In the Name of God

Obstetrics Study Guide

2

Mitra Ahmad Soltani

2008
 References
1- All India Medical Pre PG. Fetal maturity &length of foetus. 2007.
See: www.aippg.net/forum/viewtopic.php?t=33005
2-Brinholz J. Gestational age.American Journal of Roentgenography. 1984. 142 (4): 849
3- Cunningham G, Gant N, Leveno K, et al. Williams Obsterics. 22nd Ed . New York : Mc
Graw Hill, 2005.
4- Durham J .Transition to Parenthood: How accurate is your due date. 2004
see: www.transitiontoparenthood.com/ttp/parented/pregnancy/duedate.htm and
www.pregnancy.about.com/library/weekly/aa042197.htm
5- Friedman E. Obstetrical Decision Making. Harvard Medical School. 1981
6- Military Obstetrics and Gynecology. BrooksidePress. Estimating Gestational age.
2006
See: www.brooksidepress.org/.../Pregnancy /estimating_ gestational_age.htm
7-Mitchell P. A Comparison of Gestational Age Information Derived from the Birth
Certificate, 1990 1998 . Alaska Vital Sign.2000. 8 (1):1-7
See: www.hss.state.ak.us/dph/bvs/PDFs/vitalsigns/avs_0801.pdf
8- Mittendorf R, Williams M, Berkey C, Cotter P. . The Length of Uncomplicated Human
Gestation. Obstetrics & Gynecology.1990 . 75(6):929-932
Pictures and material on Breech and C/S are adapted from emedicine e-
Journal with permission:
9-Fischer R. Breech Presentation.emedicine.2006
10- Sehdev H. Cesarean Delivery. emedicine. 2005
Gestational Age
Determination
 1- Ngeles Rule
This was developed in the 1850s by Dr. Ngele.
To calculate this, one should add 7 days, and
then subtract 3 months from LMP.
((LMP + 7 days) - 3 months) = Expected Date
of Delivery
Example: ((the LMP on 1st April + 7 days) - 3
months) = January 8
This rule doesnt take into account the fact
that many women are uncertain of the date of
their last menstrual period, not all women have
28 day cycles, and not all women ovulate on
day 14 of their cycle.
 2- Mittendorfs Rule
To calculate Mittendorfs Rule, one
should add 15 days for first time
Caucasian women, or add 10 days if
non-white or this is not the first baby.
Then subtract 3 months.
((LMP + 15 days) - 3 months) =
Expected Date of Delivery for first time
pregnant Caucasian women
Example: (( LMP on 1st April + 15 days)
- 3 months) = January 16
 3- Ultrasound:

