Obstentrics_Williams

Obstentrics_Williams. An important step in vacuum extraction is proper cup placement over the lexion point. his pivot point maximizes traction, minimizes cup detachment, lexes but averts twisting the fetal head, and delivers the smallest head diameter through the pelvic oudet. This improves success rates, lowers fetal scalp injury rates, and lessens perineal trauma because the smallest fetal head diameter distends the vulva (Baskett, 2008). The lexion point is found along the sagittal suture, approximately 3 cm in front of the posterior fontanel and approximately 3em 6em /II -_ ...._-\ o\ I\ I\\ ........"------,///� FIGURE 29-17 Drawing demonstrates correct cup placement at the flexion point. Along the sagittal suture, this spot lies 3 cm from the posterior fontanel and 6 cm from the anterior fontanel.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 29-17 Drawing demonstrates correct cup placement at the flexion point. Along the sagittal suture, this spot lies 3 cm from the posterior fontanel and 6 cm from the anterior fontanel. 6 cm from the anterior fontanel. Because cup diameters range from 5 to 6 cm, when properly placed, the cup rim lies 3 cm from the anterior fontanel (Fig. 29-17). Placement of the cup more anteriorly on the fetal cranium-near the anterior fontanel-should be avoided as it leads to cervical spine extension during traction unless the fetus is small. Such placement also delivers a wider fetal head diameter through the vaginal opening. Last, asymmetrical placement relative to the sagittal suture may worsen asynclitism. For elective use, cup placement in OA positions is seldom diicult. In contrast, when the indication for delivery is failure to descend caused by occipital malpositionwith or without asynclitism or deflexion-cup positioning can be diicult.


Obstentrics_Williams

Obstentrics_Williams. During cup placement, maternal soft tissue entrapment predisposes the mother to lacerations and virtually ensures cup dislodgement, colloquially called a "pop of." Thus, the entire cup circumference should be palpated both before and after the vacuum has been created and again prior to traction to exclude such entrapment. Gradual vacuum creation is advocated by some and is generated by increasing the suction in increments of 0.2 kg/cm2 every 2 minutes until a total negative pressure of 0.8 kg/cm2 is reached 29-3). hat said, other studies have shown that negative pressure can be increased to 0.8 kg/cm2 in <2 minutes without a signiicant diference in eicacy or in maternal and fetal outcomes (Suwannachat, 2011, 2012) . TABLE 29-3. Vacuum Pressure Conversions 100 10 3.9 1.9 0.l3 200 20 7.9 3.9 0.27 300 30 11.8 5.8 OA1 400 40 15.7 7.7 0.54 500 50 19.7 9.7 0.68 600 60 23.6 11s.6 0.82


Obstentrics_Williams

Obstentrics_Williams. Once suction is created, the instrument handle is grasped, and traction is initiated. Similar to forceps delivery, traction angles mirror that in Figure 29-10. Eforts are intermittent and coordinated with maternal expulsive eforts. Manual torque to the cup is avoided as it can cause cup displacement or cephalohematomas and, with metal cups, "cookie-cutter"-type scalp lacerations. hus, OA oblique positions are corrected not by rotation, but solely by downward outward traction. During pulls, the operator should place the nondominant hand within the vagina, with the thumb on the extractor cup and one or more ingers on the fetal scalp. So positioned, descent of the presenting part can be judged and the traction angle can be adjusted with head descent. In addition, the relationship of the cup edge to the scalp can be assessed to help detect cup separation.


Obstentrics_Williams

Obstentrics_Williams. Between contractions, some physicians will lower the suction levels to decrease rates of scalp injury, whereas others will maintain suction in cases with a nonreassuring fetal heart rate to aid rapid delivery. No diferences in maternal or fetal outcome were noted if the level of vacuum was decreased between contractions or if an efort was made to prevent fetal loss of station (Boill, 1997). Once the head is extracted, the vacuum pressure is relieved and the cup removed.


Obstentrics_Williams

Obstentrics_Williams. Vacuum extraction should be considered a trial. Without early and clear evidence of descent toward delivery, an alternative delivery approach should be considered. As a general guideline, progressive descent should accompany each traction attempt. Neither data nor consensus are available regarding the number of pulls required to efect delivery, the maximum number of cup pop-ofs that can be tolerated, or optimal total duration of the procedure. Some manufacturers have recommendations regarding these in their instructional literature (Clinical Innovations, 2016; CooperSurgical, 2011).


Obstentrics_Williams

Obstentrics_Williams. During a vacuum extraction trial, cup dislodgement due to technical failure or less than optimal placement should not be equated with dislodgement under ideal conditions of exact cup placement and optimal vacuum maintenance. hese cases may merit either additional attempts at placement or, alternatively, a trial of forceps (Ezenagu, 1999; Williams, 1991). he least desirable cases are those in which traction without progress or multiple disengagements occur following correct cup application and appropriate traction. As with forceps, clinicians should embrace a willingness to abandon attempts at vacuum extraction if satisfactory progress is not made (American College of Obstetricians and Gynecologists, 2015). Accreditation Council for Graduate Medical Education: Obstetrics and


Obstentrics_Williams

Obstentrics_Williams. Accreditation Council for Graduate Medical Education: Obstetrics and Gynecology Case Logs. 20o15. Available at: http://www.acgme.org/Portals/ 0/PDFs/220_NationaLReport_Program_ Version.pdf. Accessed May 11o, 20o16 Aiken AR, Aiken CE, Alberry MS, et al: Management of fetal malposition in the second stage of labor: a propensity score analysis. Amo] Obstet Gynecol 212(3):355.e1,o2015 Alexander ]M, Leveno K], Hauth ]C, et al: Failed operative vaginal delivery. Obstet GynecoIo114(5):1017, 2009 American College of Obstetricians and Gynecologists, Society for Maternal Fetal Medicine: Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No.o1, March 2014, Reairmed 2016 American College of Obstetricians and Gynecologists: Operative vaginal delivery. Practice Bulletin No. 154, November 2015


Obstentrics_Williams

Obstentrics_Williams. Care Consensus No.o1, March 2014, Reairmed 2016 American College of Obstetricians and Gynecologists: Operative vaginal delivery. Practice Bulletin No. 154, November 2015 Bahl R, Patel R, Swingler R, et al: Neurodevelopmental outcome at 5 years after operative delivery in the second stage of labor: a cohort study. Am ] Obstet GynecoIo197:147, 2007 Bahl R, Van de Venne M, Macleod M, et al: Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study. B]OG 120(12):1526,o2013 Bailit ]L, Grobman WA, Rice IM, et al: Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am] Obstet GynecoI214(5):638.e1, 2016 Barth H ]r: Persistent occiput posterior. Obstet GynecoIo125(3):695, 2015 Bashore A, Phillips WH ]r, Brinkman CR III: A comparison of the morbidity of midforceps and cesarean delivety. Am] Obstet GynecoIo162(6): 1428, 1990


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Obstentrics_Williams. Baskett TF, Fanning CA, Young DC, et al: A prospective observational study of 1000 vacuum assisted deliveries with the OmniCup device. ] Obstet Gynaecol Can 30(7):573, 2008 Ben-Haroush A, Melamed N, Kaplan B, et al: Predictors of failed operative vaginal delivery: a single-center experience. Amo] Obstet Gynecol 197:308. e1,o2007 Bofill ]A, Rust OA, Schorr S], et al: A randomized trial of two vacuum extraction techniques. Obstet Gynecol89(5 Pt 1):758, 1997 BoIs EM, Hendriks E], Berghmans BC, et al: A systematic review of etiological factors for postpartum fecal incontinence. Acta Obstet Gynecol Scand 89(3):302,o2010 Bradley MS, Kaminski R], Streitman DC, et al: Efect of rotation on perineal lacerations in forceps-assisted vaginal deliveries. Obstet Gynecolol22(1): 132, 2013 Broman SH, Nichols PL, Kennedy WA: Preschool IQ: prenatal and early developmental correlates. Hillsdale, L. Erlbaum Associates, 1975


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Obstentrics_Williams. Broman SH, Nichols PL, Kennedy WA: Preschool IQ: prenatal and early developmental correlates. Hillsdale, L. Erlbaum Associates, 1975 Burke N, Field K, Mujahid F, et al: Use and safety of Kielland's forceps in current obstetric practice. Obstet Gynecol 120(4):766,o2012 Caughey AB, Sandberg PL, Zlatnik MG, et al: Forceps compared with vacuum. Rates of neonatal and maternal morbidity. Obstet Gynecol 106:908,2005 Cheong YC, Abdullahi H, Lashen H, et al: Can formal education and training improve the outcome of instrumental delivery? Eur ] Obstet Gynecol 113:139,o2004 Clinical Innovations: Kiwi complete vacuum delivery system instructions for use. Available at: http://clinicalinnovations.com/wp-content/ uploads/2015/03/Kiwi-IFU.pdf. Accessed May 13, 2016 Contag SA, Clifton RG, Bloom SL, et al: Neonatal outcomes and operative vaginal delivery versus cesarean delivery. Am] PerinatoI27(6):493, 2010


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Obstentrics_Williams. Contag SA, Clifton RG, Bloom SL, et al: Neonatal outcomes and operative vaginal delivery versus cesarean delivery. Am] PerinatoI27(6):493, 2010 CooperSurgical: Mityvac vacuum-assisted delivery. 2011. Available at: http:// www.coopersurgical.com/Products/DetaiIlMi tyvac-Vacuum -AssistedDelivery-Pumps-and-Accessories. Accessed May 13, 2016 Damron DP, Capeless EL: Operative vaginal delivery: a comparison of forceps and vacuum for success rate and risk of rectal sphincter injury. Am ] Obstet Gynecol 191:907,o2004 de Leeuwo]W, de Wit C, Kuijken ]P, et al: Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. B]OG 115:104,o2008 Demissie K, Rhoads GG, Smulian ]C, et al: Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis. BM] 329(7456):24,o2004


Obstentrics_Williams

Obstentrics_Williams. Demissie K, Rhoads GG, Smulian ]C, et al: Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis. BM] 329(7456):24,o2004 Dennen EH: Forceps Delivery. Philadelphia, F.A. Davis Company, 1955 de Vogel], van der Leeuw-van Beek A, Gietelink 0, et al: The efect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries. Am] Obstet GynecoI206(5):404, 2012 Dierker L], Rosen MG, Thompson K, et al: Midforceps deliveries: long-term outcome of infants. Am] Obstet Gynecol 154:764, 1986 Dolan LM, Hilton P: Obstetric risk factors and pelvic loor dysfunction 20 years ater first delivery. Int Urogynecol] Pelvic Floor Dysfunct 21:535, 2010 Ducarme G, Hamel ]F, Bouet PE, et al: Maternal and neonatal morbidity after attempted operative vaginal delivery according to fetal head station. Obstet GynecoIo126(3):521,o2015


