Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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138 Surgery and Healing in the Developing World
outside of the lower uterine flap, to reduce the risk of tears. Place the fingers of your
dominant hand between the head of the fetus and the lower segment and begin to
deliver the head. Have your assistant provide fundal pressure to assist.
Once the head is delivered, suction the nose and mouth (use deep suctioning
with a DeLee if meconium has been noted). Deliver the shoulders and body, clamp
the cord twice and cut it, then hand the baby to the midwife or other birth attendant
for assessment and resuscitation.
If the placenta is encountered anteriorly and is partially incised, quickly separate
it from the uterus and deliver the baby around it. Clamp the cord quickly to minimize
blood loss.
Start an oxytocin drip or injection or inject ergometrine.
Massage the fundus of the uterus while providing gentle traction on the umbilical
cord to help separate the placenta. You may place your palpating hand inside the
peritoneal cavity. If necessary, place your hand into the uterus and shear the placenta
from the wall of the uterus to facilitate its delivery.
Wipe out the uterus with a dry gauze pack, and have the placenta inspected to
make sure that it is complete. It is common for the uterus to be delivered through
the abdominal incision and covered with a wet gauze in order to facilitate closing
the uterine incision. This is associated with increased nausea and in some venues
increases risk of contamination. Consider leaving the uterus in situ. If you do, you
will need good lighting and a good assistant to suction or blot frequently in order to
maintain good visualization of the incision. Place clamps at the angles of the incision.
It may serve you well to place additional clamps around the cut edges of the
uterus, both to control bleeding and to help with visualization, especially if extensions
or tears have taken place. Place clamps only as necessary, as this process extends
operating time and the clamps can get in your way. Also, clamp only the edges
of the incision to avoid incorporating a ureter.
Close the uterus in one or two layers using # 0 or #1 absorbable suture. Gut is
generally preferred. Vicryl is associated with a four-fold greater risk of subsequent
scar separation than chromic gut. Palpate the uterine vessels lateral to the uterine
incision and place your first suture just lateral to the angle of the incision while
avoiding the uterines. Take full thickness of myometrium and work towards the
midline using a running locked suture. Most advise excluding the endometrium
and peritoneum from the repair. Repair the myometrium in two layers if it is very
thick. Use a second, imbricating layer (either horizontal Lembert’s or vertical Connel’s)
if necessary to achieve complete hemostasis. Additional interrupted or figure-of-eight
sutures may be needed to control bleeding. Look for bleeding sites, clear the gutters,
and inspect the adnexa.
It has been reported that there is less pain and quicker return of bowel function
if visceral and parietal peritoneum are left open (Hull and Varner, 1991; Pietrantoni,
et al, 1991). No increase in adhesions was noted when this course was followed
(Tulandi et al, 1988). However, many experts now close peritoneum and
reapproximate rectus bellies with two or three loose interrupted sutures in the belief
that this does reduce the formation of adhesions between bladder and anterior structures.
The anterior rectus sheath is closed with interrupted sutures 1 cm apart or,
more commonly, with a continuous nonlocking suture of dexon, vicryl or permanent
suture material. Some surgeons will lock the first stitch at the angles.
Close the fat/Camper’s fascia and subcutaneous tissue with simple interrupted
O suture if the incision is more than 2 cm deep. This is proven to reduce abscess