2026 Obstetrics 2 M.08 CS & CS Hysterectomy PDF

PCC SOM PCC SOM 2026 OBSTETRICS 2 M.08 CS & CS HYSTERECTOMY...

PCC SOM PCC SOM 2026 OBSTETRICS 2 M.08 CS & CS HYSTERECTOMY 2026 OBSTETRICS 2 M.08 CS & CS HYSTERECTOMY 3. Electronic fetal monitoring use is widespread  Cerebral aneurysm or arteriovenous OBSTETRICS 2 LECTURE CESAREAN SECTION/DELIVERY and associated with a higher cesarean delivery malformation LECTURER: Ma. May Grace M. Doromal, MD, FPOGS rate compared with intermittent fetal heart rate  Pathology requiring concurrent DATE: October 11,2024 1970 4.5% prevalence rate auscultation intraabdominal surgery 2009 32.9% prevalence rate 4. Most breech fetuses are now delivered by  Perimortem cesarean delivery OVERVIEW: 2018 31.9% prevalence rate cesarean DEFINITION 5. The frequency of operative vaginal delivery has MATERNAL – FETAL CESAREAN SECTION/ DELIVERY declined  Cephalopelvic disproportion o Most Common cause 6. Obesity, which is a cesarean delivery risk, has  Failed operative vaginal delivery Allowed now: low forceps o Reason for Increase CS rates reached epidemic proportions  Placenta previa or vasa previa o CS Delivery Risks 7. Rates of cesarean delivery in women with  Placental abruption Pre eccamptic px o Patient Preparation preeclampsia have risen, whereas labor o Not required to do CS in all cases. For o CS Operative techniques induction rates for these patients have declined example, if the baby died and the size of the o Joel-Cohen Misgav Ladach 8. The vaginal birth after cesarean (VBAC) rate has baby is small, you can still do vaginal Techniques decreased from a high of 28% in 1966 to 13.3% delivery. o Classical CS in 2018 (Martin, 2019) FETAL CESAREAN SECTION HYSTERECTOMY 9. Assisted reproductive technology is more likely  Nonreassuring fetal status o Indications widely used and is inked with greater cesarean -  Malpresentation o Postoperative Care delivery rates (Luke, 2019) o In cases of persistent Occiput posterior o CS Hysterectomy techniques that you cannot resolve through forceps MOST COMMON CAUSE OF CESAREAN SECTION delivery MATERNAL  Macrosomia – due to diabetic mother LEARNING OBJECTIVES  Prior cesarean delivery  Congenital anomaly  Define Cesarean Section/Delivery, Cesarean  Abnormal placentation  Abnormal umbilical cord Doppler study Hysterectomy  Maternal request  Thrombocytopenia  Know Their Indications o requested by mothers who have the fear of  Prior neonatal birth trauma  Know Their Complications childbirth.  Know The Appropriate Anesthesia Used o NOT an accepted indication for CS CESAREAN DELIVERY RISKS  Know The Operative Technique o Counsel the patient first, if the patient still  Cesarean delivery generally has higher maternal opts for CS (especially if it is against your surgical risks for the current and subsequent DEFINITION principle and you are a member FPOGS), pregnancies compared with spontaneous CESAREAN  Birth of a fetus by Indications for CSD then efer them for a second opinion vaginal birth DELIVERY Incision of abdomen laparotomy then MOST COMMON CAUSE OF CESAREAN SECTION  Prior classical hysterotomy Risk of uterine rupture is very high  For neonates CS offers lower birth traumas and hysterotomy Incision of uterus 1. Prior Cesarean Delivery  Unknown uterine scar type Previous myometry and recent pregnancy still births but higher rates of initial respiratory CESAREAN  Abdominal hysterectomy 2. Labor Dystocia or Arrest  Prior uterine incision extension difficulties HYSTERECTOMY performed at the time of 3. Fetal Jeopardy Ex. HBW of baby  Uterine incision dehiscence cesarean delivery 4. Abnormal Fetal Presentation  Prior full-thickness myomectomy