and have also been outlined by the Society for Maternal-Fetal Medicine (2010) and American College of Obstetricians and Gynecologists (2012c).
An important factor affecting the cesarean hysterectomy complication rate is whether the operation is performed electively or emergently (Briery, 2007). After anticipated or planned cesarean hysterectomy, there are lower rates of blood loss, less need for blood transfusions, and fewer urinary tract complications compared with emergent procedures (Briery, 2007; Glaze, 2008; Sakse, 2007).
Peripartum Hysterectomy Technique
Supracervical or total hysterectomy is performed using standard operative techniques. For this, adequate exposure is essential. Initially, placement of a self-retaining retractor such as a Balfour is not necessary. Rather, satisfactory exposure is obtained with cephalad traction on the uterus by an assistant, along with handheld retractors such as a Richardson or Deaver. The bladder flap is deflected downward to the level of the cervix if possible to permit total hysterectomy. In cases in which cesarean hysterectomy is planned or strongly suspected, extended bladder flap dissection is ideally completed before initial hysterotomy. Later attempts at bladder dissection may be obscured by bleeding, or excess blood may be lost while this dissection is performed.
After cesarean delivery, the placenta is typically removed. In cases of placenta accrete syndromes, in which hysterectomy is already planned, the placenta is usually left undisturbed in situ. In either situation, if the hysterotomy incision is bleeding appreciably, it can be sutured or Pennington or sponge forceps can be applied for hemostasis. If bleeding is minimal, neither maneuver is necessary.
The round ligaments are divided close to the uterus between Kocher clamps and doubly ligated (Fig. 30-13). Either 0 or No. 1 suture can be used in either chromic gut or delayed-absorbable material. The incision in the vesicouterine serosa that was made to mobilize the bladder is extended laterally and upward through the anterior leaf of the broad ligament to reach the incised round ligaments. The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tubes, uteroovarian ligaments, and ovarian vessels (Fig. 30-14). These structures together are then doubly clamped close to the uterus and divided, and the lateral pedicle is doubly ligated (Fig. 30-15). The posterior leaf of the broad ligament is divided toward the uterosacral ligaments (Fig. 30-16). Next, the bladder and attached peritoneal flap are further deflected and dissected as needed from the lower uterine segment and retracted out of the operative field. If the bladder flap is unusually adhered, as it may be after previous hysterotomy incisions, careful sharp dissection may be necessary (Fig. 30-17).
FIGURE 30-13 The round ligaments are clamped, doubly ligated, and transected bilaterally.
FIGURE 30-14 The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tube, uteroovarian ligaments, and ovarian vessels.
FIGURE 30-15 The uteroovarian ligament and fallopian tube are doubly clamped and cut bilaterally. The lateral pedicle is doubly ligated.
FIGURE 30-16 The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligament.
FIGURE 30-17 The bladder is dissected sharply from the lower uterine segment.
Special care is required from this point on to avoid injury to the ureters, which pass beneath the uterine arteries. To help accomplish this, an assistant places constant traction to pull the uterus in the direction away from the side on which the uterine vessels are being ligated. The ascending uterine artery and veins on either side are identified near their origin. These pedicles are then doubly clamped immediately adjacent to the uterus, divided, and doubly suture ligated. As shown in Figure 30-18, we prefer to use three heavy clamps—Heaney or Ballantine—to incise the tissue between the most medial clamps, and then ligate the pedicle in the clamps lateral to the uterus.
FIGURE 30-18 A. The uterine artery and veins on either side are doubly clamped immediately adjacent to the uterus and divided. A third medial clamp will prevent “back bleeding.” B&C. The vascular pedicle is doubly suture ligated.
With cesarean hysterectomy, it may be more advantageous in cases of profuse hemorrhage to rapidly double clamp and divide all of the vascular pedicles between clamps to gain hemostasis. The operator can then return to ligate all of the pedicles.