Measurement of a Crown-Rump Length

during the first trimester (1-13 weeks) will
give a gestational age that is usually accurate
to within 3 days of the actual due date.
During the second trimester (14-28 weeks),
measurement of the biparietal diameter
will accurately predict the due date within 10-
14 days in most cases.
In the third trimester, the accuracy of
ultrasound in predicting the due date is less,
with a plus or minus confidence range of as
much as 3 weeks.
 FL
Femur length measurements can have a
correlation coefficient of 0.995 with
gestational age in a group of healthy
fetuses with known date of conception.
Nevertheless, it still cannot be used
exclusively because it may be relatively
short in the presence of growth retardation,
or long when growth acceleration has
occurred, introducing comparable errors in
age estimate if the underlying growth
pattern is not appreciated.
 4- Heart Tone:
Fetal heartbeat can be heard through
Doppler starting at 9-12 weeks and
by stethoscope at 18-20 weeks.
This event, however, is less accurate
because the mother is not
permanently attached to a Doppler
device so the first heart beat can not
be clued definitely.
 5- MacDonald's Rule
Fundal Height (the distance from the
symphysis pubis joint to the fundus of
uterus) can be a rough estimate of
gestational age.
Typically, from week 24 to week 34,
fundal height in centimetres
correlates with weeks of gestation.
For example, at 28 weeks, the fundus
is probably about 28 cm.
If a tape measure is unavailable, some
rough guidelines can be used:
At 12 weeks, the uterus is just barely
palpable above the pubic bone, using
only an abdominal hand.
At 16 weeks, the top of the uterus is
1/2 way between the pubic bone and
the umbilicus.
 At 20-22 weeks, the top of
the uterus is right at the
umbilicus.
At full term, the top of the
uterus is at the level of the
ribs. (xyphoid process).
 6- Quickening
Some believe the baby will come five
months after quickening, the first time the
mother feels the baby move.
This is hard to evaluate, as women can be
more or less sensitive to these sensations,
and may notice them at different times in
their pregnancies.
First time mothers typically notice
movement around 18-20 weeks. Mothers
who have been pregnant before notice it as
early as 16 weeks.
 7-Length of fetus
a- Crown-Rump Length: CRL is
measured in first half of pregnancy;
that is, up to 20 weeks measure from
the Vertex to Coccyx. The fetal
length is more helpful in prematurity
than in post maturity, because after
term the confidence interval for
estimation surpasses 3 weeks.
 CHL- Hasses rule
b- Crown-Heel Length :
CHL in the first half of pregnancy is the
number of lunar months x 4. The CHL of
a 4 month fetus is 16cm :
4x4=16 cm
From the end of 20 weeks in the second
half of pregnancy, CHL in cm is the result
of multiplication of the number of lunar
months at the time of the assessment by
5. The CHL of an 8-month fetus is 40 cm:
8x 5 =40 cm
Normally, at the end of the
following weeks gestation:
Before 20-24wks, the height of the fundus
from pubic symphysis to umbilicus
multiplied by 2/7 equals duration of
pregnancy in lunar months or x
8/7=duration of pregnancy in weeks.
After 20 weeks, the fetal length in inches is
equal to half of the number of gestational
age in weeks. For example at 28wk the the
height of the fundus from pubic symphysis
to umbilicus is 14 inches.
8-Estimation of fetal weight
in grams:
Johnsons Formula
(applicable only in Vertex presentation):
Fundal height (cm) above the pubic
symphysis minus 12 if Vertex above
Ischial Spine or minus 11 if below Ischial
Spines- should be multiplied by 155.
This will be fetal weight in grams.
e.g., 32(fundal height)-12(constant)
x155( constant) => 20 x 155=3100gms
 9-Changes in Weight Gain:

Normally there is a steady increase

in weight of a pregnant woman until
the last 2-3 weeks of pregnancy. The
woman stops gaining weight at about
term. It may remain stationary or
may begin to fall which means that
pregnancy is at least mature.
 Weight gain
In normal pregnancy the weight gain
should not exceed 2 kilograms in any
one month or 0.9 kg in a week. The
maximum permissible weight gain
throughout the whole period of pregnancy
is about 10 or 11 kg (about 24 lbs)
although 12 kg is allowed1/3rd of this
weightincreases in the first 20 weeks,
and another 1/3rd in the next 10 weeks.
The Remaining 1/3rd would be gained
between 30 weeks to term.
 10- The age from
conception:
The date of conception from a
basal body temperature chart
or known time of intercourse
is the best measures for
gestational age determination.
But, relatively few women can
state the events.
Algorithm of uncertain date
management
 LNMP

known Unknown or uncertain

Nagele Rule
Gathering other data:
1-Date of intercourse
Matches clinical 2- Date of positive
gestational age Pregnancy test
3-Signs of pregnancy
4-First heard FHR
Accepted
5-Quickening
6-Rate of uterine growth
Doesnt match with
clinical gestational age

Ultrasound

US does not match clinical gestational age.

