Basic Format Cesarean Section Procedures Basic Format Cesarean Section A Cesarean Section is one of the most frequently performed major surgical procedures in the US. It is one of the oldest surgical procedures known. About 22.9 % of all births are C-Sections. Rates have slightly declined because of increased use of labor trials and the VBAC procedure: vaginal birth after cesarean section. History: until the 20th century, cesareans were primarily equated with an attempt to save the fetus of the dying woman. As the maternal and perinatal morbidity and mortality rates assoc w/ Cesarean birth steadily decreased throughout the 20th century, the rate of cesarean births increased. Then there became became concerns about increase in health care cossts and high rates, and it decreased from 24.7 % in 1988 to 21% in 2001 (in the US).

Objectives Assess the anatomy, physiology, and pathophysiology of the Cesarean Section. Analyze the diagnostic and surgical interventions for a patient undergoing a Cesarean Section. Plan the intraoperative course for a patient undergoing Cesarean Section. Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives Choose the appropriate patient position Identify the incision used for the procedure Analyze the procedural steps for Cesarean Section. Describe the care of the specimen Discuss the postoperative considerations for a patient undergoing Cesarean Section .

Terms and Definitions Obstetrics See Indications Same as for L & D Terms STST p. 486 Branch of medicine that deals with prenatal care, childbirth, and postpartum care

Definition/Purpose of Procedure Surgical delivery of an infant through the abdominal and uterine wall. Often performed as an emergency for abruptio placentae, placenta previa, or cephalopelvic disproportion. May be scheduled for “previous c-section.” Performed when safe vaginal delivery is questionable or immediate delivery is crucial because the well-being of the mother or fetus is threatened

Indications Abnormal presentations (breech, transverse, etc.) Abruptio Placenta Carcinoma of the Cervix Cephalopelvic Disporportion (CPD) Cervix will not dilate Fetal distress** Most common reason Habitual death of the fetus during the course of labor Placenta Previa Preeclamptic toxemia in pts where difficult labor is anticipated Presence of STDs such as genital herpes Previous cesarean section Prolapse of the umbilical cord MAVCC Unit 5 Note: a. occasionally abnormal presentations can be repositioned or rotated into cephalic presentations capable of vaginal delivery With CPD, vaginal delivery would be very difficult or impossible. The fetus is in trouble and must be delivered as soon as possible. The cause may or may not be known. Same as repeated stillbirths This is toxemia of late pregnancy characterized by HTN, albuminuria, and edema, but without convulsions. Which could be transmitted from mother to fetus during vaginal delivery. Also, many STDs are transmitted to the fetus in utero. A Cesarean section will not prevent transmission if the fetus is already infected. However, when the fetus’s infection status is unknown, a c-section may be used as a preventive measure. Previous: the uterine wall is weakened from previous c-sections, and there is a danger of the uterus rupturing. However, the surgeon may allow patients meeting specified protocol to attempt to deliver vaginally. Prolapse: protrusion of the umbilical cord ahead of the presenting part of the fetus in labor which can strangle the fetus. Emergent.

Relevant A & P Physiology of pregnancy Female anatomy (covered last week)

Blood supply to internal reproductive organs

Blood supply to vagina, ovary, uterus, & fallopian tube

Pelvic Bones

Midsagittal view in supine position with some ligaments

Pathophysiology Dependent on type of Indication

Female Pelvis: True Pelvis Inlet, Cavity (midpelvis), and Outlet

Caldwell-Maloy Pelvic Types

Sometimes the baby is in a position, like breech (buttocks-first) or transverse (cross-wise), that makes a vaginal birth risky. Other times certain medical conditions, such as placenta previa (placenta is attached too low, blocking the baby's exit) or placenta abruptio (placenta is partially or completely detached, threatening the baby's oxygen and nutrient supply), make vaginal birth nearly impossible. A Cesarean section delivery is performed if a vaginal birth is not safe or possible for the mother or the baby.

