Cesarean section of lower uterine segment

The cesarean section is a procedure in which a viable fetus and its appendages are delivered through the intact uterine wall. It does not include cesarean section performed before 28 weeks of gestation and caesarean section for removal of a ruptured uterus or abdominal pregnancy fetus. The uterine segmental cesarean section is the current routine cesarean section of obstetrics. The lower uterus cesarean section is currently the most widely used cesarean section, and it is also an ideal procedure. The operation is easy to grasp and the complications are few. Although it needs to be slightly pushed away from the bladder, it is rarely damaged. The inferior segment of the uterus is easy to suture, and can be covered with peritoneal reflexes to prevent abdominal infection and adhesion. It combines the advantages of classical cesarean section and extraperitoneal cesarean section, while at the same time making up for their shortcomings. . Treatment of diseases: fetal distress Indication I. Abnormal birth canal 1. The head basin is not called the pelvis, which is obviously narrow or deformed; if the relative head basin is not called, the effective uterine contraction is 8~10h after full trial production, and the fetal head is still not inserted into the basin after 4~6h after the membrane is broken. 2. Soft canal abnormalities Scar tissue or pelvic tumors hinder the first drop; cervical edema is hard and difficult to expand; congenital dysplasia. 2. Abnormal productivity Primary or secondary uterine insufficiency is not treated. 3. Fetal abnormalities 1. Abnormal fetal position: transverse position. Posterior position, high straight posterior position; post-occipital or occipital transverse position combined with head cavity or prolonged vaginal delivery is dangerous and difficult. The breech position combined with the following conditions to relax the indications of cesarean section: foot first exposed. pelvic stenosis. premature rupture of membranes. excessive fetal head extension. uterine weakness. Complete breech and poor history of childbirth. Estimated fetus in 3500g or more . 2. Fetal distress: treatment by oxygen and other ineffective, short-term vaginal delivery. 3. Umbilical cord prolapse: the fetus survives. 4. The fetus is too large: estimated to be greater than 4000g, the suspected head basin is not called. Pregnancy comorbidity 1. Prenatal bleeding such as placenta previa. Placental abruption. 2. The scar uterus has a history of previous cesarean section. The previous indication of surgery still exists in this pregnancy, or it is estimated that the atomic palace incision healed poorly, and the previous cesarean section incision is located in the body of the uterus; After uterine fibroids removal and cutting into the uterine cavity, this time should also consider cesarean section. 3. Pregnancy comorbidities or complications are difficult to tolerate the delivery process, requiring selective cesarean section, such as pregnancy with severe heart disease, diabetes, kidney disease, etc.; severe pregnancy-induced hypertension syndrome, intrahepatic cholestasis Wait. 4. Have done genital wart repair or old perineal III degree tear repair. 5. Aura uterine rupture should be performed for cesarean section regardless of whether the fetus survives or not. 6. High-grade maternal, pregnant or pregnant after years of infertility or drug treatment, or have a history of dystocia and no live baby. 7. The fetus is precious. If there is a history of dystocia and no surviving fetus, the history of spontaneous abortion is repeated. Those who are eager to get a live baby should appropriately relax the indications for cesarean section. 8. Fetal malformations such as twins. Contraindications 1. Stillbirth: In addition to maternal bleeding, uterine mouth has not yet expanded, can not give birth to a stillbirth in a short period of time, in order to save the maternal life should be managed to make vaginal delivery, if necessary, broken tires. 2. Teratogenicity: cesarean section is generally not considered. However, if there is a disease that endangers the life of the pregnant woman, it must be terminated immediately and the vaginal can not be completed, or a few deformities such as the joint twins through the vaginal broken tires, etc., still need to take the cesarean section to take the fetus. 3. There has been a history of abdominal surgery, especially the history of cesarean section. There are severe and difficult adhesions in the lower part of the uterus, especially those with fetal distress and urgent need to deliver the fetus. 4. The lower part of the uterus is poorly formed and the incision cannot be performed. 