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Obstentrics_Williams. Ducarme G, Hamel ]F, Bouet PE, et al: Maternal and neonatal morbidity after attempted operative vaginal delivery according to fetal head station. Obstet GynecoIo126(3):521,o2015 Duchon MA, DeMund MA, Brown RH: Laboratory comparison of modern vacuum extractors. Obstet Gynecol 72: 155, 1998 Dupuis 0, Moreau R, Pham MT: Assessment of forceps blade orientations during their placement using an instrumented childbirth simulator. B]OG 116(2):327, 2009 Dupuis 0, Moreau R, Silveira R, et al: A new obstetric forceps for the training of junior doctors: a comparison of the spatial dispersion of forceps blade trajectories between junior and senior obstetricians. m ] Obstet Gynecol 194: 1524, 2006 Dupuis 0, Silveira R, Dupont C, et al: Comparison of "instrument-associated" and "spontaneous" obstetric depressed skull fractures in a cohort of 68 neonates. Am] Obstet GynecoIo192(1):165, 2005


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Obstentrics_Williams. Dupuis 0, Silveira R, Dupont C, et al: Comparison of "instrument-associated" and "spontaneous" obstetric depressed skull fractures in a cohort of 68 neonates. Am] Obstet GynecoIo192(1):165, 2005 Evers EC, Blomquist JL, McDermott KC, et al: Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth. Am J Obstet GynecoIr207(5):425.e1,r2012 Ezenagu LC, Kakaria R, Bofill JA: Sequential use of instruments at operative vaginal delivery: is it safe? Am J Obstet Gynecol 180: 1446, 1999 Faiweather 0: Obstetric management and follow-up of the very low-birthweight infant. J Reprod Med 26:387, 1981 Fitzwater JL, Owen J, Ankumah NA, et al: Nulliparous women in the second stage of labor: changes in delivery outcomes berween rwo cohorts from 2000 and 2011. Obstet GynecoIr126(1):81, 2015 Friedman A, Sachtleben MR, Bresky PA: Dysfunctional labor, 12. Long-term efects on the fetus. Am J Obstet GynecoIr127:779, 1977


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Obstentrics_Williams. Friedman A, Sachtleben MR, Bresky PA: Dysfunctional labor, 12. Long-term efects on the fetus. Am J Obstet GynecoIr127:779, 1977 Friedman EA, Sachtleben-Murray MR, Dahrouge 0, et al: Long-term efects of labor and delivery on ofspring: a matched-pair analysis. Am J Obstet Gynecol 150:941, 1984 Gardella C, Taylor M, Benedetti T, et al: The efect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes. Am J Obstet Gynecol 185(4):896,2001 Gartland 0, MacArthur C, Woolhouse H, et al: Frequency, severiry and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. BJOG 123(7):1203,r2016 Gurol-Urganci I, Cromwell DA, Edozien LC, et al: hird-and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 120(12):1516,r2013


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Obstentrics_Williams. Gurol-Urganci I, Cromwell DA, Edozien LC, et al: hird-and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 120(12):1516,r2013 Gyhagen M, Bullarbo M, Nielsen T, et al: The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 120:144,r2013 Hagadorn-Freathy AS, Yeomans ER, Hankins GO: Validation of the 1988 ACOG forceps classiication system. Obstet Gynecol 77:356, 1991 Halpern SH, Muir H, Breen W, et al: A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor. Anesth Analg 99(5):1532,2004 Halscott TL, Reddy UM, Landy HJ, et al: Maternal and neonatal outcomes by attempted mode of operative delivery from a low station in the second stage of labor. Obstet GynecoIr126(6):1265, 2015


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Obstentrics_Williams. Halscott TL, Reddy UM, Landy HJ, et al: Maternal and neonatal outcomes by attempted mode of operative delivery from a low station in the second stage of labor. Obstet GynecoIr126(6):1265, 2015 Hamilton BE, Martin JA, Osterman MJ, et al: Births: final data for 2014. Nat! Vital Stat Rep 64(12):1, 2015 Handa L, Blomquist JL, McDermott KC, et al: Pelvic floor disorders after vaginal birth: efect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol 119(2 Pt 1):233,2012 Hirayama F, Koyanagi A, Mori R, et al: Prevalence and risk factors for thirdand fourth-degree perineal lacerations during vaginal delivery: a multicountry study. BJOG 119(3):340,2012 Hirsch E, Haney EI, Gordon TE, et al: Reducing high-order perineal laceration during operative vaginal delivery. AmJ Obstet GynecoIr198(6):668.e1, 2008 Hofmeyr GJ, Gobetz L, Sonnendecker EW, et al: New design rigid and soft vacuum extractor cups: a preliminary comparison of traction forces. BJOG 97(8):681, 1990


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Obstentrics_Williams. Hofmeyr GJ, Gobetz L, Sonnendecker EW, et al: New design rigid and soft vacuum extractor cups: a preliminary comparison of traction forces. BJOG 97(8):681, 1990 Kudish B, Blackwell S, Mcneeley SG, et al: Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol 195(3):749,r2006 Kuit JA, Eppinga HG, Wallenburg HCS, et al: A randomized comparison of vacuum extraction delivery with a rigid and a pliable cup. Obstet Gynecol 82:280, 1993 Kyser L, Lu X, Santillan 0, et al: Forceps delivery volumes in teaching and nonteaching hospitals: are volumes suicient for physicians to acquire and maintain competence? Acad Med 89(1):71, 2014 Landy HJ, Laughon SK, Bailit JL, et al: Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 117(3):627,r201r1


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Obstentrics_Williams. Landy HJ, Laughon SK, Bailit JL, et al: Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 117(3):627,r201r1 Leijonhuvud A, Lundholm C, Cnattingius S, et al: Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Am J Obstet GynecoI204(1):70.e1, 2011 Le Ray C, Deneux-haraux C, Khireddine I, et al: Manual rotation to decrease operative delivery in posterior or transverse positions. Obstet Gynecol 122(3):634,r2013 Le Ray C, Serres P, Schmitz T, et al: Manual rotation in occiput posterior or transverse positions. Obstet Gynecol 110:873, 200 Leslie KK, Dipasqule-Lehnerz P, Smith M: Obstetric forceps training using visual feedback and the isometric strength testing unit. Obstet Gynecolr1 05:377,2005 Lowe B: Fear of failure: a place for the trial of instrumental delivery. BJOG 94:60, 1987


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Obstentrics_Williams. MacArthur C, Wilson 0, Herbison P, et al: Faecal incontinence persisting after childbirth: a 12-year longitudinal study. BJOG 120(2):169,r2013 MacArthur C, X ilson 0, Herbison P, et al: Urinary incontinence persisting after childbirth: extent, delivery history, and efects in a 12-year longitudinal cohort study. Prolong Study Group. BJOG 123(6):1022,r2016 Malvasi A, Tinelli A, Barbera A, et al: Occiput posterior position diagnosis: vaginal examination or intrapartum-sonography? A clinical review. J Matern Fetal Neonatal Med 27(5):520,r2014 Marucci M, Cinnella G, Perchiazzi G, et al: Patient-requested neuraxial analgesia for labor: impact on rates of cesarean and instrumental vaginal delivery. Anesthesiology 106(5):1035, 2007 Merriam A, Ananth CV, Wright JD, et al: Trends in operative vaginal delivery, 2005-2013: a population-based study. BJOG 124(9):1365,2017


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Obstentrics_Williams. Merriam A, Ananth CV, Wright JD, et al: Trends in operative vaginal delivery, 2005-2013: a population-based study. BJOG 124(9):1365,2017 Muise L, Duchon A, Brown RH: he efect of artificial caput on performance of vacuum extractors. Obstet GynecoI81(2):170, 1993 Mulder F, Schofelmeer M, Hakvoort R, et al: Risk factors for postpartum urinary retention: a systematic review and meta-analysis. BJOG 119(12): 1440, 2012 Murphy OJ, Libby G, Chien P, et al: Cohort study offorceps delivery and the risk of epilepsy in adulthood. Am J Obstet Gynecol 191 :392, 2004 Murphy OJ, Macleod M, Bahl R, et al: A cohort study of maternal and neonatal morbidiry in relation to use of sequential instruments at operative vaginal delivery. Eur J Obstet Gynecol Reprod Bioi 156(1):41,r2011


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Obstentrics_Williams. Nelson L, Furner SE, Westercamp M, et al: Cesarean delivery for the prevention of anal incontinence. Cochrane Database Syst Rev 2:CD006756, 2010 Nilsen ST: Boys born by forceps and vacuum extraction examined at 18 years of age. Acta Obstet Gynecol Scand 63:549, 1984 Nygaard IE, Rao SS, Dawson JD: Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Obstet Gynecol 89:896, 199 O'Callaghan ME, MacLennan AH, Gibson CS, et al: Epidemiologic associations with cerebral palsy. Obstet GynecoIr118(3):576, 2011 O'Mahony F, Hofmeyr GJ, Menon V: Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev 11:CD005455, 2010 Osterman MJ, Martin JA, Menacker F: Expanded health data from the new birth certificate, 2006. Nat! Vital Stat Rep 58(5):1, 2009 Palatnik A, Grobman WA, Hellendag MG, et al: Predictors offailed operative vaginal delivery in a contemporary obstetric cohort. Obstet Gynecol 127(3): 501,r2016


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Obstentrics_Williams. Palatnik A, Grobman WA, Hellendag MG, et al: Predictors offailed operative vaginal delivery in a contemporary obstetric cohort. Obstet Gynecol 127(3): 501,r2016 Pearl ML, Roberts JM, Laros RK, et al: Vaginal delivery from the persistent occiput posterior position: influence on maternal and neonatal morbidiry. J Reprod Med 38:955, 1993 Pergialiotis V, Vlachos 0, Protopapas A, et al: Risk factors for severe perineal lacerations during childbirth. Int J Gynaecol Obstet 125(1):6,r2014 Pifarotti P, Gargasole C, Folcini C, et al: Acute post-partum urinary retention: analysis of risk factors, a case-control study. Arch Gynecol Obstet 289(6):1249,r2014 Ramphul M, Kennelly MM, Burke G, et al: Risk factors and morbidiry associated with suboptimal instrument placement at instrumental delivery: observational study nested within the Instrumental Delivery & Ultrasound randomised controlled trial ISRCTN 72230496. BJOG 122(4):558,r2015


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Obstentrics_Williams. RobertSon PA, Laros RK, Zhao L: Neonatal and maternal outcome in lowpelvic and mid-pelvic operative deliveries. Am J Obstet Gynecol 162: 1436, 1990 Rorrveit G, Dalrveit AK, Hannestad YS, et al: Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med 348:9000, 2003 Schuit E, Kwee A, Westerhuis ME, et al: A clinical prediction model to assess the risk of operative delivery. BJOG 119(8):915,r2012 Schwartz DB, Miodovnik M, Lavin JP Jr: Neonatal outcome among low birth weight infants delivered spontaneously or by low forceps. Obstet Gynecol 62:283, 1983 Skinner S, Davies-Tuck M, Wallace E, et al: Perinatal and maternal outcomes after training residents in forceps before vacuum instrumental birth. Obstet Gynecol 130(1):151,r2017 Seidman OS, Laor A, Gale R, et al: Long-term efects of vacuum and forceps deliveries. Lancet 337:1583, 1991 Solt I, Jackson S, Moore T, et al: Teaching forceps: the impact of proactive faculry. Am J Obstet Gynecol 204(5):448.e1, 2011