Either wrong estimate of gestational age or
IUGR
ROM
 SROM
Membrane rupture without
spontaneous uterine contractions
happens in 8% of term pregnancies.
At Parkland Hospital labor is
stimulated with oxytocin when
ruptured membranes are diagnosed
at term and labor does not
spontaneously ensue.
Which is an unreliable sign
for chorioamnionitis?
A-T=>38 c
B-maternal and fetal tachycardia
C-fundal tenderness
D-maternal leukocytosis

Answer:d
 Sample Chorioamnionitis
Order
General: condition/position/diet=NPO
Lab: CBC diff, MP, WW, B/C X2, U/A ,
U/C,CXR,BUN/Cr
IV : 1000cc Ringer +10 units of oxytocin
start at
2 drops /min, add 2 drops every 15 min if
FHR and contractions are normal
Amp ampicillin 2gr iv qid +gentamicin im 80mg
stat then 60 mg TDS
AMP clindamycin 900 mg iv TDS for allergic
women to penicillin(continue antibiotics after
delivery until the mother is a febrile
OTHER: Control of vital sign hourly
 Induction Indications
1) Membrane rupture without
spontaneous onset of labor
2) Maternal hypertension
3) Nonreassuring fetal status
4) Postterm gestation
5) Elective induction for the
convenience of mother or the
practitioner is not recommended.
 Induction contraindications
1) Classical incision or uterine surgery
2) Placenta previa
3) Appreciable macrosomia,
hydrocephalus,
Mal presentations
1) Non reassuring fetal status
2) CPD
3) Active genital herpes in mother
 E2 gel (dinoprostone)
Dosage:
Intracervical gel(Prepidil ):2.5 mL/0.5
mg
Vaginal insert(cervidil) 10 mg
The insert provides slower release of
medication
 E2 administration
An observation period ranging from
30 minutes to 2 hours for uterine
activity and FHR may be prudent.
Oxytocin induction should be delayed
for 6 to 12 hours.
Cautions in patients with glucoma,
severe hepatic or renal impairment,
or asthma are needed.
 E1 misoprostol(cytotec)
Oral , intravaginal but not
intracervical
Possibly superior to E2 gel
Dosage:
25 mcg intravaginal dose
100 mcg oral
 Bishop Scoring System
max=13, min=0
Scor dil ef St. Cervical Cervic
e consiste al
ncy positi
on
0 Close 0-30 -3 Firm Posteri
d or
1 1-2 40-50 -2 Medium Mid
positio
n
2 3-4 60-70 -1 Soft Anterio
r
Oxytocin contraindications

1) ab fetal presentations
2) marked uterine over distension
3) Six or more previous pregnancies
4) Previous uterine scar and a live
fetus
5) CPD
 Oxytocin regimens
Low dose: start with 0.5-1 mu/min (one drop)
add 1 mu/min every 30-40 min up to 20
mu/min
Low dose: start with 1-2 mu/min (two drops)
add 2 mu/min every 15 min up to 20 mu/min
High dose: start with 6 mu/min (12 drops)
add 6 or3 or1 mu/min (according to the
presence of recurring hyperstimulation)every
15-40 min up to 42 mu/min.
When hyperstimulation occurs the infusion
rate is halved.
 oxytocin
Mean half life 5 min,
10-20 units (10000 to
20000 mu) mixed into
1000 mL of lactated Ringer
solution which makes a 10-
20 mu/mL.
Indication for forceps or
vacuum delivery
 Classification of forceps
or vacuum
Outlet: scalp is visible at the introitus
without separating the labia
Low: leading point of fetal skull is at
station=>+2cm and not on the pelvic
floor
Mid forceps: station above +2cm but
head is
engaged
High: not included in the classification
 Contraindication for
vacuum delivery
1) Nonvertex presentations
2) Extreme prematurity
3) Fetal coagulopathies
4) known macrosomia
5) Above zero stations
6) Lack of experienced operator who
would abandoned the procedure if it
does not proceed easily or if the cup
pops off more than three times.
 Vacuum technique
The center of the cup should be over the
sagittal suture and about 3 cm in front of the
posterior fontanel.
The full circumference of the cup should be
palpated both prior to as well as after the
vacuum has been created and prior to traction.
The suction should be increased to a negative
pressure of 0.8 kg/cm .
Traction should be coordinated with maternal
expulsive efforts.
Breech Presentation
Pictures and material are adapted
from :
Fischer R. Breech
Presentation.emedicine.2006
with permission
 Incidence
Breech presentation occurs in 3-4%
of all deliveries.
25% of births prior to 28 weeks'
gestation
7% of births at 32 weeks' gestation
1-3% of births at term
 Predisposing factors
1) Fetus to AF ratio(prematurity,
polyhydramnios)
2) Intrauterine space(uterine
malformations or fibroids, placenta
previa, multiple gestation)
3) and fetal abnormalities (eg, CNS
malformations, neck masses,
aneuploidy),
 Types

