Special Operations Forces Medical Handbook

3-100

Symptom: OB Problems: Cesarean Section

MAJ Marvin Williams, MC, USA

What: The delivery of a fetus by abdominal surgery (laparotomy) requiring an incision through the uterine
wall (hysterotomy).

When: Perform this procedure only when it is absolutely necessary, and is the only life saving measure
for mother or infant! The decision to perform a C-Section must be based on the health and stability of the
mother and fetus. Recognize that performing the procedure in the eld as an untrained provider is extremely
dangerous and will likely result in signicant morbidity or mortality for both mother and infant. If a C-Section is
anticipated, prepare equipment and read this material, since the procedure must often be performed emergently
when vital signs become unstable.
The following are relative indications for cesarean delivery under eld conditions:

1. Fetal Complications:
   a. Non-vertex (not head first) such as a transverse lie or breech presentation. Attempt vaginal delivery
   first. (See Breech Birth section).
   b. Multiple gestation: triplets or greater, twins in which the first twin is not head first (vertex). Attempt
   vaginal delivery of at least one fetus. (See Breech Birth section).
   c. Large Fetus: Attempt vaginal delivery first.
   d. Fetal distress: Fetal heart rate (<90 bpm) for more than 1 minute.


2. Placental Complications:
   a. Placenta Previa (placenta lies over cervical os)
   b. Placental Abruption (premature placental separation).
   c. Although these conditions cannot be diagnosed in the field, any large vaginal hemorrhage during labor,
   or hemorrhage accompanied by fetal distress should be reason to suspect them and consider
   C-Section.


3. Uterine Complications:
   a. Previous cesarean section with midline incision (classical).
   b. Other surgery (e.g., for fibroids) where the uterine cavity was entered.
   There is an increased risk for uterine rupture in this situation. C-Sections with low transverse incisions
   are much less risky. Attempt vaginal delivery first.


4. Vaginal Complications:
   a. Obstructive conditions (e.g., genital warts, cervical cancer). If noted, these conditions may hinder
   dilation of the cervical os and descent of the fetus through the birth canal. Attempt vaginal delivery
   first.
   b. Vaginal Infections (e.g., Group B Strep, genital herpes). Delivering the infant through the birth canal
   will greatly increase the baby’s risk of contracting these infections, which will likely be deadly.


5. Maternal Complications: Any medical condition that worsens during labor in which a delayed delivery
   would harm the mother (e.g., eclampsia).


6. Abnormal labor (failure to progress): Labor that does not progress (continued cervical changes and
   fetal descent) over several hours endangers the fetus by increasing the risk of cord compression and
   neurological damage.

What You Need:
Surgical assistants (two if possible); prep solution; sterile gloves; 0 (Vicryl and Chromic), 2-0 non-absorbable,
and 3-0 or 4-0 Vicryl absorbable suture; scalpel to make the incision; IV access; anesthesia: (See Anesthesia:
Total Intravenous Anesthesia [TIVA] procedure), or use 1-2% Lidocaine with Epinephrine ONLY if TIVA is not
available. Do not exceed 300cc or 5 mg/kg (usually requires 30-50cc be aware of lidocaine toxicity). One
gram of Ancef, Rocephin or any equivalent IV antibiotic; administer Oxytocin 20-40 units, 30-45 minutes
prior to surgery if possible; sterile (at least clean) bandages; sterile surgical instruments: needle driver,
forceps, retractors, clamps, scissors and a Foley catheter if available.