DIFFICULTIES WITH CESAREAN SECTION
FULL BLADDER
If the head is deeply impacted in the pelvis and it is not possible to catherize the ordinary way one can try to push up the head manually and catheterize with a semi-rigid plastic tube - for instance a suction catheter - or with a rigid metal catheter.
If that fails as well the only remaining option is suprapubic puncture with a wide bore needle either before skin preparation and draping…..
VIDEO ← click for video
VIDEO ← click for video
HEAD DEEPLY IMPACTED IN THE PELVIS
If the head is impacted deeply in the pelvis trying to get it out the usual way with a full hand inserted through the incision may cause extensive tears of the vagina and/or uterus and is best avoided.
Instead ask an assistant to insert a (sterilegloved hand into the vagina and push the head into the uterine incision.
VIDEO ← click for video
Actually it is preferable to push the head proximal even before the uterine incision is made to prevent tearing of the uterine incision, but that is seldom practiced.
Another – and I think better – option is to insert your hand proximal into the uterine incision, localize a foot and extract the baby by the foot. That is the method I prefer.
VIDEO ← click for video
BLEEDING FROM THE UTERINE ARTERY
Even with the most careful and atraumatic technique it sometimes happen that a thin, outstretched and friable lower segment tears out and causes bleeding from one or both uterine arteries.
Just don’t panic. Pack the area tightly with sponges until you have everything ready, electric light, anesthesia, additional sponges, instruments, sutures and maybe another pair of hands to assist.
When removing the packs after a while the bleeding will have decreased substantially – sometimes even stopped completely - so that you can easily see the offending bleeders clearly and clamp them accordingly.
If it is still technically too difficult to control the bleeding, leave the pack for 24 hours and remove carefully the following day under good anesthesia and with careful preparations.
Clamp the spurting artery and suture ligate with a heavy chromic applied inside out and outside in. Use the same chromic to close the uterine incision and tears, one suture from each corner. Tie the sutures together where they meet in the middle.
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VIDEO ← click for video clip |
TEAR OF THE UTERINE INCISION
Whenever there are lateral tears of the uterine wound the closure is done with two separate continuous suture lines starting from each corner and tied at the middle. After that any remaining tears can be sutured separately as in this example
UTERINE MYOMA
Whenever doing a cesarean on a fibroid uterus do not fall for the temptation to try removing the myomas even if it might look easy. Bleeding will be torrential, putting the life of the patient at great risk.
Usually the fibroids do not make any hindrance for a lower segment transverse uterine incision.
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Do only the cesarean, and leave any eventual surgery for the fibroids for later.
(Since the lady has already proven that she can get pregnant and reach full term it will probably be wise to abstain from any further surgery until she has had the children she wants)