- Low transverse incision through the skin
- Small transverse incision strictly in the midline throuigh the subcutaneous tissue and fascia
- Split the fascia by sliding a pair of slightly opened scissors transversely to the right and left.
- That will spare the subcutaneous vessels avoiding unnecessary bleeding
- Stretch the wound manually in a vertical direction
- Open the peritoneum bluntly with your fingers
- Stretch the wound further by manual traction in a transverse direction
- Place a retractor distally in the wound
- Apply downward traction to the retractor by assistant
- Small transverse incision in the upper part of the lower segment of the uterus
- Maintain a safe distance away from the bladder.
- The more the lower segment is stretched, the higher the incision should be
- 3 to 5 fingers above the bladder.
- Do not incise the bladder peritoneum and push down the bladder to make the incision low in the lower segment as described in many textbooks. That’s a recipe for troublesome vaginal tears.
- Stretch the uterine incision manually in a transverse direction
- Apply fundal pressure by assistant
- Lift out the presenting part with
- One hand
- Sellheim’s Obstetrical Lever
- One blade of pair of ordinary obstetrical forceps
- Deliver the baby
- Clamp and cut the umbilical cord
- Lift out uterus from the abdominal cavity
- Squeeze out placenta by fundal pressure
- Or remove it by hand from the uterine cavity
- Close the incision in the lower segment with a continuous inverting suture from one corner of the incision to the other.
- Use resorbable suture such as Chromic Catgut or Polyglycolic Acid.
- One layer is enough.
- Remove blood from the abdominal cavity
- Return uterus into the abdomen
- Close the fascia with a continuous suture
- Close the skin
CHALLENGES WITH CESAREAN SECTIO
Empty bladder by suprapubic puncture
DEEPLY IMPACTED HEAD
There are two options:
- Have an assistant push the head from below with a hand in vagina
2) Perform internal version and extraction on a foot through the uterine incision
LATERAL TEARS OF THE UTERINE INCISION
- Close the wound with two continuous sutures
- Start suturing separately in each corner
- Tie the sutures together in the midline
BLEEDING FROM UTERINE ARTERY
- Clamp the artery above and below the bleeding point
- Apply suture-ligation
- Make the uterine incision in a convenient place
- Avoid the myoma(s) in the incision
- Do not try to shell out or remove the myoma(s)
- It may cause torrential and fatal bleeding.
HIV POSITIVE PATIENT:
- Use protection
- Give prophylactic medication before surgery
- Be sure to remove all abdominal packs before wound closure
- Suspect retained pack in septic complications