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Obstentrics_Williams. Solt I, Jackson S, Moore T, et al: Teaching forceps: the impact of proactive faculry. Am J Obstet Gynecol 204(5):448.e1, 2011 Spiliopoulos M, Kareti A, Jain NJ, et al: Risk of peripartum hysterectomy by mode of delivery and prior obstetric history: data from a population-based study. Arch Gynecol Obstet 283(6):1261, 2011 Spong CY, Berghella V, Wenstrom KD, et al: Preventing the first cesarean delivery: summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists X orkshop. Obstet GynecoIr120(5):1181, 2012 Stock SJ, Josephs K, Farquharson S, et al: Matenal and neonatal outcomes of successful Kielland's rotational forceps delivery. Obstet GynecoIr121(5): 1032,r2013


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Obstentrics_Williams. Stock SJ, Josephs K, Farquharson S, et al: Matenal and neonatal outcomes of successful Kielland's rotational forceps delivery. Obstet GynecoIr121(5): 1032,r2013 Suwannachat B, Laopaiboon M, Tonmat S, et al: Rapid versus stepwise application of negative pressure in vacuum extraction-assisted vaginal delivery: a multicentre randomised controlled non-inferiority trial. BJOG 118(10): 1247,r2011 Suwannachat B, Lumbiganon P, Laopaiboon M: Rapid versus stepwise negative pressure application for vacuum extraction assisted vaginal delivery. Cochrane Database Syst Rev 8:CD006636, 2012 Tahtinen RNf, Cartwright R, Tsui JF, et al: Long-term impact of mode of delivery on stress urinary incontinence and urgency urinary incontinence: a systematic review and meta-analysis. Eur Urol 70(1):148, 2016


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Obstentrics_Williams. Tempest N, Hart A, Walkinshaw S, et al: A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following diferent methods of birth for malposition in the second stage of labor. BJOG 7,r2013 Towner 0, Castro NlA, Eby-Wilkens E, et al: Efect of mode of delivery in nulliparous women on neonatal intracranial injuY. N Engl J /Ied 341: 1 09, 1999 Towner DR, Ciotti MC: Operative vaginal delivery: a cause of birth injury or is it? Clin Obstet Gynecol 50(3):563, 2007 Vacca A: Vacuum-assisted delivery. Best Pract Res Clin Obstet Gynaecol 16:17,r2002 Verhoeven CJ, Nuij C, Janssen-RolfCR, et al: Predictors for failure of vacuumassisted vaginal delivery: a case-control study. Eur J Obstet Gynecol Reprod Bioi 200:29, 2016


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Obstentrics_Williams. Verhoeven CJ, Nuij C, Janssen-RolfCR, et al: Predictors for failure of vacuumassisted vaginal delivery: a case-control study. Eur J Obstet Gynecol Reprod Bioi 200:29, 2016 Voll0yhaug I, M0rkved S, Salvesen 0, et al: Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16-24 years after irst delivery. Ultrasound Obstet Gynecol 46(4): 487,r2015 Walsh CA, Robson M, McAulife FM: Mode of delivery at term and adverse neonatal outcomes. Obstet Gynecol 121 (1): 122, 2013 Wassen MM, Hukkelhoven CW, Scheepers He, et al: Epidural analgesia and operative delivery: a ten-year population-based cohort study in The Netherlands. Eur J Obstet Gynecol Reprod Bioi 183: 125, 2014 Wen SW, Liu S, Kramer MS, et al: Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries. Am J Epidemiol 153(2):103,r2001


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Obstentrics_Williams. Wen SW, Liu S, Kramer MS, et al: Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries. Am J Epidemiol 153(2):103,r2001 Werner EF, Janevic TM, IIIuzzi J, et al: Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol 118(6): 1239,r2011 Wesley B, Van den Berg B, Reece EA: The effect of operative vaginal delivery on cognitive development. Am J Obstet Gynecol 166:288, 1992 Williams MC, Knuppel A, O'Brien WF, et al: A randomized comparison of assisted vaginal delivery by obstetric forceps and polyethylene vacuum cup. Obstet Gynecol 78:789,r1991 Yancey MK, Pierce B, Schweitzer 0,et al: Observations on labor epidural analgesia and operative delivery rates. Am J Obstet Gynecol 180(2 Pt 1):353, 1999 Yeomans ER: Operative vaginal delivery. In Yeomans ER, Hofman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 2017


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Obstentrics_Williams. Yeomans ER: Operative vaginal delivery. In Yeomans ER, Hofman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 2017 CESAREAN DELIVERY IN THE UNITED STATES . .. ... 567 CESAREAN DELIVERY RISKS ......... . . .... .. 568 PATIENT PREPARATION .... .. . . .. ... ... 569 CESAREAN DELIVERY TECHNIQUE . . . ........... 571 LAPAROTOMY ........ .... . .... ... .. .. 571 HYSTEROTOMY .. ..... .. ... ..... .. . .. . 573 PERIPARTUM HYSTERECTOMY ... ......... ...... 580 POSTOPERATIVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . 585 ?he anterior suace of the uterus is opened longitudinaly along its midline. ?his is best accomplished by making an incision a ew centimetres long with a scapel, and then rapidy enlarging it with the scissors to 16 or 18 centimetres. ?he membranes are then rupture, the child is seized by one oot and rapidy extracted -]. Whitridge Williams (1903)


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Obstentrics_Williams. From the above description, cesarean technique has evolved during the past century. For example, preference for classical hysterotomy has given way to low transverse incision. Evidence-based data now guide many surgical steps and are presented throughout this chapter. Of deinitions, cesarean delivey defines the birth of a fetus via laparotomy and then hysterotomy. This definition is not applied to removal of the fetus from the abdominal cavity in the case of uterine rupture or with abdominal pregnancy. Rarely, hysterotomy is performed in a woman who has just died or in whom death is expected soon-postmortem orperimortem cesarean delivery (Chap. 47, p. 931).


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Obstentrics_Williams. In some instances, abdominal hysterectomy is indicated following delivery. When performed at the time of cesarean delivery, the operation is termed cesarean hysterectomy. If done within a short time after vaginal delivery, it is termedpospartum hysterectomy. Peripartum hysterectomy is a broader term that combines these two. In most cases, hysterectomy is total, but supracervical hysterectomy is an option. The adnexa are not usually removed. In most instances, a simple or type I hysterectomy is performed. However, for women with invasive cervical cancer, radical hysterectomy removes the uterus, parametrium, and proximal vagina to achieve tumor excision with negative margins. Also, for cases of placenta percreta that extend toward the pelvic sidewall, similar radical excision of the parametrium may be needed.


Obstentrics_Williams

Obstentrics_Williams. In the United States, the cesarean delivery rate rose from 4.5 percent in 1970 to 32.9 percent in 2009. Following this peak, the rate has trended slightly downward, and it was 32.0 percent in 2015 (Martin, 2017). Some indications for performing cesarean delivery are shown in Table More than 85 percent of these operations are performed for four reasollSprior cesarean delivery, dystocia, fetal jeopardy, or abnormal fetal presentation. The latter three compose the main indications for primary cesarean delivery (Barber, 2011; Boyle, 2013). The reasons for persistently significant cesarean rates are not completely understood, but some explanations include the following: 1. Women are having fewer children, thus, a greater percentage of births are among nulparas, who are at increased risk for cesarean delivery. 2. The average maternal age is rising, and older women, especially nulliparas, have a higher risk of cesarean delivery. TABLE 30-1 . Some Indications for Cesarean Delivery


Obstentrics_Williams

Obstentrics_Williams. 2. The average maternal age is rising, and older women, especially nulliparas, have a higher risk of cesarean delivery. TABLE 30-1 . Some Indications for Cesarean Delivery HIV human immunodeficiency virus; HSV herpes simplex virus. 3. he use of electronic etal monitoring is widespread. This practice is associated with an increased cesarean delivery rate compared with intermittent fetal heart rate auscultation. Fetal distress accounts for only a minority of all cesareans. In many more cases, concern for an abnormal or "nonreassuring" fetal heart rate tracing prompts cesarean delivery. 4. Most fetuses presenting breech are now delivered by cesarean. 5. he frequency of operative vaginal delivery has declined. 6. Rates of labor induction continue to rise, and induced labor, especially among nulliparas, raises the cesarean delivery rate. 7. Obesi, which is a cesarean delivery risk, has reached epidemic proportions. 8.


Obstentrics_Williams

Obstentrics_Williams. 7. Obesi, which is a cesarean delivery risk, has reached epidemic proportions. 8. Rates of cesarean delivery in women with preeclampsia have increased, whereas labor induction rates for these patients have declined. 9. he rate of vaginal birth ater cesarean-BAC-has decreased from a high of 28 percent in 1996 and was 11 percent in 2014 (Hamilton, 2015). 10. Elective cesarean deliveries are increasingly being performed for various indications that include maternal request, concern for pelvic loor injury associated with vaginal birth, and reduction of etal injury rates. 11. Assisted reproductive technoloy is more widely used than in the past and is associated with greater cesarean delivery rates (Reddy, 2007). 12. Mapractice litigation related to fetal injury during spontaneous or operative vaginal delivery continues to contribute to the present cesarean delivery rate.


Obstentrics_Williams

Obstentrics_Williams. 12. Mapractice litigation related to fetal injury during spontaneous or operative vaginal delivery continues to contribute to the present cesarean delivery rate. To provide accurate informed consent, understanding both maternal and neonatal risks and beneits with surgery is essential. In broad terms, cesarean delivery has higher maternal surgical risks for the current and subsequent pregnancies compared with spontaneous vaginal birth. his is balanced against lower rates of perineal injury and short-term pelvic floor disorders. For the neonate, cesarean delivery ofers lower rates of birth trauma and stillbirth but greater rates of initial respiratory diiculties.


Obstentrics_Williams

Obstentrics_Williams. For the mother, death attributable solely to cesarean delivery is rare in the United States. Even so, numerous studies attest to increased mortality risks. Clark and colleagues (2008), in a review of nearly 1.5 million pregnancies, found maternal mortality rates of 2.2 per 100,000 cesarean deliveries compared with 0.2 per 100,000 vaginal births. In a metaanalysis of 203 studies, Guise and coworkers (2010) reported a maternal mortality rate of 13 per 100,000 with elective repeat cesarean delivery compared with 4 per 100,000 women undergoing a trial of labor after prior cesarean.


Obstentrics_Williams

Obstentrics_Williams. Similar to mortality rates, the frequencies of some maternal complications are increased with all cesarean compared with vaginal deliveries. Villar and associates (2007) reported that maternal morbidity rates increased twofold with cesarean compared with vaginal delivery. Principal among these are infection, hemorrhage, and thromboembolism. In addition, anesthetic complications, which also rarely include death, have a greater incidence with cesarean compared with vaginal delivery (Cheesman, 2009; Hawkins, 201l). Adjacent organs infrequently may be injured, which is described in detail on page 583. Women who undergo a cesarean delivery are much more likely to be delivered by a repeat operation in subsequent pregnancies. For women undergoing subsequent cesarean, the maternal risks just described are even greater (Cahill, 2006; Marshall, 2011; Silver, 2006).


