How Do I Avoid a C-Section Infection?

Low-level cesarean section is currently the most widely used cesarean section. It is also an ideal operation. The operation is easy to master and has few complications. Although it needs to be pushed away from the bladder slightly, it has very little damage. The lower incision of the uterus is easy to be sutured, and it can be covered by the peritoneal refold to prevent abdominal infection and adhesion. It has the advantages of classical cesarean section and extraperitoneal cesarean section, while making up for their disadvantage .

Low cesarean section

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Chinese name: Low cesarean section

Foreign name: lower uterine cesarean section

Low cesarean section

Lower uterine cesarean section; lower uterine cesarean section; lower uterine segment cesarean section; lower uterine segment cesarean section

Obstetrics and Gynecology / Obstetrics / Cesarean Section

74.1 01

Cesarean section (cesarean section) is a surgery to complete the uterine wall to produce a viable fetus and its appendages. It does not include cesarean section performed before 28 weeks of gestation and cesarean section to remove a ruptured uterus or abdominal pregnancy. Low cesarean section is the current cesarean section in obstetrics.

The development of cesarean section has gone through the process of cesarean section to live cesarean section. With the advancement of science and technology, the operation also removes the uterus from the uterine cervix without suture after removing the fetus and its appendages. Since 1882, Sanger's first cesarean section with longitudinal uterine incision (classical caesarean section) has laid the foundation for the development and improvement of the operation. After more than 100 years, the establishment of extraperitoneal cesarean section and intraperitoneal Transverse incision of lower uterine section for cesarean section. In recent years, with the improvement of anesthesia and the application of antibiotics, cesarean section has been widely used. A large amount of data shows that modern indications and clear timing of operation, modern cesarean section plays a huge role in improving the quality of perinatal delivery, and is an effective means to rescue mothers and infants. However, cesarean section is a large operation after all. Complications such as bleeding, organ damage, uterine scars, and infections also threaten the lives of mothers and infants. Therefore, it is very important to strictly grasp the indications of cesarean section to reduce unnecessary cesarean section rate.

When the caesarean section originated, it is difficult to determine. As far back as 715-672 BC, the Roman Catholic Church issued a decree stating that deceased births or pregnant women should not be buried without a caesarean section. This is the origin of cesarean section. By the early 16th century, records of cesarean section for live pregnant women were recorded. However, in the next 300 years, the mortality rate of pregnant women during cesarean section is as high as 52% to 100%. Because the uterine incision is not sutured due to surgery, the main causes of death are bleeding and infection. Because surgery is very dangerous, it is rarely performed. By 1876, Porro, an Italian obstetrician, removed the uterus from the cervix at the same time as cesarean section, avoiding postpartum hemorrhage and infection, which became a major progress in the treatment of dystocia. By 1882 Maxsanger pioneered the longitudinal incision and suture of the uterine floor, reducing bleeding, promoting healing and retaining the uterus, and made a revolutionary contribution. This procedure is called "Conservative Cesarean Section" or "Classic Cesarena Section". In 1907, Frank first applied trans-peritoneal cesarean section, a transverse incision was made to cut the parietal peritoneum, and then a bladder peritoneum was cut and folded back. , And then cut the lower uterus, reducing the chance of infectious cases with peritonitis. By 1908, Latzko designed the approach from the lateral fossa of the bladder to the lower uterus, which was later improved and described by Norton et al., Which is the commonly used side-entry extraperitoneal cesarean section. By 1940, Waters first found the way from the top of the bladder into the lower uterus, so a top-entry extraperitoneal cesarean section was created. Extraperitoneal cesarean section plays an important role in preventing infection, but its operation is complicated and it is easy to damage the bladder. Kronig analyzed the characteristics of extraperitoneal cesarean section by using the non-constrictive uterine segment and covering the incision with peritoneum. He applied these principles in 1912 and proposed the incision of the bladder and uterus to bend the peritoneum and expose the lower uterine segment. The method of uterine delivery is currently the most widely used "low cesarean section."

At present, due to the improvement of anesthesia and cesarean surgery, the progress of blood transfusion has been affected by perinatal medicine, eugenics, and family planning. The death rate of cesarean section and perinatal mortality have been greatly reduced. Cesarean section has replaced difficult vaginal delivery and has become the main delivery route for many pregnancy complications. Although cesarean section is a safer operation, it can increase bleeding and infection. There are also cases of major postpartum hemorrhage caused by factorial incision infection. Sometimes the uterus must be removed, which is life-threatening. There are also accidental injuries and anesthesia accidents Therefore, the indications for surgery should be strictly controlled.

Whether the indication of cesarean section is proper or not is an important indicator of the level of obstetric work. The obstetric situation is complex, and some indications are clearly called absolute indications, such as central placenta previa, pelvic stenosis, obstruction of the birth canal, and so on. There are some situations that require careful weighing to make a judgement. The general principle is to choose a cesarean section when delivery is not possible or if vaginal delivery is dangerous to the mother and baby.

1. Abnormal birth canal pelvic stricture and pelvic deformity.

2. Soft birth canal abnormalities

soft birth canal obstruction, atresia, tumor obstruction.

soft birth canal scars, scar contracture of the vulva, vagina and cervix caused by surgery or drugs, such as bladder vaginal fistula repair.

The uterine body repairs sutures and orthopedic scars.

cervical cancer and huge genital warts.

Others: severe vulvar edema, vulvar varicose veins.

3. Abnormal fertility: Various abnormalities of fertility that are invalid after correction, with fetal distress and suspected threatened rupture.

4. Poor treatment of pregnancy-induced hypertension syndrome, poor condition, should not continue pregnancy, immature labor induction conditions; eclampsia control 4 to 6 hours, can not give birth quickly through the vagina.

5. Pregnancy complications

Pregnancy complicated by severe heart disease with cardiac function grades III to IV, history of heart failure and cyanotic congenital heart disease.

pregnancy with diabetes accompanied by huge children, fetal dysplasia or severe placental dysfunction.

Other pregnancy complications include severe hepatitis, hyperthyroidism, blood diseases, chronic nephritis and renal insufficiency.

