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OBSTETRICS > CS & PERIPARTUM HYSTERECTOMY > Flashcards

CS & PERIPARTUM HYSTERECTOMY Flashcards

1
Q

Define cesarean delivery.

A

Birth of a fetus by laparotomy and then hysterotomy, excluding cases of uterine rupture or abdominal pregnancy.

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2
Q

What is cesarean hysterectomy?

A

A hysterectomy performed at the time of cesarean delivery, typically removing the uterine body and cervix.

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3
Q

Differentiate between postpartum and peripartum hysterectomy.

A

Postpartum hysterectomy occurs shortly after vaginal delivery, while peripartum hysterectomy includes both postpartum and cesarean hysterectomy.

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4
Q

What is a supracervical hysterectomy?

A

Removal of only the uterine body while leaving the cervix intact.

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5
Q

What are the risks of cesarean delivery compared to vaginal birth?

A
  • Higher maternal surgical risks for current and subsequent pregnancies
  • lower rates of perineal injury
  • initial pelvic floor disorder risks.
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6
Q

What are common maternal morbidities associated with cesarean delivery?

A

(HIVA)
- Hemorrhage
- Infection
- venous thromboembolism
- anesthetic complications.

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7
Q

What are the risks of repeat cesarean delivery?

A

Increased risks include
- abnormal placentation
- uterine infections
- adjacent organ injury
- need for cesarean hysterectomy.

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8
Q

What are the advantages of cesarean delivery?

A
  • Lower rates of urinary incontinence
  • pelvic organ prolapse compared to vaginal birth.
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9
Q

What are common neonatal injuries associated with cesarean delivery?

A
  • Skin lacerations
  • cephalohematoma
  • clavicular fractures
  • brachial plexopathy.
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10
Q

Define CDMR.

A

Cesarean delivery on maternal request, often for pelvic floor protection or convenience.

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11
Q

What is the NIH’s stance on CDMR?

A

Concluded insufficient data to recommend CDMR, emphasizing the need for more research.

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12
Q

When should elective cesarean delivery be scheduled?

A

Not before 39 completed weeks of gestation to avoid neonatal immaturity risks.

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13
Q

What is the standard antibiotic for cesarean prophylaxis?

A

A single IV dose of cefazolin (1-3 g based on weight).

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14
Q

What precautions are taken for Jehovah’s Witnesses during cesarean delivery?

A

Use of:
- clotting agents
- iron supplementation
- avoidance of primary blood components like red cells.

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15
Q

What is the role of enhanced recovery after surgery (ERAS) in cesarean delivery?

A

Guides perioperative care, including preoperative fasting, use of clear liquids, and pain management.

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16
Q

What measures reduce surgical site infections during cesarean delivery?

A

Proper hair clipping on the day of surgery and preoperative antibiotic prophylaxis.

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17
Q

What is the role of pneumatic compression stockings during cesarean delivery?

A

Used to reduce the risk of venous thromboembolism.

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18
Q

What defines a clean-contaminated surgical case?

A

Surgery like cesarean delivery with potential exposure to internal body structures but no active infection.

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19
Q

What is the recommended prophylaxis for women with MRSA undergoing cesarean delivery?

A

A single 15 mg/kg dose of vancomycin in addition to standard antibiotics.

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20
Q

What are the common incision types used for entry during cesarean delivery?

A

Suprapubic transverse incisions (Pfannenstiel or Maylard) and midline vertical incisions.

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21
Q

Why are transverse incisions preferred over vertical incisions in cesarean delivery?

A

Transverse incisions follow Langer lines, exert less stress, offer superior cosmesis, and have lower incisional hernia rates.

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22
Q

When is a midline vertical incision preferred in cesarean delivery?

A

It is preferred in cases with:
- high infection risk
- emergent entry
- large operating space is needed.

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23
Q

What is the main difference between a Pfannenstiel and a Maylard incision?

A

The Maylard incision involves transecting the rectus abdominis muscle and its sheath, requiring cutting and ligating the inferior epigastric arteries.

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24
Q

What are the benefits of using blunt dissection to open the peritoneum during cesarean delivery?

A

It lowers the risk of cystotomy and allows careful avoidance of adjacent structures like the omentum, bowel, or bladder.

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25
Q

What is the typical length of an incision for a cesarean delivery?

A

12 to 15 cm.

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26
Q

Where are the inferior epigastric vessels typically located in relation to the rectus abdominis muscle?

A

They lie outside the lateral border of the rectus abdominis muscle and beneath the fused aponeuroses of the internal oblique and transverse abdominis muscles.

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27
Q

How can the bladder be identified during challenging dissections in cesarean delivery?

A

By distending or ‘backfilling’ the bladder with fluid instilled through a Foley catheter.

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28
Q

What are the common uterine incision types for cesarean delivery?

A

Low transverse, vertical confined to the lower segment, classical, fundal, and posterior uterine incisions.

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29
Q

Why is a low transverse uterine incision preferred for most cesarean deliveries?

A

It repairs easily, causes less bleeding, promotes less adhesion, and has a lower rupture risk during subsequent pregnancies.

