Preoperative Diagnosis: (1) Pregnancy, uterine, nondelivered at 40+3 weeks estimated gestational age, (2) arrest of dilation.
Surgeon: Randy Chornack, M.D.
Anesthetist: Dr. Androsini
Anesthesia: Continuous lumbar epidural
Operation Performed: Lower primary cesarean section with Pfannenstiel skin incision and low transverse cervical uterine incision.
Indications For Surgery: The patient is a 29-year-old female, G1 P0 (this abbreviation means the first pregnancy, and that the patient has never delivered a child), last menstrual period May 24, who presented at 40+3 weeks estimated gestational age in early active labor. The patient had progressed through the transition phase at which time an intrauterine pressure catheter was placed due to difficulty assessing contractions on the external monitor. She progressed to 6 cm with fetal vertex at 0 station and in the occiput anterior position. She was contracting every two to three minutes with contractions that were 64, representative of adequate labor. The fetus had an episode of bradycardia to the 80s lasting approximately 10-12 minutes which responded to resuscitative measures including positioning and application of oxygen with a return to a baseline of 160s with some hypervariability; however, no further deceleration (slowing of fetal heart rate). In the face of adequate spontaneous labor and failure to progress beyond 6 cm for a period of two and a half hours, decision was made to proceed to primary cesarean delivery.
Findings: At 10:03 p.m. the patient was delivered of a liveborn female infant with Apgar scores of 9 and 9 and weight of 3,422 grams.
Description of Operation: In the OR under continuous lumbar epidural, the patient was prepped and draped in the usual fashion for cesarean delivery including sterile insertion of Foley catheter. She was placed in the supine position with a right hip role. A Pfannenstiel skin incision was made, the rectus fascia was dissected off of the underlying muscles that were then separated in the midline and the peritoneal cavity was entered. The visceroperitoneum overlying the lower uterine segment was elevated, incised, and the bladder was dissected away from the lower uterine segment. A low transverse cervical incision was made and was extended with the bandage scissors. The amniotic cavity was entered, revealing moderate meconium.
The fetal vertex was palpated, elevated and delivered. The baby was suctioned on the maternal abdomen. The remainder of the infant was delivered. The cord was doubly clamped and cut. The infant was passed up to the pediatricians in attendance. The placenta was manually extracted intact. It was a three-vessel cord. Pitocin and 2 gm of Ancef were added to the IV fluid after delivery of the placenta.
The uterus was exteriorized and the uterine incision was examined. There was found to be a right inferolateral extension. There was also noted to be dissection in the myometrial layers of the lower uterine segment where a venous sinus had been entered with copious bleeding. This was controlled with interrupted figure-of-eight sutures and reapproximation of the myometrial layers. Closure of the right inferolateral extension incorporated the right uterine artery in the repair. This was closed in a running locking fashion with #1 chromic suture, as was the remainder of the uterine incision. Good hemostasis was obtained. The bladder flap was then approximated using a running stitch of 2-0 chromic suture. The abdominal cavity was thoroughly irrigated and suctioned free of clots. The uterus was returned to the abdominal cavity, the parietal peritoneum and the fascia were closed. The subcutaneous tissues were thoroughly irrigated and found to be hemostatic. The skin was closed with staples and sterile dressing was applied. The patient left for the recovery room in stable condition. She received 2400 cc of lactated Ringer's interoperatively and had 125 cc of urine output. Estimated blood loss was 1,000 cc.
The patient tolerated the procedure well. There were no complications.
Addendum: The pediatricians suctioned the infant postpartum, revealing no meconium below the cord.