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The Caesarean Section
Erik Domini, Sara Guazzini, Monica Guidi, Stefano Vicentini
SECTION 1: ANATOMY AND PHYSIOLOGY OF PARTURITION
CHAPTER 1:
Parturition
CHAPTER 2:
Birth Canal (Passageway)
BONY PELVIS
Pelvic Bone (OS Coxa)
Sacrum
Coccyx (Fig. 2.1)
Pelvic Joints
Pubic Symphysis (Fig. 2.11)
Sacroiliac Joint
Lumbosacral Joint (Fig. 2.15)
True Pelvis
Pelvic Inlet (Superior Pelvic Strait)
Diameters
Transverse Diameters (Figs 2.19 and 2.20)
Pelvic Cavity
Pelvic Outlet (Inferior Pelvic Strait)
Obstetric Pelvis
Morphology and Size of the Pelvis
Classifications of the Small Pelvis
Caldwell–Moloy Pelvic Classification
MIXED TYPES
Long Pelvis According to Kirchhoff
Inclination of the Pelvis
CHAPTER 3:
Uterus
MECHANICAL FUNCTIONS
Preventing Expulsion of the Product of Conception
Composition of Connective Tissue
Delivering the Product of Conception
HISTOLOGY OF THE UTERUS
Myometrium
Muscle Component
Superficial Layer or Neomyometrium (Fig. 3.1A)
Middle Layer, Plexiform or Paleomyometrium Layer (Fig. 3.1B)
Internal or Subendometrial Layer (Fig. 3.1C)
Connective Tissue Component
Lower Uterine Segment
Uterine Cervix
CONTRACTILE ACTIVITY
Physiology of Placental Circulation
Contractile Activity of the Myometrium
Normal Uterine Polarity with Hyperkinesis (Overactive Contractile Activity)
THERAPY
CHAPTER 4:
Passenger (Foetus)
CHAPTER 5:
Mechanism and Physiopathology of Parturition
INTRODUCTION
MECHANISM OF PARTURITION
PRESENTATION
ENGAGEMENT
Normal Pelvis
Long Pelvis
DESCENT, ROTATION AND PROGRESS
MECHANISM OF PARTURITION IN VARIOUS PELVIC TYPES
CONCLUSION
SECTION 2: DIAGNOSIS
CHAPTER 6:
Diagnosis in Clinical Obstetrics
INSTRUMENTS
DIAGNOSIS IN CLINICAL OBSTETRICS
Case History
General Medical History
Previous Obstetric History
Pain
Physical Examination
General Physical Examination
Organs and Systems
Reflexes
Obstetric Physical Examination
Clinical Examination of the Abdomen
Observation
Palpation
Approach by Examiner
Auscultation of Foetal Heartbeat
Assessment of the True Pelvis
Dimensions
PELVIC INLET (SUPERIOR PELVIC STRAIT)
Midpelvis
Pelvic Outlet (Inferior Pelvic Strait)
Morphology
Evaluation of Anterior Pelvis and Pelvic Inlet (Method Developed by the Authors)
Width of the Forepelvis Angle (Prepubic Angle)
Evaluation of the Posterior Pelvis
Site of Lumbosacral Hinge
Inclination
Method
Pelvic Examination
Examination of the Soft Parts
Determination of the Intertuberous Diameter and Significance
Assessing the Subpubic Arch
Determining the Retropubic Angle
Outline of Pelvic Inlet; Characteristics of the Linea Terminalis
Identifying the Sacral Promontory, Its Characteristics, the Diagonal Conjugate
Characteristics of the Ischial Spines
Assessment of the Sacral Cavity
Assessment of Characteristics of the Uterine Cervix; Bishop's Score
Characteristics of the Membranes
Diagnosing Presentation, Engagement and Position
Abdominal/Pelvic Scores (Knight, 1993)
Soft-tissue Edema and Caput Succedaneum (Fig. 6.15)
CHAPTER 7:
Partograph
INTRODUCTION
STRUCTURE OF THE PARTOGRAPH
PROGRESS OF LABOUR
UTERINE CONTRACTILE ACTIVITY
FOETAL WELL-BEING
TREATMENT
MATERNAL CONDITION
FILLING IN THE PARTOGRAPH
Subsequent Recording
Suggested Protocols
A. Latent Stage
B. Active Phase
Abnormal Active Phase in a Multipara
MATANY PARTOGRAPH
