Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
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formation. Consider placing a drain for 48 hours if the patient is obese. Bohman et
al, 1992; Naumann et al, 1995 report that this decreases wound disruption.
Close skin with vertical mattress sutures of 4-0, or staples if available, or (if you
feel that there is no tension on the wound and very little risk of infection) a running
subcuticular 4-0 suture.
Classical (Vertical) Cesarean Section (Lapara-Hysterotomy)
Indications
The classical Cesarean section (Sanger incision) involves a midline vertical uterine
incision from the lower uterine segment to the fundus (and is generally preceeded
by a vertical skin incision as well). Once a classical Cesarean procedure has been
performed, there is a great danger of uterine rupture with subsequent pregnancies,
even before onset of uterine contractions. Fortunately, indications for a classical
Cesarean are relatively rare. Some of these will be anticipated, and others encountered
only after the patient has entered labor or an operative delivery is underway.
They include the following:
Anticipated Indications
1. Hysterectomy is indicated following delivery (e.g., carcinoma of the cervix)
2. Transverse lie of a large fetus, especially with limb presenting or back down.
Urgent Indications
1. Preterm breech (use low vertical uterine incision)
Emergent Indications
1. Fetal distress
2. Postmortem
Intraoperative Indications
1. During a primary or repeat Cesarean that was planned to be LTCS, adhesions
are encountered that make it unsafe to attempt dissection of the bladder
from the lower uterine segment.
2. At laparotomy a large myoma is encountered in the lower uterine segment.
3. During a repeat Cesarean indicated for a prior classical incision, and that
was planned to be LTCS, you notice that the prior classical scar has healed
poorly.
4. At laparotomy you encounter a placenta previa which extends anteriorly, or
you encounter many thick veins on the lower segment (a sign of placenta
previa or low anterior placenta).
5. You encounter a small breech fetus and an unthinned lower uterine segment.
6. You encounter a poorly developed lower uterine segment, one that can’t
allow a large enough incision to safely deliver the fetus (similar to a preterm
breech).
Procedure
As with the primary LTCS, consider giving perioperative antibiotics, establish
IV access, provide anesthesia, and place a Foley catheter. Position, prep and drape
the patient essentially as for a LTCS. (In both cases, the antiseptic wash should be
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