1. Cesarean Section Basics for FP
Matthew Snyder, DO
Family Medicine/Obstetrics

2. Overview Indications Do’s & Don’ts of first-assisting
Post-operative management
Post-partum counseling

3. Objectives List 3 maternal and fetal indications for performing a C/S
Identify the primary surgical instruments used in C/S
List 5 potential complications associated with C/S

4. C/S Indications - Fetal
Fetal Macrosomia (over 5000g, GDM – 4500g)
Multiple Gestations
Fetal Intolerance to Labor
Malpresentation / Unstable Lie – Breech or Transverse presentation

5. C/S Indications - Fetal
Non-reassuring Fetal Heart Tracing
Repetitive Variable Decelerations
Repetitive Late Decelerations
Fetal Bradycardia
Fetal Tachycardia
Cord Prolapse

6. C/S Indications - Maternal
Elective Repeat C/S
Maternal infection (active HSV, HIV)
Cervical Cancer/Obstructive Tumor
Abdominal Cerclage
Contracted Pelvis
Congenital, Fracture
Medical Conditions
Cardiac, Pulmonary, Thrombocytopenia

7. C/S Indications – Maternal/Fetal
Abnormal Placentation
Placenta previa
Vasa previa
Placental abruption
Conjoined Twins
Perimortem
Failed Induction / Trial of Labor

8. C/S Indications – Maternal/Fetal
Arrest Disorders
Arrest of Descent (no change in station after 2 hours, <10 cm dilated)
Arrest of Dilation (< 1.2 cm/hr nullip; < 1.5 cm/hr multip)
Failure of Descent (no change in station after 2 hours, fully dilated)

9. C/S Indications – Maternal/Fetal

10. Surgical Instruments Uses: Adson: Skin Bonney: Fascia
DeBakey: soft tissue, bleeders
Russians: uterus/muscle

11. Surgical Instruments Uses: Allis-Adair: tissue, uterus
Pennington: tissue, uterus
These are suitable for hemostasis use

12. Surgical Instruments
Uses:
Kocher clamp: fascia, thicker tissues

13. Surgical Instruments Uses: Richardson: general retractor
Goelet: subQ retractor
Fritsch bladder blade

14. Surgical Instruments Uses: Mayo, curved: fascia
Metzenbaum, curved: soft tissue
Bandage scissors: cord cutting, uterine extension

15. First-assisting General principles:
Ensure proper exposure of the working field
Anticipate next move and be proactive
Listen carefully to surgeon’s instructions
If unsure of surgeon’s preferences – ASK!!
Have good situational awareness

16. Cesarean Section Preparation phase:
Ensure pt is moved to OR in timely fashion – strong, respectful encouragement to staff may be necessary
Ensure good FHT before prepping!!
If possible, don’t make primary surgeon wait on you
Assist draping pt., connecting suction & bovie

17. Cesarean Section: Incision to Fascia
Provide traction/counter-traction to increase exposure during skin and subQ incision

18. Cesarean Section: Incision to Fascia
Be ready with DeBakey forceps to grab bleeders – especially the Superficial Epigastric vessels

19. Cesarean Section: Fascial Incision to Peritoneum
Use Richardson retractors in superior/lateral fashion to assist in incising rectus fascia
Assist with elevating superior and inferior edges of rectus fascia with Kocher clamps, provide counter- traction, ensure adequate lighting

20. Cesarean Section: Peritoneal Incision/Bladder Flap Creation
With bladder blade inserted, use Richardson to retract superior tissue for optimum exposure

21. Cesarean Section: Uterine Incision to Delivery
With pressure applied to suction tip, suction uterine incision during passes of scalpel to ensure adequate visualization and prevent fetal injury

22. Cesarean Section: Delivery of Infant
After incision is made, give adequate retraction if uterine extension is needed and prepare for fundal pressure
Be ready for bladder blade removal on surgeon’s command before head delivery
Once infant is delivered, either bulb suction infant or clamp/cut cord
Hand infant off to waiting NRP staff

