Duke Regional Hospital Onboarding: Cesarean Section Steps, Equipment, Op Note

• •Patient ID (name, DOB, MRN)
• •Consent for procedure (primary or repeat LSCS vs. Classic)
• •Consent for blood
• •Allergies
• •Antibiotics: 2-3 grams of Ancef (depending on BMI < or >40); Azythromycin 500mg is they have been laboring)
• •Position (Dorsal supine position with a leftward tilt)
• •X-Ray + Implants?
• •Electrosurgery level (Bovie level 50-50)
• •Planned Specimens
• •Agreement (Questions, comments, concerns?)

• •Test the level of Anesthesia with Allis clamp
• ◦Pinch the skin in 4 quadrants (upper and lower) and see if the patient notices, avoid wiggling hand as patient can sense the proprioception – what you are testing for is pain!
• •Make a mark central 2 fingerbreadths above the pubis symphysis
• ◦A hand width is ~7cm, so after marking mid-line, you can use your hand as makeshift ruler for total length of 14cm
• •Make a Pfannenstiel incision with a #10 blade knife
• •Carry the incision down through skin and subcutaneous fat to the fascia, where you make a midline incision.
• •Use two Richardson (“rich”) retractors, a pair of ferris-smiths (“pick-ups with teeth”), and curved mayos to dissect the facia, extending the incisions bilaterally
• ◦When you extend you want to keep the tips of your scissors up and curve of “smile” up with the line of your extension
• •Grasp the superior aspect for the fascial incision with two Kocher clamps
• •Dissect the fascia off of the rectus abdominis muscle bluntly or with curved mayos
• ◦Throughout this process you will be using the Bovie intermittently to buzz areas and ensure hemostasis

• •Bluntly separate the rectus muscle
• •Grasp the peritoneum with two Kelly clamps or tonsils, and bluntly extend the dissections (sharp entry)
• ◦Most of the attendings do this bluntly, by sticking their index finger in between the rectus muscles and swiping until a clear plane of peritoneum is identified and entered bluntly (blunt entry)
• •Expand the entry into the peritoneum

• •Retract the upper portion with a Richardson (“rich”) retractor and protect the bladder with the bladder blade
• •Bladder flap: Use russian forceps (smooth pickups) and Metzenbaum scissors to create bladder flap
• ◦Ah, the bladder flap. This took me a week to figure out what this even means because not everyone makes a flap and some people just go for it. But essentially when you make a flap, you are releasing some of the serosal tissue that overlays the uterus so that the bladder will fall down further and you avoid injury to it. Sometimes you can do this bluntly by pushing down with a dry lap. Evidence doesn’t support a bladder flap because it can cause serosal bleeding, but sometimes that bladder is just pretty damn close and you want to make sure its far, far away from where you will make hysterotomy

• •Check for the position of the fetus and and for uterine vessels
• ◦Literally stick your hold hand in there up to the fundus and feel if the vessels and round ligaments are equidistant on both sides, you will also feel for adhesions (if any). By feeling the fundus you can see if the uterus is tilted, and that informs the placement of your hysterotomy
• •Score the uterus with a #10 blade knife to make a low transverse incision
• ◦Make a semi circle incision (smiley face), the attending will follow your incision with the suction to promote visibility. You will want to be gentle here, and once you get to a thin enough spot you can stick your index finger straight down to enter into the uterus.
• •Rupture the amniotic sac bluntly or with an Allis clamp (if not popped already)
• ◦At this point you will have both index fingers in the hole you have made and you will be stretching vertically and horizontally (to noon and 6 o’clock). I found using two fingers on each hand helpful.
• •Remove bladder blade
• ◦The attending and scrub tech will be retracting for you and will know when to remove it and when to apply fundal pressure to help deliver the baby