Frank breech (50-70%) - Hips flexed,

knees extended (pike position)
Complete breech (5-10%) - Hips
flexed, knees flexed (cannonball
position)
Footling or incomplete (10-30%) - One
or both hips extended, foot presenting
 Vaginal Delivery
Spontaneous breech delivery: No traction
or manipulation of the infant is used. This
occurs predominantly in very preterm
deliveries.
Assisted breech delivery: This is the most
common type of vaginal breech delivery.
The infant is allowed to spontaneously
deliver up to the umbilicus, and then
maneuvers are initiated to assist in the
delivery of the remainder of the body,
arms, and head.
 Total Breech Extraction
Total breech extraction: The fetal feet
are grasped, and the entire fetus is
extracted.
Total breech extraction should be used
only for a noncephalic second twin.
Total breech extraction for the
singleton breech is associated with a
birth injury rate of 25% and a mortality
rate of approximately 10%.
Footling breech presentation:
A singleton gestation should not be
pulled by the feet because this action
may precipitate head entrapment in an
incompletely dilated cervix or may
precipitate nuchal arms. As long as the
fetal heart rate is stable and no physical
evidence of a prolapsed cord is evident,
management may be expectant while
awaiting full cervical dilation.
Assisted vaginal breech delivery1:
Thick meconium passage is common
as the breech is squeezed through the
birth canal. This is usually not
associated with meconium aspiration
because the meconium passes out of
the vagina and does not mix with the
amniotic fluid.
Assisted vaginal breech delivery2:
The Ritgen maneuver is applied to take
pressure off the perineum during
vaginal delivery. Episiotomies are
often performed for assisted vaginal
breech deliveries, even in multiparous
women, to prevent soft tissue
dystocia.
Assisted vaginal breech delivery3:
No downward or outward traction
is applied to the fetus until the
umbilicus has been reached.
Assisted vaginal breech delivery4:
With a towel wrapped around the fetal
hips, gentle downward and outward
traction is applied in conjunction with
maternal expulsive efforts until the
scapula is reached. An assistant should
be applying gentle fundal pressure to
keep the fetal head flexed.
Assisted vaginal breech
delivery5:
The anterior arm is followed
to the elbow, and the arm is
swept out of the vagina.
Assisted vaginal breech delivery6:
The fetus is rotated 180, and the
contralateral arm is delivered in a
similar manner as the first. The
infant is then rotated 90 to the
backup position in preparation for
delivery of the head.
Assisted vaginal breech delivery7:
The fetal head is maintained in a
flexed position by using the
Mauriceau maneuver, which is
performed by placing the index and
middle fingers over the maxillary
prominence on either side of the
nose. The fetal body is supported in a
neutral position, with care to not
overextend the neck.
Piper forceps application:

