CS & PERIPARTUM HYSTERECTOMY Flashcards
Define cesarean delivery.
Birth of a fetus by laparotomy and then hysterotomy, excluding cases of uterine rupture or abdominal pregnancy.
What is cesarean hysterectomy?
A hysterectomy performed at the time of cesarean delivery, typically removing the uterine body and cervix.
Differentiate between postpartum and peripartum hysterectomy.
Postpartum hysterectomy occurs shortly after vaginal delivery, while peripartum hysterectomy includes both postpartum and cesarean hysterectomy.
What is a supracervical hysterectomy?
Removal of only the uterine body while leaving the cervix intact.
What are the risks of cesarean delivery compared to vaginal birth?
- Higher maternal surgical risks for current and subsequent pregnancies
- lower rates of perineal injury
- initial pelvic floor disorder risks.
What are common maternal morbidities associated with cesarean delivery?
(HIVA)
- Hemorrhage
- Infection
- venous thromboembolism
- anesthetic complications.
What are the risks of repeat cesarean delivery?
Increased risks include
- abnormal placentation
- uterine infections
- adjacent organ injury
- need for cesarean hysterectomy.
What are the advantages of cesarean delivery?
- Lower rates of urinary incontinence
- pelvic organ prolapse compared to vaginal birth.
What are common neonatal injuries associated with cesarean delivery?
- Skin lacerations
- cephalohematoma
- clavicular fractures
- brachial plexopathy.
Define CDMR.
Cesarean delivery on maternal request, often for pelvic floor protection or convenience.
What is the NIH’s stance on CDMR?
Concluded insufficient data to recommend CDMR, emphasizing the need for more research.
When should elective cesarean delivery be scheduled?
Not before 39 completed weeks of gestation to avoid neonatal immaturity risks.
What is the standard antibiotic for cesarean prophylaxis?
A single IV dose of cefazolin (1-3 g based on weight).
What precautions are taken for Jehovah’s Witnesses during cesarean delivery?
Use of:
- clotting agents
- iron supplementation
- avoidance of primary blood components like red cells.
What is the role of enhanced recovery after surgery (ERAS) in cesarean delivery?
Guides perioperative care, including preoperative fasting, use of clear liquids, and pain management.
What measures reduce surgical site infections during cesarean delivery?
Proper hair clipping on the day of surgery and preoperative antibiotic prophylaxis.
What is the role of pneumatic compression stockings during cesarean delivery?
Used to reduce the risk of venous thromboembolism.
What defines a clean-contaminated surgical case?
Surgery like cesarean delivery with potential exposure to internal body structures but no active infection.
What is the recommended prophylaxis for women with MRSA undergoing cesarean delivery?
A single 15 mg/kg dose of vancomycin in addition to standard antibiotics.
What are the common incision types used for entry during cesarean delivery?
Suprapubic transverse incisions (Pfannenstiel or Maylard) and midline vertical incisions.
Why are transverse incisions preferred over vertical incisions in cesarean delivery?
Transverse incisions follow Langer lines, exert less stress, offer superior cosmesis, and have lower incisional hernia rates.
When is a midline vertical incision preferred in cesarean delivery?
It is preferred in cases with:
- high infection risk
- emergent entry
- large operating space is needed.
What is the main difference between a Pfannenstiel and a Maylard incision?
The Maylard incision involves transecting the rectus abdominis muscle and its sheath, requiring cutting and ligating the inferior epigastric arteries.
What are the benefits of using blunt dissection to open the peritoneum during cesarean delivery?
It lowers the risk of cystotomy and allows careful avoidance of adjacent structures like the omentum, bowel, or bladder.
What is the typical length of an incision for a cesarean delivery?
12 to 15 cm.
Where are the inferior epigastric vessels typically located in relation to the rectus abdominis muscle?
They lie outside the lateral border of the rectus abdominis muscle and beneath the fused aponeuroses of the internal oblique and transverse abdominis muscles.
How can the bladder be identified during challenging dissections in cesarean delivery?
By distending or ‘backfilling’ the bladder with fluid instilled through a Foley catheter.
What are the common uterine incision types for cesarean delivery?
Low transverse, vertical confined to the lower segment, classical, fundal, and posterior uterine incisions.
Why is a low transverse uterine incision preferred for most cesarean deliveries?