1. Fetal distress.

2. Abnormal fetal position horizontal position, star-like hip position, abnormal forehead first exposed, high upright position, posterior skeletal position, forward lean unevenness.

3. Expired pregnancy with oligohydramnios, intrauterine distress, and placental dysfunction.

4. Huge children with relative pelvis or pregnancy with diabetes or expired pregnancy.

5. Twins when the first child is breech or lateral position, or with other pregnancy complications or complications.

6. Fetal intrauterine growth retardation is monitored by the fetus viable.

1. Central placenta.

2. Placental abruption has severe bleeding and cannot be delivered through the vagina within a short period of time.

3. Umbilical cord prolapse, uterine cavity operation is complete, short-term can not give birth through vagina.

(1) Pelvic stenosis: The pelvic stenosis is measured at the entrance, middle cavity, or exit of the pelvis through the inside and outside.

(2) The pelvic pelvis does not mean that the pelvic diameter is in the normal range, but the fetus is too large or the proportion of the fetal head and the pelvis is not suitable, which hinders the labor process, which is the main indication of cesarean section.

(3) Horizontal position: If the horizontal position cannot be corrected, a cesarean section should be selected when the fetus can survive.

(4) Abnormalities of the soft birth canal: Caesarean section is rare due to abnormalities of the soft birth canal, but there are mainly the following: obstruction of the soft birth canal, severe scar contracture of the cervix, vagina or vulva due to trauma or surgery, which can obstruct delivery . In addition, those who have cervical fibroids, ovarian tumors, giant genital warts, and congenital abnormalities in the vagina that prevent the first exposure from descending need to undergo cesarean section. Cervical cancer Vaginal birth can cause laceration of the birth canal and the risk of major bleeding. Cervical cancer can also cause cancer to spread and cesarean section should be performed.

(5) Central placenta previa: If the gestational age reaches 36 weeks, the fetus can be alive and elective cesarean section; if the gestational age is less than 36 weeks and the vaginal bleeding does not stop, cesarean section should be performed immediately to stop bleeding.

(6) Early placental dissection: The diagnosis is affirmative, and those who cannot deliver through the vagina within a short period of time.

(7) Umbilical cord prolapse: The fetal life is seriously threatened when the umbilical cord prolapses. As long as the cervix is not fully opened, it is not possible to deliver quickly through the vagina.

(1) Fetal distress: There are many causes of fetal distress, and the indications should be carefully grasped, observe and analyze more, but do not hesitate to lose the rescue opportunity.

(2) Hip position: The hips are exposed first, the primiparas are over 35 years of age, the estimated weight of the fetus is over 3.5kg, the fetal head is overstretched, and the combined pregnancy is expired.

(3) Partial placenta previa or low placenta: cesarean section should be performed when there is more vaginal bleeding or fetal distress. Some clinical manifestations are repeated small amounts of vaginal bleeding, because once the uterine cavity is opened, there may be major bleeding. If the hospital does not have sufficient blood source conditions, as long as the fetus is mature and can survive, the cesarean section should be timely.

(4) Expired pregnancy: the fetus is often unable to tolerate uterine contraction pressure, causing distress or even intrauterine death. If combined with too little amniotic fluid or obvious fecal staining of amniotic fluid, or detection of abnormal placental function, or fetal intrauterine distress should be removed Miyako.

(5) Premature delivery and fetal growth retardation: this type of fetus is difficult to tolerate uterine contraction pressure during childbirth, and it is easy to cause intracranial damage during vaginal delivery. If the neonatal monitoring system is perfect, the survival rate of premature babies is high, and caesarean section is feasible. In the case of unpredictable fetal survival, care should be taken with regard to cesarean section.

(6) Pregnancy-induced hypertension syndrome: After 4h of eclampsia control, those who cannot deliver quickly from the vagina, those with premature eclampsia who have failed treatment and whose conditions of induction of labor are immature.

(7) Heart disease: Those who have severe insufficiency of cardiac function compensation above Grade III should choose elective cesarean section.

(8) Other complications of pregnancy: such as diabetes, severe hepatitis, hyperthyroidism, blood diseases, etc. often cannot tolerate vaginal delivery, and can be administered in time with the assistance of a physician.

(9) Huge children: Caesarean section is safer for mothers and infants who are estimated to have a fetus above 4.0kg, have a mild pelvic disproportion, or have a mother with diabetes, or have a pregnancy that has expired.

1. Stillbirth except major maternal hemorrhage, uterine orifice has not been expanded, stillbirth can not be delivered within a short period of time, in order to save the life of the maternal, all efforts should be made to vaginal delivery, if necessary, the broken baby.

2. Teratomy is generally not considered for cesarean section. However, if there is a disease that endangers the life of the pregnant woman, the childbirth must be terminated immediately and the transvaginal can not be completed, or a small number of deformities such as twin congenital twins with difficulty in transvaginal fetus, etc., still need cesarean section to take the fetus.

3. Previous history of abdominal surgery, especially cesarean section, the lower part of the uterus has severe and difficult to separate adhesions, especially those with fetal distress who urgently need to give birth.

4. Poor formation of the lower segment of the uterus, incision cannot be performed.

5. There are a large number of varicose blood vessels in the lower part of the uterus, and surgery may cause major bleeding.

6. Pelvic deformity and draping abdomen, the uterus is extremely forward and cannot expose the lower uterus.

7. Horizontal position, non-labor, and insufficient expansion of the lower segment. If the fetal back is underneath, the lower incision is difficult to pull the carcass.

According to the problems that may occur during the operation, develop corresponding measures to prepare for routine neonatal resuscitation and first aid, and other gynecological abdominal surgery.

1. Choice of surgery timing

Whether the timing of cesarean operation is appropriate is directly related to the safety of the mother and baby. According to statistics, the rates of emergency cesarean mothers and infants are 2 to 3 times higher than those of elective surgery. Therefore, emergency cesarean sections should be reduced as much as possible. Generally speaking, after full-term pregnancy, the lower part of the uterus is formed, the uterine opening is enlarged, the maternal is not tired, and the fetus has no signs of hypoxia, which is the best time to perform surgery.