Even if total hysterectomy is planned, we find it in many cases technically easier to finish the operation after amputating the uterine fundus and placing Ochsner or Kocher clamps on the cervical stump for traction and hemostasis. Self-retaining retractors also may be placed at this time. To remove the cervix, the bladder is mobilized further if needed. This carries the ureters caudad as the bladder is retracted beneath the symphysis and will prevent laceration or suturing of the bladder during cervical excision and vaginal cuff closure.
If the cervix is effaced and dilated considerably, its softness may obscure palpable identification of the cervicovaginal junction. The junction location can be ascertained through a vertical uterine incision made anteriorly in the midline, either through the open hysterotomy incision or through an incision created at the level of the ligated uterine vessels. A finger is directed inferiorly through the incision to identify the free margin of the dilated, effaced cervix and the anterior vaginal fornix. The contaminated glove is replaced. Another useful method to identify the cervical margins is to transvaginally place four metal skin clips or brightly colored sutures at 12, 3, 6, and 9 o’clock positions on the cervical edges in cases of planned hysterectomy.
The cardinal ligaments, the uterosacral ligaments, and the many large vessels these ligaments contain are clamped systematically with Heaney-type curved or straight clamps (Fig. 30-19). The clamps are placed as close to the cervix as possible, taking care not to include excessive tissue in each clamp. The tissue between the pair of clamps is incised, and the lateral pedicle is suture ligated. These steps are repeated caudally until the level of the lateral vaginal fornix is reached. In this way, the descending branches of the uterine vessels are clamped, cut, and ligated as the cervix is dissected from the cardinal ligaments.
FIGURE 30-19 The cardinal ligaments are clamped, incised, and ligated.
Immediately below the level of the cervix, a curved clamp is placed across the lateral vaginal fornix, and the tissue is incised above the clamp (Fig. 30-20). The excised lateral vaginal fornix can be simultaneously doubly ligated and sutured to the stump of the cardinal ligament. The cervix is inspected to ensure that it has been completely removed, and the vagina is then repaired. Each of the angles of the lateral vaginal fornix is secured to the cardinal and uterosacral ligaments to mitigate later vaginal prolapse (Fig. 30-21). Following this step, some surgeons prefer to close the vagina using figure-of-eight sutures. Others achieve hemostasis by using a running-lock stitch placed through the mucosa and adjacent endopelvic fascia around the circumference of the vaginal cuff (Fig. 30-22).
FIGURE 30-20 A curved clamp is placed across the lateral vaginal fornix below the level of the cervix, and the tissue incised medially to the point of the clamp.
FIGURE 30-21 The lateral angles of the vaginal cuff are secured to the cardinal and uterosacral ligaments.
FIGURE 30-22 A running-lock suture approximates the vaginal wall edges.
If a self-retaining retractor has not already been placed, some clinicians choose to insert one at this point. The bowel is then packed out of the field, and all sites are examined carefully for bleeding. One technique is to perform a systematic bilateral survey from the fallopian tube and ovarian ligament pedicles to the vaginal vault and bladder flap. Bleeding sites are ligated with care to avoid the ureters. The abdominal wall normally is closed in layers, as previously described for cesarean delivery (p. 597).
To perform a subtotal hysterectomy, the uterine body is amputated immediately above the level of uterine artery ligation. The cervical stump may be closed with continuous or interrupted chromic catgut sutures of 0 or No. 1 gauge. Subtotal hysterectomy is often all that is necessary to stop hemorrhage. It may be preferred for women who would benefit from a shorter surgery or for those with extensive adhesions that threaten significant urinary tract injury.
Because of the large adnexal vessels and their close proximity to the uterus, it may be necessary to remove one or both adnexa to obtain hemostasis. Briery and colleagues (2007) reported unilateral or bilateral oophorectomy in a fourth of cases. Preoperative counseling should include this possibility.
