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Cesarean Delivery and Peripartum Hysterectomy: Introduction

Cesarean delivery is defined as the birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall

(hysterotomy). This definition does not include removal of the fetus from the abdominal cavity in the case of rupture of the uterus

or in the case of an abdominal pregnancy. In some cases, and most often because of emergent complications such as intractable

hemorrhage, abdominal hysterectomy is indicated following delivery. When performed at the time of cesarean delivery, the

operation is termed cesarean hysterectomy. If done within a short time after vaginal delivery, it is termed postpartum

hysterectomy.

Historical Background

The origin of the term cesarean is obscure, and three principal explanations have been suggested.

In the first, according to legend, Julius Caesar was born in this manner, with the result that the procedure became known as the

Caesarean operation. Several circumstances weaken this explanation. First, the mother of Julius Caesar lived for many years after

his birth in 100 BC, and as late as the 17th century, the operation was almost invariably fatal. Second, the operation, whether

performed on the living or the dead, is not mentioned by any medical writer before the Middle Ages. Historical details of the origin

of the family name Caesar are found in the monograph by Pickrell (1935).

The second explanation is that the name of the operation is derived from a Roman law, supposedly created in the 8th century BC by

Numa Pompilius, ordering that the procedure be performed upon women dying in the last few weeks of pregnancy in the hope of

saving the child. This lex regia—king's rule or law—later became the lex caesarea under the emperors, and the operation itself

became known as the caesarean operation. The German term Kaiserschnitt—Kaiser cut—reflects this derivation.

The third explanation is that the word caesarean was derived sometime in the Middle Age from the Latin verb caedere, to cut. This

explanation seems most logical, but exactly when it was first applied to the operation is uncertain. Because section is derived from

the Latin verb seco, which also means cut, the term caesarean section seems tautological—thus cesarean delivery is used. In the

United States, the ae in the first syllable of caesarean is replaced with the letter e. In the United Kingdom, Australia, and most

commonwealth nations, the ae is retained.

From the time of Virgil's Aeneas to Shakespeare's Macduff, poets repeatedly have referred to persons "untimely ripped" from their

mother's womb. Ancient historians such as Pliny, moreover, say that Scipio Africianus, the conqueror of Hannibal, as well as

Martius and Julius Caesar were all born by cesarean. In regard to Julius Caesar, Pliny adds that it was from this circumstance that

the surname arose by which the Roman emperors were known. Birth in this extraordinary manner, as described in ancient

mythology and legend, was believed to confer supernatural powers and elevated the heroes so born above ordinary mortals.

In evaluating these references to abdominal delivery in antiquity, it is pertinent that no such operation is even mentioned by

Hippocrates, Galen, Celsus, Paulus, Soranus, or any other medical writer of those periods. If cesarean delivery actually was

employed, it is particularly surprising that Soranus, whose extensive work written in the 2nd century AD covers all aspects of

obstetrics, does not refer to it.

Several references to abdominal delivery appear in the Talmud between the 2nd and 6th centuries AD, but whether they had any

background in terms of clinical usage is conjectural. There can be no doubt, however, that cesarean delivery in dead women was

first practiced soon after the Christian Church gained dominance, as a measure directed at baptism of the child. Confidence in the

validity of some of these early reports is rudely shaken, however, when they glibly state that a living, robust child was obtained 8

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to 24 hours after the death of the mother.

Cesarean deliveries in the living were first recommended, and the current name of the operation used, in the celebrated work of

Francois Rousset (1581) entitled Traité Nouveau de l'Hystérotomotokie ou l'Enfantement Césaerien. Rousset had never performed

or witnessed the operation, and his information was based chiefly on letters from friends. He reported 14 successful cesarean

deliveries, a fact in itself difficult to accept. When it is further stated that 6 of the 14 operations were performed on the same

woman, the credulity of the most gullible is exhausted!

The apocryphal nature of most early reports on cesarean delivery is stressed because many of them have been accepted without

question. Authoritative statements by dependable obstetricians about early use of the operation, however, did not appear in the

literature until the mid-17th century. An example is the classical work of the French obstetrician, Francois Mauriceau, first published

in 1668. This shows without doubt that the operation was employed on the living in rare and desperate cases, and that it was

usually fatal. Details of the history of cesarean deliveries are found in Fasbender's classic text (1906).