Obstentrics_Williams

Obstentrics_Williams. As an advantage, cesarean delivery is associated with lower rates of urinary incontinence and pelvic organ prolapse than is vaginal birth (Glazener, 2013; Gyhagen, 2013a,b; Handa, 2011; Leijonhuvud, 2011). Rates of anal incontinence appear uninluenced by delivery route (Fritel, 2007; Nelson, 2010). Protective advantages persist to some degree over time, but cesarean delivery is not totally protective. Moreover, longitudinal studies suggest that initial pelvic floor advantages gained from cesarean delivery are lost as women age (Dolan, 2010; MacArthur, 2011, 2013; Nelson, 2010). To address this, the National Institutes of Health (2006) held a conference on cesarean delivery on maternal request. It summarized that stress urinary incontinence rates after elective cesarean delivery are lower than those following vaginal delivery. However, the duration of this protection is unclear, particularly in older and multiparous populations. This same panel considered the evidence implicating


Obstentrics_Williams

Obstentrics_Williams. than those following vaginal delivery. However, the duration of this protection is unclear, particularly in older and multiparous populations. This same panel considered the evidence implicating vaginal delivery in other pelvic loor disorders to be weak and not favoring either delivery route.


Obstentrics_Williams

Obstentrics_Williams. Cesarean delivery is associated with a lower rate of fetal trauma (Linder, 2013; Moczygemba, 2010). lexander and colleagues (2006) found that fetal injury complicated 1 percent of cesarean deliveries. Skin laceration was most common, but others included cephalohematoma, clavicular fracture, brachial plexopathy, skull fracture, and facial nerve palsy. Cesarean deliveries following a failed operative vaginal delivery attempt had the highest injury rate, whereas the lowest rate-0.5 percentoccurred in the elective cesarean delivery group. hat said, Worley and colleagues (2009) noted that approximately a third of women who were delivered at Parkland Hospital entered spontaneous labor at term, and 96 percent of these delivered vaginally without adverse neonatal outcomes.


Obstentrics_Williams

Obstentrics_Williams. Some evidence shows higher asthma and allergy rates in those delivered by cesarean. With the hope to improve neonatal microbiota, swabbing the newborn mouth with a gauze that was incubated in the maternal vagina 1 hour before surgery is described in preliminary studies. However, the American College of Obstetricians and Gynecologists (2017 e) does not encourage this practice due to few data and the potential for transmission of harmful organisms. Some women request elective cesarean delivery. Data regarding the true incidence of cesarean delivey on matenal request (CDMR) are poor. Rate estimates range from 1 to 8 percent in the United States (Barber, 2011; Declercq, 2005; Gossman, 2006; Menacker, 2006).


Obstentrics_Williams

Obstentrics_Williams. Reasons for the request include pelvic floor protection, convenience, fear of childbirth, and reduced risk of fetal injury. Data to address these concerns are slowly accruing. One study of more than 66,000 Chinese parturients compared outcomes of those who elected planned vaginal or primary cesarean delivery (Liu, 2015). Short-term serious maternal morbidity and neonatal mortality rates were similar. For the newborns, rates of birth trauma, infection, and hypoxic ischemic encephalopathy were low in both groups but statistically lower with cesarean delivery. Respiratory distress syndrome rates were greater in the CMDR cohort. A smaller study comparing these two routes of delivery support these findings (Larsson, 2011).


Obstentrics_Williams

Obstentrics_Williams. he debate surrounding CDMR includes these medical points, the concept of informed free choice by the woman, and the autonomy of the physician in ofering CMDR. During the National Institutes of Health panel (2006) cited above, participants noted that most of the maternal and neonatal outcomes examined had insuicient data to permit recommendations. Despite this, the panel was able to draw a few conclusions, which are echoed by the American College of Obstetricians and Gynecologists (2017a). Namely, CMDR should not be performed before 39 weeks' gestation unless fetal lung maturity is conirmed. Cesarean delivery is ideally avoided in women desiring several children because of placental implantation abnormalities and cesarean hysterectomy risks. Finally, CMDR should not be motivated by the unavailability of efective pain management.


Obstentrics_Williams

Obstentrics_Williams. No nationally recognized standard of care currently dictates the acceptable time interval to begin cesarean delivery. Previously, a 30-minute decision-to-incision interval was recommended. In studying this, Bloom and coworkers (2001) found that 69 percent of 7450 cesareans performed in labor commenced more than 30 minutes after the decision to operate. In a second study, Bloom and colleagues (2006) evaluated cesarean deliveries performed for emergency indications. They reported that failure to achieve a cesarean delivery decision-to-incision time of less than 30 minutes was not associated with a negative neonatal outcome. A subsequent systematic review echoed this inding (ToIcher, 2014). Despite this, when faced with an acute, catastrophic deterioration in fetal condition, cesarean delivery usually is indicated as rapidly as possible, and thus purposeful delays are inappropriate. he American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017)


Obstentrics_Williams

Obstentrics_Williams. usually is indicated as rapidly as possible, and thus purposeful delays are inappropriate. he American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend that facilities giving obstetrical care should have the ability to initiate cesarean delivery in a time frame that best incorporates maternal and fetal risks and beneits.


Obstentrics_Williams

Obstentrics_Williams. Obtaining informed consent is a process and not merely a medical document (American College of Obstetricians and Gynecologists, 2015). The conversation should enhance a woman's awareness of her diagnosis and contain a discussion of medical and surgical care alternatives, procedure goals and limitations, and surgical risks. For women with a prior cesarean delivery, the option of a trial of labor should be included for suitable candidates. lso, in those desiring permanent sterilization or intrauterine device insertion, consenting for these can be completed concurrently. n informed patient may decline a particular recommended intervention, and a woman's decision-making autonomy must be respected. In the medical record, clinicians should document her reasons for refusal and should note that the intervention's value and the health consequences of not proceeding with it have been explained.


Obstentrics_Williams

Obstentrics_Williams. For Jehovah's Witnesses, informed consent discussions regarding blood products ideally begin early in pregnancy. Acceptable blood products vary widely among individual women, and a preoperative checklist of approved products allows superior preparation (Hubbard, 2015; Husarova, 2016). In general, red cells, white cells, platelets, and plasma are viewed as primary blood components and are eschewed. However, certain clotting factors or cell fractions may be acceptable (Lawson, 2015). Before and after surgery, iron, folate, and, if necessary, erythropoietin are accepted agents to help maximize hemoglobin levels. Perioperatively, phlebotomy should be limited, and pediatric collection tubes are preferable. Intraoperative options include treatment of atony to limit blood loss; topical hemostatic agents, tranexamic acid, and desmopressin to promote clot formation; red blood cell salvage or acute normovolemic hemodilution to provide autologous donation; and controlled hypotensive anesthesia,


Obstentrics_Williams

Obstentrics_Williams. agents, tranexamic acid, and desmopressin to promote clot formation; red blood cell salvage or acute normovolemic hemodilution to provide autologous donation; and controlled hypotensive anesthesia, uterine artery embolization, occlusive vascular balloons, and temporary aortic compression for uncontrolled bleeding (Belfort, 2011; vlason, 2015).


Obstentrics_Williams

Obstentrics_Williams. • Timing of Scheduled Cesarean Delivery Adverse neonatal sequelae from neonatal immaturity with elective delivery before 39 completed weeks are appreciable (Clark, 2009; Tita, 2009). To avoid these, assurance of fetal maturity before scheduled elective surgery is essential as outlined by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) and discussed in Chapter 31 (p. 597). To assist with this and other components of cesarean delivery planning, the American College of Obstetricians and Gynecologists (2011, 20 14b) has created Patient Safety Checklists to be completed before the planned surgery.


Obstentrics_Williams

Obstentrics_Williams. If cesarean delivery is scheduled, a sedative may be given at bedtime the night before surgery. In general, no other sedatives, narcotics, or tranquilizers are administered until after the fetus is born. In one small randomized trial, no benefits were gained from a presurgical enema (Lurie, 2012). Solid food intake is stopped at least 6 to 8 hours before the procedure. Uncomplicated patients may have moderate amounts of clear liquids up to 2 hours before surgery (American Society of Anesthesiologists, 2016). his comports with Enhanced Recovery After Surgery (ERAS) protocols that strive to maintain anabolic homeostasis and advocate clear carbohydrate drinks up to 2 hours before scheduled surgery and early postoperative feeding (Ljungqvist, 2017). Although evidence supports an ERAS approach for many procedures, data specifically addressing this for cesarean delivery are scarce (Wrench, 2015).


Obstentrics_Williams

Obstentrics_Williams. The woman scheduled for repeat cesarean delivery typically is admitted the day of surgery and evaluated by the obstetrical and anesthesia teams. Recently performed hematocrit and indirect Coombs test are reviewed. If the latter is positive, then availability of compatible blood must be ensured.


Obstentrics_Williams

Obstentrics_Williams. As discussed in Chapter 25 (p. 490), regional analgesia is preferred for cesarean delivery. An antacid is given shortly before regional analgesia or induction of general anesthesia. One example is Bicitra, 30 mL orally in a single dose. This minimizes the lung injury risk from gastric acid aspiration. Once the woman is supine, a wedge beneath the right hip and lower back creates a left lateral tilt to aid venous return and avoid hypotension. Data are insuicient to determine the value of fetal monitoring before scheduled cesarean delivery in women without risk factors. Our practice is to obtain a 5-minute tracing prior to elective cases. At minimum, fetal heart sounds should be documented in the operating room prior to surgery.


Obstentrics_Williams

Obstentrics_Williams. Of urther preparations, hair removal at the surgical site does not lower surgical site infection (SSI) rates (Kowalski, 2016). However, if hair is obscuring, it is removed the day of surgery by clipping, which is associated with fewer SSIs than shaving (Tanner, 2011). Chemical depilation the night before surgery compared with clipping has similar SSI rates (Lefebvre, 2015). An electrosurgical grounding pad is placed near the surgical incision and typically on the lateral thigh. n indwelling bladder catheter is typically placed at Parkland Hospital to collapse the bladder away from the hysterotomy incision, to avert urinary retention secondary to regional analgesia, and to allow accurate postoperative urine measurement. Small studies show that catheterization may be withheld in hemodynamically stable women to minimize urinary infections (Abdel-Aleem, 2014; Li, 2011; Nasr, 2009).


Obstentrics_Williams

Obstentrics_Williams. he risk of venous thromboembolism is increased with pregnancy and almost doubled in those undergoing cesarean delivery Oames, 2006). Accordingly, for all women not already receiving thromboprophylaxis, the American College of Obstetricians and Gynecologists (2017d) recommends initiation of pneumatic compression hose before cesarean delivery. These are usually discontinued once the woman ambulates. Recommendations between organizations vary, and the American College of Chest Physicians suggests only early ambulation for women without risk factors who are undergoing cesarean delivery (Bates, 2012). For women already receiving prophylaxis or those with increased risk factors, they support escalation of prophylaxis. Last, the Royal College of Obstetricians and Gynaecologists (2015) are the most conservative and suggest pharmacological prophylaxis for the largest proportion of patients. hese various methods and recommendations are discussed in Chapter 52 and are shown in Table 52-6 (p.