POSTMORTEM/  Hysterotomy performed  Genital tract obstructive mass PERIMORTEM on a woman who has just REASONS FOR INCREASING CS RATES  Invasive cervical cancer CESAREAN died or in whom death is 1. Women are having fewer children; thus, a  Prior trachelectomy DELIVERY expected soon greater percentage of births are among  Permanent cerclage POSTPARTUM  Hysterectomy done nulliparas, who are at increased risk for  Prior pelvic reconstructive surgery HYSTERECTOMY shortly after vaginal cesarean delivery  Prior significant perineal trauma delivery Uterus may be ruptured 2. Average maternal age is rising, and older  Pelvic deformity PERIPARTUM  Broader term for both women, especially older nulliparas, have a  HSV or HIV infection HYSTERECTOMY higher cesarean delivery risk  Cardiac or pulmonary disease NOTE TAKER: ABDELKAWI Page 1 | 12 NOTE TAKER: ABDELKAWI Page 2 | 12  PCC SOM PCC SOM 2026 OBSTETRICS 2 CESAREAN SECTION COMPLICATIONS M.08 CS & CS HYSTERECTOMY  Should the obstetrician agree to an elective 2026 OBSTETRICS 2 M.08 CS & CS HYSTERECTOMY (POGS CLINICAL PRACTICE GUIDELINES ON CESAREAN  The antibiotic prophylaxis may be MATERNAL FETAL CS, a well- written informed consent, SECTION, 2009, P 30.) administered preoperatively (before skin PRIMARY CS  Skin laceration: most approved by the Institutional Ethical Review incision) or after cord clamping. (LEVEL 1,  Infection common Bord (IERB), should signed by the patient PREOPERATIVE CARE GRADE A)  Hemorrhage  Cephalhematoma Prolonged dystocia prior to conduct of the elective CS.  NPO at least 6 hours prior to surgery  Venous  Clavicular fracture Breech  Uncomplicated cases: clear liquids up to 2 (POGS CLINICAL PRACTICE GUIDELINES ON CESAREAN thromboembolism  Brachial plexopathy (POGS CLINICAL PRACTICE GUIDELINES ON CESAREAN hours prior surgery SECTION, 2009, P 33.)  Anesthetic  Skull fracture SECTION, 2009, P 23.)  Bowel prep NOT recommended. complications  Facial nerve palsy  Recent hematocrit, and indirect Coomb’s test, ABDOMINAL INCISION In risk for placenta accreta: suturing of endometrium PATIENT PREPARATION blood typing A. Recommendations: REPEAT CS DELIVERY AVAILABILITY  Regional anesthesia is preferred  Transverse abdominal incision should be  Abnormal placentation  Acceptable time interval to begin caesarean o You may use general anesthesia when performed during CS. The transverse incision (placenta accreta) delivery. for your example your patient came in of choice is the JOEL-COHEN incision. (LEVEL  Wound and uterine o within 5 minutes after you have found labor and is eclamptic 1, GRADE A) infections an indication, some would say within 30  Adjacent organ injury minutes. Now, once you have SHAVING (POGS CLINICAL PRACTICE GUIDELINES ON CESAREAN o Ureter or bladder determined an indication, do the SECTION, 2009, P 36.)  Cesarean hysterectomy procedure immediately. A. Recommendations:  JOEL-COHEN incision is more preferred than  Bloody transfusion  Pre-operative shaving of the site is NOT Pfannenstiel because it has: Less fever, pain and reactions INFORMED CONSENT routinely recommended. However, if it is analgesic requirements, blood loss, shorter a. Medical and surgical care alternatives necessary to remove hair then it is preferable duration of surgery and hospital stay. b. Procedure goals and limitations to use clippers rather than shaving with a JOEL COHEN INCISION CESAREAN DELIVERY ON MATERNAL REQUEST c. Operative risks Immediate IUD insertion after delivery razor as this results in fewer surgical site  Skin incision:  Protection of pelvic floor support d. Permanent sterilization or IUD insertion infections (SSI). (LEVEL 1, GRADE