2. Preoperative preparation for elective cesarean section

Admission is required in advance. Women who have clear surgical indications during prenatal examinations or who may have a cesarean section should be admitted before the due date. Active treatment of complications. For those who have complications, they should be actively treated. For example, pregnancy-induced hypertension syndrome, opportunistic surgery should be selected when it is not completely controlled after treatment. Anemia in pregnant women should be checked for causes and correct anemia. Heart failure in pregnant women with heart failure should be controlled first. In the case of co-infection, active anti-infection is required. Actively promote the maturity of the fetus. If the fetus is immature and must give birth, promote fetal lung maturity in time. Elective surgery can be done with all the preparations done soon after the start of labor, or at an appropriate time before labor is considered appropriate.

3. Preparing for emergency cesarean section

Most of the emergency cesarean section encountered difficulties during the labor process, or the pregnancy had to be terminated immediately due to sudden changes in pregnancy complications, accounting for more than half of all cesarean sections, some of which were treated earlier because of earlier admissions . If you are admitted to the emergency department, the doctor should take the time to review the medical history, do a systematic physical examination and necessary auxiliary examinations, fully estimate the situation of the mother and baby, and clarify the surgical indications.

4. Specific preparations

Correct the general situation and deal with it according to different conditions. Pay special attention to correct maternal dehydration, electrolyte disorders, and actively handle fetal distress. If there is hemorrhagic shock, blood volume should be replenished in a timely manner. Blood preparation, obstetric hemorrhage is often very urgent and large, so be prepared for blood transfusion at any time. Patients with prenatal bleeding should undergo surgery at the same time as blood transfusion. Because patients with major prenatal hemorrhage need surgery to effectively stop bleeding, the rescue time cannot be delayed. skin preparation, according to the scope of gynecological abdominal surgery. Place the urinary catheter. Pre-operative medication. Antibiotics should be given to pregnant women who are infected or likely to be infected. For immature fetuses. Preoperative medication promotes fetal lung maturity. Be prepared for rescue infants, including tracheal intubation and umbilical vein injection. It is best to have a neonatal physician participate in the rescue.

Epidural anesthesia is preferred; local anesthesia can also be used when the fetus is in urgent need of delivery or without anesthesia.

1. Epidural anesthesia is simple, muscle relaxation is good, and analgesia is complete. It is currently the first choice for cesarean section in China.

2. Local anesthesia Local infiltration anesthesia and nerve block anesthesia are safe for mothers and infants, but the muscles are loose and the pain is incomplete, which can be used in emergency situations.

3. Laughing gas-oxygen balance anesthesia has no adverse effects on mothers and infants. Pain relief and muscle relaxation are satisfactory. It is especially suitable for pregnant women with complications, such as pregnancy-induced hypertension syndrome, hematopathy and heart disease.

The traditional posture is the supine position, and those with heart disease or respiratory insufficiency can take the supine position. In order to prevent the "low supine hypotension syndrome", the patient should be inclined to the left side by 10 ° to 15 °, which is considered as the best position for cesarean section.

Cut open the abdominal wall

Common abdominal wall incisions for cesarean section are midline longitudinal incision, midline longitudinal incision and transverse incision. The former two are simple in operation, sufficient in exposure, less time consuming, and less bleeding, and are suitable for those who need to complete the operation urgently. The latter technique is more complicated, but the peritoneal response is light; due to the natural wrinkles along the skin, the scars are not more beautiful. No matter which incision is used, the principle of full exposure of the lower uterus and the smooth delivery of the fetus should be the principle.

Midline longitudinal incision: 1cm away from the pubic symphysis to cut the skin and subcutaneous fat, protect the skin incision with a gauze pad, cut the anterior sheath of the rectus abdominis longitudinally in the center of the incision, clamp the incision margin, and use elbow scissors to extend into the muscle Sheath to separate from the rectus abdominis, and cut up and down. Use the knife handle to free a part of the side of the rectus abdominis from the white line of the abdomen, and then use the two fingers to pull the rest away to expose the cone muscle. Pull one side of the conical muscle bundle and cut the back sheath. When pulling the rectus abdominis with your fingers, avoid damaging the blood vessels communicating with the abdominal wall and causing bleeding or hematoma. Reveal and cut the abdominal transverse fascia, lift the peritoneum, make sure that there is no bladder, bowel loops, and omentum. Cut a small opening with a knife to confirm that it has entered the abdominal cavity. Use the index and middle fingers to protect the organs and expand with scissors. Incisions are usually cut open layer by layer to avoid injury to the bladder.

Midline lateral longitudinal incision: A normal midline longitudinal incision is performed when a maternal takes a left oblique position. Make a longitudinal incision at 2 cm to the right of the midline of the abdomen. The method is the same as that of the midline longitudinal incision. When cutting the anterior sheath of rectus abdominis and free rectus abdomen, pay attention to the blood vessels and nerves that enter the rectus abdominis from the outside, cut off the sutures of the blood vessels, and pull the nerve to the inside to avoid injury when cutting the peritoneum. with.

Horizontal incision: There is a natural half-moon skin wrinkle at about 3cm above the pubic symphysis, that is, Pfannenstiel wrinkles, which can be cut along this, also known as Fannestiel incision. First estimate the length of the incision. Generally, the skin and subcutaneous fat are cut into the abdominal muscle fascia from 12 to 14 cm along the folds from left to right. Vulvar arteries, vein branches and superficial abdominal arteries and vein branches may be cut at both ends of the incision. Ligation and hemostasis should be performed. The surgeon and the assistant tear apart to the two sides with two fingers, which can not cut off the outer blood vessels. Sometimes it can be seen that it is free from the incision. Avoid injury during operation. Make 2cm horizontal incisions on the left and right sides of the ventral white line, lift the incision edge, insert the muscle sheath with curved blunt scissors to separate and cut open to the sides of the rectus abdominis muscle, the fascia is divided into shallow and deep Two layers, the outer layer is the external oblique muscle and the internal oblique fascia, and the deep layer is the transverse abdominal fascia. When expanding the incision, the two layers of fascia must be cut and include some muscle fibers. Pay special attention to the branch of the abdominal artery Clamp, cut, and ligate if necessary. Lift the upper incision margin in the middle of the incision, use scissors to cut the adhesion of the fascia on the ventral white line, and swim away the rectus abdominis and fascia. Also exposed below the cone muscles. The peritoneum can be cut longitudinally, and the operation is the same as that of a longitudinal incision. A small incision can also be made on the peritoneum. The surgeon and the assistant tear with their hands pointing to both sides, often achieving satisfactory exposure. The lower edge is on top of the bladder, which is not easy to damage the bladder.