Obstentrics_Williams

Obstentrics_Williams. most conservative and suggest pharmacological prophylaxis for the largest proportion of patients. hese various methods and recommendations are discussed in Chapter 52 and are shown in Table 52-6 (p. 1020).


Obstentrics_Williams

Obstentrics_Williams. Some women scheduled for cesarean delivery have concurrent comorbidity that requires specific management in anticipation of surgery. Among others, these include insulin-requiring or gestational diabetes, coagulopathy or thrombophilia, chronic corticosteroid use, and signiicant reactive airway disease. Surgical preparations are discussed in the respective chapters covering these topics.


Obstentrics_Williams

Obstentrics_Williams. Cesarean delivery is considered a clean contaminated case, and postoperative febrile morbidity is common. Numerous goodquality trials show that a single dose of an antibiotic given at the time of cesarean delivery signiicantly decreases infectious morbidity (Smaill, 2014). Although more obvious for women undergoing unscheduled cesarean delivery, this practice also pertains to women undergoing elective surgery (American College of Obstetricians and Gynecologists, 2016). Depending on drug allergies, most recommend a single intravenous dose of a 3-lactam antibiotic-either a cephalosporin or extended-spectrum penicillin. A 1-g dose of cefazolin (Ancd) is an eicacious and cost-efective choice. Additional doses are considered in cases with blood loss > 1500 mL or with duration longer than 3 hours. Recommen dations for the best dose in obese parturients are conflicting (Ahmadzia, 2015; Maggio, 2015; Swank, 2015; Young, 2015).


Obstentrics_Williams

Obstentrics_Williams. levels with a 2-g dose for cesarean deliveries lasting 1.5 hours. women if surgeries were longer (Grupper, 2017). A growing body of evidence supports extending the antibiotic spectrum (Andrews, 2003; Tita, 2008). One large randomized trial added azithromycin, 500 mg intravenously, to standard prophylaxis prior to cesarean delivery for women in labor or with ruptured membranes (Tita, 2016). Rates of wound infection and endometritis were signiicantly lower in the extended-spectrum group compared with those in the standard prophylaxis cohort. In pregnant women with a history of infection with methicillin-resistant Staphylococcus aureus (MRSA), a single dose of vancomycin added to the standard prophylaxis for cesarean deliveries can be elected. Decolonization plays a limited role but may be considered prior to a planned cesarean delivery in women with known MRSA colonization (American College of Obstetricians and Gynecologists, 2016).


Obstentrics_Williams

Obstentrics_Williams. Significant penicillin or cephalosporin allergy, which manifests by anaphylaxis, angioedema, respiratory distress, or urticaria, merits prophylaxis with a single 600-mg intravenous dose of clindamycin combined with a weight-based dose of an aminoglycoside as an alternative. A 900-mg clindamycin dose is used for obese patients. Antibiotic administration before surgical incision lowers postoperative infection rates without adverse neonatal efects compared with drug administration after umbilical cord clamping (Mackeen, 2014b; Sullivan, 2007; Witt, 2011). Prophylaxis is ideally administered within the 60 minutes prior to the start of planned cesarean delivery. For emergent delivery, antibiotics are given as soon as feasible.


Obstentrics_Williams

Obstentrics_Williams. Preoperative preparation of the abdominal wall skin is efective to prevent wound infection. Either chlorhexidine or povidone-iodine solutions are suitable (Hadiati, 2014; Ngai, 2015; Springel, 2017). In studies that found a diference, chlorhexidine was favored, and this is our practice (Menderes, 2012; Tuuli, 2016a). In addition, preoperative vaginal cleansing with a povidone-iodine scrub has been evaluated in small randomized trials (Haas, 2014; Caissutti, 2017). Some showed lower rates of metritis, especially for those with ruptured membranes or active labor, but not lower rates of wound infection (Haas, 2010; Memon, 2011; Yildirim, 2012). Some recommend preoperative vaginal cleansing, bur we do not do this at Parkland Hospital.


Obstentrics_Williams

Obstentrics_Williams. Antibiotic prophylaxis against infective endocarditis is not recommended for most cardiac conditions-exceptions are women with cyanotic heart disease, prosthetic valves, or both (American College of Obstetricians and Gynecologists, 2016). Regimens selected for routine cesarean infection prophylaxis will also serve as appropriate endocarditis coverage (Chap. 49, p. 965).


Obstentrics_Williams

Obstentrics_Williams. Glycemic control in diabetics lowers wound infection rates and is emphasized in Chapter 57 (p. 1105). Smoking is another modiiable risk, and its mitigation is especially helpful for morbidly obese women (Alanis, 2010; Avila, 2012; Shree, 2016). Intraoperative normothermia lowers wound infection rates in general surgery and is a Surgical Care Improvement Project measure (Kurz, 1996; he Joint Commission, 2016). his tenet might logically be extrapolated to cesarean delivery, although deinitive studies are lacking (Carpenter, 2012). Perioperative supplementation with high-concentration inspired oxygen does not lower wound infection rates (Duggal, 2013; Klingel, 2013).


Obstentrics_Williams

Obstentrics_Williams. he Joint Commission (2013) established a protocol to prevent surgical errors. For cesarean delivery, all relevant documents are veriied immediately before surgery, and a "time out" is completed. The "time out" requires attention of the entire team to confirm that the patient, site, and procedure are correct. Important discussions also include introduction of the patient-care team members, veriication of prophylactic antibiotics, estimation of procedure length, and communication of anticipated complications. Additionally, requests for special instrumentation should be addressed preoperatively to prevent potential patient compromise and intraoperative delays. An instrument, sponge, and needle count before and after surgery is crucial to surgical safety. If counts are not reconciled, radiographic imaging for retained foreign objects is obtained (American College of Obstetricians and Gynecologists, 20 14a).


Obstentrics_Williams

Obstentrics_Williams. With minor variations, surgical performance of cesarean delivery is comparable worldwide. Most steps are founded on evidence-based data, and these have been reviewed by Dahlke and associates (2013). As with all surgery, a clear understanding of relevant anatomy is essential, and this is described and illustrated in Chapter 2 (p. 14). In obstetrics, a suprapubic transverse incision or a midline vertical one is chosen for laparotomy. Transverse abdominal entry is by either Pfannenstiel or Maylard incisions. Of all these, the Pfannenstiel incision is selected most frequently for cesarean delivery. Transverse incisions follow Langer lines of skin tension.


Obstentrics_Williams

Obstentrics_Williams. Thus, compared with vertical ones, Pfannenstiel incisions ofer superior cosmesis and lower incisional hernia rates. Use of the Pfannenstiel incision, however, is often discouraged for cases in which a large operating space is essential or in which access to the upper abdomen may be needed. With transverse incisions, because of the layers created during incision of the internal and external oblique aponeuroses, purulent fluid can collect between these. Therefore, some favor a midline vertical incision for cases with high infection risks. Emergent entry is typically faster with vertical incision during primary and repeat cesarean delivery (Wylie, 2010). Last, neurovascular structures, which include the ilioinguinal and iliohypogastric nerves and supericial and inferior epigastric vessels, are often encountered with transverse inCISIons. Logically, bleeding, wound hematoma, and neurological disruption may more frequently complicate these incisions compared with vertical ones. he best


Obstentrics_Williams

Obstentrics_Williams. are often encountered with transverse inCISIons. Logically, bleeding, wound hematoma, and neurological disruption may more frequently complicate these incisions compared with vertical ones. he best incision for the morbidly obese parturient is unclear (Smid, 2016). As discussed in Chapter 48 (p. 943), our preference with very obese women is a periumbilical midline vertical incision.


Obstentrics_Williams

Obstentrics_Williams. he Maylard incision difers mainly from the Pfannenstiel in that the bellies of the rectus abdominis muscle are transected horizontally to widen the operating space. It is technically more diicult due to its required muscle cutting and isolation and ligation of the inferior epigastric arteries, which lie laterally to these muscle bellies. Once access is gained, metal handheld retractors provide exposure for hysterotomy. A few small randomized studies have evaluated postcesarean wound infection rates with a disposable plastic barrier retractor (Alexis-O). Results showing benefit are contradictory (Hinkson, 2016; Scolari Childress, 2016; heodoridis, 2011).


Obstentrics_Williams

Obstentrics_Williams. With the Pfannenstiel incision, the skin and subcutaneous tissue are incised using a low, transverse, slightly curvilinear incision. his is made at the level of the pubic hairline, which is typically 3 cm above the superior border of the symphysis pubis. The incision is extended laterally suiciently to accommodate delivery-12 to 15 cm is typical. Sharp dissection is continued through the subcutaneous layer to the fascia. The supericial epigastric vessels can usually be identiied halway between the skin and fascia, several centimeters from the midline, and are coag ulated. If lacerated, these may be suture ligated with 3-0 plain gut suture or coag ulated with an electro surgical blade.


Obstentrics_Williams

Obstentrics_Williams. he fascia is then incised sharply at the midline. he anterior abdominal fascia is typically composed of two visible layers, the aponeurosis from the external oblique muscle and a fused layer containing aponeuroses of the internal oblique and transverse abdominis muscles. Ideally, the two layers are individually incised during lateral extension of the fascial incision. The inferior epigastric vessels usually lie outside the lateral border of the rectus abdominis muscle and beneath the fused aponeuroses of the internal oblique and transverse abdominis muscles. hus, although infrequently required, extension of the fascial incision further laterally may cut these vessels. With extension, these vessels are best identiied and coagulated or ligated to prevent bleeding and vessel retraction.


Obstentrics_Williams

Obstentrics_Williams. Once the fascia is incised, the inferior fascial edge is grasped with Kocher clamps and elevated by an assistant as muscle either bluntly or sharply until the superior border of the symphysis pubis is reached. Next, the superior fascial edge is grasped and again, separation of fascia from the rectus muscle is completed. Blood vessels coursing between the sheath and muscles are clamped, cut, and ligated, or they are coagulated with an electrosurgery blade. Meticulous hemostasis is imperative to lower rates of incisional hematoma and infection. he fascial separation progresses cephalad and laterally to create a semicircular area above the transverse incision with a radius of approximately 8 cm. This will vary depending on fetal size. he rectus abdominis and pyramidalis muscles are then separated in the midline, irst superiorly and then inferiorly, by sharp and blunt dissection to expose the transversalis fascia and peritoneum.


Obstentrics_Williams

Obstentrics_Williams. he transversalis fascia and preperitoneal fat are bluntly dissected away to reach the underlying peritoneum. The peritoneum near the upper end of the incision is opened carefully, either bluntly or by elevating it with two hemostats placed approximately 2 cm apart. his upper site lowers cystotomy risks. The tented fold of peritoneum between the clamps is examined and palpated to ensure that omentum, bowel, or bladder is not adjacent. he peritoneum is then incised. The peritoneal incision is extended superiorly to the upper pole of the fascial dissection and downward to just above the peritoneal relection over the bladder. Importantly, in women with prior intraabdominal surgery, including cesarean delivery, omentum or bowel may be adhered to the undersurface of the peritoneum. In women with obstructed labor, the bladder may be pushed cephalad almost to the level of the umbilicus.