The appalling maternal mortality rate of cesarean delivery continued until the beginning of the 20th century. In Great Britain and

Ireland, the maternal death rate from the operation in 1865 was 85 percent. In Paris, during the 90 years ending in 1876, not a

single mother survived cesarean delivery. Harris (1879) noted that as late as 1879, cesarean deliveries actually were more

successful when performed by the patient herself or when the abdomen was ripped open by the horns of a bull! He found nine such

cases in the literature with five recoveries, and contrasted them with 12 cesarean deliveries performed in New York City during the

same period, with only one recovery.

The turning point in the evolution of cesarean operations came in 1882, when Max Sänger, then a 28-year-old assistant of Credé at

Leipzig, introduced suturing of the uterine wall. The long neglect of so simple an expedient had not been from oversight, but

stemmed from a deeply rooted belief that sutures in the uterus were superfluous as well as harmful by virtue of serving as the site

for severe infection. In meeting these latter objections, Sänger, who had himself used sutures in only one case, documented their

value not from the sophisticated medical centers of Europe but from frontier America. There, in outposts from Ohio to Louisiana, 17

cesarean deliveries had been reported in which silver wire sutures had been used, with the survival of eight mothers—an

extraordinary record in those days. Thus, hemorrhage was the first and most serious problem to be solved. The review by Eastman

(1932) details these findings.

Although the introduction of uterine sutures reduced mortality from the operation from hemorrhage, generalized peritonitis

remained the dominant cause of death. Hence, various types of operations were devised to combat this scourge. The earliest was

the Porro procedure (1876), which combined subtotal cesarean hysterectomy with marsupialization of the cervical stump. The first

extraperitoneal operation was described by Frank in 1907. With various modifications, this technique was introduced by Latzko

(1909) and Waters (1940), and it was employed until recent years.

In 1912, Krönig contended that the main advantage of the extraperitoneal technique was that the uterine incision was covered by

peritoneum. To accomplish this, he cut through the vesical reflection of the peritoneum from one round ligament to the other and

separated it and the bladder from the lower uterine segment. Then, through a vertical median incision, the child was extracted by

forceps. The uterine incision was then closed and buried under the vesical peritoneum. With minor modifications, this low-segment

technique was introduced into the United States by Beck (1919) and popularized by DeLee (1922) and others. A particularly

important modification was recommended by Kerr in 1926, who preferred a transverse rather than a longitudinal uterine incision.

Boley (1991) and Sewell (1993) have provided extensive reviews of the history of cesarean delivery.



Cesarean Delivery

Contemporary Status of Cesarean Delivery

Frequency

From 1965 through 1988, the cesarean delivery rate in the United States rose progressively from only 4.5 percent of all deliveries

to almost 25 percent (U.S. Public Health Service, 1991). Most of this increase took place in the 1970s and early 1980s and occurred

throughout the western world (Fig. 25–1). Between 1989 and 1996 the annual rate of cesarean delivery decreased in the United

States (Fig. 25–2). This was due in large part to an increased rate of vaginal birth after cesarean (VBAC) and to a lesser extent, a

small decrease in the primary cesarean rate (see Fig. 25–2). Since 1996, however, the total cesarean rate has increased every

year, and in 2002 it was 26.1 percent, the highest rate ever recorded in the United States.

Figure 25–1.

Percentage of deliveries by cesarean: Selected countries, 1970–1978. (From Smith, 1987, with permission.)

Figure 25–2.



Total and primary cesarean and vaginal birth after cesarean (VBAC) rates: United States, 1989–2001. The total rate is expressed as the

percent of all live births by cesarean delivery (CD). The primary cesarean rate is per 100 live births to women who have not had a previous

cesarean. The rate of VBAC delivery is calculated per 100 live births to women with a previous cesarean delivery. (Data from Hamilton and

associates, 2003.)

From these figures, it is apparent that the 1991 U.S. Public Health Service goal of an overall cesarean delivery rate of 15 percent

by the year 2000 was not achieved. More recently, the American College of Obstetricians and Gynecologists Task Force on

Cesarean Delivery Rates (2000) recommended two benchmarks for the United States for the year 2010:

1. A cesarean rate of 15.5 percent for nulliparous women at 37 weeks or more with a singleton cephalic presentation.

2. A vaginal birth rate after a prior cesarean of 37 percent in women at 37 weeks or more with a singleton cephalic presentation

who had one prior low-transverse cesarean delivery. The U.S. Department of Health and Human Services (2000) has

established similar goals for 2010.

The reasons why the cesarean rate quadrupled between 1965 and 1988 and its continued rise are not completely understood, but

some explanations include the following:

1. Women are having fewer children, thus, a greater percentage of births are among nulliparas, who are at increased risk for

cesarean delivery.

