Cesarean Sections/Operative Deliveries/VBAC

Procedure:

Bladder Flap: McDonald, Lawrence, Tryska

Rectus closure: Doublestein and Cree

Hysterotomy closure: Cree puts needle through serosa, everyone else avoids serosa. Sando and Sikkenga do not lock hysterotomy closure.

Leave uterus interior: Hess

Freel:

After skin, cut down through subcutaneous with bovie, then blunt dissection to extend subcutaneous corners.

Bovie through fascia. Enter rectus/peritoneum in usual fashion.

Place allis' laterally at bladder peritoneum fold. Use metz to create flap.

Scalpel through initial layer of uterus, then allis on superior and inferior edge. Then continue through to amniontic sac/baby.

Close hysterotomy with locked 0 monocryl locked, then imbricating layer with 0 monocryl

Close rectus and peritoneum together with 0 vicryl.

Close fascia with 0 vicryl (start at each corner and tie in midline.

Subcuticular 4-0 vicryl, then dermabond tape.

Skin closure:

Most attendings use 4-0 vicryl on Keith needle.

Hess: 4-0 Monocryl on PS2 or PS3 needle (PS2 is larger than PS3).

Vandermark: closes with 4-0 monocryl, using 2 sutures, both starting in the midline with running subcuticular laterally. *Now uses Quill suture.

Vertical Cesareans:

Hysterotomy: Start incision in lower uterine segment, and incise up toward fundus.

Closure: 3 layers: running to close endometrium, then imbricating to re-approximate myometrium, then "baseball stitch" to close serosa.

Prevena Patient Guide: https://www.mskcc.org/pdf/cancer-care/patient-education/prevena-patient-guide

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Operative Deliveries:

Cree forceps: simpsons (long blades, better for molded head)

Lawrence: tucker-mclane (round, unmolded head)

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VBAC:

- VBAC Calculator (MFMU): https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

- “There is good and consistent evidence that a woman who has undergone only one previous cesarean delivery via a low transverse hysterotomy incision has the lowest risk of uterine scar separation during a subsequent trial of labor; thus, TOLAC is a reasonably safe option for these women. In this setting, the body of evidence suggests a VBAC rate of 60 to 80 percent, with an estimated uterine rupture rate of 0.4 to 0.7 percent.” (UpToDate, Aug 2018).

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