A) o Straight  Convenience o While getting informed consent, also  Removing hair before surgery using o 3 cm below the line that joins anterior  Fear of childbirth ask if they are also interested in depilatory cream results in fewer SSI than superior iliac spines slightly higher than  Reduced risk of fetal injury (there are still fetal contraception. What contraception shaving. (LEVEL 1, GRADE A) Pfannenstiel. injuries even in CS, Doc Doromal) would like: permanent (tubal ligation), o Subsequent layers opened bluntly if temporary (postpartum IUD) (POGS CLINICAL PRACTICE GUIDELINES ON CESAREAN necessary extended with scissors and MATERNAL REQUEST FOR CESAREAN SECTION SECTION, 2009, P 35.) not a knife. A. Recommendation TIMING OF SCHEDULED CESAREAN DELIVERY  If a patient requires for CS without a clear INFECTION PREVENTION indication, the reason for the request should OPTIMAL TIME OF PLANNED CESAREAN SECTION  Cesarean section is considered a clean be examined, discussed and documented. contaminated case. The discussion should include the overall A. Recommendations:  1g dose of Cefazolin benefits and risks of CS delivery compared  Elective CS should be scheduled at 39 weeks with vaginal birth. (LEVEL III, Grade C) gestation (LEVEL II-1, Grade B) PROPHYLACTIC ANTIBIOTICS  If the reason for the maternal request for CS  Elective CS should be undertaken before 39 is fear of childbirth, the obstetrician should weeks gestation if there is an obstetric or - A. Recommendations: take time to talk to the patient or to offer medical indication (LEVEL III, Grade C)  Antibiotic prophylaxis is recommended in - counseling in order to help her address fer Patients should be informed of the possibility women about to undergo CS. (LEVEL 1, fears. (LEVEL III, Grade C) of labor prior to the scheduled elective CS, GRADE A)  It is the option of the clinician to refuse to do o Midline vertical follows the linea nigra. Maylard and should be advised to immediately  A single dose of AMPICILLIN or First- CS ad to refer to the patient to another is curvilinear just like Pfannenstiel incision, but is consult once with signs of labor. (LEVEL III, generation cephalosporin is recommended. doctor for second opinion. (LEVEL III, Grade higher. Joel-Cohen incision is between Maylard Grade B) (LEVEL 1, GRADE A). C) and Pfannenstiel, but is a straight incision and is about 10cm. NOTE TAKER: ABDELKAWI Page 3 | 12 NOTE TAKER: ABDELKAWI Page 4 | 12  PCC SOM PCC SOM 2026 OBSTETRICS 2 M.08 CS & CS HYSTERECTOMY  This is made at the pubic hairline, which is 2026 OBSTETRICS 2 M.08 CS & CS HYSTERECTOMY  The lower edge of peritoneum is elevated, and typically 3 cm above the superior border of the D. INSERTION OF BLADDER RETRACTOR the bladder is gently separated from the symphysis pubis. underlying lower uterine segment with blunt or B. SEPARATION OF FASCIA sharp dissection within this vesicouterine space. Self-retaining retractor SURGICAL SAFETY  “TIME OUT” Bladder retractor o Patient name o Site E. INCISION AT LOWER UTERINE SEGMENT  Sharp dissection is continued through the LATERALLY EXTENDED BLUNTLY USING o Procedure o Operative team members subcutaneous layer to the fascia. SURGEON’S INDEX FINGERS o Verification of prophylactic antibiotics C. SEPARATION OF ABDOMINAL MUSCLES F. DELIVERY OF FETUS FOLLOWED BY DELAYED o Estimation of procedure length CORD CLAMPING AND CUTTING OF CORD  Instrument, sponge and needle count before and after surgery is essential. G. FETUS HANDED OFF TO AWAITING PEDIATRICIAN CESAREAN SECTION OPERATIVE TECHNIQUES H. DELIVERY OF PLACENTA A. PFANNENSTIEL INCISION (Transverse Incision)  Suitable transverse incisions are Pfannenstiel or Maylard incisions, and the Pfannenstiel type is selected most frequently.  