2. Exploring the abdominal cavity

The right hand enters the abdominal cavity, and the direction and degree of uterine rotation, the expansion of the lower segment, the size of the fetal head, and the height of the first exposure are estimated to estimate the position and size of the uterine incision. After the investigation, saline gauze pads were filled between the sides of the uterine body and the abdominal wall to prevent amniotic fluid and blood from entering the abdominal cavity, and the bowel can be pushed open to avoid obstructing the operation.

3. Push away from the bladder and expose the lower uterus

Use abdominal hooks to pull apart the abdominal wall on both sides, and use the pubic hooks to reveal the field of vision. Clamp the uterus and bladder and fold the peritoneum to make a small incision. Fold the lower edge of the peritoneum and push your bladder down 4 ~ 5cm with your fingers, so that the lower part of the uterus is fully exposed. The finger should be on the uterine wall to prevent damage to the bladder. If the posterior bladder blood vessels are obvious, you can cut the anterior cervical fascia and push away from the bladder under the fascia to reduce bleeding, and then pull the free bladder with the pubic hook to the lower end of the incision to fully expose the muscle layer of the lower uterus.

4. Cut the uterus

In order to ensure that the uterine incision is centered, the rotating uterus should be straightened first. The uterine incision can be a horizontal incision or a vertical incision. Generally, a horizontal incision is used, and an emergency incision is used in special cases.

The height of the incision should be determined according to the height of the fetal head. Generally, it is at the most inflated position of the lower section, that is, the level of the largest diameter of the fetal head. The depth of the incision in the basin is low. The incision of the fetal head should be high. It is advisable to cut 2cm below the junction of the uterine body, and do not cut at the junction, because the thickness of the palace wall is far away, it is difficult to suture, and it affects healing. First cut 2 to 3 cm horizontally in the middle, try not to cut the membrane, and expand the incision by about 11 to 12 cm. The surgeon can use two fingers to tear apart with appropriate strength. When resistance occurs, use scissors to cut open. The tip of the scissors should be slightly upward to avoid damage to the uterine artery and venous plexus on both sides. The left hand can also be guided with a blunt scissors to look directly at the lower arc. Cut to both ends to avoid damage to uterine arteries and venous plexus, but muscle fibers and small blood vessels are cut off and bleeding is more. The former walks along the arched vessels and muscle fibers when torn apart, with less damage and less bleeding. However, it is difficult to reach the desired level for those who are not in labor or the labor time is short and the lower stage is not fully expanded.

It is only possible to complete a sufficiently long incision when the lower segment is fully expanded, so it is only suitable for cases where the labor is long, the lower segment has been fully expanded and varicose veins on both sides, so it is rarely used at present. If the lower segment is not long enough, It is necessary to extend to the uterine body in order to give birth to the fetus to become the lower stage-uterine cesarean section, which has the disadvantages of uterine cesarean section. During the operation, make a longitudinal incision of 2 to 3 cm in the middle of the lower segment to keep the amniotic sac intact. Guide with the left hand and the middle finger into the incision. Hold the blunt-ended scissors to the right 2 cm away from the free edge of the bladder to prevent injury during delivery. The lower part of the bladder is cut upwards in the same way. If the incision is not large enough, it can be extended to the bottom of the uterus. If the incision is too small, not only the bladder may be injured, but the cervix may be torn, and even the vagina may be affected.

It is generally underestimated in advance. It is found that the lower part of the uterus is not sufficiently expanded, the transverse incision is not large enough, and it is difficult to give birth to the child. It is impossible to extend the incision to both sides. Incision, or cut the uterine body upward in the middle of the incision to form a "" -shaped incision. The above two types of incisions are more disadvantageous than classical incisions. The -shaped incision is difficult to sew at the longitudinal and transverse junctions, and the healing is poor. The -shaped incision needs to cut thick arched blood vessels and cause more bleeding. Therefore, the above incisions should be as much as possible. avoid. But when it is needed urgently, it should still be implemented decisively.

5. The fetus is delivered

Use a vascular forceps to puncture the fetal membrane and aspirate the amniotic fluid. To avoid clamping the fetal membrane when the fetal wall is clamped after the fetus is delivered and to prevent the fetal membrane from being sewn when the uterine incision is sewn, you can use the index finger to reach the uterine wall after completing the uterine incision. Between the membrane and the fetal membrane, gently peel it for 1 week, and then rupture the membrane. After aspirating the amniotic fluid, expand the membrane rupture and remove the pubic hook to estimate the size of the incision. The surgeon reached into the uterine cavity with his hand to explore the position and height of the first exposure. He inserted his hand under the fetal head and raised the fetal head from the uterine incision according to the delivery machine. At the same time, the operator pulled the upper edge of the uterine incision with his left hand to facilitate The fetal head is delivered. When the incision has been exposed, the assistant pressurizes the uterine floor to assist in giving birth to the fetal head. Immediately after the delivery of the fetal head, the liquid in the fetal mouth and nasal cavity is squeezed out by hand. If the rubber ball or suction tube is used to suck the liquid out of the nasal cavity, the liquid in the nasal cavity is better, which can prevent the newborn from inhaling a large amount of liquid and causing suffocation. Then, as with vaginal delivery, the fetal neck is tilted to one side, and after one shoulder is delivered, it is pulled to the opposite side, and after the shoulders are delivered, the carcass is pulled outward. After the fetus is delivered, the umbilical cord is broken, and four oval forceps are used to clamp the two corners of the uterine incision and the upper and lower edges, and 10U is injected into the uterine body to promote uterine contraction.