2. The average maternal age is rising, and older women, especially nulliparas, are at increased risk of cesarean delivery (Fig.

25–3).

3. The use of electronic fetal monitoring is widespread. This technique is associated with an increased cesarean delivery rate

compared with intermittent fetal heart rate auscultation (see Chap. 18, Introduction). Although cesarean delivery performed

primarily for "fetal distress" comprises only a minority of all such procedures, in many more cases concern for an abnormal,

or "nonreassuring," fetal heart rate tracing lowers the threshold for cesarean deliveries performed for abnormal progress of

labor.



4. The vast majority of fetuses presenting as breech are now delivered by cesarean (see Chap. 24, Current Status of Vaginal

Breech Delivery).

5. The incidence of midpelvic forceps and vacuum deliveries has decreased (see Chap. 23, Forceps Delivery).

6. Rates of labor induction continue to rise, and induced labor, especially among nulliparas, increases the risk of cesarean

delivery (see Chap. 22, Elective Induction of Labor).

7. The prevalence of obesity has risen dramatically, and obesity also increases the risk of cesarean delivery (see Chap. 43,

Maternal Morbidity).

8. Concern for malpractice litigation has contributed significantly to the present cesarean delivery rate. More than a decade ago,

it was reported that failure to perform a cesarean delivery and thus avoid adverse neonatal neurological outcome or cerebral

palsy was the dominant obstetrical claim in the United States (Physicians Insurance Association of America, 1992). Although

more recent data are aggregated differently, they suggest that this picture has changed little. Specifically, in 2001 a brain-

damaged infant was the claim responsible for 40 percent of all medicolegal indemnity paid by obstetricians-gynecologists

(Physicians Insurance Association of America, 2002). This reality is especially troubling in view of the well-documented lack

of association between cesarean delivery and any reduction in childhood neurological problems. According to Foley and

colleagues (2002), the incidence of neither neonatal seizures nor cerebral palsy diminished as the rate of cesarean delivery

increased (see also Chap. 29, Brain Disorders).

9. Some elective cesarean deliveries are now performed due to concern over pelvic floor injury associated with vaginal birth

(Nygaard and Cruikshank, 2003).

Figure 25–3.

Primary cesarean delivery rates by maternal age and birthweight among nulliparous women in Washington State, 1987–1990. (From Parrish

and co-workers, 1994, with permission.)

Indications

As shown in Table 25–1, repeat cesarean deliveries and those performed for dystocia have been the leading indications in both the

United States and other western industrialized countries. Although it is not possible to catalog comprehensively all appropriate

indications for cesarean delivery, over 85 percent are performed because of prior cesarean delivery, dystocia, fetal distress, or

breech presentation.



Table 25–1. Contribution by Indication to Overall Cesarean Delivery Rate in Four Countries During

1990

Cesarean Delivery Rate per 100 Total Deliveries

Indications Norway Scotland Sweden United States

Previous cesarean 1.3 3.1 3.1 8.5

Breech 2.1 2.0 1.8 2.6

Dystocia 3.6 4.0 1.7 7.1

Fetal distress 2.0 2.4 1.6 2.3

Other 3.7 2.7 2.4 3.2

Overall cesarean rate 12.8 14.2 10.7 23.6

Modified from Notzon and colleagues (1994), with permission.

Prior Cesarean Delivery

Management of the woman with a prior cesarean delivery is discussed in Chapter 26.

Dystocia

Some form of dystocia is the most frequent indication for cesarean delivery in the United States. An analysis of dystocia as a

contributing factor to the cesarean rate is difficult, however, because of the heterogeneity inherent in the condition (see Chap. 20,

Overdiagnosis of Dystocia). Indeed, there are 16 different ICD-9 (2003) codes applicable to cesarean delivery performed for a labor

abnormality! Descriptive terms vary from more precise definitions promulgated by Friedman (1978)—secondary arrest of dilatation,

arrest of descent—to more ambiguous and commonly used terms such as cephalopelvic disproportion and failure to progress.

Fetal Distress

Electronic fetal monitoring was employed in 85 percent of labors in the United States in 2002 (Martin and colleagues, 2003). Its use

increases the cesarean delivery rate, perhaps by as much as 40 percent (Thacker and associates, 2001). Unfortunately, despite

initial optimism, it has become well established that management based on electronic monitoring is no better in reducing the risk of

cerebral palsy or perinatal death than that based on intermittent heart rate auscultation. Indeed, the performance of cesarean

delivery per se may have no bearing on the neurodevelopmental prognosis of the infant. Scheller and Nelson (1994), in a report

from the National Institutes of Health, and Lien and associates (1995) presented data specifically refuting any association between

cesarean delivery and either cerebral palsy or seizures.

