Assisting in lower segment cesarean section

this slide includes the role of assistant surgeron in lscs surgery

1. Assisting in Lower Segment Cesarean section Prakat aryal Intern ; Department of Obstetrics and Gynecology.

2. Introduction Surgical method of delivering the baby. Surgical procedure combining laparotomy and hysterotomy for delivery of fetus. Most common operation performed worldwide. Dates back to ancient romans; previously done always to save the baby done these days safely for various indications.

3. LSCS Newer, more beneficial technique of cesarean delivery. Includes a transverse cut just above the edge of the bladder Less blood loss Easier to repair Better healing.

4. Indications Previous C.S Dystocia or dysfunctional labor: -Cephalopelvic disproportion - Tumors complicating pregnancy - Fetal macrosomia - Malpresentations - Abnormal uterine action - Failed forceps or vacuum

5. Contd • Failed induction • Fetal distress and cord prolapse Breech presentation complicated breech and footling presentation Severe intrauterine growth restriction • Multiple pregnancy Antepartum hemorrhage: Placenta previa Abruptio placenta

6. contd Elderly nullipara Prolonged period of infertility or pregnancy following in vitro fertilization • Bad obstetric history • Severe preeclampsia and diabetes

7. Most Common Indications (85% of the cases) • Previous CS (most common) • Dystocia • Fetal distress • Breech Presentation

8. Instruments Surgical blade Scalpel Towel clips Artery Forceps Allice Tissue Forceps Green Armitage Forceps Doyen Retractor Sponge Holding Forceps  Towel Clip Toothed Forceps

9. Contd.. Non toothed forceps Needle Holder

10. Anesthesia General anesthesia Regional anesthesia: spinal / epidural Sellick’s maneuver : rapid sequence induction

11. Procedure Abdominal Incisions Pfannensteil Incision ▫ Most commonly used ▫ Transverse curvilinear incision just above the pubic hairline. Joel Cohen Incision ▫ A modified transverse incision placed about 3 cm below the line joining the anterior superior iliac spines. ▫ Higher than the Pfannensteil incision & not curved.

12. Maylard Incision ▫ Where more exposure needed

13. A transverse skin incision is associated with reduced postoperative pain and is more esthetically acceptable to patients compared with a vertical incision (classic). The Pfannenstiel incision is slightly curved and made 2 to 3 cm above the symphysis pubis. The incision should allow for at least 15 cm of exposure. The skin and subcutaneous fat is incised with electrocautery.

14. Uterine Incision The anterior rectus sheath is incised transversely. The rectus muscles are separated in the midline. The parietal peritoneum is opened. The loose peritoneum over the lower uterine segment is held and incised transversely, for about 10 cm in a semilunar fashion with its edges directed upwards. The bladder is dissected downward and is retained behind a Doyen's retractor placed over the symphysis. Membranes are ruptured by toothed or Kocher’s forceps.

15. Delivery of baby The head is delivered by introducing the right hand gently below it and lifting it up helped by fundal pressure done by the assistant, using one blade of the forceps or, using Wrigley’s forceps. If the head is deep in the pelvis it can be pushed up vaginally by an assistant. The Doyen’s retractor is removed after the hand or forceps blade is applied and before head extraction. Suction for the fetus is carried out before delivery of the head. In breech or transverse lie the fetus is extracted as breech. Once the umbilical cord is clamped and cut, it is time to deliver the placenta via spontaneous extraction

16. If the presentation is breech, ▫ The feet are hooked out. ▫ The rest of the baby delivered as in case of a vaginal breech delivery. Transverse or Oblique lie, ▫ Corrected to a longitudinal lie before the uterine incision is made. If transverse lie with ruptured membranes and an undeveloped lower segment, ▫ Extension of the uterine incision may be needed

17. Gentle traction is placed on the cord and oxytocin is used to enhance uterine contractions. The placenta is checked to make sure it is complete and the uterus is explored with one hand/ moist pad to remove any remaining membranes or placental tissue. The uterus is than massaged to promote contraction. Oxytocin is given to promote uterine contraction and involution.

18. Repair of the uterus Oxytocin infusion is started. ▫ Placenta and membranes are removed by controlled cord traction. ▫ The uterine edges are held with Allis forceps or green- Armytage forceps. Repair of the uterus can be facilitated by manual delivery of the uterine fundus through the abdominal incision. Externalizing the uterine fundus facilitates uterine massage, the ability to assess whether the uterus is atonic, and the examination of the adnexa.   Repair of a low transverse uterine incision should be performed in either a 1-layer or 2-layer fashion with 0 or 2-0 chromic or polyglactin suture. 

19. The first layer should include stitches placed lateral to each angle, with prior palpation of the location of the lateral uterine vessels. Any bleeding site is checked and closed with figure of 8 suture Once the uterus has been closed, attention must be paid to its overall tone. If the uterus does not feel firm and contracted with massage and IV oxytocin, consider intramuscular (IM) injections of prostaglandin (15-methyl-prostaglandin, Hemabate ) or methyl-ergonovine, and repeat as appropriate

20. If the uterine incision is hemostatic, the uterine fundus is replaced into the abdominal cavity (unless a concurrent tubal ligation is to be performed). The incision is re-inspected for hemostasis The paracolic gutters are visualized, and any blood clots are removed with laparotomy sponges.

21. Closure of the Abdomen Closed in layers after confirming mop and instrument count. The parietal peritoneum need not be closed.[Peritoneal closure is no longer recommended as it is associated with increased adhesion formation and may increase surgical time as well as length of hospital stay.] The rectus sheath is carefully approximated with delayed absorbable sutures to minimize the chance of wound dehiscence. The skin approximated with mattress sutures, a subcuticular suture or clips.

22. Post Operative Care First 6-8hrs, monitor the vitals and look for vaginal bleeding and condition of the uterus. First Day, paraenteral fluids are given, blood transfusion if needed,antibiotics , thromboprophylaxis, breast feeding after 4hrs & oral fluid started after 6hrs. Second day, catheter and dressing removed and early ambulation. Third day, light solid diet can be started

23. Assisting LSCS as an intern doctor ROLE OF THE SURGICAL ASSISTANT The surgical assistant is responsible for assisting the surgeon under direct and indirect supervision throughout preoperative, intraoperative, and post-operative duties and procedures at all times. Preoperative: Preparation of patient for the surgery( assessing surgical fitness, preop investigations, arranging blood that may be required, counselling, consent, shifting patient to OT.) Introduction of indwelling catheter Skin prepared by antiseptic solution and draped

24. Intraoperative Ensuring the primary surgeon's view remains unobstructed Employing sutures to hold body tissue together Packing surgical openings with sponges to soak up blood and Securing retractors to hold back tissue. Assistant surgeons sometimes help the primary surgeon achieve hemostasis(electrocautery, suction, mop), which is to stop bleeding so the surgery can proceed

25. Postoperative Asses post op vitals ; urine output ; post op Hb . Clinical assessment of the patient early in the first post operative day. Ensure the surgeon gets enough information to evaluate and decide the further course of management.

26. Thank you. http://work.chron.com/roles-assistant-surgeon-operating-room-21324.html http://www.surgicalassistant.org/index.php/surgical-assisting/surgical-assisting http://tube.medchrome.com/2012/07/cesarean-section-lscs-operative.html https://emedicine.medscape.com/article/263424-overview Dc dutta’s text book of obstretics .