The above is the method of giving birth to a fetus during a general cesarean section. If you can't reach the goal, you can give birth by the following special methods:

In particular, those who have not yet formally delivered labor should choose a higher transverse incision in the lower part of the uterus. When the uterus is opened, when the fetal head is exposed at or above the incision, use the left hand to compress the fetus at the bottom of the abdomen to prevent the fetal head from being returned. Retraction, if still unable to deliver, can be delivered with fetal head aspirator or forceps. When using forceps, first turn the fetal head to the occipital straight position or posterior occipital straight position. The forceps placement method is the same as the vaginal forceps. After the buckle is pulled, it is pulled toward the lower limb of the mother. When the fetal head is moved to the uterine incision, it is changed upward. Extract, and then give birth to the fetal head. There are also fetuses born in the industry.

The following method can be used as appropriate: pulling the fetal shoulder: the operator uses the index and middle fingers to pull the fetal left and right shoulders upwards to pull the fetal head out of the pelvis, and then give birth to the fetus by common methods. Push the fetal head up through the vagina: if the above method doesn't work, the assistant can push the fetal head up with the hand into the vagina under sterile conditions, and the surgeon will use the upper method to deliver the fetus. Extending the incision to the uterine body: In case of difficulty in giving birth to the head and umbilical cord pressure, in order to quickly remove the fetus, an emergency incision can be used when necessary to deliver the fetus by breech traction. forceps delivery head: single-leaf forceps can be used. The operator holds the forceps in his left hand and slowly inserts them into the front of the fetal head under the guidance of the right palm. You can also use two-leaf forceps to pull the fetal head out of the pelvic entrance after buckling, then pull the fetal head upwards toward the pelvis, and then pull the fetal head side to bend the fetal head. Giving birth. The bilobal forceps are suitable for posterior occipital positions with the face forward. If the oblique or lateral position of the fetal head is difficult to correct, cesarean section forceps can be used to place the two temporal parts, and the fetal head can be delivered with anterior or posterior pillow while rotating and pulling.

For those with single buttocks and shallow pelvis, the surgeon inserts his right hand in front of the buttocks and pulls the fetal buttocks toward the uterine incision. At the same time, the assistant presses the bottom of the uterus. . If the foot is exposed first, the operator indicates that the right hand is placed on the popliteal fossa, the thumb is placed on the lower end of the femur, and the two fingers are holding the fetal leg and pulling upwards to flex the fetal knee joint. fetus. If the knee is exposed first, the surgeon uses four fingers to extend below the fetal knee, lifts the fetal knee upwards, flexes the hip joint, and then pulls the fetal foot to traction and deliver. If the buttocks are exposed to the pelvic outlet, both the buttocks or the lower limbs can cause fetal injury. At this time, it should be determined immediately and an emergency incision should be used to deliver the fetal head first.

If the back of the fetus is on, there is generally no difficulty. The surgeon grasps the fetal foot and delivers it by breech traction. If the fetal back is down and the fetal head and lower limbs are higher in the uterine cavity, the surgeon should hold the lower fetal foot along the fetal buttocks, and then pull the fetus along the arcuate path in a prone position and slowly produce a uterine incision. If the fetal foot of the uterine incision is approached by mistake, the tension of the incision will increase due to the fetal turnover, which will easily damage the mother and baby.

6. Placenta cleansing the uterine cavity

After the fetus is delivered, the myometrium is injected with 10U. When the uterus contracts and the placenta is peeled off, you can pull the umbilical cord to hold it to the uterine incision and hold it with your hand. The assistant helps clamp the fetal membrane and make the fetal membrane during rotation. Try not to remain in the uterine cavity. If the placenta is not stripped 5 minutes after the delivery of the fetus, or the uterine incision is bleeding or the placenta is partially peeled off after the delivery, the placenta can be quickly removed by hand. If the placenta, the fetal membrane is intact, the uterus is contracted, and the bleeding is small, it is not necessary to wipe the uterine cavity. Unnecessary operations will destroy the natural hemostatic mechanism of the uterine wound, and sometimes cause increased bleeding. If the placenta or membrane is left, you can use oval forceps to remove it, or wipe the uterine cavity with gauze to let it out. If there is a small placenta adhesion, you can separate it with your fingers or use a large curette to remove it.

7. Suture the uterine incision

The tissues of the uterine incision margin should be exactly aligned, and the 0 or 1 chromium intestinal thread or absorbable synthetic thread is sutured in two layers. The first layer of traditional methods is to avoid the endometrium as much as possible to avoid the formation of endometriosis. However, in recent years, some people believe that the endometrium has no ability to regenerate in late pregnancy and advocate full-layer suture because of its good hemostatic effect. In the past, intermittent sutures were mostly used in the first layer to ensure better blood flow and avoid complete rupture of the uterine incision once the continuous sutures were broken. However, in recent years, continuous sutures have been increasingly used. It is believed that the operation is simple, rapid, and the hemostatic effect is good, and the uterus is a contracted organ. As long as the suture is not damaged, the incision does not need to be concerned. The second layer of traditional suture is continuous or intermittent mattress suture, and continuous mattress suture is now more commonly used. The key is to see the anatomical relationship. As for the suture method, it depends on the situation.

8. Suture the peritoneal reflex

Lift up the peritoneum with vascular forceps and carefully check the suture of the cut edge of the uterus, especially the two horns and the bladder surface for bleeding. Completely stop the bleeding and remove the clot. Suture the peritoneum to fold back.

9. Suture the peritoneal incision

Before closing the abdominal cavity, check the uterus and bilateral accessories for abnormalities. If a tumor is found, it should be removed. Thoroughly remove the peritoneal effusion and blood clots, and carefully count the dressings and instruments.

Midline and midline incision suture method: peritoneum is sutured continuously with round needle and No. 4 silk thread; rectus abdominis sheath is sutured with round needle No. 4 silk thread, and hemostasis should be completely stopped before suture; Pay attention to the level when sewing, strict alignment, not leaving dead space.