SECTION 3: CAESAREAN SECTION AND MANAGEMENT
CHAPTER 8:
Indications for Caesarean Section Outside Labour
MATERNAL INDICATIONS
Maternal Illness During Pregnancy
Cardiopathy
Maternal Illness Due to Pregnancy (3rd Trimester Gestosis)
Gestational Oedema Proteinuria Hypertension (GEPH)
Gestational Hypertension (G E0 P0 H+)
Therapy
Preeclampsia
Epidemiology
Monitoring for Preeclampsia
Treatment of Mild Preeclampsia
Treatment of Severe Preeclampsia
Timing of Delivery
Postpartum Clinical Management
Eclampsia
Aetiopathogenesis
Onset
Sequence of Symptoms
Diagnosis
Therapy
Well-being of the Mother
Monitoring
Alternative Regimens to Magnesium Sulphate
Intravenous Administration
Foetal Well-being
Birth Canal Anomalies
FOETAL INDICATIONS
CHAPTER 9:
Indications for Caesarean Section During Labour
PRELIMINARY CONSIDERATIONS
COMPROMISE OF MATERNAL–FOETAL GAS EXCHANGE
Umbilical Cord Pathology
Uterine Rupture
OBSTACLES TO THE ENGAGEMENT AND PROGRESS OF LABOUR
Unfavourable Foetal Lie or Presentation
Unfavourable Foetal Lie
Unfavourable Presentation: Breech
Unfavourable Presentation: Cephalic
Presenting Part
Pelvis
A leading limb
Changes in Uterine Morphology
Changes to the Soft Tissue of the Birth Canal
Hyperthermia
Expulsive Phase Anomalies
THE TWO INDICATIONS PRESENTED ABOVE IN VARYING RELATIONS TO EACH OTHER
Maternal Indications
CHAPTER 10:
Trial of Labour
PRELIMINARY ASSESSMENT OF THE GRAVID PATIENT
Suitability for Trial of Labour for a Patient Who has not Undergone C-section
Suitability for Trial of Labour for a Patient who has Undergone C-section
Anamnestic Criteria
Obstetric Physical Examination
ACTUAL LABOUR
Spontaneous Onset of Labour
Elective Induction of Labour
Induction by Medical Means
Induction by Surgical Means
Progress of Labour is to be Monitored Carefully
CHAPTER 11:
Preparing for the Operation
PREOPERATIVE FASTING
INTRAVENOUS ACCESS
VENOUS CUT DOWN
MATERNAL INTENSIVE CARE
Therapeutic Approach
Introduction to the Concept of Water Balance
Water Deficit or Dehydration
Hypertonic Dehydration
Administration of Antibiotics
Determination of Blood Group and of Haemoglobin
CHAPTER 12:
Anaesthesia
BASIC EQUIPMENT
BASIC MEDICATIONS
PATIENT'S POSITION
TYPES OF ANAESTHESIA
FUNDAMENTAL RULE
PREMEDICATION FOR ANAESTHESIA
MONITORING ANAESTHESIA
SPINAL ANAESTHESIA (ISOBARIC SUBARACHNOID)
Method
Drawbacks
Local Anaesthesia (Combined)
GENERAL ANAESTHESIA
Ketamine
CHAPTER 13:
Laparotomies
REFRESHER OF SURGICAL ANATOMY OF THE ABDOMINAL WALL
Anterior Wall (Fig. 13.1)
Lateral Wall (Fig. 13.4)
LAPAROTOMY
Vertical Laparotomies
Midline Subumbilical Laparotomy
General Principles
Method
Incision of Superficial (Scarpa's) Fascia
Opening of the Transversalis Fascia and of the Peritoneum
Transverse Laparotomies
Laparotomy Site
Techniques not Involving Transection of the Rectus Muscles, but their Separation
Techniques Involving Transection of the Rectus Abdominis Muscles
Procedure Followed by the Authors
Height and Site of Incision
Opening the Peritoneum in Presence of Widespread Adhesions
Isolation of the Site for the Hysterotomy
CHAPTER 14:
The Various Types of Hysterotomy—Criteria of Choice
HYSTEROTOMY
LOWER UTERINE SEGMENT
CRITERIA OF HYSTEROTOMY CHOICE
CHAPTER 15:
Transverse Hysterotomies
INTRODUCTION
TRANSVERSE TRANSPERITONEAL HYSTEROTOMIES
TECHNIQUE USED BY THE AUTHORS