It repairs easily, causes less bleeding, promotes less adhesion, and has a lower rupture risk during subsequent pregnancies.
What are the risks of lateral extension of a low transverse uterine incision?
Tears may extend into uterine vessels, cervix, or vagina, leading to complications such as blood loss or uterine rupture.
What are the advantages of using blunt stretch over sharp expansion for uterine incision?
Blunt stretch is associated with fewer unintended extensions, shorter operative times, and less blood loss.
What are the J, U, and T incisions, and when are they used in cesarean delivery?
They are extensions of a low transverse incision into the contractile myometrium used when more space is needed for fetal delivery.
Why is a classical uterine incision rarely preferred for cesarean delivery?
It has higher risks of uterine rupture in subsequent pregnancies and greater intraoperative blood loss.
What techniques are used to deliver a fetal head tightly wedged in the birth canal?
- Push method (upward vaginal pressure)
- pull method (breech extraction)
- use of a fetal pillow.
What are the potential risks associated with creating a bladder flap during cesarean delivery?
Shorter incision-to-delivery time but risks of incision into the cervix or vagina.
What should be done to the uterine incision after delivery of the placenta to manage bleeding?
Clamp vigorously bleeding sites with Pennington or ring forceps.
What is the benefit of spontaneous delivery of the placenta prompted by gentle steady cord traction?
It may reduce the risk of operative blood loss and infection.
What techniques are coupled with traction to hasten placental separation and delivery?
Fundal massage.
What should be done immediately after placental delivery?
The uterine cavity is suctioned and wiped out with a gauze sponge to remove avulsed membranes
What is the role of tranexamic acid (TXA) in postpartum hemorrhage prevention?
TXA can be added to oxytocin infusion to help prevent blood loss but may not lower rates of secondary clinical outcomes.
Why might the uterus be exteriorized during uterine repair?
It allows quicker recognition of atony
What type of sutures may reduce the formation of cesarean scar niches?
Single-layer closure.
What factors can reduce scarring and adhesion formation after cesarean delivery?
Delicate tissue handling
What is a common consequence of cesarean delivery involving adhesions?
Increased incision-to-delivery time and operative time.
What incision technique is associated with shorter operative times and reduced blood loss?
Joel-Cohen and Misgav Ladach techniques.
What are common indications for a classical cesarean incision?
Dense adhesions
What are some agents used for hemorrhage prophylaxis during cesarean delivery?
Oxytocin
What are the cosmetic and infection outcomes of using sutures vs. staples for skin closure?
Cosmetic results and infection rates are similar
What is the main disadvantage of a classical cesarean incision for future pregnancies?
It increases the risk of uterine rupture.
What is the benefit of using adhesive glue like Dermabond for skin closure?
It has outcomes equivalent to sutures for Pfannenstiel incisions.
How should the subcutaneous tissue be handled if it is less than 2 cm thick during abdominal closure?
It usually does not need to be closed.
What is a key difference between Joel-Cohen and Misgav Ladach techniques compared to Pfannenstiel-Kerr?
Greater use of blunt dissection and different initial incision placement.
Why might a vertical uterine incision be initiated higher than usual?
To avoid dense adhesions
What are the most common indications for peripartum hysterectomy?
- Intractable uterine atony
- surgical trauma/tears
- abnormal placentation.
What factors have contributed to the rise in peripartum hysterectomy rates?
Increasing rates of cesarean delivery and its associated complications in subsequent pregnancies.
What are the major complications of peripartum hysterectomy?
Greater blood loss and risk of urinary tract damage.
How does the complication rate of cesarean hysterectomy differ between elective and emergent procedures?
Elective procedures have lower rates of blood loss, blood transfusion, and urinary tract complications.
What technique is typically used to perform a total or supracervical hysterectomy?
Standard operative techniques, with adequate exposure and use of retractors.
What is the preferred method to obtain exposure during hysterectomy?
Cephalad traction on the uterus by an assistant with handheld retractors.
In cases of placenta accreta syndrome, how is the placenta typically handled during hysterectomy?
It is left undisturbed in situ.
What is the role of the round ligament in a hysterectomy procedure?
It is divided close to the uterus and ligated to access the anterior leaf of the broad ligament.
How is the posterior leaf of the broad ligament addressed in hysterectomy?
It is perforated just beneath the fallopian tube, uteroovarian ligaments, and ovarian vessels.