The operator separates the fascial sheath from  Pfannenstiel type -- often discouraged for cases the underlying rectus abdominis muscle either in which a large operating space is essential or bluntly or sharply until the superior border of  Scissors are inserted between peritoneum and in which access to the upper abdomen may be the symphysis pubis is reached. lower-uterine-segment myometrium. needed.  Open scissors are pushed laterally from the midline on each side.  Scissors are directed slightly cephalad  It is better to deliver the placenta spontaneously, not by manual extraction. You can massage the fundus before delivering it.  While delivering, you may rotate the placenta so that nothing will retain. I. THOROUGH SPONGING OF UTERINE CAVITY J. INITIAL NEEDLE AND SPONGE COUNT  skin and subcutaneous tissue are incised using a  Fascial separation progresses cephalad and low, transverse, slightly curvilinear incision. laterally exposing the peritoneum which is incised. NOTE TAKER: ABDELKAWI Page 5 | 12 NOTE TAKER: ABDELKAWI Page 6 | 12  PCC SOM PCC SOM 2026 OBSTETRICS 2 M.08 CS & CS HYSTERECTOMY 2026 OBSTETRICS 2 M.08 CS & CS HYSTERECTOMY K. CLOSURE OF UTERINE INCISION IN 1 OR 2 CLASSICAL CESAREAN SECTION POSTOPERATIVE CARE LAYERS USING VICRYL 1 IN CONTINUOUS INDICATIONS 3. WOUND CARE/ GAUZE AND DRESSING FOR INTERLOCKING/SIMPLE CONTINUOUS  Prior radical trachelectomy 1. EARLY SKIN TO SKIN CONTACT AND BREAST C.S.  Myoma at the lower uterine segment FEEDING AFTER C.S.  Massive obesity A. Recommendations:  Placenta previa with anterior implantation A. Recommendations:  Remove the dressing 24 hours after the C.S.  Transverse lie of large fetus with shoulder  Newborns delivered via C.S. (as with all (Level III, Grade C). impaction newborns), should be placed preferably skin  Monitor the patient for fever (Level III, Grade  Back down transverse lie to skin with the mother as soon as possible (if C).  Very small fetus in breech baby and mother are deemed stable). They  Asses the wound for signs of infection (such should be given the opportunity to latch on as increasing pain, redness or discharge) and in the recovery room within one hour after separation or dehiscence. (Level III, Grade C). birth or ASAP, if latching on in the OR was not  Gently clean and dry the wound daily. (Level performed. (Level 1A, Grade A). III, Grade C).  Endometrium is not closed to avoid placenta  If needed, plan the removal of sutures or accreta in the next delivery. (POGS CLINICAL PRACTICE GUIDELINES ON CESAREAN clips. (Level III, Grade C). SECTION, 2009, P 52.)  Combination of antibiotic ointment. L. THOROUGH SPONGING OF PARACOLIC GUTTERS s Polysporin is preferred for routine post- operative wound care. (Level III, Grade C). 2. MATERNAL FEEDING AFTER CESAREAN SECTION  Encourage the woman to wear loose, M. FINAL COUNTING OF NEEDLES/SPONGES comfortable clothes and cotton underwear. /INSTRUMENTS  For incision closure, one method employs a A. Recommendations: (Level III, Grade C). layer of 0- or no. 1 chromic catgut with a  There is no evidence to recommend a policy  Currently, there appears to be no clear N. CLOSURE OF ABDOMINAL WALL IN LAYERS running stitch to approximate the deeper length of delaying oral fluids and food after C.S. evidence or recommendation regarding 1. FASCIA - Vicryl 1 of the incision. Postpartum women who are recovering well which type of dressing, dry gauze versus 2. SUBCUTANEOUS TISSUE  The myometrium should be closed by layers after an uncomplicated C.S. can be allowed transparent polyurethane dressings o