23. Cesarean Section: Hysterotomy Closure
Use a moist lap sponge to wrap uterus and retract once placenta is delivered
Facilitate closure of the uterine incision by ensuring locking of suture by flipping suture loop over needle

24. Cesarean Section: Rectus Fascia closure & Subcut/skin closure
Assist with maintaining hemostasis, irrigating rectouterine pouch and gutters and closure of fascia/skin
Fascia closed with non-locking suture – do not want to strangulate vessels
SubQ space closed if over 2 cm depth
If needed, clear lower uterine segment and vagina of clots once skin is closed and dressed

25. Post-Operative Care
Pt. must urinate within four hours of Foley removal, otherwise replace Foley for another 12 hours
Any fever post-op MUST be investigated
Wind: Atelectasis, pneumonia
Water: UTI
Walking: DVT, PE, Pelvic thromboembolism
Wounded: Incisional infection, endomyometritis, septic shock

26. Post-Operative Care
In the first hours, the dressing may become soaked with serosanguinous fluid – if saturated, replace dressing otherwise no action needed
After Foley is removed (usually within 12 hours post-op), encourage ambulation of halls, not just room
Dressing may be removed in hours post-op (attending specific), use maxipad
Ensure pt. is tolerating PO intake, urinating well and has flatus before discharge
Watch for post-op ileus

27. Delayed Complications
Subsequent Pregnancies
Uterine rupture/dehiscence
Abnormal placental implantation (accreta, etc)
Repeat Cesarean section
Adhesions
Scaring/Keloids

28. Wound Dehiscence
Noted by separation of wound usually during staple removal or within 1-2 weeks post-op
Must explore entire wound to determine depth of dehiscence (open up incision if needed) – if through rectus fascia, back to the OR
If dehiscence only in subQ layer, debride wound daily with 1:1 sterile saline/H2O2 mixture and pack with gauze
May use prophylactic abx – Keflex, Bactrim, Clinda
KEY: Close f/u and wound exploration

29. Post-partum counseling: Pharm
Continue PNV
Colace
Motrin 800 mg q8
Percocet 1-2 tabs q4-6 for breakthrough
OCP (start 4-6 wks post-partum)

30. Post-partum counseling: Activity
No lifting objects over baby’s wt.
Continue ambulation
No strenuous activity
NOTHING by vagina (sex, tampons, douches, bathtubs, hot tubs) for 6 wks!!

31. Post-partum counseling: Incision Care
Only showers – light washing
If pt has steristrips, should fall off in days, otherwise use warm, wet washcloth to remove
If pt has staples – removal in 3-7 days outpt.
F/u in office in about 2 wks for wound check

32. Post-partum counseling: Notify MD/DO
Fever (100.4)/Chills HA
Vision changes
RUQ/Epigastric pain
Mastitis sx
Increasing abd. pain
Erythema/Induration/ increasing swelling around incision
Purulent drainage
Serosanguinous drainage over half dollar size on pad
Wound separation
Purulent vaginal discharge
Vaginal bleeding over 1 pad/hr or golf ball size clots
Calf tenderness

33. Do’s & Don’ts of First-Assisting Last Thoughts
Remember, Exposure is the key!
Listen carefully to the surgeon
Have good situational awareness
Don’t overlook post-op fever
Have a low threshold for consulting surgeon if indications warrant

34. Summary Indications Do’s & Don’ts of first-assisting
Post-operative management
Post-operative complications
Post-partum counseling

35. References
Cunningham, F., Leveno, Keith, et al. Williams Obstetrics. 22nd ed., New York,
Gabbe, Steven, Niebyl, Jennifer, et al. Obstetrics: Normal and Problem Pregnancies. 4th ed., Nashville, 2001.
Gilstrap III, Larry, Cunningham, F., et al. Operative Obstetrics. 2nd ed., New York,