Cesarean Section (C-Section)

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.