Piper forceps are specialized forceps

used only for the after-coming head of a
breech presentation.
They are used to keep the fetal head
flexed during extraction of the head.
An assistant is needed to hold the
infant while the operator gets on one
knee to apply the forceps from below.
Assisted vaginal breech delivery8:
Low 1-minute Apgar scores are not
uncommon after a vaginal breech
delivery. A pediatrician should be
present for the delivery in the event
that neonatal resuscitation is
needed.
 Pinard Maneuver
The Pinard maneuver may be needed
with a frank breech to facilitate
delivery of the legs, only after the
fetal umbilicus has been reached.
Pressure is exerted against the inner
aspect of the knee. Flexion of the
knee follows, and the lower leg is
swept medially and out of the
vagina.
 Mauriceau Smellie Veit
maneuver
The flexed position of fetal head can
be accomplished by using the
Mauriceau Smellie Veit maneuver, in
which the operator's index and
middle fingers lift up on the fetal
maxillary prominences, while the
assistant applies suprapubic
pressure.
 Risks1
1) Lower Apgar scores, especially at 1
minute
 Risks 2
Fetal head entrapment . This occurs in 0-8.5%
of vaginal breech deliveries. This
percentage is higher with preterm fetuses
(<32 wk).
Dhrssen incisions (ie, 1-3 cervical incisions
made to facilitate delivery of the head) may
be necessary to relieve cervical
entrapment.
The Zavanelli maneuver involves replacement
of the fetus into the abdominal cavity
followed by cesarean delivery.
 Risks 3
Nuchal arms, in which one or both arms are
wrapped around the back of the neck, are
present in 0-5% of vaginal breech deliveries and
in 9% of breech extractions.
Nuchal arms may result in neonatal trauma
(including brachial plexus injuries) in 25% of
cases. Risks may be reduced by avoiding rapid
extraction of the infant during delivery of the
body.
To relieve nuchal arms, rotate the infant so that the
fetal face turns toward the maternal symphysis
pubis; this reduces the tension holding the arm
around the back of the fetal head.
 Risks4
Cervical spine injury is predominantly
observed when the fetus has a
hyper-extended head (star gazing)
prior to delivery.
 Risk 5
Cord prolapse occurs in 7.5% of all breeches.
This incidence varies with the type of breech:
0-2% with frank breech, 5-10% with complete
breech, and 10-25% with footling breech.
Cord prolapse occurs twice as often in
multiparas (6%) than in primigravidas (3%).
Cord prolapse may not always result in
severe fetal heart rate decelerations because
of the lack of presenting parts to compress
the umbilical cord (ie, that which predisposes
also protects).
 Candidates for vaginal
delivery
1- gestational age>37 weeks
2- EFW< 4000 g,
3-A frank breech presentation is preferred when
vaginal delivery is attempted. Complete
breeches and footling breeches are still
candidates, as long as the presenting part is
well applied to the cervix and both obstetrical
and anesthesia services are readily available
in the event of a cord prolapse,
4-The fetus should show no neck
hyperextension on ultrasound images
 C/S of breech
Maneuvers for cesarean delivery
are similar to those for vaginal
breech delivery, including the
Pinard maneuver (wrapping the
hips with a towel for traction,
head flexion during traction,
rotation and sweeping out of
arm) and the Mauriceau Smellie
Veit maneuver.
 C/S of Breech
Some practitioners routinely perform low
vertical uterine incisions for preterm breeches
prior to 32 weeks' gestation to avoid head
entrapment and the kind of difficult delivery
that cesarean delivery was meant to avoid.
If a low transverse incision is attempted, the
physician should try to keep the membranes
intact as long as possible and move quickly
once the breech is extracted in order to
deliver the head before the uterus begins to
contract.
 Candidates for External
cephalic version
No marked CPD
No placenta previa
Early gestational age is preferred
Vertical pocket of 2 cm or greater
 ECV
Prepare for the possibility of cesarean delivery:
Obtain a type
an anesthesia consult
The patient should be NPO for at least 8
hours prior to the procedure.
Perform an ultrasound to confirm breech,
check growth and amniotic fluid volume, and
rule out anomalies associated with breech.
Perform a NST (biophysical profile as backup)
prior to ECV to confirm fetal well-being.
 ECV
ECV is accomplished by judicious manipulation of
the fetal head toward the pelvis while the breech
is brought up toward the fundus. Attempt a
forward roll first and then a backward roll if the
initial attempts are unsuccessful.
Following an ECV attempt, whether successful or
not, repeat the nonstress test (biophysical profile
if needed) prior to discharge. Also, administer Rh
immune globulin to women who are Rh-negative.
In those with an unsuccessful ECV, the
practitioner has the option of sending the patient
home or proceeding with a cesarean delivery.
 Risks of ECV
fractured fetal bones,
precipitation of labor
premature rupture of membranes,
abruptio placentae,
fetomaternal hemorrhage (0-5%),