Obstentrics_Williams

Obstentrics_Williams. the operator separates the fascial sheath FIGURE 30-1 The loose peritoneum above the bladder reflection is grasped with forceps from the underlying rectus abdominis and incised with Metzenbaum scissors, This incision begins 2 to 3 cm above the superior margin of the symphysis. It should suiciently long to allow fetal delivery, and 12 to 15 cm is typical. Sharp or electrosurgical blade dissection through the subcutaneous layers ultimately exposes the anterior rectus sheath. A small opening is made sharply with scalpel in the upper half of the linea alba. Placement here helps avoid potential cystotomy. Index and middle ingers are placed beneath the fascia to elevate it, and the fascial incision is extended irst superiorly and then inferiorly with scissors. Midline separation of the rectus muscles and pyramidalis muscles and peritoneal entry are similar to those with the Pfannenstiel incision.


Obstentrics_Williams

Obstentrics_Williams. Most often, the lower uterine segment is incised transversely as described by Kerr in 1921. Occasionally, vertical incision conined solely to the lower uterine segment may be elected (Kronig, 1912). In contrast, a classical incision begins as a low-vertical incision, which is then extended cephalad into the active portion of the uterine corpus. Last, a fundal or even posterior incision may be selected for cases with placental accrete syndromes. For most cesarean deliveries, this incision is preferred. Compared with a classical incision, it is easier to repair, causes less incision-site bleeding, and promotes less bowel or omentum adherence to the myometrial incision. Located in the inactive segment, it also is less likely to rupture during a subsequent pregnancy.


Obstentrics_Williams

Obstentrics_Williams. Before any hysterotomy, the surgeon palpates the fundus to identiy degrees of uterine rotation. The uterus may be rotated so that one round ligament is more anterior and closer to the midline. In such cases, the uterus can be FIGURE 30-2 This peritoneal edge is elevated and incised laterally. bladder is gently separated from the underlying lower uterine segment with blunt or sharp dissection within this vesicouterine space (Fig. 30-3). This bladder lap creation efectively moves the bladder away from the planned hysterotomy site. It also helps prevent bladder laceration if an unintended inferior hysterotomy extension occurs during fetal delivery. In general, this caudad separation of bladder does not exceed 5 cm and usually is less. However, in instances in which cesarean hysterectomy is planned or anticipated, extended caudad dissection is recommended to aid total hysterectomy and decrease the risk of cystotomy.


Obstentrics_Williams

Obstentrics_Williams. manually reoriented and held to permit centering of the incision. This avoids incision extension into and laceration of the adjacent uterine artery. A moist sponge may be used to pack protruding bowel away from the operative ield. he relection of peritoneum at the upper margin of the bladder and overlying the lower uterine segment is grasped in the midline with forceps and incised transversely with scissors (Fig. 30-1). Following this initial incision, scissors are inserted between peritoneum and lower uterine segment. Open scissors are pushed laterally from the midline on each side. This transverse peritoneal incision extends almost the full length of the lower uterine segment. As the lateral margin on each side is approached, the scissors are directed slightly cephalad (Fig. 30-2). The lower FIGURE 30-3 Cross section shows blunt dissection of the bladder of the uterus to edge of peritoneum is elevated, and the expose the lower uterine segment.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-4 The myometrium is incised with shallow strokes to avoid cutting the fetal head. FIGURE 30-5 After entering the uterine cavity, the incision is extended laterally with fingers or with bandage scissors (inset). Some surgeons do not create a bladder lap. The main advantage is a shorter skin incision-to-delivery time. However, data supporting this practice are limited (O'Neill, 2014; Tuuli, 2012). Uterine Incision. The uterus is entered through the lower uterine segment. Digital palpation to find the physiological border between irmer upper segment myometrium and the more flexible lower segment can guide placement. The bladder flap incision can also serve as a guide, and a hysterotomy site near this line is often selected.


Obstentrics_Williams

Obstentrics_Williams. For women with advanced or complete cervical dilatation, the hysterotomy is placed relatively higher. Failure to adjust increases the risk of lateral extension of the incision into the uterine arteries. It may also lead to incision of the cervix or vagina rather than the lower uterine segment. Such incisions into the cervix can distort postoperative cervical anatomy.


Obstentrics_Williams

Obstentrics_Williams. The uterus can be incised by various techniques. Each is initiated by using a scalpel to transversely incise the exposed lower uterine segment for 1 to 2 cm in the midline (Fig. 30-4). Repetitive shallow strokes avoid fetal laceration. As the myometrium thins, a fingertip can then bluntly enter the uterine cavity. Once the uterus is opened, the hysterotomy is lengthened by simply spreading the incision, using lateral and slightly upward pressure applied with each index inger 30-5). Some evidence also supports widening the lower-uterine-segment incision instead with ingers pulling in opposition in a cephalocaudad direction (Cromi, 2008; Xodo, 2016).


Obstentrics_Williams

Obstentrics_Williams. Alternatively, if the lower uterine segment is thick and unyielding, cutting laterally and then slightly upward with bandage scissors will lengthen the incision. Importantly, when scissors are used, the index and midline fingers of the nondominant hand should be insinuated beneath the myometrium and above fetal parts to prevent fetal laceration. Comparing blunt and sharp expansion of the initial uterine incision, blunt stretch is associated with fewer unintended incision extensions, shorter operative time, and less blood loss. However, the rates of infection and need for transfusion do not difer (ASIClOglu, 2014; Saad, 2014). The uterine incision is made large enough to allow delivery of the fetus without tearing into the uterine vessels that course along the lateral uterine margins. If the placenta is encountered in the incision line, it must be either detached or incised. Placental function is thereby compromised, and thus delivery is performed expeditiously.


Obstentrics_Williams

Obstentrics_Williams. At times, a low transverse hysterotomy is selected but provides inadequate room for delivery. In such instances, one corner of the hysterotomy incision is extended cephalad into the contractile portion of the myometrium-a J incision. If this is completed bilaterally, a U incision is formed. Last, some prefer instead to extend in the midline-a T incision. As expected, each has higher intraoperative blood loss (Boyle, 1996; Patterson, 2002). Moreover, as these extend into the contractile portion, a trial of labor is more likely to be complicated by uterine rupture in future pregnancies. Delivey of the Fetus. In a cephalic presentation, a hand is slipped into the uterine cavity between the symphysis and fetal head. The head is elevated gently with the ingers and palm through the incision. Once the head enters the incision, delivery may be aided by modest transabdominal fundal pressure (Fig. 30-6).


Obstentrics_Williams

Obstentrics_Williams. After a long labor with cephalopelvic disproportion, the fetal head may be tightly wedged in the birth canal. Release of an impacted fetal head raises the risk of hysterotomy extension, of associated blood loss, and of fetal skull fracture. In FIGURE 30-6 Delivery of the fetal head. this situation, there are three considerations for delivery. First, a "push" method may be used. With this, upward pressure exerted by a hand in the vagina by an assistant will help to dislodge the head and allow its delivery above the symphysis. If this is anticipated, a patient in frog-leg position may allow easier vaginal access. Second, as an alternative, a "pull" method grasps the fetal legs to bring them through the hysterotomy. he fetus is then delivered by traction as one would complete a breech extraction.


Obstentrics_Williams

Obstentrics_Williams. Second, as an alternative, a "pull" method grasps the fetal legs to bring them through the hysterotomy. he fetus is then delivered by traction as one would complete a breech extraction. ized trials and retrospective cohort studies (Berhan, 2014; J eve, 2016; Nooh, 2017). A low vertical hysterotomy incision, which will give more room for the "pull" technique, may be selected. If a low transverse incision has already been made, then this can be extended to a J-, U-, or T-incision as previously discussed. The third method is use of the "fetal pillow," which is a distensible intravaginal balloon that when inflated, elevates the fetal head. The device is available outside the United States, but evidence for its eicacy is limited (Safa, 2016; Seal, 2016).


Obstentrics_Williams

Obstentrics_Williams. Conversely, in women without labor, the fetal head may be unmolded and without a leading cephalic point. The round head may be diicult to lift through the uterine incision in a relatively thick lower segment that is unattenuated by labor. In such instances, either forceps or a vacuum device may be used to deliver the fetal head (Fig. 30-7).


Obstentrics_Williams

Obstentrics_Williams. fter head delivery, a inger should be passed across the fetal neck to determine whether it is encircled by one or more umbilical cord loops. If present, these are slipped over the head. The head is rotated to an occiput transverse position, which aligns the fetal bisacromial diameter vertically. The sides of the head are grasped with two hands, and gentle downward traction is applied until the anterior shoulder enters the hysterotomy incision (Fig. 30-8). Next, by upward movement, the posterior shoulder is delivered. During delivery, abrupt or powerful force is avoided to avert brachial plexus injury. With steady outward traction, the rest of the body then readily follows. Gentle fundal pressure may aid this.


Obstentrics_Williams

Obstentrics_Williams. With some exceptions, current American Heart Association neonatal resuscitation recommendations eschew suctioning immediately following birth, even with meconium present (Wyckof, 2015). A fuller discussion of this and delayed umbilical cord clamping is found in Chapter 27 (p. 518). he umbilical cord is clamped, and the newborn is given to the team member who will conduct resuscitative eforts as needed.


Obstentrics_Williams

Obstentrics_Williams. Comparing elective cesarean under neuraxial anesthesia and spontaneous vaginal deliveries, studies show that the need for neonatal resuscitation is not practically signiicant between the two (Atherton, 2006; Gordon, 2005; Jacob, 1997). he American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend that "a qualiied person who is skilled in neonatal resuscitation should be in the delivery room." At Parkland Hospital, pediatric nurse practitioners attend uncomplicated, scheduled cesarean deliveries. Notably, as anticipated neonatal risks rise, so too should the resuscitative skills of the attendants (Wyckof, 2015). To promote breastfeeding, the American College of Obstetricians and Gynecologists (2017b) recommends skin-to-skin contact between newborn and mother in the delivery room. FIGURE 30-7 A.The first cesarean forceps blade is placed. B. Slight upward and outward traction is used to lit the head through the incision.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-7 A.The first cesarean forceps blade is placed. B. Slight upward and outward traction is used to lit the head through the incision. Although most randomized trials focus on vaginal birth, several small studies support such contact following cesarean delivery, and this our practice (Moore, 2016; Stevens, 2014).


Obstentrics_Williams

Obstentrics_Williams. After birth, an intravenous infusion containing two ampules or 20 units of oxytocin per liter of crystalloid is infused at 10 mLlmin. Some prefer higher infusion dosages, however, nondilute boluses are avoided because of associated hypotension (Roach, 2013). Once the uterus contracts satisfactorily, the rate can be reduced. An alternative is carbetocin-a longer-acting oxytocin derivative that is not available in the United Statesthat provides suitable, albeit more expensive, hemorrhage prophylaxis Qin, 2016). Ergot-alkaloids are second-tier agents and carry hypertensive side efects. Carboprost, a IS-methyl derivative of prostaglandin F2> is another second-tier agent used to treat uterine atony. Some but certainly not all studies indicate that misoprostol appears to perform similarly to oxytocin (Chaudhuri, 2014; Conde-Agudelo, 2013). Finally, some recommend the use of tranexamic acid added to a standard oxytocin infusion to decrease blood loss (Simonazzi, 2016; Wang, 2015). Its


Obstentrics_Williams

Obstentrics_Williams. to oxytocin (Chaudhuri, 2014; Conde-Agudelo, 2013). Finally, some recommend the use of tranexamic acid added to a standard oxytocin infusion to decrease blood loss (Simonazzi, 2016; Wang, 2015). Its antifibrinolytic action and efects on thromboembolism rates in pregnant surgical patients are unclear. Larger trials are needed before widespread use. Additional discussions of all these agents are found in Chapter 41 (p. 759).


