CS and Hysterectomy Flashcards
Surgical procedure where in one or more incisions are made through a mother’s abdomen and uterus to deliver one or more fetus, or rarely, to remove a dead fetus
Cesarean delivery
2 techniques employed in CS
Laparotomy- Abdomen
Hysterotomy- Uterine wall
True/ False
Cesarean section and removal of fetus in Uterine rupture or abdominal surgery is the same
False
What is PERImortem CS?
performed in a woman about to die
for emergent complications like intractable hemorrhage
What is POSTmortem CS?
performed in a woman after death
Compare Cesarean Hysterectomy vs. Postpartum Hysterectomy
CH- at the time of CS
PH- after vaginal delivery
basta pag postpartum hysterectomy, nag vaginal delivery na saka pa lang hysterectomy, pag cesarean hysterectomy naman sabay na after CS the proceed to hysterectomy
4 major reasons for CS to be perfomed
Prior CS
Dystocia
Fetal Distress
Abnormal Fetal Presentation
12 explanation for increasing CS rates
- Increasing number of nulliparas
- Increasing maternal age
- Increased availability and utilization of electronic fetal monitoring
- Breech presentation
- Increased decline to perform operative VD
- Increased rates of labor induction
- Increasing number of obesity
- Increasing rates of preeclampsia
- Repeat CS is now the norm
- Increasing maternal request (pelvic floor injury concern and fetal injury concern in VD)
- Increasing use of assisted reproductive technology
- Increased number of malpractice litigation
What is CDMR
Cesarean delivery on maternal request
4 Major reason for CDMR
Pelvic floor protection
Convenience
Fear of childbirth
Reduced risk of fetal injury
Recommendation of ACOG in performing CDMR
Established fetal lung maturity (usually at 39 weeks)
True or False?
Cesarean delivery is ideally avoided in women desiring several children because of placental implantation abnormalities and cesarean hysterectomy risks
True
True or False?
CDMR should be motivated by the unavailability of effective pain management.
False (should not be motivated)
3 PRINCIPAL MATERNAL risk after CS
Infection
Hemorrhage
Thromboembolism
Give 6 complications of CS
- Anesthetic complications
- Adjacent organ injuries ( bladder, ureters, bowel)
- Repeat CS with future pregnancy
- Infection
- Hemorrhage
- Thromboembolism
Give 3 complication that is higher in VD compared to CS
Pelvic floor injury
Urinary incontinence
Perineal injury
True or false?
Anal incontinence is higher in Vaginal delivery
False (Anal incontinence risk is the same for VD and CS)
What is the most common Neonatal morbidity in CS?
Skin laceration
True or false?
Cesarean delivery is associated with a higher rate of fetal trauma
False (Lower rate than VD)
Give 6 NEONATAL complication of CS
Skin laceration Cephalohematoma Clavicular fracture Brachial plexopathy Skull fracture Facial nerve palsy
What circumstance gives the HIGHEST neonatal injury rate in CS?
Failed operative vaginal delivery
What circumstance gives the LOWEST neonatal injury rate in CS?
If done elective
True/ False?
Offspring with Asthma and Allergy is linked to being born cesarean
True
What are the 6 patient preparation before performing CS?
- Delivery availability
- Informed Consent
- Timing/ Scheduling
- Perioperative care
- Infection prevention
- Surgical Safety
What principle is being valued when seeking Informed consent”?
Autonomy
True/ False?
For women with a prior cesarean delivery, the option of a trial of labor should be included for suitable candidates
True
True/ False?
In those women desiring permanent sterilization or intrauterine device insertion, consenting for these can be completed concurrently
True
True or False?
ACOG recommend delaying nonmedically indicated deliveries until 39 completed weeks of gestation or beyond
True
What are the 3 criteria used for accurate gestational age dating?
- Sonography
- Fetal heart sound
- B-hcg
In dating gestational age, when is sonographic measurements taken?
Before 20 weeks
In dating gestational age, what is the duration for documenting Fetal Heart Sound?
Documented for at least 30 weeks
In dating gestational age, what is the duration for documenting B-HCG positivity?
Documented for at least 36 weeks
When is sedative being given as part of perioperative care?
Bedtime the night before surgery
At least how many hours of fasting is required before CS?
6-8 hours
At least how many hours does the patient may take CLEAR fluid before CS?
2 hours before
What are the goal and protocols of ERAS (Enhanced Recovery after surgery)?
Goal: Strive to maintain anabolic homeostasis
Protocol:
- Advocate clear carbohydrate drink up to 2 hours before surgery
- Early post operative feeding.
What should be done to reduce risk of gastric aspiration in CS?
Administer antacid before REGIONAL anesthesia or use general anethesia
In what way does wedge beneath the right hip and lower back creating a lateral tilt can help?