Diagnostics Exams Multiple methods depending on problem Standard Assessments: Client history, determining gestational age (EDB); uterine assessment, fetal development, pelvic adequacy Preoperative Testing: typical for any surgery (CBC, blood chemistries, U/A) Olds Maternal-Child Nursing p. 339. Typical antepartal assessments include determination of due date. To calculate the estimated date of birth, it is helpful to know first day of LMP—but since that information is not always accurate, there are other techniques, such as evaluating uterine size, determining when quickening occurs, using ultrasound, and auscultating fetal heart rate. The most common method of determining EDB is Nagele’s Rule: First day of LMP, Subtract 3 months, Add 7 days, and that would be the EDB. Uterine assessment includes PE, Fundal Height: cm tape is used to measure distance from top of symphysis pubis over the curve of the abd to the top of the uterine fundus. Fundal height in cm correlates well w/weeks of gestation between 22 & 24 wks and 34 weeks. Fetal development is determined : Quickening: fetal movements felt by mother—may give some indication that fetus is nearing 20 wks gestation. Fetal heartbeat is auscultated primarily using ultrasonic Doppler device. Assessment of Pelvic Adequacy: a series of measurements –assessing vaginally to determine whether size and shape of pelvis are adequate for birth. The procedure is called clinical pelvimetry, performed by obstetricians and APNs. Very detailed. In general, the inlet, midpelvis, and outlet are measured/assessed. Important anteriorposterior diameters of inlet for childbearing are the diagonal conjugate, the obstetric conjugate, and conjugata vera. Other diameters are transverse and oblique. Midpelvis: important measurements include the plane of least dimension, or midplane (AP diameter), posterior sagittal diamter, and transverse diameter. An evaluation of adequacy is made based on the prominence of the ischial spines and degree of convergence on side walls. Pelvic Outlet: AP diameter, which extends from back border of symphysis pubis to tip of sacrum, can be measured digitally., Transervse diameter of outlet is measured by placing the fist between the ischial tuberosities. Posterior saggital diameter is measured.

External Cephalic Version

Surgical Intervention: Special Considerations Patient Factors Psychological status Significant other present or not Room Set-up: all preparations are made before the anesthetic is administered. If regional anesthesia is planned, the set-up, counts, and preliminary routines can be performed simultaneously w/anesthesia procedures. If general, the set-up, prep, catheterization, gowning & gloving of all personnel and draping are performed before anesthesia induction. Why? The OR team must be acutely aware and understanding of the patient’s psychological status—she may be gravely concerned for the infant’s well-being due to the emergent situation. If she participated in childbirth classes, she may feel like a failure. The birthing partner may be allowed to come to the OR for the birth-for emotional support and to witness the birth. Why? General anesthesia is the last thing done to prevent prolonged depression of the fetus

Surgical Intervention: Anesthesia Method: Regional (Epidural preferred or Spinal) or Local or General Equipment: spinal or epidural tray Other meds: Oxytocin (Pitocin) 10-20 u per liter of IV fluids once infant is delivered to minimize blood loss Oxytocin may be used to induce or continue labor, contract the uterus post delivery; stimulate lactation Carbopost (Hemabate) parenteral oxytocic used to control uterine hemorrhage following childbirth Ergonovine, Methylergononvine (Ergotrate, Methergine) causes uterine muscle contraction MAVCC Unit 5 When spinal anesthesia is used, the patient will be prepped after being anesthetized.

Many doctors prefer using general anesthesia, which renders the patient unconscious, for emergency C-sections because it can be administered quickly and takes effect almost immediately. When the C-section is planned, the doctor may order regional anesthetics (a spinal or an epidural), which numbs only the lower portion of the body

Surgical Intervention: Positioning Position during procedure Supine with roll at Rt hip to displace the uterus & prevent aortocaval compression Supplies and equipment: rolled sheet for hip roll, safety belt Special considerations: high risk areas: bony prominences; assistance PRN –awkward and in pain/between contractions MAVCC Unit 5 When the patient is placed in the supine position, her right hip is usually elevated, using a sheet roll under her hip. This is placed after any regional anesthesia, but before a general induction begins. It facilitates oxygenation of the infant by preventing aortocaval compression.

Surgical Intervention: Skin Prep Method of hair removal: wet prep or clippers Anatomic perimeters: Similar to laparotomy—table side to table side; to xiphoid process extending down to mid thigh: NO Vaginal prep Solution options: Betadine or Duraprep or Hibiclens Insert foley before prep

Surgical Intervention: Draping/Incision Types of drapes: C-Section pack includes laparotomy drape, which may sticky clear plastic around fenestration and fluid-catching channels Order of draping: 4 towels, abd drape Special considerations State/Describe incision Skin: Low transverse Pfannenstiel (Most common) or low midline vertical; length depends on estimated size of fetus Uterus: type depends on the need for the c-section MAVCC Unit 5 For a C-Section, the surgeon will most likely use a Pfannenstiel incision. IT is made across the lowest and narrowest part of the abdomen. It is made just below the pubic hair line, and is almost invisible after healing. Other advantages: less bleeding and better healing. --But the limitation is that it does not allow for extension of the incision. This incision is used when time is not of the essence (no fetal or maternal distress). Vertical (infraumbilical midline) is made between the naval and symphysis pubis and is quicker and therefore preferred in cases of nonreassuring fetal status when rapid birth is indicated, with preterm and macrosomic infants, or when the woman is obese.