Transverse incision suture method: peritoneum, the same as the longitudinal incision suture method. For fascia, use No. 4 or No. 7 or 2-0 synthetic thread. First sew a stitch at the midpoint to ensure accurate alignment, then start the suture intermittently from one end of the incision, or continue suture on both sides. There is no need to layer , You can sew together. Subcutaneous fat and skin are sutured intermittently with a triangular needle, No. 4 or No. 7 silk thread, and the distance between the upper incision edge and the incision is wider than the lower incision edge to keep the incision curved. When stitching, the whole fat layer and the skin are sutured together. Generally, 5 stitches can align the cut edges neatly.

After the operation, properly cover the incision, compress the palace floor, and squeeze out the blood clot in the uterine cavity. During the operation, the mouth of the uterus has not been expanded. The operator or assistant keeps the sterility. After disinfecting the vulva, the hand is extended into the vagina to expand the cervix to facilitate the drainage of Lilu and clear the blood in the vagina.

1. Do not use too much force when cutting the skin and subcutaneous fat, and cut it layer by layer to prevent accidentally cutting the uterus and damaging the fetus.

2. Make the subcutaneous tissue and skin incisions large, avoiding large outside and small inside.

3. Fully estimate the thickness of the abdominal wall, do not use too much force to go straight into the abdominal cavity, and even cut the uterus by mistake and damage the fetus.

4. When opening the peritoneum, be careful not to damage the intestines and bladder. For women with a long labor period and an elongated lower uterine segment, the bladder can rise as the lower uterine segment expands, and the intestinal canal moves to the front of the uterus due to flatulence. When opening the peritoneum, it must be clearly identified.

5. Do not press down with force when incision of the uterine wall, so as not to hurt the fetus.

6. After puncturing the fetal membrane, promptly suck up the amniotic fluid and clamp the open blood sinus to prevent amniotic fluid embolism.

7. When the fetal head is pulled out from the uterine incision in the breech or lateral position, it should not be too fierce, in order to reduce the sudden expansion, rupture and bleeding of the fetal cerebral blood vessels due to external pressure.

8. When suture the uterine incision, do not overly dense or too thin, carefully discern the anatomical relationship, do not fold the posterior wall of the uterine body at the junction of the lower segment with the uterine incision and mistakenly close the uterine cavity.

Supine hypotension syndrome

Often occurs during cesarean section under epidural anesthesia.

Reasons: due to supine pregnancy, uterine compression of the inferior vena cava caused insufficient blood volume; epidural anesthesia was too wide, extensive sympathetic nerve block caused peripheral blood vessels to dilate, venous blood volume decreased, and even due to sympathetic nerve block Reduces myocardial contractility. Reduced effective circulating blood volume, causing blood pressure to drop or accompanied by dizziness, and even syncope.

Prevention and treatment: Make up for blood volume as much as possible before dehydration and blood loss; Select a needle in the L2 L3 of the waist to prevent the anesthesia level from becoming too high; When performing intravertebral block, first establish a venous channel to supplement blood volume in time; During the operation, take the left 15 ° 30 ° supine position, or change the left supine position after the blood pressure drops in the supine position; The operation should be light after entering the abdominal cavity to avoid pulling stimulation; oxygen inhalation; when the blood pressure drops to 90 / 60mmHg Or when the original value is reduced by 20%, fetal distress may occur. Necessary boosting treatments should be performed, such as limiting anesthetic medication, accelerating the rate of fluid replacement, using ephedrine 15 to 20 mg intravenously, etc., and stopping the operation as soon as possible after the blood pressure rises. Give birth to a fetus.

2. Abnormal uterine bleeding

(1) Uterine incision bleeding: When performing a low cesarean section of the uterus, if the incision site has large blood vessels, or if the placenta is attached to the anterior wall of the uterus or is adjacent to the incision, the incision bleeding will be more.

Treatment: If large varicose veins are found on the surface of the uterine wall during the operation, the blood vessels can be sutured above and below the predetermined incision to avoid bleeding when the uterine wall is cut. In case of uterine incision bleeding, the bleeding site can be clamped first, the placenta is delivered, and the uterine incision is quickly sutured after the uterine cavity is cleaned to stop bleeding. Generally, the hemostasis can be stopped after conventional uterine incision. If there is still bleeding, intestinal or silk suture can be used to stop bleeding. Note that the suture should not penetrate the endometrial layer. Both sides of the suture incision should exceed about 0.5cm, so as not to miss the seam due to vascular shrinkage.

(2) Uterine incision laceration and bleeding of vascular rupture: Uterine incision laceration during cesarean section is common in cesarean section of inferior uterine transverse incision. Incisional lacerations can be down the cervix, even extending to the upper part of the vaginal wall, or transversely to the sides. The lacerations can spread to the uterine blood vessels and even extend to the broad ligament.

Common causes of uterine incision laceration include small uterine incisions, low uterine incisions, too large fetal heads, too low fetal heads, prolonged labor, local compression caused by tissue edema, excessive head labor, improper exertion or rough manipulation.

Prevention: The height of the uterine incision is generally 1.5 ~ 2.0cm below the reflex peritoneum. The incision of the fetus with deep fetal head should be slightly lower. You can choose 3cm below the reflex peritoneum. The size of the incision is usually 10-12cm. Should be upwardly curved. For fetal head incarcerated pelvis, the vulva should be disinfected before the operation. Once the fetal head is difficult to deliver, the assistant can push the fetal head from the vagina, which can reduce the difficulty of the operator's head. The fetal head can be turned into a pillow when giving birth. Anterior or occipital transverse position to reduce the diameter of the fetal head delivery, be gentle when turning the fetal head. Double-leaf forceps can also be placed to pull out the fetal head to avoid tearing the uterine incision due to violent delivery.

Treatment: Quickly clamp the torn tip of the incision and bleeding blood vessels, sew up and stop bleeding in time, do not sew too densely, cause poor blood supply and cause late postpartum hemorrhage. When the laceration extends to the broad ligament, be careful not to damage the ureter, and if necessary, free the ureter before ligation and hemostasis.

