Primary Low Transverse C-Section

CHAPTER 1

So, I'm Juliana Taney. I am an ob/gyn attending at Mass General Hospital in Boston, Massachusetts. And the procedure that we did is a primary low transverse c-section. So, to go through the steps of the procedure, the first step is that you do the skin incision, and then you take that through to the subcutaneous tissues, and you get to the fascia. And once you get to the fascia, you incise the fascia in the center, and then you make sure you're getting through both layers of the fascia, and you extend that incision laterally on both sides. You then lift up the fascia, trying to separate it off from the rectus muscles that are underneath it. And you do that going caudally and also cranially. And then once you do that, you separate the rectus in the midline, and you expose the peritoneum. And then you can either get into the peritoneum bluntly, or sharply, which we did bluntly in this circumstance. Once you get in, you are extending that peritoneal opening to expose the uterus. You then pick up the area around the bladder, and you wanna make sure that you're making a bladder flap. Some people don't always make a bladder flap, but in this scenario we did. And the point of that, is just to bring the bladder away from where you're making the hysterotomy. So at that point, you make sure that everyone's ready for delivery of the baby, and you make the hysterotomy in the lower uterine segment of the uterus. You then extend that opening bluntly, or you can do it sharply if you prefer. In this case, we did it bluntly. And then you extend it enough that you make sure that you have enough space to get the fetal head out. So at that point, after it's extended, you put your hand in, and you put your hand around the baby's head, and you elevate it out of the pelvis, and you bring it to the hysterotomy. You give some fundal pressure to help deliver the baby. And then, once the baby's delivered, you bring the baby over to the warmer, and then you come back, you deliver the placenta, and then you can either exteriorize the uterus, or leave it inside. We exteriorized it in this case. And then you start to close the hysterotomy. So, the hysterotomy is closed in two separate layers. So, one is a running locked layer, and then the other is an imbricating layer. Once you complete the closure of the hysterotomy, you make sure that you have hemostasis. And then once you have hemostasis, you can return the uterus into the abdomen. Once you do that, you again make sure that you have hemostasis, and then you start closing all those layers that you opened up. So, you first will make sure that there's no bleeding on the muscle, and you make sure that the gutters are cleared of all clots. And you make sure that your serosal edge where you brought down the bladder is hemostatic. And then you can start to close the fascia. And so you do that in a running suture. And then once that is closed, you can reapproximate the subcutaneous tissues. You can do that running or interrupted. And then you close the skin.

CHAPTER 2

You can test. Any pain? No. Perfect. We were just pinching you really, really hard. Oh great. Okay. I would go as close to her crease as you can. You can go a little lower. I like hiding it.

CHAPTER 3

Can we get her partner please? Yeah, I'm gonna go call for him. I'll get this started. Skin. Time. Okay, we have fifty-six... We're getting down to the fascia. Making some windows to the rectus. We're gonna spread the subcutaneous tissues. I'll take a rat tooth and Mayo's, please. You can go first.

So you pick up the two layers of the fascia. Spread underneath to separate it off from the rectus muscles. So you can see the two layers here, this is under the first layer. And this is the second layer. All right. I'm gonna take Kochers, times two. So you elevate the rectus - or the fascia, you separate the muscle down. Sometimes you can just push. You can't push in this case, so you're gonna separate the muscle off of the rectus. Sometimes, you can just push. All right. Now we're gonna go down. And do the same thing. Separate the muscle off from the fascia. So press down anything that might be up against it. We're gonna go right against the fascia. Separate off the muscles until you get all the way down to the pubic bone. Perfect. I'll take a Rich.

So now we're going to get into the peritoneum by separating the rectus muscles. You can see separation there. You go high to avoid any adhesions for the bladder. So, we're in the peritoneum there. We're going to pull. Some pressure here. Yep. Grab your Bovie. So there's a little bit of a band here, as you can see. So we're gonna come through that up high with the Bovie. Keep going to what you can see. Perfect. All right. I'll take a bladder blade. So you can see the bladder on this side and then suppress it with the bladder blade.

Smooth pickups and Metz. We're gonna make the bladder flap. Pull that down a little bit. You go pretty low. You pick up the serosa. Snip, undermine. Other direction, same thing. And then, with your finger pointing towards the uterus so you don't accidentally make a hole in the bladder. And then you replace the bladder blade in front of that. Okay.

CHAPTER 4

Okay. Okay. Uterine. Time. All right, and you spread. And so you see the membranes there. We're gonna rupture membranes. Clear fluid. Clear fluid. Can I have the bed down, please? Bed down. Tell me when you want that out. Okay, bladder blade out. You can take the Rich out. All right. The head's up. Some fundal pressure. Hey, when you get a second, your step's here. Keep going. Do you want me to bring it in closer for you? So if the baby's head's not coming out properly, you can cut the muscle. Okay. Okay, go. Keep pushing. Okay, time. (baby cries). There you go. Hold on one sec. Can you bring him over? Sure. (baby grunts and cries). Pause, pause, pause. Are you okay with us doing drapes down? Okay. (baby wails). All right, drapes down is good. All right, we're gonna have the pediatricians take a look at him, okay? One minute. One minute. (baby cries). (baby cries). (baby cries).

CHAPTER 5

We massage the uterus and put gentle traction on the placenta through the cord. Okay. Massaging. Pull some of the trailing membranes. Placenta. All right, 09, thank you.

CHAPTER 6

And exteriorize the uterus. (baby cries distantly). Clear out the uterus. I'll grab the top. Clean out the cornua. Can we get our pit going if it's not already going? The pit is at max. Awesome, thank you. One minute after birth. Thanks.

CHAPTER 7

Kochers. What are your thoughts? We're fine. Okay. I'll take a stitch. Perfect. Bladder blade back. Russians. Thanks. Make sure you get your apex. Needle down, protected. You can take that off. Snap. Tag the corner. And then you have to hold that. If it's thick, you'll have to take it in two. These are lock stitches. I need some more slack on it. 15, 16, 17, 18, 19, 20. Thank you. Do you have the scissors, please. Mhm. Okay. The count's correct. Now you go parallel to the incision for an imbricating stitch. Do you want gases? No.

CHAPTER 8

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CHAPTER 9

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CHAPTER 10

So, during this procedure in particular this patient had an extensive history of spinal surgery. And so, there was a question at the beginning as to whether or not she would be able to achieve adequate anesthesia with an epidural or a spinal. And so, there was consideration of potentially needing to do the procedure under general anesthesia if after placing the spinal or the epidural, she didn't have adequate pain control. She did in this case, and so we didn't end up having to do it under general anesthesia. And so, under general anesthesia, you just try to do things a little bit more efficiently, because we know that the anesthetic can pass through the placenta. But in this case, we were able to do it slowly and controlled because her epidural worked, which is great. The other thing that I'll point out in this procedure is delivery of the fetal head was a little bit challenging. So part of that is you have to ensure that you have enough space in the lower uterine segment and also the tissues that are around the lower uterine segment that would also be holding up the delivery of the head. And so in this case, we ended up cutting her rectus muscle on the left side in order to give us a little bit more space. And that is a lot of the time, one of the first things that you try to do if you're noticing that the rectus is the thing that's holding up delivery. And so, a lot of the times what I do before I even deliver the baby, is I feel for what might be the tightest part that would be hindering the delivery of the fetal head, in case we have a hard time. And so in this case, it was the rectus muscle. So you can just cut that and then that gives you a little bit more space. And as you can see in the video, that helped us in achieving delivery of the baby.