What is the key anatomical landmark for preventing injury to the ureters during hysterectomy?
The ureters pass beneath the uterine arteries.
How are the uterine vessels secured during hysterectomy?
By clamping them adjacent to the uterus, with lateral tissue pedicles doubly ligated.
What is a key strategy in cases of profuse hemorrhage during hysterectomy?
Clamping and dividing all pedicles quickly, then returning to ligate each one individually.
In a total hysterectomy, why is it easier to complete the operation after amputating the uterine fundus?
It allows for better traction and hemostasis with Ochsner or Kocher clamps placed on the cervical stump.
How are the cardinal and uterosacral ligaments managed during a total hysterectomy?
They are clamped with Heaney-type clamps, and the tissue is incised between the clamps for ligation.
What is done if the cervix is dilated and everted during a hysterectomy?
The cervicovaginal junction is identified via the hysterotomy or a vertical uterine incision.
How is the vagina closed after a total hysterectomy?
With a transfixing suture and interrupted stitches for the lateral vaginal cuff.
What is the purpose of securing the lateral vaginal fornix to the uterosacral ligaments?
To mitigate later vaginal prolapse.
What is a subtotal (supracervical) hysterectomy?
The uterine body is amputated above the level of uterine artery ligation, and the cervical stump is closed.
In what situations might subtotal hysterectomy be preferred?
For women requiring a shorter surgery or those with extensive adhesions that could cause significant urinary tract injury.
What is the role of salpingo-oophorectomy in peripartum hysterectomy?
To remove one or both adnexa to obtain hemostasis if needed.
What percentage of peripartum hysterectomy cases involve unilateral or bilateral oophorectomy?
A fourth of the cases.
What is the rate of bladder lacerations during cesarean delivery?
The bladder laceration rate is approximately 2 injuries per 1000 cesarean deliveries.
What is the rate of bowel injuries during cesarean delivery?
Bowel injury occurs in about 1 in 1000 cesarean deliveries.
What are common risks for bladder laceration during cesarean delivery?
Prior cesarean delivery, comorbid adhesive disease, emergency cesarean delivery, cesarean hysterectomy, especially with morbidly adherent placenta, and surgery in second-stage labor.
How is cystotomy confirmed in suspected bladder injury?
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.
What should be done before bladder cystotomy repair?
Ureters are examined by seeking urine jets from each orifice to confirm patency.
How is bladder cystotomy repaired?
Bladder is closed with a two- or three-layer running closure using a 3-0 absorbable or delayed-absorbable suture.
What is the recommended postoperative care for bladder injury repair?
Continuous bladder drainage for 7 to 14 days, with no need for uropathogen prophylaxis during this period.
How is ureteral injury diagnosed during cesarean delivery?
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.
What is the preferred method to confirm ureteral obstruction?
A 4F to 6F open-ended catheter is inserted into the ureteral orifice to check for ease of advancement. Failure to advance suggests obstruction.
What should be done if ureteral injury is suspected?
Inspection for extravasation, dye-stained urine jets, and possible insertion of ureteral catheters to confirm patency.
How are crush injuries to the ureter treated?
Crush injuries are inspected for vital tissue, and ureteral stents are left in place to prevent stricture.
What is the treatment for proximal ureteral injuries?
For proximal injuries, ureteroneocystostomy, ureteroureterostomy, or psoas hitch may be required.
How is bowel injury typically repaired?
Small bowel serosal tears are oversewn with fine absorbable or nonabsorbable sutures, while larger lacerations may require consultation with a general surgeon.
What is the recommended fluid management strategy during cesarean delivery?
Euvolemic replacement with crystalloid solutions like lactated Ringer’s or solutions containing 5% dextrose.
How should postoperative pain be managed after cesarean delivery?
Long-acting neuraxial analgesia is recommended with additional options like NSAIDs or opioid analgesia for breakthrough pain.
What is the typical postoperative care following cesarean delivery?
Monitoring vital signs, uterine tone, urine output, and vaginal bleeding, with hematocrit measured the morning after surgery.
What is the role of postoperative mobilization and ambulation in recovery?
Early ambulation helps reduce the risk of venous thromboembolism (VTE) and facilitates recovery.
What is the typical hospital stay duration after an uncomplicated cesarean delivery?
The average hospitalization length is 3 to 4 days for uncomplicated cesarean deliveries.