(3) Local bleeding on the inner surface of the uterine cavity: Most are placental hemorrhage, especially the detached surface of the placenta previa, which is characterized by local bleeding even when the contraction is good. The bleeding site can be sutured quickly using the intestinal line "8" after seeing the bleeding site, but care must be taken not to penetrate the entire uterus and accidentally damage the surrounding tissue.

(4) Flaccid uterine bleeding: It is the most common cause of postpartum hemorrhage. The following measures can be taken:

Drug treatment: multi-point injection of oxytocin 20U uterine body and lower uterine segment, or ergometrine 0.2mg intravenously or injection into the lower uterine segment, or (and) carboprost 1mg oral or anal.

Massage the uterus: Lift the uterus out of the abdominal cavity, massage the uterus with both hands or warm saline gauze to massage the uterus.

Packing the palace gauze: When the above method is ineffective, the palace gauze can be packed. After it is proved to be effective, one end is placed in the vagina through the cervix, and then the uterine incision is sutured. The gauze can be removed after 12 to 24 hours.

Stitching large blood vessels: When the above methods are not effective, the ascending branch of the uterine artery or the internal iliac artery can be ligated. Blood vessels can be reopened in the future, and fertility can still be retained.

Removal of the uterus: When the above methods are ineffective, cut the uterus immediately and avoid irreversible shock.

(5) Placental adhesion or implantation bleeding: Generally, the incision is used to stop bleeding by intestinal line "8" suture. If it is invalid, the uterine artery can be ligated, and the uterine cavity can be packed with gauze. The uterus is removed if necessary.

3. Organ damage

(1) Bladder injury: Bladder injury during cesarean section is seen in the following cases: accidental injury due to adhesion or high bladder position when incision of the parietal peritoneum; injury due to adhesion when the bladder is separated from the lower cesarean section; separation of extraperitoneal cesarean section Bladder fascia is damaged; the uterine incision is torn and the bladder is involved when the fetal head is delivered. In case of damage, repair in time. Use 2-0 or 3-0 intestinal suture to close the bladder muscle layer and serous muscle layer. It is best not to penetrate the mucosa to prevent the formation of stones in the future. Postoperative catheterization was continued for 7 to 14 days, and antibiotics prevented infection. Prompt discovery and timely repair have a better prognosis.

(2) Intestinal injury: Intestinal injury is rare during cesarean section. It is seen in those with extensive pelvic and abdominal adhesions caused by a previous history of abdominal surgery or severe infection of the pelvic and abdominal cavity. Treatment: It was found that the small intestine was repaired immediately, and the postoperative gastrointestinal decompression was given broad-spectrum antibiotics. For colon injury, fistulas can be made first to control abdominal infections. After the wounds have healed, the colon fistula can be closed. Those with minor injuries can also be repaired directly.

(3) Ureteral injury: ureteral injury is rare during cesarean section. It occurs when the uterine incision tears and affects the ureter, or it is caused by bleeding from the laceration, blind clamping, suture, and hemostasis. It can also be seen after cesarean section. Time. It is very important to detect and repair in time after the injury. Once the ureteral vaginal fistula is formed, it will cause great pain to the mother.

4. Amniotic fluid embolism

Causes of amniotic fluid embolism during cesarean section: The intrauterine pressure is too high, such as ankylosing uterine contraction, squeezing the uterine base to make the intrauterine pressure too high, and the amniotic fluid enters the mother along the lacerated internal cervical vein or placental marginal sinus. Blood circulation; abnormal opening of uterine blood vessels, such as uterine rupture, placenta previa, placental abruption, etc., cause abnormal opening of uterine blood vessels, and amniotic fluid enters the blood circulation of the mother; open uterine incision blood vessels, classical caesarean section is more likely to occur.

The clinical manifestations are related to the amount of amniotic fluid and traits that enter the mother's blood. The milder ones only show transient chills, chest tightness, and severe ones can cause breathing difficulties, cyanosis, shock, DIC, etc.

Preventive measures: After incision of the uterus and rupture of the membrane, absorb the amniotic fluid in time, and give birth to the fetal head. The uterine incision is large enough to prevent the intrauterine pressure from increasing due to excessive resistance when the uterine fundus is squeezed. After the residual amniotic fluid is sucked off, the placenta is delivered.

5. Postoperative complications and management

The morbidity and infection after cesarean section are 10-20 times that of vaginal delivery. Bacteria invade the surgical incision and the placenta peeling surface through various ways, causing genital and systemic infections during puerperium. In addition to cesarean section infection, in addition to bacterial species, quantity and toxicity, the body's disease resistance is an important factor.

Susceptibility factors: pregnancy with malnutrition, anemia, diabetes, reproductive tract infections and premature rupture of membranes, prolonged labor, frequent vaginal examinations and anal examinations and intra-fetal monitoring, poor anticoagulant function, poor disinfection, and equipment pollution .

Treatment: For patients with susceptible factors, preventive application of antibiotics before and after surgery is recommended for extraperitoneal cesarean section. Those who have been infected should be given sensitive or broad-spectrum antibiotics.

In addition to the infection of the abdominal wall and uterine incisions, in addition to general susceptibility factors, it is also related to suture reactions, necrosis of sutures, and hematoma formation. Uterine abdominal wall fistula is caused by uterine incision infection, necrosis, and adhesion to the abdominal wall to form a fistula. The diagnosis of uterine abdominal wall fistula is mainly based on lipiodol angiography or injecting methylene blue solution into the fistula to observe whether it flows out through the vagina. Removal of abdominal wall incision infection is feasible for those with a small range of infection, and wide range should be expanded to remove necrotic tissue and sutures as much as possible to promote wound healing. For those who have developed a fistula of the uterus and abdominal wall, the treatment methods are: local drainage, scraping, stuffing with iodine gauze strips, and antibiotic treatment to close the fistula; open the fistula to explore and remove the fistula; severe cases need to remove the uterus.