cord entanglement ( <1.5%) ,
transient slowing of the fetal heart rate (in as
many as 40% of cases). This risk is believed to
be a vagal response to head compression with
ECV. It usually resolves within a few minutes
after cessation of the ECV attempt and is not
usually associated with adverse sequelae for the
fetus.
Contraindications of ECV
 C/S
Adapted from :
Sehdev H. Cesarean Delivery.
emedicine. 2005
With permission
C/S Maternal indications
1) a cerclage in place
2) Obstructive lesions in the lower
genital tract
3) prior vaginal colporrhaphy and
major anal involvement from
inflammatory bowel disease
 C/S Fetal Indications
1) Malpresentation:
2) preterm breech presentations and
nonfrank breech term fetuses
3) a second twin in a nonvertex
4) Congenital anomalies
5) Nonreassuring fetal heart rate
6) an active vaginal herpes infection
(especially with primary outbreak)
7) Human immunodeficiency virus infections
 C/S Maternal and fetal
indications:
Abnormal placentation
Abnormal labor due to CPD
Contraindications to labor: In women
who have a uterine scar (prior
myomectomy in which the uterine
cavity was entered or cesarean
delivery in which the upper contractile
portion of the uterus was incised)
 C/S contraindication
When maternal status is
compromised by a surgery,
If the fetus has a known karyotypic
abnormality (trisomy 13 or 18),
known congenital anomaly that may
lead to death (anencephaly),
 VBAC candidates
One or two prior low-transverse c/s
Clinically adequate pelvis
No other uterine scars or previous
rupture
Availability for emergency cesarean
delivery
 Criteria for timing of
elective repeated Cesarean
Delivery
At least one of these criteria must be met in a
woman with normal cycles and no immediate
antecedent use of OCP:
FH sound documented for 20 wks by
nonelectronic fetoscope or 30 wks by Doppler.
36 wks since a positive serum or urine chorionic
gonadotropin test was performed.
CRL obtained by US at 6-11 wks supports a
gestational age at least 39 wks.
US at 12-20 wks supports a gestational age at
least 39 wks.
 Abdominal incision1
Infraumbilical incision :
a vertical incision may provide
easier access into the abdomen,
with better visualization for a
patient with significant intra-
abdominal adhesions from prior
surgeries.
Abdominal incision2-vertical
Upon reaching the rectus sheath, either the
rectus sheath can be incised with a scalpel for
the entire length of the incision or a small
incision in the fascia can be made with a
scalpel
Then extended superiorly and inferiorly with
scissors.
Then, the rectus muscles (and pyramidalis
muscles) are separated in the midline by sharp
and blunt dissection. This act exposes the
transversalis fascia and the peritoneum.
 Abdominal incision3
The peritoneum is identified and entered
at the superior aspect of the incision to
avoid bladder injury. Prior to entering the
peritoneum, care is taken to avoid incising
adjacent bowel or omentum.
Once the peritoneal cavity is entered, the
peritoneal incision is extended sharply to
the upper aspect of the incision superiorly
and to the reflection over the bladder
inferiorly.
 Abdominal incision4
Transverse incisions
The Pfannenstiel incision is curved slightly
cephalad at the level of the pubic hairline.
The incision extends slightly beyond the
lateral borders of the rectus muscle
bilaterally and is carried to the fascia.
Then, the fascia is incised bilaterally for the
full length of the incision.
Then, the underlying rectus muscle is
separated from the fascia both superiorly
and inferiorly with blunt and sharp
dissection.
 Abdominal incisions5
transverse incisions
A Maylard incision is made
approximately 2-3 cm above the
symphysis and is quicker than a
Pfannenstiel incision. It involves a
transverse incision of the anterior rectus
sheath and rectus muscle bilaterally.
Identify and possibly ligate the superficial
inferior epigastric vessels (located in the
lateral third of each rectus).
 Abdominal incision 6
For most cesarean deliveries, only
the medial two thirds of each rectus
muscle usually needs to be divided. If
more than two thirds of the rectus
muscle is divided, identify and ligate
the deep inferior epigastric vessels.
The transversalis fascia and
peritoneum are identified and incised
transversely.
 Uterine incision1
Dissect the bladder free of the lower
uterine segment. Grasp the loose
uterovesical peritoneum with
forceps, and incise it with
Metzenbaum scissors. The incision is
extended bilaterally in an upward
curvilinear fashion.
 Uterine incision2
The lower flap is grasped gently, and
the bladder is separated from the
lower uterus with blunt and sharp
dissection. A bladder blade is placed
to both displace and protect the
bladder inferiorly and to provide
exposure for the lower uterine
segment (the contractile portion of
the uterus).
 Uterine incision3
One of essentially 2 incisions can be made on
the uterus, either a transverse or vertical
incision.
In more than 90% of cesarean deliveries, a
low transverse (Monroe-Kerr) incision is
made. The incision is made 1-2 cm above the