5. There are a large number of varicose vessels in the lower uterus, and surgery may cause major bleeding. 6. Pelvic deformity and uvula, the uterus is extremely forward and cannot expose the lower uterus. 7. Horizontal position, no labor, insufficient expansion of the lower part, if the fetal back is down, the lower section of the incision is difficult to pull the carcass. Preoperative preparation First, according to the problems that may occur during the operation, formulate corresponding measures to prepare for routine neonatal resuscitation and first aid. Second, anesthesia and posture Epidural anesthesia is preferred, and local anesthesia may be used when the fetus is in urgent need of delivery or no anesthesia. 1. Epidural anesthesia: simple method, good muscle relaxation, complete pain relief, is the preferred anesthesia for cesarean section in China. 2. Local anesthesia: Local anesthesia and nerve block anesthesia are safe for mothers and infants, but muscle relaxation is poor, pain relief is incomplete, and it can be used in case of emergency. 3. Laughing gas-oxygen balance anesthesia: no adverse reactions to mother and baby, pain relief and muscle relaxation are satisfactory, especially suitable for pregnant women with complications, such as pregnancy-induced hypertension syndrome, blood disease and heart disease. The traditional position is supine, supine, heart attack or respiratory insufficiency, and the supine position is preferred. In order to prevent "supine hypotension syndrome", it should be inclined to the left side of 10 ° ~ 15 °, is considered to be the best position for cesarean section. Surgical procedure (A) abdominal wall incision: from 4 to 5 cm below the umbilicus, cut to the upper edge of the pubic symphysis, about 10 to 12 cm long. There are also those who remove the curved incision of the abdomen. (B) incision of the uterus bladder reflexive peritoneum: After entering the abdominal cavity, lift the uterine bladder peritoneum, and make an arc-shaped incision about 12cm long at 1~2cm below the peritoneal reflex. After incision of the reflexed peritoneum, first free up to the reflexed position, to facilitate the final suture, and then loose the connective tissue plane along the cervix of the bladder, use the fingers to gently peel the bladder down about 4 ~ 5cm, and then to the two sides to the near uterus At the lateral edge, the lower part of the uterus is revealed. (C) cut the lower part of the uterus: retract the bladder, 2 to 3 cm below the reflexed incision, first make a 3cm horizontal incision. The longer the period of labor, the thinner the wall of the lower uterus, sometimes only 2 to 3 mm thick. Slowly cut with a knife (be careful not to damage the fetus), rupture the membrane and absorb amniotic fluid when the membrane is exposed. Use a bandage cut to extend to both sides to form an arcuate cut with a curvature of about 12 cm. It can also be extended into the direction of the fiber and gently separated to the side edge of the lower part of the uterus. If the opening is not large enough, it can be cut and expanded upward at both ends. Do not cut straight to the sides to avoid damage to large blood vessels. (4) Fetal delivery: reach into the uterine cavity, turn the occipital part of the head upwards, then lift the head up, and the other hand pushes down from the bottom of the palace outside the abdomen, and the head can be delivered smoothly. When taking the fetus, you can temporarily remove the hook to facilitate operation. After the child is delivered, the mucus in the mouth can be removed first, so that the airway is unobstructed, and then the body is slowly pulled out, and then the placenta membrane is removed by hand. Wipe the uterine cavity with clean gauze for 1 or 2 times. In the case of premature rupture of membranes, the iodine gauze can be used to wipe the uterine cavity. Wipe it again with 75% alcohol gauze to help prevent intraoperative contamination. Intrauterine injection of ergometrine and oxytocin 10 ~ 20U. The incision can be clamped by a ring clamp to stop bleeding, and at the same time used for traction to facilitate suturing. (5) Stitching: The uterine incision was sutured with 2 layers of chrome gut. The inner layer is intermittent or continuous suture, does not pass through the inner membrane, and the outer layer is continuously sutured. Finally, the uterine bladder is reversed and the peritoneum is continuously sutured. Check for no bleeding, remove effusion and blood in the pelvic cavity, and close the abdominal cavity after clearing the gauze. complication 1. Supine hypotension syndrome. 2. Abnormal bleeding in the uterus. 3. Organ damage. 4. Amniotic fluid embolism.