Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
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Extraperitoneal Cesarean
This procedure was described in the early 20th century as a means of excluding
infected uterine contents from the peritoneum. It may still have its place if you are
bereft of antibiotics. Essentially, enter the abdomen through a vertical midline incision,
but do not enter the peritoneum. Identify and grasp the median umbilical
ligament and work from here to mobilize the parietal peritoneum superiorly and
laterally for several centimeters in the plane of her lower uterine segment. Incise the
peritoneum in this plane, keeping close to the bladder reflection. Grasp the parietal
peritoneum at the vesicouterine fold and elevate and incise the posterior parietal
peritoneum to join the anterior incision that you have just completed. Mobilize the
peritoneum off of the lower segment. Free enough peritoneum to allow you to place
a continuous suture through the peritoneum to create a purse-string closure of the
superior edges of the peritoneal incision. This should be without tension and form a
tight closure.
Reflect the bladder downward and complete a low transverse Cesarean section in
the usual fashion. When closing, leave a drain over the suture line. King et al recommend
introducing a second drain on the opposite side to enable intermittent irrigation
and suction drainage of the extraperitoneal space.
Hemorrhagic Complications
Massive bleeding that does not respond to oxytocin and fundal massage and is
clearly not due to retained fragments or to unattended lacerations will require further
surgical management. Your choices include hypogastric artery ligation, uterine
artery ligation, placement of the B-Lynch suture, and hysterectomy.
Uterine Artery Ligation
This procedure requires less exposure and dissection than internal iliac artery
ligation and is clearly your first choice to avoid a hysterectomy. It may become
necessary following Cesarean, or you may find it necessary to perform a laparotomy
to tie the uterine arteries to treat severe postpartum hemorrhage after vaginal birth.
Deviate the uterus away from the side to be ligated. Use a large curved needle
and 0-chromic suture. If the ligation is necessary following a Cesarean, place your
suture below the level of the uterine incision. Enter the myometrium medial to the
uterine artery and exit behind the uterus and broad ligament. Incorporating myometrium
in this way avoids the ureters and any risk of avulsing the uterines. You will
also compress inferior branches of the artery. Reload your needle and penetrate the
broad ligament from posterior to anterior in a bare area. This avoids laceration of a
vessel while providing a guarantee that the artery will be incorporated in your knot.
Tie for hemostasis. Clear the uterus of clots and debris and observe.
You may need to place one or two more sutures, in particular if your first was not
tight enough or failed to incorporate a major branch of the artery. If bleeding is
lessened but still continues despite placement of several sutures, consider ligation of
the ovarian artery adjacent to the cornua. If bleeding is from the placental site following
Cesarean, as in accreta/increta/percreta, you will need to oversew any rent in
the uterus and place figure-of-eight sutures in the implantation site. In this situation,
ligation of the hypogastric (internal iliac) arteries may be necessary, as described
below.
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