Obstentrics_Williams

Obstentrics_Williams. Delivey of the Placenta. he uterine incision is observed for any vigorously bleeding sites. These should be quickly clamped with Pennington or ring forceps. Although some surgeons may prefer , manual removal of the placenta, spontaneous delivery prompted by some cord traction may reduce the risk of operative blood loss and infection (Anorlu, 2008; Baksu, 2005). Fundal massage may FIGURE 30-8 The anterior (A) and then the posterior (B) shoulder are delivered. begin as soon as the fetus is delivered to hasten placental separation and delivery (Fig. 30-9).


Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-8 The anterior (A) and then the posterior (B) shoulder are delivered. begin as soon as the fetus is delivered to hasten placental separation and delivery (Fig. 30-9). Immediately after delivery and quick gross inspection of the placenta, the uterine cavity is suctioned and wiped out with a gauze sponge to remove avulsed membranes, vernix, and clots. In the past, double-gloved fingers or ring forceps placed through the hysterotomy incision were used to dilate an ostensibly closed cervix. his practice does not reduce infection rates from potential hematometra and is not recommended (Kirscht, 2017; Liabsuetrakul, 2011).


Obstentrics_Williams

Obstentrics_Williams. Uterine Repair. Ater placental delivery, the uterus is lited through the incision and onto the draped abdominal wall, and the fundus is covered with a moistened laparotomy sponge. We favor this and believe a relaxed, atonic uterus can be recognized quickly and massage applied. Incision and bleeding points are more easily visualized and repaired, especially if there have been extensions. Adnexal exposure is superior, and thus, tubal sterilization is easier. Instead, some clinicians prefer to close the hysterotomy with the uterus in situ. Comparing these two approaches, febrile morbidity, pain, and blood loss are not signiicantly diferent (Walsh, 2009; Zaphiratos, 2015).


Obstentrics_Williams

Obstentrics_Williams. Before hysterotomy closure, previously clamped large vessels may be ligated separately or incorporated within the running incision closure. IUD insertion, if planned, is completed prior to hysterotomy closure (Chap. 38, p. 685). One angle of the uterine incision is grasped to stabilize and maneuver the incision. he uterine incision is then closed with one or two layers of continuous 0-or no. 1 absorbable suture (Fig. 30-10). Chromic catgut suture is used by many, but some prefer synthetic delayed-absorbable polyglactin 910 (Vicryl). In subsequent pregnancy, neither suture type has been shown superior by mitigating against greater rates of adverse pregnancy outcomes such as uterine incision rupture (CORONIS Collaborative Group, 2016). Single-layer closure is typically faster and is not associated with higher rates of infection or transfusion (CAESAR Study Collaborative Group, 2010; Dodd, 2014; Roberge, 2014). Moreover, most studies observed that the number of layers does not


Obstentrics_Williams

Obstentrics_Williams. is not associated with higher rates of infection or transfusion (CAESAR Study Collaborative Group, 2010; Dodd, 2014; Roberge, 2014). Moreover, most studies observed that the number of layers does not significantly afect complication rates in the next pregnancy (Chapman, 1997; CORONIS Collaborative Group, 2016; Durnwald, 2003; Roberge, 2011).


Obstentrics_Williams

Obstentrics_Williams. At Parkland Hospital, we use a one-layer uterine closure with chromic catgut. he initial suture is placed just beyond one angle of the uterine incision. A continuous, locking suture line for hemostasis is then performed, with each suture penetrating the full thickness of the myometrium. he suture line then extends to a point just beyond the opposite incision angle. If approximation is not satisfactory after a single layer or if bleeding sites persist, then more sutures are required. Either another layer of running suture is placed to achieve approximation and hemostasis, or individual bleeding sites can be secured with targeted figure-of-eight or mattress stitches. FIGURE 30-9 Placenta bulging through the uterine incision as the uterus contracts. A hand gently massages the fundus to help aid spontaneous placental separation.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-9 Placenta bulging through the uterine incision as the uterus contracts. A hand gently massages the fundus to help aid spontaneous placental separation. Traditionally, the peritoneum in the anterior cul-de-sac is approximated with a continuous 2-0 chromic catgut suture line. Multiple randomized trials suggest that omission of this step causes no postoperative complications (Grundsell, 1998; Irion, 1996; Nagele, 1996). If tubal sterilization is to be performed, it is completed as described in Chapter 39 (p. 702). FIGURE 30-10 The cut edges of the uterine incision are approximated with a running, locking suture.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-10 The cut edges of the uterine incision are approximated with a running, locking suture. Following cesarean delivery, adhesions commonly form within the vesicouterine space or between the anterior abdominal wall and uterus. And, with each successive pregnancy, the percentage of afected women and adhesion severity rise (Morales, 2007; Tulandi, 2009). Adhesions can significantly lengthen incision-to-delivery time and total operative time (Rossouw, 2013; Sikirica, 2012). Although occurring infrequently, rates of cystotomy and bowel injury are also increased because of adhesive disease (Rahman, 2009; Silver, 2006).


Obstentrics_Williams

Obstentrics_Williams. Intuitively, scarring can be reduced by handling tissues delicately, achieving hemostasis, and minimizing tissue ischemia, infection, and foreign-body reaction. Most recent data on shortand long-term outcomes show no benefit to peritoneal closure (CAESAR Study Collaborative Group, 2010; CORONIS Collaborative Group, 2013, 2016; Kapustian, 2012). Similarly, most studies show no benefit from placement of an adhesion barrier at the hysterotomy site (Edwards, 2014; Kiefer, 2016). Any laparotomy sponges are removed, and the paracolic gutters and cul-de-sac are gently suctioned of blood and amnionic fluid. Some surgeons irrigate the gutters and cul-de-sac, especially in the presence of infection or meconium. Routine irrigation in low-risk women, however, leads to greater intraoperative nausea but not to lower postoperative infection rates (Eke, 2016; Viney, 2012).


Obstentrics_Williams

Obstentrics_Williams. Prior to abdominal closure, correct sponge and instrument counts are verified. he rectus abdominis muscle bellies are allowed to fall into place. With significant diastasis, the rectus muscles may be approximated with one or two figure-of-eight sutures of 0 or no. 1 chromic gut suture. The overlying rectus fascia is closed by a continuous, nonlocking technique with a delayed-absorbable suture. In patients with a higher risk for infection, there may be theoretical value in selecting a monoilament suture here rather than braided material.


Obstentrics_Williams

Obstentrics_Williams. The subcutaneous tissue usually need not be closed if it is less than 2 em thick. With thicker layers, however, closure is recommended to minimize seroma and hematoma formation, which can lead to wound infection and/or disruption (Bohman, 1992; Chelmow, 2004). One recent metaanalysis found lower rates of seroma formation and of developing any wound complication with closure, but hematoma and wound infection rates were unafected (Pergialiotis, 2017). Addition of a subcutaneous drain does not prevent significant wound complications (Hellums, 2007; Ramsey, 2005).


Obstentrics_Williams

Obstentrics_Williams. Skin is closed with a running subcuticular stitch of 4-0 delayed-absorbable suture, with adhesive glue, or with staples. In comparison, final cosmetic results and infection rates appear similar, skin suturing takes longer, but wound separation rates are higher with metal staples (Basha, 2010; Figueroa, 2013; Mackeen, 2014a, 2015). Poliglecaprone 25 (NIonocryl) or polyglactin 910 (Vieryl) are both suitable (Tuuli, 2016b). Outcomes with 2-octyl cyanoacrylate adhesive (Dermabond) were equivalent to sutures for Pfannenstiel incisions (Daykan, 2017; Siddiqui, 2013). A sterile thin abdominal wound dress ing is suicient. In morbidly obese women, application of a prophylactic negative-pressure device atop the closed skin incision to prevent seroma and subsequent infection does not appear to lower wound complication rates (Hussamy, 2018; Smid, 2017).


Obstentrics_Williams

Obstentrics_Williams. The Pfannenstiel-Kerr technique just described has been used for decades. More recently, Joel-Cohen and Misgav Ladach techniques have been added (Holmgren, 1999). These difer from traditional Pfannenstiel-Kerr entry mainly by their initial incision placement and greater use of blunt dissection.


Obstentrics_Williams

Obstentrics_Williams. he Joel-Cohen technique creates a straight 10-cm transverse skin incision 3 em below the level of the anterior superior iliac spines (Olofson, 2015). he subcutaneous tissue layer is opened sharply 2 to 3 em in the midline. This is carried down, without lateral extension, to the fascia. A small transverse incision is made in the fascia, and curved Mayo scissors are pushed laterally on each side and beneath intact subcutaneous fat to incise the fascia. With this incision completed, an index finger from each hand is inserted between the rectus abdominis muscle bellies and beneath the fascia. One finger is moved cranially and the other caudally, in opposition, to separate the bellies and further open the fascial incision. hen, a finger from each hand hooks under each belly to stretch the muscles laterally. The peritoneum is entered sharply, and this incision is sharply extended cephalocaudad. Entry with the Misgav Ladach technique difers in that the peritoneum is entered bluntly


Obstentrics_Williams

Obstentrics_Williams. the muscles laterally. The peritoneum is entered sharply, and this incision is sharply extended cephalocaudad. Entry with the Misgav Ladach technique difers in that the peritoneum is entered bluntly (Holmgren, 1999).


Obstentrics_Williams

Obstentrics_Williams. Modiications to the Joel-Cohen method abound. For emergency delivery, we begin along a line somewhat lower on the abdomen. For speed, we extend the fascial incision bluntly by hooking index fingers in the fascial incision's lateral angles and pulling laterally (Hofmeyr, 2009; Olofson, 2015). Index fingers insinuated between the rectus bellies then move cephalocaudad in opposition to stretch the incision. Blunt index-finger dissection enters the peritoneum, and again, cranial and caudad opposing stretch opens this layer. Last, all the layers of the abdominal wall are grasped manually and pulled laterally in opposition to further open the operating space. These techniques have been associated with shorter operative times and with lower rates of intraoperative blood loss and postoperative pain (Mathai, 2013). They may, however, prove diicult for women with anterior rectus fibrosis and peritoneal adhesions (BoIze, 2013).


Obstentrics_Williams

Obstentrics_Williams. Indications. This incision is usually avoided because it encompasses the active upper uterine segment and thus is prone to rupture with subsequent pregnancies. Some indications stem from diiculty in exposing or safely entering the lower uterine segment. For example, a densely adhered bladder from previous surgery is encountered; a leiomyoma occupies the lower uterine segment; the cervix has been invaded by cancer; or massive maternal obesity precludes safe access to the lower uterine segment. A classical incision is also preferred for placenta previa with anterior implantation, especially those complicated by placenta accrete syndromes. In extreme cases of this, the typical classical hysterotomy may be placed even higher in the uterine body or posteriorly to avoid the placenta. As such, fetuses with cephalic presentation are then delivered in a manner similar to total breech extraction (Chap. 28, p. 548).