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30
Q

What are the risks of lateral extension of a low transverse uterine incision?

A

Tears may extend into uterine vessels, cervix, or vagina, leading to complications such as blood loss or uterine rupture.

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31
Q

What are the advantages of using blunt stretch over sharp expansion for uterine incision?

A

Blunt stretch is associated with fewer unintended extensions, shorter operative times, and less blood loss.

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32
Q

What are the J, U, and T incisions, and when are they used in cesarean delivery?

A

They are extensions of a low transverse incision into the contractile myometrium used when more space is needed for fetal delivery.

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33
Q

Why is a classical uterine incision rarely preferred for cesarean delivery?

A

It has higher risks of uterine rupture in subsequent pregnancies and greater intraoperative blood loss.

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34
Q

What techniques are used to deliver a fetal head tightly wedged in the birth canal?

A
  • Push method (upward vaginal pressure)
  • pull method (breech extraction)
  • use of a fetal pillow.
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35
Q

What are the potential risks associated with creating a bladder flap during cesarean delivery?

A

Shorter incision-to-delivery time but risks of incision into the cervix or vagina.

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36
Q

What should be done to the uterine incision after delivery of the placenta to manage bleeding?

A

Clamp vigorously bleeding sites with Pennington or ring forceps.

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37
Q

What is the benefit of spontaneous delivery of the placenta prompted by gentle steady cord traction?

A

It may reduce the risk of operative blood loss and infection.

38
Q

What techniques are coupled with traction to hasten placental separation and delivery?

A

Fundal massage.

39
Q

What should be done immediately after placental delivery?

A

The uterine cavity is suctioned and wiped out with a gauze sponge to remove avulsed membranes

40
Q

What is the role of tranexamic acid (TXA) in postpartum hemorrhage prevention?

A

TXA can be added to oxytocin infusion to help prevent blood loss but may not lower rates of secondary clinical outcomes.

41
Q

Why might the uterus be exteriorized during uterine repair?

A

It allows quicker recognition of atony

42
Q

What type of sutures may reduce the formation of cesarean scar niches?

A

Single-layer closure.

43
Q

What factors can reduce scarring and adhesion formation after cesarean delivery?

A

Delicate tissue handling

44
Q

What is a common consequence of cesarean delivery involving adhesions?

A

Increased incision-to-delivery time and operative time.

45
Q

What incision technique is associated with shorter operative times and reduced blood loss?

A

Joel-Cohen and Misgav Ladach techniques.

46
Q

What are common indications for a classical cesarean incision?

A

Dense adhesions

47
Q

What are some agents used for hemorrhage prophylaxis during cesarean delivery?

A

Oxytocin

48
Q

What are the cosmetic and infection outcomes of using sutures vs. staples for skin closure?

A

Cosmetic results and infection rates are similar

49
Q

What is the main disadvantage of a classical cesarean incision for future pregnancies?

A

It increases the risk of uterine rupture.

50
Q

What is the benefit of using adhesive glue like Dermabond for skin closure?

A

It has outcomes equivalent to sutures for Pfannenstiel incisions.

51
Q

How should the subcutaneous tissue be handled if it is less than 2 cm thick during abdominal closure?

A

It usually does not need to be closed.

52
Q

What is a key difference between Joel-Cohen and Misgav Ladach techniques compared to Pfannenstiel-Kerr?

A

Greater use of blunt dissection and different initial incision placement.

53
Q

Why might a vertical uterine incision be initiated higher than usual?

A

To avoid dense adhesions

54
Q

What are the most common indications for peripartum hysterectomy?

A
  • Intractable uterine atony
  • surgical trauma/tears
  • abnormal placentation.
55
Q

What factors have contributed to the rise in peripartum hysterectomy rates?

A

Increasing rates of cesarean delivery and its associated complications in subsequent pregnancies.

56
Q

What are the major complications of peripartum hysterectomy?

A

Greater blood loss and risk of urinary tract damage.

57
Q

How does the complication rate of cesarean hysterectomy differ between elective and emergent procedures?

A

Elective procedures have lower rates of blood loss, blood transfusion, and urinary tract complications.

58
Q

What technique is typically used to perform a total or supracervical hysterectomy?

A

Standard operative techniques, with adequate exposure and use of retractors.

59
Q

What is the preferred method to obtain exposure during hysterectomy?

A

Cephalad traction on the uterus by an assistant with handheld retractors.

60
Q

In cases of placenta accreta syndrome, how is the placenta typically handled during hysterectomy?

A

It is left undisturbed in situ.

61
Q

What is the role of the round ligament in a hysterectomy procedure?

A

It is divided close to the uterus and ligated to access the anterior leaf of the broad ligament.

62
Q

How is the posterior leaf of the broad ligament addressed in hysterectomy?

A

It is perforated just beneath the fallopian tube, uteroovarian ligaments, and ovarian vessels.

63
Q

What is the key anatomical landmark for preventing injury to the ureters during hysterectomy?

A

The ureters pass beneath the uterine arteries.

