Cesarean Section
Cesarean section is one of the most commonly performed operations in the United States. A transverse or vertical entry laparotomy is performed. A transverse incision is selected more frequently (by a ratio of 10 to 1). The uterus may be left in situ within the abdominal cavity, or it may be exteriorized.
The technique of low transverse cesarean section is performed as follows. The bladder is emptied by the insertion of a Foley catheter. First, a bladder blade is inserted anteriorly (Fig. 18–1). The small and large intestines are packed away with moistened abdominal (laparotomy) pads, which should be carefully counted and tagged. The round ligaments should be identified so the degree and direction of uterine rotation can be determined. Identification of enlarged or aberrant vessels should be documented.
The reflection of peritoneum from the bladder dome to the uterus is grasped with a Kelly clamp (Fig. 18–2). The peritoneal reflection is elevated. With a Metzenbaum scissors, the bladder peritoneal reflection is sharply divided and is extended transversely for the length of the proposed uterine incision, typically 8 to 10 cm (Figs. 18–3 and 18–4). The bladder is gently pushed inferiorly away from the lower uterine segment. This not uncommonly results in small-vessel disruption and light bleeding (Fig. 18–5).
A trace incision is made into the uterus above the bladder reflection (Fig. 18–6). With the use of a scalpel, a deeper central cut, approximately 4 cm in length, is carried down to the amniotic sac, which bulges through the wound (Fig. 18–7A, B). Alternatively, the sharp incision is stopped just short of entry into the uterine cavity. At this point, the muscle may be spread with the surgeon’s index fingers and the cavity entered bluntly (Fig. 18–8A, B).
In either case, once the bulging membranes have been identified, the incision may be extended to right and left by using scissors or by spreading with fingers (Fig. 18–9). The location of the uterine arteries should be ascertained to avoid inadvertent extension of the incision through them. The membranes are opened, and amniotic fluid is suctioned as it pours out into the wound.
The head of the infant (cephalic presentation) appears beneath the incision (Fig. 18–10