Obstentrics_Williams

Obstentrics_Williams. In other instances, fetal indications dictate the need. Transverse lie of a large etus, especially if the membranes are ruptured and the shoulder is impacted in the birth canal, usually necessitates a classical incision. A fetus presenting as a back-down transverse lie is particularly di.cult to deliver through a transverse uterine incision. In instances when the fetus is very small and breech, a classical incision may be preferable (Osmundson, 2013). In such cases, the poorly developed lower uterine segment provides inadequate space for the manipulations required for breech delivery. Or, less commonly, the small fetal head may become entrapped by a contracting uterine fundus following membrane rupture. Last, with multiple fetuses, a classical incision again may provide suitable room for extraction of fetuses that may be malpositioned or preterm (Osmundson, 2015).


Obstentrics_Williams

Obstentrics_Williams. Uterine Incision and Repair. A vertical uterine incision is initiated with a scalpel beginning as low as possible and preferably within the lower uterine segment (Fig. 30-11). If adhesions, insu.cient exposure, a tumor, or placenta percreta preclude development of a bladder flap, then the incision is made above the level of the bladder. Once the uterus is entered with a scalpel, the incision is extended cephalad with bandage scissors until it is long enough to permit delivery of the fetus. With scissor use, the fingers of the nondominant hand are insinuated between the myometrium and fetus to prevent fetal laceration. As the incision is opened, numerous large vessels that bleed profusely are commonly encountered within the myometrium. The remainder of fetal and placental delivery mirrors that with a low transverse hysterotomy. For incision closure, one method employs a layer of 0-or no. 1 chromic catgut with a running stitch to approximate the


Obstentrics_Williams

Obstentrics_Williams. For incision closure, one method employs a layer of 0-or no. 1 chromic catgut with a running stitch to approximate the FIGURE 30-11 An initial small vertical hysterotomy incision is made in the lower uterine segment. Fingers are insinuated between the myometrium and fetus to avoid fetal laceration. Scissors extend the incision cephalad as needed for delivery. (Reproduced with permission from Johnson DD: Cesarean delivery. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201o7.) deeper length of the incision (Fig. 30-12). he outer layer of myometrium is then closed along its length with similar suture and with a running suture line. To achieve good approximation and to prevent the suture from tearing through the myometrium,


Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-12 Classical incision closure. The deeper half (left) and superficial half (middle) of the incision are closed in a running fashion. The serosa is then closed (right). (Reproduced with permission from Johnson DD: Cesarean delivery. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201o7.) it is helpul to have an assistant compress the uterus on each side of the wound toward the midline as each stitch is placed.


Obstentrics_Williams

Obstentrics_Williams. Hysterectomy is most commonly performed to arrest or prevent hemorrhage from intractable uterine atony or abnormal placentation (Bateman, 2012; Hernandez, 2012; Owolabi, 2013). It is more often completed during or after cesarean delivery but may be needed following vaginal birth. If all deliveries are considered, the peripartum hysterectomy rate in the United States approximates 1 per 1000 births and has risen signiicantly during the past few decades (Bateman, 2012; Govindappagari, 2016). During a 25-year period, the rate of peripartum hysterectomy at Parkland Hospital was 1.7 per 1000 births (Hernandez, 2012). Most of this rise is attributed to the increasing rates of cesarean delivery and its associated complications in subsequent pregnancy (Bateman, 2012; Bodelon, 2009; Flood, 2009; Orbach, 2011). Of hysterectomies, approximately one half to two thirds are total, whereas the remaining cases are supracervical (Rossi, 2010; Shellhaas, 2009).


Obstentrics_Williams

Obstentrics_Williams. Major complications of peripartum hysterectomy include greater blood loss and risk of urinary tract damage. Blood loss is usually appreciable because hysterectomy is being performed for hemorrhage that frequently is torrential, and the procedure itself is associated with substantial bleeding. lthough many cases with hemorrhage cannot be anticipated, those with abnormal implantation are oten identiied antepartum. Preoperative preparations for placenta accreta are discussed in Chapter 41 (p. 781) and have also been outlined by the Society for Maternal-Fetal FIGURE 30-14 The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tube, uteroovarian ligaments, and ovarian vessels. FIGURE 30-13 The round ligaments are clamped, doubly ligated, FIGURE 30-15 The uteroovarian ligament and fallopian tube are and transected bilaterally. clamped and cut. The lateral pedicle is doubly ligated.


Obstentrics_Williams

Obstentrics_Williams. Medicine (2010) and American College of Obste tricians and Gynecologists (2017 c). An important factor afecting the cesarean hysterectomy complication rate is whether the operation is performed electively or emergently. tomy, rates of blood loss, blood transfusion, and urinary tract complications are lower that with emergent procedures (Briery, 2007; Glaze, 2008).


Obstentrics_Williams

Obstentrics_Williams. tomy, rates of blood loss, blood transfusion, and urinary tract complications are lower that with emergent procedures (Briery, 2007; Glaze, 2008). Total or supracervical hysterectomy is performed using standard operative techniques. Adequate exposure is essential, but initially, placement of a self-retaining retractor such as a Balfour is not necessary. Rather, satisfactory exposure is obtained with cephalad traction on the uterus by an assistant, along with handheld Richardson or Deaver retractors. he bladder lap is deflected downward to the level of the cervix if possible to permit total hysterectomy. In cases in which cesarean hysterectomy is planned or strongly suspected, extended bladder flap dissection is ideally completed before initial hysterotomy. Later attempts at bladder dissection may be obscured by bleeding, or excess blood may be lost while this dissection is performed.


Obstentrics_Williams

Obstentrics_Williams. After cesarean delivery, the placenta is typically removed. In cases of placenta accrete syndrome for which hysterectomy is already planned, the placenta is usually left undisturbed in situ. In either situation, if the hysterotomy incision is bleeding appreciably, it can be sutured or Pennington or sponge forceps can be applied for hemostasis. If bleeding is minimal, neither maneuver is necessary.


Obstentrics_Williams

Obstentrics_Williams. he round ligament is divided close to the uterus between clamps, and each pedicle is ligated (Fig. 30-13). Either 0 or no. 1 suture can be used in either chromic gut or delayedabsorbable material. he anterior leaf of the broad ligament is incised downward to meet the former bladder flap incision. he posterior leaf of the broad ligament adjacent to the uterus is bluntly or sharply perforated just beneath the fallopian tube, uteroovarian ligament, and ovarian vessels (Fig. 30-14). hese structures together are then divided between sturdy clamps placed close to the uterus 30-15). he lateral pedicle is doubly ligated. The medial clamp remains and is removed later with the entire uterine specimen. he posterior leaf of the broad ligament is incised toward the uterosacral ligaments (Fig. 30-16). Next, the bladder and attached peritoneal flap are further deflected and dissected as needed. If the bladder flap is unusually adhered, as it may be after previous hysterotomy incisions, careful sharp


Obstentrics_Williams

Obstentrics_Williams. the bladder and attached peritoneal flap are further deflected and dissected as needed. If the bladder flap is unusually adhered, as it may be after previous hysterotomy incisions, careful sharp dissection may be necessary (Fig. 30-17).


Obstentrics_Williams

Obstentrics_Williams. Posterior leaf of broad ligament Uterosacral :n�s � FIGURE 30-16 The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligament. -. .k7{ FIGURE 30-17 The bladder is dissected sharply from the lower uterine segment. ::=:\!i ..., FIGURE 30-18 The uterine vessels are clamped, and a third medial clamp helps prevent "back bleeding." Once divided, the lateral vascular pedicle is doubly ligated to ensure hemostasis.


Obstentrics_Williams

Obstentrics_Williams. Special care is required from this point on to avoid injury to the ureters, which pass beneath the uterine arteries. To help accomplish this, an assistant places constant traction to pull the uterus in the direction away from the side on which the uterine vessels are being ligated. he ascending uterine artery and veins on either side are identiied. These vessels are then clamped adjacent to the uterus. For security, some may prefer two lateral clamps as shown in Figure 30-18. he most medial clamp helps prevents back bleeding from the uterus and remains for later removal with the specimen. The uterine vessels are divided, and the lateral tissue pedicle is doubly suture ligated. After securing the uterine vessels on one side, the round ligament, adnexal pedicle, and uterine vessels are then addressed on the contralateral side.


Obstentrics_Williams

Obstentrics_Williams. With cesarean hysterectomy, it may be more advantageous in cases of profuse hemorrhage to rapidly double clamp and divide all of the vascular pedicles between clamps to gain hemostasis. The surgical team can then return to ligate all of the pedicles. Even if total hysterectomy is planned, we find it technically easier in many cases to finish the operation after amputating the uterine fundus and placing Ochsner or Kocher clamps on the cervical stump for traction and hemostasis. Self-retaining retractors also may be placed at this time. To remove the cervix, the bladder is mobilized further if needed. This carries the ureters caudad as the bladder is retracted beneath the symphysis and will prevent laceration or suturing of the bladder during cervical excision and vaginal cuf closure. FIGURE 30-19 The cardinal ligaments are clamped, incised, and ligated.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 30-19 The cardinal ligaments are clamped, incised, and ligated. The cardinal ligament, the uterosacral ligaments, and the many large vessels these ligaments contain are clamped systematically with sturdy Heaney-type curved or straight clamps (Fig. 30-19). he clamps are placed as close to the cervix as possible, taking care not to include excessive tissue in each clamp. The tissue between the pair of clamps is incised, and the lateral pedicle is suture ligated. hese steps are repeated caudally and bilaterally until the level of the lateral vaginal fornix is reached on each side. In this way, the descending branches of the uterine vessels are clamped, cut, and ligated as the cervix is separated from the cardinal ligaments.


Obstentrics_Williams

Obstentrics_Williams. If the cervix is efaced and dilated considerably, its softness may obscure palpable identiication of the cervicovaginal junction. he junction location can be ascertained through a vertical uterine incision made anteriorly in the midline, either through the open hysterotomy incision or through an incision created at the level of the ligated uterine vessels. A finger is directed inferiorly through the incision to identiy the free margin of the dilated, efaced cervix. The contaminated glove is replaced. Another useful method to identiy the cervical margins in cases of planned hysterectomy is to transvaginally place four metal skin clips or brightly colored sutures at 12, 3, 6, and 9 o'clock positions on the cervical edges.


Obstentrics_Williams

Obstentrics_Williams. Immediately below the level of the cervix, a curved clamp is placed across the lateral vaginal fornix on each side, and the vagina is incised above the clamp (Fig. 30-20).The cervix is inspected to ensure that it has been completely removed. A transfixing suture is used for vaginal cuf closure as each clamp is removed. Interrupted stitches may be added to approximate the middle portion FIGURE 30-20 A curved clamp is placed across the lateral vaginal fornix below the level of the cervix, and the tissue incised medially to the point of the clamp.