Surgery and Healing in the Developing World - Dartmouth-Hitchcock

15
140 Surgery and Healing in the Developing World
extended well above the umbilicus in anticipation.) Again, confirm the efficacy of
your anesthesia and hemodynamic stability of your patient and begin the procedure.
Create a vertical midline skin incision with 1/3 of the incision above and 2/3
below the umbilicus. Either skirt the umbilicus with your incision or retract the
umbilicus laterally as you approach with the blade from above. The incision can
then be extended vertically without the need to circumlocute the navel. The latter
method is quicker and runs less risk of creating a beveled incision.
Carry your incision down through the underlying tissues to identify the anterior
rectus sheath. Clear off the sheath in the midline and make a nick through the
sheath with your scalpel. Elevate the sheath with forceps and extend the fascial incision
cephalad, then caudad using scissors. Separate the rectus muscles in the midline
and enter the peritoneum essentially as described for a low transverse approach. If
adhesions are encountered, take these down with great care to avoid bowel. Palpate
the uterus and center it. Place moist packs on either side of the uterus. Identify the
bladder. You may not be able to create a bladder flap. In many indications for the
classical section there either will not be time for this or adhesions will make it impossible.
However, you may be able to reflect the bladder downwards in ideal cases
to include the lower uterine segment in your incision.
Begin a vertical midline incision in the uterus starting just above the point of
attachment of the bladder and carry this cephalad for a total length of 10-12 cm. In
the thick upper segment, this will require several passes with the knife, taking care to
remain in the center of your original incision. Upon entering the cavity of the uterus,
put down the knife, place two fingers of your nondominant hand in the wound and
and use bandage scissors to extend the incision. There will be many bleeding myometrial
vessels, most of which can be dealt with after delivery of the fetus. You may
encounter the placenta. Try not to cut it. You may be able to separate it partly from
the uterine wall in order to work past it. Use due haste.
Find a leg and deliver the fetus as in a breech delivery. Start pitocin. Deliver the
uterus through the abdominal incision, hold it in a warm moist gauze, and deliver
the placenta. Remove any remaining membranes, clots and other debris with a dry
swab.
The vertical incision is in thick myometrium, and it will be necessary to close
this in two layers. Close the inner half of the myometrium with a continuous suture
of 0-chromic gut. Close the outer layer with the same suture using interrupted,
figure-of-eight, or a running locked suture. It will be important to have your assistant
compress the uterus to enable you to reapproximate the muscle layers without
putting tension on your suture. Close the serosa with 2-0 chromic gut. The rest of
the operation is completed essentially as described above in section (C1).
Special Cases
Postmortem Cesarean
The outcome of this approach depends entirely upon the speed of your decision
to perform the procedure, followed by an equally rapid classical Cesarean section.
Commit to the procedure immediately upon maternal cardiac arrest. Deliver the
baby by a classic vertical Cesarean approach. It should take you only seconds to
incise the skin and fascia, continuing directly into the uterus. Good retraction by
your assistants will be critical. Deliver the baby either as a vertex or a breech, depending
upon the presenting parts that you may encounter. Begin neonatal resuscitation
immediately.