Hysterotomy
Extension and Morphology of the Hysterotomy (Curvilinear Path)
Delivery of the Foetus
Possible Errors there are Two
Cord Clamping
HIGH TRANSVERSE HYSTEROTOMY (FIG. 15.2D)
Uterine Exteriorization
Third Stage of Labour
Hysterorraphy
Scar Quality and Extension
METHOD USED BY THE AUTHORS
Peritoneal Closure
Intraoperative Measurement of the Obstetric Conjugate
Lavage of the Abdominal Cavity
Bringing the Uterus Back in Line
EXTRAPERITONEAL TRANSVERSE HYSTEROTOMIES
Elective Extraperitoneal C-section
a. The Botella Llusia (1949) Hysterotomy
b. Crichton's Hysterotomy Technique (1974)
Emergency Extraperitoneal C-section
CHAPTER 16:
Vertical Hysterotomies
INTRODUCTION
LOW VERTICAL C-SECTION
PREDOMINANTLY LOWER-SEGEMENT C-SECTION
VERTICAL CORPUS/LOWER-SEGMENT C-SECTION
Indications
Method
CHAPTER 17:
Management of Intraoperative Complications
CONTROL OF HAEMORRHAGE
Haemorrhages may Originate
Prophylaxis
Surgical Control of Haemorrhages
HAEMOSTATIC PROCEDURES
From the Edges of a Hysterotomy
From Downwards and Central Expansion of Hysterotomy Lower Margin
From a Lateral Extension of a Hysterotomy Affecting the Uterine Blood Vessels
UTERINE DEVASCULARISATION
From a Lateral Extension of the Hysterotomy, which Advances to the Broad Ligament
Haemorrhage not Controlled Through Uterine Devascularization
Managing Haemorrhages by the B-Lynch Technique
Injuries of the Lower Uterine Segment that are Difficult to Visualize
INJURY TO THE URINARY TRACT
Bladder Injury
Incidence and Risk Factors
Site
Pathogenesis
Diagnosis
Prophylaxis
Diagnosis
Therapy
Repair of the Bladder Dome
Repair of Posterior Bladder Wall
Injuries to the Ureter
Prophylaxis
Diagnosis
Ureteral Reimplantation
Preliminary Steps
Reimplantation, Blind Technique
Materials Required
Method
Reimplantation, Open Technique
CHAPTER 18:
Tubal Sterilization
INDICATIONS
Classic Indications
Vertical Hysterotomy
Repeat C-sections
Uterine Ruptures
Elective Indications
Complications
Method
CHAPTER 19:
Abdominal Wall Closure
PHYSIOLOGICAL INTRODUCTION OF WOUND HEALING
REPAIR OF A VERTICAL LAPAROTOMY WOUND
Guiding Principles
Layered Closure following Anatomical Layers
Continuous Suturing
Method
Interrupted Sutures
Single-layer Closure (Mass Stitching)
Closure of Subcutaneous Layer and of Skin
Skin
Load-easing or Deep Tension or Retention Sutures
REPAIR OF A TRANSVERSE LAPAROTOMY WOUND
Layered Closure following Anatomical Strata
CHAPTER 20:
Perimortem and Postmortem Caesarean Delivery
PHYSIOPATHOLOGY
Cardiocirculatory System
Respiratory System
INDICATIONS
METHOD
CHAPTER 21:
Uterine Rupture
UTERINE RUPTURE DURING PREGNANCY
Rupture of Native (Unscarred) Uterus
Rupture of Scarred Uterus
UTERINE RUPTURE DURING LABOUR
Maternal Mortality
Foetal Mortality
Risk Factors
Aetiopathogenesis of Rupture in Unscarred and Scarred Uteri
Uterine Rupture following Obstetrical Manoeuvres
Pathological Anatomy
Injuries to the Bladder
Symptomatology
Diagnosis
Diagnosis of Uterine Rupture during Labour
Maternal Symptomatology
Foetal Symptomatology
Abdominal and Pelvic Clinical Picture
Diagnosis of Uterine Rupture following Delivery
Therapy
Conservative Management
Destructive Surgery
Closure
CHAPTER 22:
Monitoring Caesarean Section: Postoperative Recovery
WARD DOCTOR
OBSERVATION
THERAPY
Infusion Therapy
Antibiotic Therapy