Factors affecting uterine incision healing: Systemic factors: anemia, infection, hypoalbuminemia, vitamin B and C deficiency, and inappropriate application of corticosteroids are not conducive to incision healing. Incision site: Transverse incisions in the lower part of the uterus are superior to various incisions in the uterine body, but incisions at the interface between the lower uterus and the body also prevent the incision from healing. Operation: The tightness and density of the suture should be moderate, the joints should be neat, and the hemostasis should be reliable, but multiple blind sutures should be avoided.

Treatment: Intensive supportive treatment, application of broad-spectrum antibiotics and uterine contraction agents. For those who are not effective in conservative treatment of severe late postpartum hemorrhage, necrotic tissue should be removed and sutured. If the infection is severe, hysterectomy can be considered.

Refers to the major bleeding that occurs during the puerperium 24 hours after surgical delivery, which usually occurs 2 to 6 weeks after surgery, and most often occurs within 10 to 19 days after surgery.

Reasons: Incomplete restoration of the placenta attachment site: The infection of the placenta attachment site is often affected by infection, and bleeding occurs when the local decidua falls off. Poor healing of the uterine incision or dehiscence of infection: often caused by uterine incision bleeding during surgery, repeated sutures are too dense and tight. Residual bleeding of placenta and membrane: rare. endometritis.

Treatment: Use one or more tocolytics. Apply broad-spectrum antibiotics. In case of suspected placenta and fetal membrane residue, the above treatment can be performed for 3 to 5 days, and uterine cervix surgery should be performed after preparation for open surgery. When the above treatments are ineffective, vascular embolization or uterine resection can be performed.

There are two types of thromboembolic phlebitis after cesarean section, namely septic pelvic thrombophlebitis caused by infection and pelvic and lower extremity venous thromboembolism caused by non-infective factors.

Septic thrombophlebitis: It is a severe and rare pelvic infection comorbidity, which is common in puerperal infection or post-cesarean infection. It is divided into pelvic thrombophlebitis and lower limb thrombophlebitis.

Patients with pelvic and lower extremity venous blood flow are slow after operation. If there are infectious factors, pelvic phlebitis may be caused.

Clinical manifestations and diagnosis: Pelvic thrombophlebitis is usually unilateral, and chills, high fever, and lower abdominal pain, cervical pain, uterine tenderness, and deep periuterine tenderness often occur in the first 2 weeks after delivery. Gynecological examinations can cause rapid high fever due to bacteremia. Blood bacterial cultures were positive. The affected side of the thrombophlebitis of the lower extremity is painful, swollen, skin is white, and the local temperature is increased. Sometimes it can touch the hard cord and tenderness caused by venous embolism. Gastrocnemius and plantar pain and tenderness occur during deep vein thrombosis of the lower leg, and dorsiflexion of the ankle can cause tension pain in the deep muscle of the lower leg. It can also assist in diagnosis by measuring lower limb venous pressure or ultrasound Doppler measurement of lower limb blood vessels. Thrombophlebitis of the lower limbs has a long course, and often the swelling will gradually disappear after the collateral circulation is established.

Treatment: bedridden, raising the affected limb; strong and effective antibacterial drugs are selected; 50mg of heparin is added to 200ml of 5% dextrose solution, intravenously for 6h, and continuously used for 10d. Generally, the condition can be improved within 1 to 2d after treatment, and those who have failed heparin treatment should Consider the presence or absence of pelvic abscess; venous thrombosis of lower limbs can be treated with urokinase and low molecular dextran on the basis of heparin. Surgical treatment is only applicable to those who have failed drug treatment, continued expansion of septic thrombus, and contraindication to anticoagulation. The surgical scope includes inferior vena cava ligation, ovarian vein ligation, and lower limb vein ligation. Continue to use antibiotics and anticoagulation after surgery.

Non-infectious thrombophlebitis

Causes: Hypercoagulable blood in late pregnancy, slow venous blood flow in the pelvic cavity and lower extremities; blood condensing and vascular wall damage during pregnancy complicated with pregnancy-induced hypertension; lower limb venous expansion and blood flow stasis during cesarean section and epidural Postoperative supine position, less movement; intravenous fluid infusion.

Clinical manifestations and diagnosis: Except for the high fever caused by infection factors, the clinical manifestations are similar to sepsis and thrombophlebitis. "Pulmonary swelling" is caused by the formation of thrombosis in the deep and superficial veins of the lower limbs, which is specific. Symptoms of deep vein thrombosis of the lower leg are hidden, and the edema is not obvious.

Treatment: Similar to septic thrombophlebitis, for those who have arterial spasm and cause severe pain, vascular spasmolytic agents such as papaverine and torasoline can be applied. For conservative treatment, deep venous thrombectomy is feasible.

Occasionally, mechanical intestinal obstruction is mostly caused by intestinal adhesions. Paralytic intestinal obstruction can develop from severe abdominal distension or mechanical intestinal obstruction. The main treatment is gastrointestinal decompression, fluid replacement, and anti-inflammatory. When conservative treatment is not effective, a laparotomy should be performed as soon as possible.

Endometriosis after cesarean section is common in the abdominal wall incision, the induration increases with menstrual cycle with pain, and the conservative treatment is not effective. Do not sew the endometrium when suture the uterine incision. Careful irrigation of the incision may avoid endometriosis after cesarean section.

Newborns born by cesarean section, because they are not squeezed by the birth canal, lack plasmin and immune factors in the body, are prone to hyaline membrane disease and cause respiratory distress, which is called cesarean section syndrome. Its clinical features are normal at birth, onset 4 to 6 hours after birth, progressive dyspnea, and gradually appearing symptoms of cyanosis with hypoxic symptoms such as expiration moaning. It is more likely to occur in preterm, IUGR and diabetic neonates. In order to prevent cesarean section syndrome, the left side is tilted 15 ° -30 ° during operation. Pay attention to the depth of anesthesia. For high-risk neonates, lecithin preparations can be administered by intratracheal drip or ultrasonic nebulization. Treatment includes measures such as thermal insulation, keeping the airway open, inhaling oxygen, correcting water, electrolytes, and acid-base balance, and prophylactic antibiotics.

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