Uterine Incisions Kerr Incision vs Sellheim Incision vs Classical Olds p. 761: The type of uterine incision depends on the need for the c-section. The choice affects the woman’s opportunity for a subsequent vaginal birth and her risks of a ruptured uterine scar with subsequent pregnancy. In non-emergency C-sections, the surgeon usually makes a horizontal incision (a bikini cut) across the abdomen, just above the pubic area. In an emergency situation, the surgeon may prefer a vertical cut, from below the navel to just above the pubic area. A vertical cut allows quicker access to the baby Two major locations: lower uterine segment and upper segment of the uterine corpus. The most common lower uterine segment incision is a transverse incision, which is preferred for a number of reasons. 1. Thinnest portion of the uterus and involves less blood loss 2. Requires only moderate dissection of the bladder from underlying myometrium 3. It is easier to repair, although repair takes longer 4. Site is less likely to rupture during subsequent pregnancies 5. Decreased chance of adherence of bowel or omentum into the incision line. There are some disadvantages: a. Takes longer to make b. Limited in size because of presence of major blood vessels on either side of uterus c. Greater tendency to extend laterally into the uterine vessels d. The incision may stretch and become a thin window, but it usually does not create problems clinically until subsequent labor ensues. The lower uterine segment vertical incision is preferred for multiple gestatation, abnormal presentation, placenta previa, nonreassuring fetal status, and preterm and macrosomatic fetuses. Disadvantages: 1. Incision may extend down into cervix 2. More extensive dissection of the bladder is needed to keep the incision in the lower uterine segment 3. If the incision extends upward into the upper segment, hemostasis and closure are more difficult Vertical incision carries higher risk of rupture for subsequent pregnancies—so usually future births need to be via c-section The CLASSIC incision is now used infrequently –increased risk of uterine rupture with subsequent pregnany, labor, and birth because the upper segment is the most contractile portion of the uterus. Kerr Incision vs Sellheim Incision vs Classical

Surgical Intervention: Supplies General: prep set, C-Section pack, basin set, gloves Specific Bulb syringe for infant suction Cord clamps, 2 per infant Delee suction device Cord blood tubes (2) Blood gas tubes on standby Suture/dressings of choice Medications on field (name & purpose) Catheters & Drains: Foley catheter is placed preoperatively

Surgical Intervention: Instruments General: those for a major GYN laparotomy plus (below) or C-Section tray (facility specific) Specific Delivery forceps (in room), a cord clamp, mucus aspiration bulb, possible Delee suction trap, Lister bandage scissors, Foerster ring forceps, Pennington forceps, Delee retractor, (2) lab tubes for cord blood

Surgical Intervention: Equipment General: ESU, Suction Specific: Infant radiant warmer mobile unit and possibly additional transport device depending on location of procedure (OR vs L & D) Fetal monitor

Procedure Overview The pelvis & uterus are entered. The head of the infant is delivered & the infant’s airways are cleared The infant’s body is delivered The placenta is removed The uterus is closed. The abdomen is closed.

Surgical Intervention: Procedure Steps Incision is made (#10 blade) and tissues of abdomen are divided w/usual fashion: have goulet or army-navy ready for muscle separation at midline & fascial incision and dissection Peritoneal covering over bladder is palpated (to ensure no inclusion of bladder, bowel, or omentum) and incised (exposing distended uterus). 2 crile hemostats are used to elevate the peritoneum about 2 cm apart. Bleeding sites will be clamped but not ligated until later (typically) The uterus is quickly palpated to determine fetal placement & position STSR: Be ready with dry lap sponges, bulb syringe, and suction MAVCC Unit 5 After the initial incision, the surgeon incises the peritoneal covering of the bladder to expose the uterus.

Step 6: Creation of bladder flap at vesicouterine fold 6. To perform the uterine incision, the line representing the bladder peritoneal reflection on the uterus is identified. The bladder is freed from the uterus and retracted inferiorly

Step 7: Bladder flap retracted & transverse incision made in lower uterine segment A small transverse incision is made in the lower uterine segment and carried bilaterally with blunt or sharp dissection. (STSR : are all the infant supplies ready for use?). The amniotic sac may or may not need incising. Note the color of the amniotic fluid. If meconium stained, a Delee suction may be required.

Finally, the surgeon cuts through the amniotic sac enclosing the baby Finally, the surgeon cuts through the amniotic sac enclosing the baby. He then allows the amniotic fluid to escape

Surgical Intervention: Procedure Steps Amniotic fluid is quickly evacuated from field Assistant retracts the bladder downward with the bladder blade or other similar retractor Surgeon nicks the uterus w/deep knife and extends the incision w/bandage scissors (blunt tips prevent injury to fetus) STSR may be asked to remove bladder retractor & simultaneously assistant pushes firmly on upper abd while surgeon grasps infant’s head & rotates upward Head is delivered from wound & airways immediately suctioned with bulb (poss Delee) MAVCC Unit 5 What does the surgeon use to remove mucus from the newborn’s airway? Bulb syringe After the newborn is delivered, he/she is normally handed over to the Pediatrician for neonatal care and assessment.