Pertinent to the diagnosis of fetal distress are the recommendations of the American Academy of Pediatrics and the American

College of Obstetricians and Gynecologists (2002) that facilities giving obstetrical care have the capability of initiating a cesarean

delivery within 30 minutes of the decision to operate. Misinterpretations of this guideline are common. Specifically, this

recommendation addresses facilities and does not govern clinical decision making. There is no nationally recognized standard of

care that codifies an acceptable time interval for performance of cesarean delivery. In most instances, operative delivery is not

necessary within this 30-minute time frame. Indeed, Bloom and co-workers (2001) from the National Institute of Child Health and

Human Development (NICHD) Maternal–Fetal Medicine Units Network reported that 69 percent of 7450 cesareans performed in

labor commenced more than 30 minutes after the decision to operate. Moreover, Chauhan and co-workers (1997) and MacKenzie

and Cooke (2002) reported that failure to achieve a cesarean delivery decision-to-incision time of less than 30 minutes was not

associated with a negative impact on neonatal outcome. On the other hand, when faced with an acute, catastrophic deterioration in

fetal condition, cesarean delivery usually is indicated as rapidly as possible and purposeful delays of any time period would be

inappropriate.

Breech Presentation

Management of the breech-presenting fetus is discussed in Chapter 24. Concern for fetal injury, as well as the infrequency with

which a breech presentation meets criteria for a trial of labor, make it likely that its contribution to the overall cesarean delivery



rate will remain relatively static.

Methods to Decrease Cesarean Delivery Rates

Several investivgators have documented the feasibility of achieving significant reductions in institutional cesarean delivery rates

without increased perinatal morbidity or mortality (DeMott, 1990; DeMuylder, 1990; Porreco, 1990; Pridijian, 1991; Sanchez-

Ramos, 1990, and all of their co-workers). Programs aimed at reducing the number of cesarean deliveries generally are focused on

educating physicians, peer reviewing, encouraging a trial of labor after prior transverse cesarean delivery, and restricting cesarean

deliveries for dystocia only to women who meet strictly defined criteria. In a recent randomized study from 34 Latin American

hospitals, Althabe and colleagues (2004) reported that a mandatory second opinion was associated with a small but significant

reduction in the cesarean delivery rate without an adverse effect on maternal or perinatal morbidity.

Maternal Mortality and Morbidity

In the United States, maternal death attributable solely to cesarean delivery is rare. In 1980, Frigoletto and colleagues reported a

series of 10,000 consecutive operations with no maternal deaths. In 1988, Sachs and associates observed only seven deaths as a

direct result of more than 121,000 cesarean deliveries performed between 1976 and 1984.

Even so, larger data sets attest to the mortality risks. In a population-based case-control study from North Carolina, which

encompassed the 7-year period from 1992 to 1998, cesarean delivery was associated with an almost fourfold risk of death, even

after controlling for pregnancy complications (Harper and colleagues, 2003). In another study, Hall and Bewley (1999) compiled

data from over 2 million births in the United Kingdom from 1994 through 1996. They showed that whereas emergency cesarean

delivery was associated with an almost ninefold risk of maternal death relative to that of vaginal delivery, even elective cesarean

delivery was associated with an almost threefold risk (Table 25–2). In a recent Network study, Landon and associates (2004)

reported a fivefold increased maternal death rate in women with a failed versus successful vaginal delivery who underwent a trial of

labor after a prior cesarean delivery.

Table 25–2. Direct Death Rates by Mode of Delivery in the United Kingdom, 1994–1996

Mode of Delivery Total Births Total Deaths Death Rate (per 100,000) Risk Ratio (95% CI)

Vaginal 1,845,957 38 2.1 1.0

Cesarean

Elective 153,829 9 5.9 2.84 (1.72–4.70)

Emergency 197,781 36 18.2 8.84 (5.60–13.94)

Total 351,610 45 12.8 6.22 (3.90–9.90)

Adapted from Hall and Bewley (1999), with permission.

