00:01
Now we'll talk about
Cesarean section.
00:05
So what is the indication
for C-section?
It can be fetal
intolerance of labor.
00:09
Meaning a Category 3 tracing.
00:12
Arrest of dilation
or descent in labor.
00:15
Meaning the cervix doesn't
dilate after 2 hours
or the baby doesn't descent
after 2 hours when they are
in the second stage of labor.
00:22
Malpresentation such as breech.
00:24
Placental abnormalities such
as placenta acreta, increta
or percreta.
00:29
And previous uterine
surgeries such as myomectomy.
00:32
Or if a patient has had
more than two C-sections.
00:36
For C-section techniques, let's
first talk about anesthesia.
00:41
Now this is discussed in more
detail in another lecture.
00:43
But let's briefly
talk about it here.
00:45
So there's three options.
00:46
Epidural, spinal or general.
00:48
With epidural, the anesthesia
is placed in the epidural space
through a catheter allowing
for continuous pain relief.
00:56
Generally used for
labor in patients.
00:59
Spinal is one injection
into the subarachnoid space.
01:02
This last approximately
2 to 4 hours.
01:04
With general anesthesia we only
perform this in an emergency.
01:12
Next let's talk about the type
of skin incisions we can have
during a C-section.
01:16
First is Pfannestiel.
01:18
That's what is demonstrated
here in this picture.
01:20
With Pfannestiel there is
less risk of dehiscence.
01:24
Cosmetically is preferred.
01:27
But the downside there's not as
much as exposure to the abdomen
as when we see a midline
incision.
01:34
With midline you have a faster
entry into the abdomen.
01:37
There's less blood loss.
01:39
However, the downside is
a higher rate of dehiscence.
01:44
So let's talk about the layers
that we go through
when we are performing
a C-section.
01:48
First we go through the fascia.
01:51
After the fascia is opened, we
see a rectus abdominal muscles.
01:55
You can see them displayed here.
01:57
Those are separated and we
identify the peritoneum.
02:01
Once the peritoneum is entered,
then we make it to our uterus.
02:05
So with our uterine incisions
there's a few options there.
02:10
Low transverse is the most
common uterine incision.
02:13
Because the incision is made in
the lower uterine segment,
the non-contact top
part of the uterus.
02:18
This is the least
likely to rupture.
02:20
So if a patient have had one
C-section, she is a candidate
for trial of labor
after cesarean.
02:26
And there is a low
risk of rupture.
02:28
Less than 1%.
02:30
Low vertical incision is
utilize if the fetus is in
a presentation such as
transverse back down that would
not allow delivery through
a low transverse incision.
02:41
Classical incisions are utilized
when C-section is performed
at an earlier gestation.
02:46
And the lower uterine segment
has not developed
or has not thinned out.
02:51
And then T-incision is an upward
extension of the low transverse
incision when there's
difficulty delivering the baby.
02:57
Now this incision has a
highest risk of rupture during
subsequent pregnancies
if labor occurs.
03:03
The only type of uterine
incision where we do evocate for
a vaginal birth after cesarean
or a trial of labor after
cesarean is the low
transverse incision.
03:15
Now let's talk about
repair of the hysterectomy.
03:19
Now this is done in
one or two layers.
03:21
And the big part of the repaired
of the hysterectomy,
the most important part is
we need to maintain hemostatsis.