original upper margin of the bladder with a
scalpel. The initial incision is small and is
continued into the uterine wall until either the
fetal membranes are visualized or the cavity is
entered.
 Uterine incision4
The incision is extended bilaterally and
slightly cephalad. The incision can be
extended with either sharp dissection or
blunt dissection (usually with the index
fingers of the surgeon).
Blunt dissection has the potential for
unpredictable extension, and care should
be taken to avoid injury to the uterine
vessels. The presenting part of the fetus is
identified, and the fetus is delivered either
as a vertex presentation or as a breech.
 Indications for classical
(vertical) uterine
incisions
the lower uterine segment can not be
exposed or entered safely (adhesion,
myoma, carcinoma)
there is a transverse lie of a large fetus
Placenta previa of anterior implantation
Massive maternal obesity
Lower uterine segment is not thinned
out (like cases of very small fetuses)
 Uterine incision5
In a vertical(classical) incision
again, the bladder is dissected
inferiorly to expose the lower
segment, and the bladder blade is
placed.
 Uterine incision 6
The vertical incision again is initiated
with a scalpel in the inferior portion of
the lower uterine segment.
When the cavity is entered, the
incision is extended superiorly with
sharp dissection. The fetus is
identified and delivered. Note the
extent of the superior portion of the
uterine incision.
 Uterine incision7
With a true low vertical incision, the risk of
uterine rupture with a trial of labor is
approximately 1-4%, with most recent
reports finding a risk for uterine rupture of
less than 2%.
If the incision should be either extended
into the contractile portion of the uterus or
is made almost completely in the upper
contractile portion, the risk of uterine
rupture in future pregnancies is 4-10% .
 Uterine incision8
A vertical incision also may be considered in:
those cases where a hysterectomy may be
planned
in the setting of a placenta accreta
if the patient has a coexisting cervical cancer
A vertical incision is associated with
increased blood loss and longer operating
time (takes longer to close) with less risk of
injury to the uterine vessels than a low
transverse incision.
 repair1
Externalizing the uterine fundus facilitates
uterine massage, the ability to assess
whether the uterus is atonic, and the
examination of the adnexa.
The uterine cavity usually is wiped clean of
all membranes with a dry laparotomy
sponge, and the cervix can be dilated with
an instrument, such as a Kelly clamp, if the
patient underwent delivery with a previously
undilated cervix. Typically, an Allis clamp is
placed at the angles of the uterine incision.
 repair2
Repair of a low transverse uterine incision can
be performed in either a 1-layer or 2-layer
fashion with zero or double-zero chromic or
Vicryl suture.
The first layer should include stitches placed
lateral to each angle, with prior palpation of
the location of the lateral uterine vessels. Most
physicians use a continuous locking stitch.
If the first layer is hemostatic, a second layer
(Lembert stitch), which is used to imbricate the
incision, does not need to be placed.
 repair3
Closure of a vertical incision usually
requires several layers because the
incision is through a thicker portion
of the uterus.
Again, note the extent of a vertical
uterine incision because it impacts
how a patient should be counseled
regarding future pregnancies.
 repair4
When the uterus is closed, attention
must be paid to its overall tone.
If the uterus does not feel firm and
contracted with massage and
intravenous oxytocin, consider
intramuscular injections of prostaglandin
(15-methyl-prostaglandin, Hemabate) or
methylergonovine and repeat as
appropriate.
 repair5
If the uterine incision is hemostatic,
the uterine fundus is replaced into
the abdominal cavity (unless a
concurrent tubal ligation is to be
performed).
 Repair 6
The vesicouterine peritoneum and
parietal peritoneum can be
reapproximated with a running chromic
stitch. Many physicians prefer to not
close the peritoneum because these
surfaces reapproximate within 24-48
hours and can heal without scar
formation. Furthermore, the rectus
muscles to do not need to be
reapproximated.
 repair7
The subfascial tissue is inspected for bleeding,
and, if hemostatic, the fascia is closed.
The fascia can be closed with a running stitch,
and synthetic braided sutures are preferred
over chromic sutures.
If the patient is at risk for poor wound healing
(eg, those with chronic steroid use), then a
delayed absorbable or permanent suture can
be used.
Place stitches at approximately 1-cm intervals
and more than 1 cm away from the incision
line.
 repair8
The subcutaneous tissue does not have
to be reapproximated, but in patients
who are obese (subcutaneous depth >2
cm), a drain may be placed and
connected to an external bulb suction
apparatus.
The skin edges can be closed either with
a subcuticular stitch or with staples
(removed 3 or 4 d postoperatively).
Patient should know why and what
type