Administration of Tetanus Toxoid (TT)
Postoperative Pain Management
WARD EXAMINATION
Clinical Examination of Patient
Nasogastric Intubation
ABDOMINAL COMPARTMENT SYNDROME (ACS)
Aetiology
Quantification
Physiopathology of Intra-abdominal Hypertension
Respiratory System
Cardiocirculatory System
Diagnosis
Therapy
Examination of the Wound
Monitoring Uterine Involution
Retrovesical or ‘Bladder Flap’ Haematoma
Urinary System
Observation of the External Genitalia
Examination of the Lower Limbs
Ulcers
CHAPTER 23:
Complications of the Laparotomic Wound Suture
WOUND DEHISCENCE
Aetiopathogenesis
Preoperative Risk Factors
Intraoperative Risk Factors
Postoperative Risk Factors
Symptomatology
Therapeutic Approach
ENTERIC FISTULAS
Symptomatology
Therapy
CHAPTER 24:
Postcaesarean Wound Dehiscence
EARLY UTERUS AND ABDOMINAL WALL SYNCHRONOUS DEHISCENCE
Aetiology
Symptomatology
Therapy
Prophylaxis
LATE DEHISCENCE OF HYSTERORRHAPHY
Symptomatic Late Dehiscence
Aetiology
Symptomatology
Ultrasonography
Diagnosis
Treatment
Asymptomatic Late Dehiscence
CHAPTER 25:
Obstructed Labour Injury Complex
VESICOVAGINAL FISTULAS
Aetiopathogenesis
Anatomical Classification
Functional Classification
Documentation of Fistulas
ANATOMICAL FUNCTIONAL CLASSIFICATION OF RECTOVAGINAL FISTULAS
Diagnosis
Neurological Lesions
Trauma of the Sacral Plexus
Lesion of the Common Peroneal Nerve
Treatment of Vesicovaginal Fistulas
Timing of Surgery
Method
Surgery
CHAPTER 26:
The Newborn
INTRODUCTORY REMARKS ON PHYSIOPATHOLOGY
MECONIUM ASPIRATION SYNDROME
LABOUR ASSISTANCE AND ASSISTANCE TO THE NEWBORN
Delivery Assistance and Immediate Postnatal Assistance in Vertex Vaginal Delivery
Assistance During Labour
Postnatal Assistance
Amniotic Fluid not Stained with Meconium
Term Newborn with Birth Asphyxia
Cardiac Massage
Applying a Catheter or Cannula to the Umbilical Cord
Administration of Medication and Fluids
AMNIOTIC FLUID STAINED WITH MECONIUM
Assistance to the Newborn Delivered Vaginally in Breech Presentation
Assistance to the Newborn Delivered by Caesarean Section
Assessment, Diagnostic Score
Complications
SECTION 4: ALTERNATIVES TO CAESAREAN SECTION
CHAPTER 27:
Version—Breech Presentation, Transverse and Oblique Lies
BREECH PRESENTATION
Aetiology
External Version
Conditions
Safety of the Mother
Safety of the Foetus
Method
Delivery Following External Version
Version by Postural Management
The Authors’ View
TRANSVERSE LIE
Single Foetus
Second Twin
Oblique Lie
Incision of the Cervix (the Duhrssen Incision)
CHAPTER 28:
Symphysiotomy–Vacuum Extraction (Foetus Alive–Head Engaged)
SYMPHYSIOTOMY
Indications
Conditions
Foetus is Alive
Contraindications
Advantages
Anatomical and Theoretical Basis of Symphysiotomy
Circumference
Surface Area
Procedure
Course of the Delivery
Postpartum and Puerperium
VACUUM EXTRACTION
Indications
Contraindications
Conditions
Advantages
Disadvantages
Procedure
Method and Direction of Traction
CHAPTER 29:
Destructive Operations—A Vanishing Art in Modern Obstetrics (P Sikka, 2011)
CRANIOTOMY
Indications
Conditions
Instruments
Sites of Perforation
Procedure
Craniotomy in Breech Presentation
Cleidotomy
Decapitation
Indications
Conditions
Instruments
Procedure
EVISCERATION
Indications
Procedure
Spondilotomy
Indications
Procedure
INDEX
TOC
Index
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