Maternal morbidity is increased dramatically with cesarean compared with that of vaginal delivery. Principal sources are puerperal

infection, hemorrhage, and thromboembolism (Burrows and associates, 2004). Not all morbidity is immediate, and Lydon-Rochelle

and colleagues (2000) reported that rehospitalization in the 60 days following cesarean delivery was nearly twice as common as

after vaginal delivery—17 versus 10 hospitalizations per 1000 women delivered. Rajasekar and Hall (1997) reported that the

incidence of bladder laceration with cesarean operation was 1.4 per 1000 procedures, and the incidence of ureteral injury was 0.3

per 1000. Although bladder injury was immediately identified, the diagnosis of ureteral injury often was delayed. Uterine infection

is relatively common after cesarean delivery. The diagnosis and management of pelvic and wound infections following cesarean

delivery are discussed in Chapter 31. As discussed in Chapter 43 (see Maternal Morbidity), morbidity associated with cesarean

delivery is increased dramatically in obese women.

All of these morbidities, as well as the increased recovery time, result in a twofold increase in costs for cesarean versus vaginal

delivery (Henderson and associates, 2001).

Patient Choice in Cesarean Delivery

As cesarean delivery has become safer and more commonly performed, and women have taken a more active role in their



obstetrical care, it has been argued that women should be able to choose to undergo elective cesarean delivery (Harer, 2000). The

issue is currently quite contentious. Putative reasons for this choice include avoidance of pelvic floor injury during vaginal birth,

reduction in the risk of fetal injury, and convenience (Al-Mufti and colleagues, 1997). Conversely, the motivation of physicians in

offering this choice, its medical rationale from both a maternal and fetal-neonatal standpoint, and even the concept of informed

free choice have been questioned (Wagner, 2000).

Bewley and Cockburn (2002a, 2000b) found the concept of elective cesarean delivery to lack both ethical and medical merit.

Clearly, and usually only with the benefit of hindsight, it can be said that some women and infants who have undergone difficult

vaginal birth may have been better served by cesarean delivery instead. In most cases, however, clinically robust means of

prospectively identifying otherwise uncomplicated pregnancies in which the woman or her fetus-infant would benefit from elective

cesarean delivery are lacking. Minkoff and Chervenak (2003) and Minkhoff and colleagues (2004) concluded that although current

evidence does not support routine elective cesarean delivery, it does ethically support an obstetrical decision to accede to an

informed patient's request for such a delivery. At this time, we conclude that it is difficult to justify a laissez faire approach to this

major operation.

Technique for Cesarean Delivery

With minor variations, surgical performance of cesarean delivery is comparable worldwide.

Abdominal Incisions

Usually either a midline vertical or a suprapubic transverse incision is used. Only in especial circumstances would a paramedian or

midtransverse incision be employed.

Vertical Incision

An infraumbilical midline vertical incision is quickest to make. The incision should be of sufficient length to allow delivery of the

infant without difficulty. Therefore, its length should correspond with the estimated fetal size. Sharp dissection is performed to the

level of the anterior rectus sheath, which is freed of subcutaneous fat to expose a strip of fascia in the midline about 2 cm wide.

Some surgeons prefer to incise the rectus sheath with the scalpel throughout the length of the fascial incision. Others prefer to

make a small opening and then incise the fascial layer with scissors. The rectus and the pyramidalis muscles are separated in the

midline by sharp and blunt dissection to expose transversalis fascia and peritoneum.

The transversalis fascia and preperitoneal fat are dissected carefully to reach the underlying peritoneum. The peritoneum near the

upper end of the incision is opened carefully, either bluntly, or by elevating it with two hemostats placed about 2 cm apart. The

tented fold of peritoneum between the clamps is then examined and palpated to be sure that omentum, bowel, or bladder is not

adjacent. In women who have had previous intra-abdominal surgery, including cesarean delivery, omentum or bowel may be

adherent to the undersurface of the peritoneum. The peritoneum is incised superiorly to the upper pole of the incision and

downward to just above the peritoneal reflection over the bladder.

Transverse Incisions

With the modified Pfannenstiel incision, the skin and subcutaneous tissue are incised using a lower transverse, slightly curvilinear

incision. The incision is made at the level of the pubic hairline and is extended somewhat beyond the lateral borders of the rectus

muscles. After the subcutaneous tissue has been separated from the underlying fascia for 1 cm or so on each side, the fascia is

incised transversely the full length of the incision. Sequentially, first the superior and then the inferior edge of the fascia is grasped

with suitable clamps and elevated by the assistant as the operator separates the fascial sheath from the underlying rectus muscles

either bluntly or sharply. Blood vessels coursing between the muscles and fascia are clamped, cut, and ligated, or they are

fulgurated with electrocautery. Meticulous hemostasis is imperative. The fascial separation is carried near enough to the umbilicus

to permit an adequate midline longitudinal incision of the peritoneum. The rectus muscles are then separated in the midline to

expose the underlying peritoneum. The peritoneum is opened as discussed earlier.