Rarely, and usually in women who have had a previous cesarean delivery, the bladder may be lacerated. This complication may occur during cesarean delivery, but it is more common with cesarean hysterectomy, especially if there is abnormal placental implantation.
Bladder injury is typically identified at the time of surgery, and initially, a gush of clear fluid into the operating field may be seen. If cystotomy is suspected, it may be confirmed with retrograde instillation of sterile infant formula through a Foley catheter into the bladder. Leakage of opaque milk aids in laceration identification and delineation of its borders. In some cases, cystoscopy may be indicated to further define bladder injury. Primary repair is preferred and lowers the risk of postoperative vesicovaginal fistula formation. Once ureteral patency is confirmed, the bladder may be closed with a two- or three-layer running closure using a 3-0 absorbable or delayed-absorbable suture (Fig. 30-23). The first layer inverts the mucosa into the bladder, and subsequent layers reapproximate bladder muscularis. Postoperative care requires continuous bladder drainage for 7 to 10 days.
FIGURE 30-23 Cystotomy repair. A. The primary layer inverts the bladder mucosa with running or interrupted sutures of 3-0 delayed-absorbable or absorbable suture. B. Second and possibly a third layer approximate the bladder muscularis to reinforce the incision closure.
During and after cesarean delivery, requirements for intravenous fluids can vary considerably. Intravenously administered fluids consist of either lactated Ringer solution or a similar crystalloid solution with 5-percent dextrose. Typically, at least 2 to 3 L is infused during surgery. Blood loss with uncomplicated cesarean delivery approximates 1000 mL. The average-sized woman with a hematocrit of 30 percent or more and with a normally expanded blood and extracellular fluid volume most often will tolerate blood loss up to 2000 mL without difficulty. Unappreciated bleeding through the vagina during the procedure, bleeding concealed in the uterus after its closure, or both commonly lead to underestimation.
Blood loss averages 1500 mL with elective cesarean hysterectomy, although this is variable (Pritchard, 1965). Most peripartum hysterectomies are unscheduled, and blood loss in these cases is correspondingly greater. Thus, in addition to close monitoring of vital signs and urine output, the hematocrit should be determined intra- or postoperatively as indicated (Chap. 41, p. 781).
Close monitoring of the amount of vaginal bleeding is necessary for at least an hour in the immediate postoperative period. The uterine fundus is also identified frequently by palpation to ensure that the uterus remains firmly contracted. Unfortunately, as conduction analgesia fades or the woman awakens from general anesthesia, abdominal palpation is likely to produce pain. An analgesic given by intermittent intravenous injection can be effective (Table 30-4). A sterile thin abdominal wound dressing is sufficient, and indeed, a thick, heavily taped padded dressing will interfere with fundal palpation and massage. Deep breathing and coughing are encouraged. Once regional analgesia begins to fade or the woman becomes fully awake following general anesthesia, criteria for transfer to the postpartum ward include minimal bleeding, stable vital signs, and adequate urine output.
TABLE 30-4. Typical Settings for Administration of Intravenous Opioids via a Patient-Controlled Analgesia Pump
Hospital Care until Discharge
Analgesia, Vital Signs, Intravenous Fluids
A number of schemes are suitable for postoperative pain control. Some basic regimens are shown in Table 30-4. In a trial at Parkland Hospital, Yost and associates (2004) found that morphine provided superior pain relief to meperidine and was associated with significantly higher rates of breast feeding and continuation of infant rooming in. Breast feeding can be initiated the day of surgery. If the mother elects not to breast feed, a binder that supports the breasts without marked compression usually will minimize discomfort (Chap. 36, p. 675).
After transfer to her room, the woman is assessed at least hourly for 4 hours, and thereafter at intervals of 4 hours. Vital signs, uterine tone, urine output, and bleeding are evaluated. The hematocrit is routinely measured the morning after surgery. It is checked sooner if there was unusual blood loss or if there is hypotension, tachycardia, oliguria, or other evidence to suggest hypovolemia. If the hematocrit is decreased significantly from the preoperative level, the measurement is repeated and a search is instituted to identify the cause. If the hematocrit stabilizes, the mother can be allowed to ambulate, and if there is little likelihood of further blood loss, iron therapy is preferred to transfusion.