Step 10: Delivery of infant w/umbilical cord clamped

Surgical Intervention: Procedure Steps STSR: Once the head is controlled, all sharp and metal objects are removed prior to elevating the infant’s head The umbilical cord is clamped and cut. Cord blood sample is collected (surgeon may milk the cord) The infant is passed off to the pediatrician and into the warmed crib for assessment and possible emergency resuscitation measures STSR: Protect your sterile field The placenta is delivered, inspected, & removed to back table (usually in a basin)

Step 12: Dissection of the placenta from the uterine wall

Surgical Intervention: Procedure Steps The uterine interior may be cleaned w/a moist lap sponge. Oxytocin MAY be injected into the uterus to help with hemostasis The surgeon closes the uterus in 2 layers with 2-0 or 0 absorbable suture (chromic catgut, Vicryl, or Dexon)—running stitch

Step 14: Uterus is closed in 2 layers

Surgical Intervention: Procedure Steps The bladder flap may be approximated or not—if so, a 2-0 or 3-0 absorbable suture w/fine taper needle is often used The abdominal cavity is examined for bleeding, sponges, etc and is irrigated. Surgeon closes abd wall and skin for low transverse incision; subcuticular stitch or staples are used for closure. Blood clots are expressed from the uterus (STSR may be asked for basin at perineum). Wound and vaginal area are cleaned Dressing & perineal pad applied

Counts Initial: Before case begins: sponges, sharps, instruments, bovie tip cleaner First closing: Closure of uterus Second count: beginning closure of abd cavity Final closing Sponges Sharps & sm items Instruments

Dressing, Casting, Immobilizers, Etc. Types & sizes Abdominal dressing and perineal pad Type of tape or method of securing Silk, paper, foam tape. Elastoplast for compression dressing as ordered.

Specimen & Care Identified as: Placenta is sent per surgeon request for evaluation Cord blood tubes x 2 filled Blood gasses of cord may be ordered and drawn by circulator or peds from the artery within the umbilical cord Handled: Placenta is usually sent in formalin, if sent

Postoperative Care Destination Allow for bonding time with infant if possible PACU Expected prognosis (Good, Depends on Indication and any anesthetic complications) * mortality is 4-6 times that assoc w/vaginal delivery Maternal: healing & care of surgical wound increased risk of future C-section Infant: prognosis depends on reason for C-section and extent of oxygen deprivation

A typical hospital stay after C-section delivery is two to four days A typical hospital stay after C-section delivery is two to four days. Usually, the doctor encourages the mother to get up and move around soon after surgery to aid healing and to prevent complications. For the first few weeks, the abdominal incision will be sore. The scar will lighten as it heals

Postoperative Care Potential complications Hemorrhage: Fundus must be massaged just after delivery and become firm to help stop bleeding Infection Other: Injury to surrounding structures Surgical wound classification: II

References Alexander Ch 14, pp. 513-517 www.Allrefer.com Berry & Kohn Ch 34, pp. 694-697 Fuller pp. 362-363 MAVCC Unit 5

Vaginal Delivery Procedure 15-1

Delivery Presentation

Labor & Delivery Terminology Stage one: onset of labor Stage two: complete dilatation of cervix Stage three: birth of the infant Stage four: after placenta is delivered

What is an episiotomy? Intentional incision at perineum to ease birth process or to protect mother from uncontrolled perineal lacerations. During the procedure, the STSR should note amt of local medication used. For primary & secondary incisions, a handheld vaginal retractor may be used. For 3rd & 4th degree, may use a Gelpi perineal retractor. Improperly closed wounds can lead to postpartum hemorrhage, sepsis, fistulas, and coital pain

Perineal Lacerations & Incisions First degree Second degree Third degree Fourth degree STST p. 497 Commonly used definitions. Involves vaginal mucosa or perineal skin Extends into vaginal submucosa or perineum w/or without perineal body musculature being involved Involves anal sphincter Involves rectal mucosa

Episiotomies: Midline & Rt Mediolateral Olds page 754: The 2 most common types of episiotomies are midline and mediolateral. A midline episiotomy is performed along the median raphe of the perineum. It extends down from the vaginal oriface to the fibers of the rectal sphincter. It is the preferred method if the perineum is of adequate length and no difficulty is anticipated during the birth because it entails less blood loss, is easy to repair, and heals with less discomfort for the mother. The main disadvantage is that it may extend thru the anal sphincter and rectum. In the presences of a short perineum, macrosomia, and instrument-assisted birth (use of forceps or vacumn extractor), a mediolateral episiotomy provides more room and decreases the possibility of a traumatic extension into the rectum. Usually performed w/regional or local anesthesia. Repair of episiotomy (episiorrhaphy) and any lacerations is performed either during the period between birth of the baby and before expulsion of the placenta or after expulsion of the placenta.