Aid venous return
Avoid hypotension
What is the protocol for hair removal during CS?
Clipping, not shaving
Done the day of CS
(Fewer surgical site infections)
Where is electro-grounding pad usually placed?
Lateral thigh
3 reasons why indwelling catheter should be inserted
- to collapse the bladder away from incision
- Prevent urinary retention in regional anesthesia
- Allow post-op urine measurement
How to prevent Venous thrombosis?
- Initiate thomboprophylaxis
2. Initiate pneumatic compression hose before CS and discontinued when woman abulates
What kind of wound is CS delivery?
Clean Contaminated wound
What is the cost effective Antibiotic of choice for infection prevention?
Cefazolin 1g/dose
What are the usual prophylactic antibiotics given in CS delivery?
IV route– B lactam antibiotic either Cephalosporins or Extended spectrum Penicillins
In what condition does the physician add another dose of antibiotics?
- Blood loss >1500 mL
2. Three hours duration of surgery
How many dose or antibiotic is usually given in CS?
1 dose
What are the different laparotomy incisions?
Transverse and Vertical
What do you call the transverse laparotomy insicion?
Pfannenstiel or Maylard incision
When would you do a Pfannensteil Incision?
- For cosmetic purpose
2. To lower incisional hernia rates
When would you not do a Pfannensteil Incision?
- When large operating space is essential
- When access to the upper abdomen is needed
- When risk for infection is high
- When reducing risk of bleeding, wound hematoma and neurological disruption
Why is Transverse laparotomy incision not done if there is high risk of infection?
Because of the layers created during incision of the internal and external oblique aponeuroses, purulent fluid can collect between these.
Why is transverse laparotomy incision superior in cosmesis?
- Because it follows the langer lines of the skin tension
2. Incision can be covered “bikini cut”
For repeat CS, which laparotomy incision has more faster reentry?
Vertical
Why is Transverse laparotomy incision more time consuming and difficult for reentry?
Because of scarring
When would you do a a vertical laparotomy Incision?
- When minimizing blood loss
- When needing access to the upper abdomen
- When extending or larger space is needed.
- When better visualization of the uterus is needed
- If you need less operative time
When would you not do a a vertical laparotomy Incision?
- If cosmesis is a concern
2. When reducing risk of fascial dehiscence and incisional hernia
In transverse laparotomy incision, cut is made where?
UPPER BORDER: At the level of pubic hairline (3 cm above superior border of symphysis pubis
LATERAL BORDERS: Rectus abdominis muscles
What is the adequate width of transverse laparotomy incision to accommodate delivery?
12-15 cm
What vessel is usually identified halfway between the skin and facia several cm from the midline that should be coagulated
Superficial epigastric Vessel
What are the 2 visible layers of anterior abdominal fascia?
- Aponeurosis of external oblique
2. Aponeurosis of internal oblique and transverse abdominis muscle (fused)
What is the importance of incising individually the 2 layers of anterior abdominal fascia?
To spare the INFERIOR EPIGASTRIC VESSEL
It usually lie outside the lateral border of rectus abdominis muscle and beneath the fused aponeuroses
What is the name of the clamp used to grasp the inferior fascial edge once fascia was incised?
Kocher Clamp
Why is fascial separation is carried near enough to the umbilicus?
To permit adequate midline longitudinal peritoneal incision.
What is being exposed when separating the rectus abdominis and pyramidalis muscles in the midline?
Transversalis fascia and peritoneum
For midline laparotomy vertical incision, cut is made where?
2-3 cm above the superior margin of the symphysis up to the infraumbilical area
Incision length should
correspond to estimated fetal size, approximately
12-15 cm
How is accidental cystotomy prevented?
Small opening is made sharply with scalpel in the upper half of the linea alba
What are the different hysterotomy incisions?
Low transverse
Classical
Low segment vertical
Advantage of low transverse hysterotomy incision
✓ Easier to repair
✓ Located at a site least likely to rupture during a subsequent pregnancy
✓ Does not promote adherence of bowel or omentum to the incisional line
Classical incision uses vertical or transverse insicion?
Vertical
Indication of Classical Hysterotomy incision
If the LUS cannot be exposed or entered safely because of:
1. Bladder adherent densely from the previous surgery
2. Myoma in the lower uterine segment
3. Invasive cancer of the cervix
4. Large fetus in the transverse lie (dorsoanterior or backdown)
5. Placenta previa with anterior implantation
6. Very small fetuses in breech with LUS knot
7. Massive maternal obesity where upper uterus is easily
accessible
Vertical incision at the lower uterine segment
Low segment vertical incision
A vertical incision into the body of the uterus above the lower uterine segment and reaches the uterine fundus
Classical incision
Lower uterine segment is incised transversely
Low transverse incision