As described in Chapter 36 (p. 671), the puerperium is characterized by excretion of fluid that was retained during pregnancy. At least with elective cesarean delivery, significant extracellular fluid sequestration in the bowel wall and lumen does not occur, unless perhaps it was necessary to pack the bowel away from the operative field. Thus, the woman who undergoes routine cesarean delivery rarely develops fluid sequestration in the extracellular space. On the contrary, she normally begins surgery with a physiologically enlarged extravascular volume acquired during pregnancy that she mobilizes and excretes after delivery. As a generalization, 3 L of fluid should prove adequate during the first 24 hours after surgery. If urine output falls below 30 mL/hr, however, the woman should be reevaluated promptly. The cause of the oliguria may range from unrecognized blood loss to an antidiuretic effect from infused oxytocin.
Women undergoing unscheduled cesarean delivery may have pathological retention or constriction of the extracellular fluid compartment caused by severe preeclampsia, sepsis syndrome, vomiting, prolonged labor without adequate fluid intake, and increased blood loss.
Bladder and Bowel Function
The Foley catheter most often can be removed by 12 hours postoperatively, or more conveniently, the morning after surgery. The prevalence of urinary retention following cesarean delivery approximates 3 to 7 percent. Regional analgesia and failure to progress in labor are identified risks (Chai, 2008; Liang, 2007). Thus, surveillance for bladder overdistention should be implemented as with vaginal delivery.
In uncomplicated cases, solid food may be offered within 8 hours of surgery (Bar, 2008; Orji, 2009). Although some degree of adynamic ileus follows virtually every abdominal operation, in most cases of cesarean delivery, it is negligible. Symptoms include abdominal distention, gas pains, and an inability to pass flatus or stool. The pathophysiology of postoperative ileus is complex and involves inflammatory and neural factors that are incompletely understood (van Bree, 2012). If associated with otherwise unexplained fever, an unrecognized bowel injury may be responsible. Treatment for ileus has changed little during the past several decades and involves intravenous fluid and electrolyte supplementation. If severe, nasogastric decompression is necessary.
Ambulation and Wound Care
As discussed on page 590, women undergoing cesarean delivery have an increased risk of venous thromboembolism compared with those delivering vaginally. Additional risks include age > 35; obesity; parity > 3; emergency cesarean; cesarean hysterectomy; concurrent infection, major illness, preeclampsia, or gross varicosities; recent immobility; and prior deep-vein thrombosis or thrombophilia (Marik, 2008). Postoperative thromboprophylaxis is discussed in Chapter 52 (p. 1045). Early ambulation lowers the risk of venous thromboembolism. In most instances, by the day after surgery, a woman should get briefly out of bed with assistance at least twice to walk. Ambulation can be timed so that a recently administered analgesic will minimize discomfort. By the second day, she may walk without assistance.
The incision is inspected each day, and skin sutures or clips often can be removed on the fourth postoperative day. If there is concern, however, for superficial wound separation—for example, in obese patients—the suture or clips should remain in place for 7 to 10 days. By the third postpartum day, showering is not harmful to the incision.
Unless there are complications during the puerperium, the mother generally is discharged on the third or fourth postpartum day (Buie, 2010). Data from small studies suggest that earlier discharge may be feasible for properly selected and motivated women (Strong, 1993; Tan, 2012). Activities during the first week should be restricted to self-care and newborn care with assistance. Driving can be resumed when pain does not limit the ability to brake quickly and when narcotic medications are not in use. Return to work is variable. Six weeks is commonly cited, although many women use the Family and Medical Leave Act to allow up to 12 weeks for recovery and newborn bonding.
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