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Cesarean section

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Cesarean section Powered By Docstoc
					Ext. Aomumporn Sarnthoy
               4/5/2552
Overview
•   Definition
•   Indication and Contraindication
•   Preoperaive management
•   Intraoperative management
•   Postoperative management
•   Complication
Cesarean section
Definition
 Operative procedure performed to deliver the fetus
 through an incision in abdominal wall (laparotomy) and
 uterine wall (hysterotomy)
Common indications
 Repeat cesarean section
 Dystocia or failure to progress
 Breech presentation
 Fetal distress
Accepted indications
 Failed induction       Active genital
 CPD                     herpes infection
 Fetal distress         Abdominal cerclage
 Placental abruption    Conjoined twin
 Placental previa       Abdominal pelvic
 Umbilical cord
                          bone
 prolapse                Transverse lie and
                          persistent
                          mentoposterior
Controversial indications
 Breech presentation        Footling breech
 Repeat cesarean section     presentation,
  or prior uterine scar       hyperextended head
 Immune                     Twins
  thrombocytopenia           Severe preeclampsia
 Severe Rh immunization     High risk for fetal
 Prior vaginal surgery       distress
 Large vulvar               Assisted reproductive
  condylomata                 technology
Contraindications
 Death fetus in utero
 Fetal anomaly
Anatomy
   Skin
   Subcutaneous tissue
   Anterior rectus sheet
   Rectus muscles
   Preperitoneal fat
   Peritoneum
   Vesicouterine membrane (serosa)
   Urinary bladder
   Uterus
Arterial supply of abdominal wall
Preoperative management
• Patient education and Inform consent
• NPO at least 8 hrs
• IV fluid
• Pre-operative lab
   • Hct ,Hb level
   • Blood is typed and screen
 PRC 1-2 unit
Preoperative management
• Urinary catheterization
• SSE
• Preparation of the abdomen and genitalia
• Prophylactic ATB
• Personnel trained in neonatal resuscitation
  should be available
Intraoperative management
 Position
    Left lateral tilt
 Anesthesia
    General anesthesia
    Spinal block
    Epidural block
 Skin preparation
    Antiseptic solution (povidone-iodine scrub)
    Drying
    Paint iodine solution
Intraoperative management
 Skin Incision
    Vertical midline incision
    Transverse incision
        Pfannenstiel incision
        Maylad incision
        Cherney incision
 Subcutaneous tissue incision
 Anterior rectus fascia incision & dissection
Skin incision




                Midline vertical

                  Maylard incision

                Pfannenstiel incision
Intraoperative management
   Separation of rectus muscle
   Peritoneal incision
   Vesicouterine reflection identification & incision
   Uterine incision
       Low transverse incision
       Low vertical incision
       Classical incision
       J-shaped incision
       T-shaped incision
 Fetal delivery
 Placental delivery
Divided rectus muscle
Vesicouterine reflection identification and
                 incision
AP and lateral vesicouterine
space
                             Lower uterine incision




Classical uterine incision




                             other uterine incision
Low vertical uterine incision
Extension of low transverse uterine
              incision
Fundal pressure and manual head
            delivery
Manual head delivery
Neonatal delivery
Deep engage and manual head delivery
Forceps head delivery
Short hale forceps delivery
Vectis
forceps
delivery

      Vectis forceps delivery
Manual removal placenta
Intraoperative management
 Myometrial wound closure
   Two-layer running-locking suture
   Single-layer running suture

 Vesicouterine closure
 Check bleeding & remove blood clot
 Adnexa examination
Closure of uterine incision
Closure of low transverse uterine incision
Repair classical incision
Abdominal wall closure
Smead Jones suture
Intraoperative management
 Abdominal wall closure
     Parietal peritoneum
     Rectus sheet
     Subcutaneous tissue
     Skin closure
Postoperative management
 Analgesic      Wound care
 Vital signs    Lab investigation
 Urination      Breast feeding
 Feeding        Discharge
 Ambulation
Complications
 Intraoperative
      Fetal injury
      Uterine and genital injury
      Uterine atony  bleeding
      Urinary tract injury
      Gastrointestinal tract injury
      Anaesthetic complication
Postoperative complications
 Early complication
       Paralytic ileus
       Endomyometritis
       Wound infection
       Urinary tract infection
       Intraabdominal and pelvic infection
       Intraabdominal bleeding
       Respiratory tract infection
       Thromboembolic disease
Postoperative complications
 Late complication
    Intestinal infection
    Dehiscence of uterine incision
    Placenta accreta

				
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