Overall, patients attempting a vaginal

birth after a prior cesarean delivery
can expect success approximately
70% of the time.
If a patient had a cesarean delivery
for presumed CPD attempting a
vaginal birth with the next pregnancy
is associated with a decreased risk of
success.
 Why and what kind
If the cesarean delivery was
performed because of an abnormal
fetal heart pattern or for a
malpresentation, then expectations
for a successful vaginal birth can be
higher than 70%.
 Why and what kind
If the uterine incision was vertical, the
risk of uterine rupture is increased above
the approximate 1% risk associated with
a low transverse incision.
If the incision extended into the upper
contractile portion, the risk of uterine
rupture can approach 10%, with 50% of
these occurring prior to the onset of
labor.
 Why and what kind
The risk of placenta accreta in a
patient with previa is
approximately 4% with no prior
cesarean deliveries; the risk
increases to approximately 25%
with 1 prior cesarean delivery
and to 40% with 2 prior cesarean
deliveries.
Sample C/S orders
 Emergency C/S
Prep 2 units of pc
Amp keflin 2 gr iv
Prepare for C/S
Transfer to OR
The night before elective
C/S
CBC, BG, Rh, (FBS,BUN/CR, CXR,
ECG)
Prep 2 units of pc
NPO from 12 am
Iv Ringer KVO
Check of FHR and contractions
 8 hours after C/S
fair, RBR, surgical diet,
IV 2 lit Ringer
Continue keflin
Supp bisacodyl 2 stat then tab
bisacodyl bid
Foley DC,
I/O DC
F/U CBC
 24 hours after C/S
Condition good ,RBR, reg diet,
IV as heparin lock
Continue keflin
tab bisacodyl bid
 36-48 hours after C/S
Remove dressing
Discharge with
Cap cephalexin 500 mg qid
Cap mefenamic acid 500 mg tds
Cap hematinic (according to Hb)
 Diabetic elective C/S
NPO from 12 am
Prep 2 units of PC
1000 cc Ringer IV fluid q8 hrs the night before
surgery

Amp keflin 2 gr iv stat half an hour before surgery

Before operation: 10 units of regular +1000 cc
DW5% 150cc/hr
Check of BS q6h after operation

Inform in cases of ROM or bleeding or pain