3-101
What to Do:
Surgical Procedure
- Place the patient in supine position with a roll under her left side (leftward tilt for uterine displacement).
- Prep her with some sort of cleaning solution (Betadine or equivalent), and catheterize her with a Foley
catheter, if available. - Provide anesthesia. If TIVA sedation is not available, use Lidocaine to infiltrate just below the skin
and into the subcutaneous tissue following a vertical pattern from 2-3 cm above the pubic bone to 1-2
cm below the umbilicus. - Take the scalpel blade and make a vertical incision beginning 1-2 cm below the umbilicus to
approximately 2-3 cm above the pubic bone. The incision should initially cut through the skin and some
of the subcutaneous tissue (fat). Carefully cut through the remaining fat with shallow strokes. Be careful
not to cut directly through the uterus! - Once you reach the rectus fascia (shiny white tissue), make a shallow midline vertical incision through it,
being careful not to injure the rectus muscles. Have your assistant (if you have one) elevate the fascia
with a retractor while you cut. Separate the abdominal muscles in the midline. - The next layer you encounter is the peritoneum, a clear, thin layer of tissue. If you look closely, you may
be able to see bowel (intestines) through it. Pick up the peritoneum with forceps or a clamp; with
scissors, make a small incision into the peritoneum. Extend the incision vertically (both superiorly and
inferiorly) exposing the abdominal contents. Make sure you can visualize everything before cutting to
avoid potential injury to bowel or bladder. - Visualize the uterus and notice the shiny peritoneal surface located on the lower aspect of it (uterovesical
peritoneum). Grasp and elevate this area in the midline with forceps or clamp. Make a small incision
laterally. With your fingers, bluntly dissect the peritoneum off of the uterus, creating a bladder flap, which
decreases the chance of injury to the bladder. After the bladder flap has been developed, use a retractor
to retract the bladder anteriorly and inferiorly to facilitate exposure of the intended incision site. - Make an incision at the inferior margin of the lower segment of the uterus and insert your first 2 fingers
toward the fundus (top of the uterus). QUICKLY extend the incision toward the fundus by cutting between
the spread fingers (vertical incision) with scissors (or a scalpel). Have an assistant frequently suction or
wipe the area with each cut to help you visualize the incision. Be careful not to cut the infant! Perform the
remainder of steps prior to giving oxytocin quickly to avoid massive blood loss. - Remove all retractors and insert a hand into the uterine cavity to elevate and flex the fetal head through
the incision. Should the head be deeply wedged into the pelvis, an assistant can apply upward pressure
through the vagina to dislodge the head. - Once the head is present through the incision, suction the infant’s nose and mouth.
- When suctioning is complete, deliver the baby by applying moderate fundal pressure on the uterus from
the abdomen. - Doubly clamp the cord and hand the infant off to your assistant (see section on Vaginal Delivery for
care of the newborn). - Following delivery of the newborn, 20-40 units of oxytocin can be mixed with a 1 L bag of Lactated
Ringer’s and run via IV (do not exceed more than 500-600 cc/hr with the first bag. Decrease the rate
to 100-125 cc/hr for the second bag). - Remove the placenta manually by applying gentle traction on the cord until the placenta is expelled from
the uterus. Exteriorize (lift it out of the abdominal incision) the uterus and place it on the abdomen.
Cover the top of the uterus (fundus) with a sterile, moist sponge (bandage). Use a sterile, dry sponge
to wipe the uterine cavity clean of all clots and placental debris. Do not expose the uterus or other
intraperitoneal structures to any non-sterile objects, if at all possible.
15.Inspect the uterine incision and control any bleeding points temporarily with clamps (Ring/Sponge forceps
or Allis clamps). Then take a number 0 suture and begin just inferior to the lower margin of the incision,
tie your suture and with subsequent stitches, run them toward the fundus in a continuous locking manner
(see figure). Place stitches 1 cm from the edge of the incision, 1 cm apart and attempt to keep them
out of the uterus. Use a second inverting layer only if hemostasis is not obtained with the first layer. The
bladder peritoneum need not be closed. - Inspect for any bleeding from the incision, and control it with interrupted figure-of-eight stitches. The