• •Use fundal pressure to assist in delivery of baby, clamp the cord with plastic clamps and cut the cord with straight mayo scissors
• ◦Delivering the head is the hardest and scariest part (at least for me). When it goes wrong, it can be very intimidating! When it goes smoothly, things just pop out no problem. I think everyone has their own way of doing this so it’s a little trial by fire. My tips, for whatever they are worth: Grasp as much of the head as you can (and then go a little farther); keep your wrist straight, and don’t be afraid to over communicate if you do not have it. Communicating with the attending will help them know what you are feeling, and give you longer to attempt delivery!
• •Massage the uterus in-situ to facilitate the delivery of the uterus. Remove the trailing membranes, using a Pennington clamp and place the placenta in the bin.
• •Exteriorize the uterus (if mobile). Use a wet lap to hold the uterus, and then a dry lap to swipe the inside

• •Control bleeding by placing pennington clamps on the edges of the hysterotomy
• ◦This is the second place where things can get a little scary… If someone is going to bleed this is it. Getting to close the hysterotomy is something that you have to do in order to control the bleeding. The more comfortable you are with your needwork, the easier this step will become.

• •Reapproximate the edges of the uterus with Russian forceps (“smooth pickups”) and close the uterine incision using a 0-monocryl or #1 biosyn running, locked suture technique (inspect for hemostasis)
• •Close the second layer of the hysterotomy with a 0-monocryl or #1 biosyn using a vertical or horizontal imbricating suture technique (inspect for hemostasis)
• ◦Most people do not do this layer unless things are not looking hemostatic. The evidence does not support two-layer closures, but sometimes it can be helpful for hemostasis. I would still familiarize yourself with a horizontal mattress stitch.
• •Suction out the posterior cul-de-sac, examine the ovaries and tubes
• ◦As a general rule you never just suction in the abdominal cavity - you always want to put a moist or sloppy wet lap in the belly and suction on top of it to avoid damaging anything with direct suction.

• •Replace the uterus, and reinsert the bladder blade (inferior) and Richardson retractor (superior)
• •Irrigate with warm water and wet laps, inspecting hysterotomy for hemostasis
• •Regrasp the fascia with two Kocher clamps, inspect the rectus muscle and subfascial spaces for hemostasis

• •Reapproximate fascia, using 0-0 polysorb and a pair of ferris-smiths (pick-ups with teeth) using a running suture technique

• •Inspect all subcutaneous spaces for hemostasis, if there is bleeding use electrocautery
• •If the patient is obese, close the adipose layer with 3.0 Vicryl, Plain Velosorb with simple interrupted sutures
• ◦Some personally prefer a running stitch, like “subcuticular” but in the subcutaneous fat, some like simple interrupted - but depends on attending
• •Close the skin with Adsons and a 4.0 Biosyn on a KS needle in a subcuticular fashion
• ◦At DRH you are able to leave after this is done, no need to wait with a patient or bring them to recovery or help put on the dressing. The surgical techs (April and Amie) are good at what they do, and will be your bestie in these cases. If they are handing you something it’s because you need it. ;)
• •Add Steri-strips and a sterile dressing

• •Orders
• •Op Note
• •Add to DRH Patient List
• •Complete Handoff
• •Start their Discharge Summary

.hckopcsection

OPERATIVE FINDINGS: *** intra-abdominal adhesions were noted. The uterus, tubes, and ovaries bilaterally were*** normal. The amniotic fluid was ***. A *** infant was delivered in *** presentation. Neonate had apgars of *** and ***, weight *** g.

OPERATIVE REPORT: The risks, benefits and alternatives of the procedure were discussed with the patient and informed consent obtained before proceeding to the operating room. Once in the operating room, the patient was administered neuraxial anesthesia and placed in the dorsal supine position with leftward table tilt. ***Patient had neuraxial anesthesia anesthesia prior to entering the operating room. She was placed in the dorsal supine position with leftward table tilt.*** Fetal heart tones were obtained prior to the procedure. The patient was then prepped and draped in the normal sterile fashion.