64
Q

How are the uterine vessels secured during hysterectomy?

A

By clamping them adjacent to the uterus, with lateral tissue pedicles doubly ligated.

65
Q

What is a key strategy in cases of profuse hemorrhage during hysterectomy?

A

Clamping and dividing all pedicles quickly, then returning to ligate each one individually.

66
Q

In a total hysterectomy, why is it easier to complete the operation after amputating the uterine fundus?

A

It allows for better traction and hemostasis with Ochsner or Kocher clamps placed on the cervical stump.

67
Q

How are the cardinal and uterosacral ligaments managed during a total hysterectomy?

A

They are clamped with Heaney-type clamps, and the tissue is incised between the clamps for ligation.

68
Q

What is done if the cervix is dilated and everted during a hysterectomy?

A

The cervicovaginal junction is identified via the hysterotomy or a vertical uterine incision.

69
Q

How is the vagina closed after a total hysterectomy?

A

With a transfixing suture and interrupted stitches for the lateral vaginal cuff.

70
Q

What is the purpose of securing the lateral vaginal fornix to the uterosacral ligaments?

A

To mitigate later vaginal prolapse.

71
Q

What is a subtotal (supracervical) hysterectomy?

A

The uterine body is amputated above the level of uterine artery ligation, and the cervical stump is closed.

72
Q

In what situations might subtotal hysterectomy be preferred?

A

For women requiring a shorter surgery or those with extensive adhesions that could cause significant urinary tract injury.

73
Q

What is the role of salpingo-oophorectomy in peripartum hysterectomy?

A

To remove one or both adnexa to obtain hemostasis if needed.

74
Q

What percentage of peripartum hysterectomy cases involve unilateral or bilateral oophorectomy?

A

A fourth of the cases.

75
Q

What is the rate of bladder lacerations during cesarean delivery?

A

The bladder laceration rate is approximately 2 injuries per 1000 cesarean deliveries.

76
Q

What is the rate of bowel injuries during cesarean delivery?

A

Bowel injury occurs in about 1 in 1000 cesarean deliveries.

77
Q

What are common risks for bladder laceration during cesarean delivery?

A

Prior cesarean delivery, comorbid adhesive disease, emergency cesarean delivery, cesarean hysterectomy, especially with morbidly adherent placenta, and surgery in second-stage labor.

78
Q

How is cystotomy confirmed in suspected bladder injury?

A

Cystotomy can be confirmed with retrograde instillation of fluid through a Foley catheter, using options like dilute sterile infant formula or methylene blue-stained saline.

79
Q

What should be done before bladder cystotomy repair?

A

Ureters are examined by seeking urine jets from each orifice to confirm patency.

80
Q

How is bladder cystotomy repaired?

A

Bladder is closed with a two- or three-layer running closure using a 3-0 absorbable or delayed-absorbable suture.

81
Q

What is the recommended postoperative care for bladder injury repair?

A

Continuous bladder drainage for 7 to 14 days, with no need for uropathogen prophylaxis during this period.

82
Q

How is ureteral injury diagnosed during cesarean delivery?

A

IV dye (e.g., methylene blue or sodium fluorescein) is administered, and the pelvis is directly inspected for dye-stained urine jets from each ureteral orifice.

83
Q

What is the preferred method to confirm ureteral obstruction?

A

A 4F to 6F open-ended catheter is inserted into the ureteral orifice to check for ease of advancement. Failure to advance suggests obstruction.

84
Q

What should be done if ureteral injury is suspected?

A

Inspection for extravasation, dye-stained urine jets, and possible insertion of ureteral catheters to confirm patency.

85
Q

How are crush injuries to the ureter treated?

A

Crush injuries are inspected for vital tissue, and ureteral stents are left in place to prevent stricture.

86
Q

What is the treatment for proximal ureteral injuries?

A

For proximal injuries, ureteroneocystostomy, ureteroureterostomy, or psoas hitch may be required.

87
Q

How is bowel injury typically repaired?

A

Small bowel serosal tears are oversewn with fine absorbable or nonabsorbable sutures, while larger lacerations may require consultation with a general surgeon.

88
Q

What is the recommended fluid management strategy during cesarean delivery?

A

Euvolemic replacement with crystalloid solutions like lactated Ringer’s or solutions containing 5% dextrose.

89
Q

How should postoperative pain be managed after cesarean delivery?

A

Long-acting neuraxial analgesia is recommended with additional options like NSAIDs or opioid analgesia for breakthrough pain.

90
Q

What is the typical postoperative care following cesarean delivery?

A

Monitoring vital signs, uterine tone, urine output, and vaginal bleeding, with hematocrit measured the morning after surgery.

91
Q

What is the role of postoperative mobilization and ambulation in recovery?

A

Early ambulation helps reduce the risk of venous thromboembolism (VTE) and facilitates recovery.

92
Q

What is the typical hospital stay duration after an uncomplicated cesarean delivery?

A

The average hospitalization length is 3 to 4 days for uncomplicated cesarean deliveries.

OBSTETRICS (13 decks)

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