Broad ligament hematoma

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After the placenta is removed and the uterine cavity wiped clean, the edges of the cesarean incision are grasp with T-clamps or mucosal clamps. These help control the bleeding from the wound edges and steady the uterus for suturing. The uterus can usually be sutured satisfactorily within the abdominal cavity. If it seems necessary to eventrate the uterus through the abdominal incision for better exposure, the organ should be wrapped in gauze pads moistened with warm saline solution. Chromic catgut sutures should be used in the closure.

Some authorities advocate interrupted sutures, but we have found the continuous technique to be simpler, faster, and equally effective. Three suture layers are placed, each beginning and ending slightly beyond the ends of the incision, to ensure hemostasis at the angles. The first suture layer should approximate the deeper half of the myometrium, adjacent to the mucosa. There are theoretical objections to penetrating the endometrium with this suture (tract for infection; adenomyosis in the scar), but we have seen no such ill effects resulting.

The second suture approximates the superficial half of the myometrium; and the third and the outermost layer, of finer catgut, reunites serosa to serosa. The peritoneal cavity is then sponged free of blood, clots, and amniotic fluid, and the abdominal wall sutured in layers as in any other laparotomy. Because of the advantages already indicated in the lower segment incision over the classical, we routinely perform the former in preference to the latter, except in cases of central placenta previa, transverse lie, and the occasional fetal or maternal condition that dictates extreme haste.

Lower segment incisions are of 2 types, transverse and longitudinal. The former is actually slightly curvilinear (elliptical), with its convexity toward the bladder. It has the advantage of being confined in its entire extent to the lower uterine segment, whereas in patients not in labor with a poorly formed lower segment, the longitudinal incision must often be extended into the lower part of the fundus. On the other hand, the transverse incision has the disadvantage of occasionally extending laterally during the extraction of a large infant, tearing the uterine vessels, and causing a broad ligament hematoma.

Experienced obstetricians are about equally divided in their preference; neither type of incision is clearly superior to the other. To expose the lower segment, the bladder peritoneum must first be incised transversely near its line of attachment to the uterus. The bladder peritoneum is picked up in the midline near its uterine attachment with a thumb forceps and incised with a scalpel or scissors. Then the incision is extended laterally in a gentle ellipse to either side, toward the uterine attachment of the ground ligament, by means of a curved dissecting scissors.

It is most important to separate the bladder into proper areolar plane, to minimize the bleeding. The index finger is insinuated behind the bladder, and frees it from its attachment to the lower uterine segment. The bladder is pushed downward with a sponge or gauze covered finger and protected behind a broad retractor. If the operation is carried under local infiltration anesthesia, this step is facilitated by the preliminary injection of anesthetic solution under the bladder peritoneum.

If the lower segment is to be incised longitudinally, a short peritoneal flap should also be dissected upward off the uterus; the transverse incisions, this is unnecessary. Occasionally one may tear large veins while stripping down the bladder. It is usually unnecessary to attempt control of bleeding from this source at this time, because after the uterus is evacuated and it contracts down, this bleeding usually ceases and markedly diminishes spontaneously.

After adequate exposure of the lower segment it is incised with a scalpel and the incision extended in either direction with bandage scissors over the advancing fingers, as in the classical incision. The hand of the operator nearer the foot of the table is then inserted into the uterus and insinuated between the pelvic brim and the fetal head like a shoehorn, and the head delivered with the aid of fundal pressure applied by the assistant through the abdominal wall of the mother.

The fetus is thus extracted by the head. If the head is deeply engaged and difficulty in extraction is anticipated, it is helpful to have in assistant push it up out of the pelvis by sterile glove vaginal manipulation just before the operation is begun. If this has not been done one blade of a short-handled forceps can be used as a vectis to facilitate extraction, or both blades can be applied to the sides of the head after manual rotation of the occiput anteriorly.

After manual removal of the placenta and the administration of the oxytocic, the uterine incision is sutured 2 layers with continuous chromic catgut and peritonized with the bladder flap by means of a third finer suture, inserted transversely. This suture line should be placed sufficiently high to cover the upper end of a longitudinal incision in the lower segment. The advancement of the bladder which they may necessitate causes no subsequent discomfort.

Until the present era of chemotherapy and antibiotics, cesarean section in the presence of infection was usually accompanied by hysterectomy, to remove the septic focus. An infected uterus could be retained only at the expense of jeopardy to the patient’s life by peritonitis. To circumvent the hazard of peritonitis in infected or potentially infected cases without sacrificing the uterus, extraperitoneal cesarean section was devised, to evacuate the uterus abdominally without contaminating the peritoneal cavity.

This operation, which is technically more difficult and time consuming than ordinary types of cesarean section, has found only limited acceptance, because its introduction to obstetric practice almost coincide with the parade of antibacterial drugs of ever-increasing versatility, which have largely eliminated need for the extraperitoneal operation In our experience patients with potential or mild intrapartum infection who require cesarean section can be treated satisfactorily by the lower segment operation plus antibiotics pre- and postoperatively.

We have not found it necessary to resort to extraperitoneal cesarean section. On the other hand, in patients with severe intrapartum infection, retention of the uterus at cesarean section entails a grave risk; hysterectomy must therefore be considered, as a lifesaving measure, together with intensive antibiotic therapy. Other conditions in which cesarean-hysterectomy is sometimes indicated include myoma uteri, uterine rupture, placenta accreta, and extensive hemorrhage in the myometrium and broad ligaments associated with placental abruption (Couvelaire uterus).

The operation is also gaining in favor as a method of sterilization. If the uterus is to be removed at the time of cesarean section the type of uterine incision is obviously of no great importance. We have found it convenient, however, to perform lower segment incisions in such cases because of minor advantages offered by this approach. If the hysterectomy is to be subtotal, amputation of the uterus is easily completed by simply continuing the lower segment incision posteriorly after the upper broad ligaments and the uterine vessels have been ligated or clamped and divided.

If total hysterectomy is planned, the lower segment incision permits insertion of the finger down into the cervical canal for identification of the external os. Otherwise it may be difficult to determine the extent of the cervix and its junction with the vagina by palpation through the unopened lower segment, especially if labor has already commenced and the cervix is dilated.

When total hysterectomy is performed and the cervix is dilated as a result of labor, special care must be taken to avoid injury of the ureters, which lie now in closer proximity to the cervix than in the nonpregnant state. A repeat cesarean section is more difficult than the primary operation if intra-abdominal adhesions are present. Since this complication can never be foretold, special caution must be exercised in entering the abdominal cavity of the patients who have had a previous cesarean section, myomectomy, or other lower abdominal surgery.

If there has been a previous lower segment operation, one must be wary of incising the bladder when opening the peritoneal cavity, particularly if the bladder was advanced to cover a longitudinal type incision. The bladder usually strips down as easily in secondary as in primary operations. Although there is no physical limit to the number of cesarean sections that a patient may safely undergo, it is common practice to offer sterilization at a time of the third section if the couple already have 2 living children.

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