Once anesthesia was tested and found to be adequate, a Pfannenstiel skin incision was made with scalpel and carried down to the level of the fascia with electrocautery***. The fascia was incised with a scalpel and the incision extended bilaterally with Mayo scissors. The superior aspect of this incision was grasped with Kocher clamps, elevated upward, and the underlying rectus muscles dissected away bluntly and then sharply with the scalpel***. Attention was then turned to the inferior aspect of this incision, which was grasped with Kocher clamps, elevated upward, and the underlying pyramidalis muscles dissected away bluntly and then sharply with Mayo scissors***. The rectus muscles were separated in the midline and the peritoneum entered bluntly. The peritoneum was stretched bluntly after ensuring no immediate intraabdominal adhesions.

Sharp entry: The rectus muscles were separated in the midline. An area of clear peritoneum was identified, opened with Metzenbaum scissors, and carefully dissected with electrocautery.***

Bladder flap: The vesicouterine reflection was grasped with smooth pickups, incised with Metzenbaum scissors, and the incision extended bilaterally. The inferior aspect of this incision was grasped with smooth pick ups and the bladder flap developed bluntly. The bladder blade was replaced into the newly created bladder flap and the uterine incision was made with scalpel in a low transverse manner. The incision was stretched bluntly.***

The bladder blade was then placed and the uterine incision was made with scalpel in a low transverse manner. The incision was stretched bluntly.

The fetus was noted to be in the *** presentation. The infant was then elevated to the level of the hysterotomy and delivered atraumatically in the standard fashion. The umbilical cord was clamped twice and cut and the neonate handed off to the awaiting pediatricians for resuscitation. The placenta was removed with the assistance of fundal massage. The uterus was exteriorized, wrapped in wet lap sponge, and the interior swept of all clots and debris with a dry lap sponge. The hysterotomy was then closed with 1-0 Biosyn in a running, locked fashion. ***A second imbricating layer of the same suture was then used to reinforce the hysterotomy repair.***

The hysterotomy was inspected and *** hemostasis was noted. The uterus was returned to the abdomen and the abdomen irrigated using moist lap sponges. Inspection of the hysterotomy again revealed excellent hemostasis. The undersides of the fascia were inspected, as were the rectus muscles, and were all found to be hemostatic. The fascia was then closed with 0 Vicryl/1-Maxon*** in a running fashion. The subcutaneous space was irrigated using a moist lap sponge and hemostasis was achieved with judicious use of electrocautery. The subcutaneous space was then reapproximated *** running continuous sutures of 2-0 Velosorb. The skin was closed with 4-0 Biosyn in a subcuticular fashion. Steri-Strips and a sterile dressing were then applied.

***In situ repair: The fetus was noted to be in the *** presentation. The infant was then elevated to the level of the hysterotomy and delivered atraumatically in the standard fashion. The umbilical cord was clamped twice and cut and the neonate handed off to the awaiting pediatricians for resuscitation. The placenta was removed with the assistance of fundal massage and the interior of the uterus was swept of all clots and debris with a dry lap sponge. The hysterotomy was then closed with 1-0 Biosyn in a running, locked fashion with uterus in situ. ***A second imbricating layer of the same suture was then used to reinforce the hysterotomy repair. The abdomen irrigated using moist lap sponges.*** Inspection of the hysterotomy revealed excellent hemostasis. The undersides of the fascia were inspected, as were the rectus muscles, and were all found to be hemostatic. The fascia was then closed with 0 Vicryl/1-Maxon*** in a running fashion. The subcutaneous space was irrigated using a moist lap sponge and hemostasis was achieved with judicious use of electrocautery. The subcutaneous space was then reapproximated with ***running continuous sutures of 2-0 Velosorb. The skin was closed with 4-0 Biosyn in a subcuticular fashion. Steri-Strips and a sterile dressing were then applied. ***

The patient tolerated the procedure well, was taken to recovery in stable condition. At the end of procedure all lap, sponge, instrument and needle counts were correct x2.

VTE PROPHYLAXIS: SCDs

ANTIBIOTICS: Ancef *** g and Azithromycin 500 mg ***