The cosmetic advantage of the transverse skin incision is apparent. Whether it is stronger and less likely to undergo dehiscence is

debated (Hendrix and co-workers, 2000). There definitely are some disadvantages in its use. Exposure in some women is not as



optimal as with a vertical incision, and the latter can more easily be extended to increase exposure—a particular advantage if the

woman is obese. With repeat cesarean delivery, reentry through a Pfannenstiel incision usually is more time consuming and difficult

because of scarring.

When a transverse incision is desired and more room is needed, the Maylard incision provides a safe option (Ayers and Morley,

1987; Giacalone and colleagues, 2002). In this incision, the rectus muscles are divided sharply or with electrocautery. The incision

also may be especially useful in women with significant scarring resulting from previous transverse incisions.

Uterine Incisions

Most often the incision is made in the lower uterine segment transversely as described by Kerr in 1926. Occasionally, a low-

segment vertical incision as described by Krönig in 1912 may be used. The so-called classical incision is a vertical incision into the

body of the uterus above the lower uterine segment and reaching the uterine fundus. This incision is seldom used today. For most

cesarean deliveries, the transverse incision is the operation of choice. Its advantages are that it (1) is easier to repair, (2) is

located at a site least likely to rupture during a subsequent pregnancy, and (3) does not promote adherence of bowel or omentum

to the incisional line. If the fetus is not presenting by the vertex, if there are multiple fetuses, or if the fetus is very immature and

the woman has had no labor, a lower-segment vertical or even a classical incision may, at times, prove to be advantageous.

Technique for Transverse Cesarean Incision

Commonly, the uterus is found to be dextrorotated so that the left round ligament is more anterior and closer to the midline than

the right. With thick meconium or infected amnionic fluid, some surgeons prefer to lay a moistened laparotomy pack in each lateral

peritoneal gutter to absorb fluid and blood that escape from the opened uterus. The rather loose reflection of peritoneum above the

upper margin of the bladder and overlying the anterior lower uterine segment—the bladder flap—is grasped in the midline with

forceps and incised transversely with a scalpel or scissors (Fig. 25–4). Scissors are inserted between the vesicouterine serosa and

myometrium of the lower uterine segment and are pushed laterally from the midline, and then withdrawn while partially opening

the blades intermittently, to separate a 2-cm–wide strip of serosa, which is then incised. As the lateral margin on each side is

approached, the scissors are directed somewhat more cephalad (Fig. 25–5). The lower flap of peritoneum is elevated, and the

bladder is gently separated by blunt or sharp dissection from the underlying myometrium (Fig. 25–6). In general, the separation of

bladder should not exceed 5 cm in depth and usually should be less. It is possible, especially with an effaced, dilated cervix, to

dissect downward so deeply as inadvertently to expose and then enter the underlying vagina rather than the lower uterine segment.

Figure 25–4.



The loose vesicounterine serosa is grasped with the forceps. The hemostat tip points to the upper margin of the bladder. The retractor is

firmly positioned against the symphysis. (m. = muscle.)

Figure 25–5.



The loose serosa above the upper margin of the bladder is elevated and incised laterally.

Figure 25–6.



Cross section showing dissection of the bladder off the uterus to expose the lower uterine segment.

The uterus is entered through the lower uterine segment about 1 cm below the upper margin of the peritoneal reflection. It is

important to place the uterine incision relatively higher in women with advanced or complete cervical dilatation to minimize both

lateral extension of the incision into the uterine arteries and unintended entry into the vagina. This is done by using the

vesicouterine serosal reflection as a guide.

The uterine incision can be made by a variety of techniques. Each is initiated by using a scalpel to transversely incise the exposed

lower uterine segment for 1 to 2 cm in the midline. This must be done carefully to avoid injury to the fetus (Fig. 25–7). Skin

laceration was the most common fetal injury seen with 37,110 cesarean deliveries in the Network study reported by Alexander and

colleagues (2005). Careful blunt entry using hemostats or fingertip to split the muscle may be helpful. Once the uterus is opened,

the incision can be extended by cutting laterally and then slightly upward with bandage scissors. Alternatively, when the lower

uterine segment is thin, the incision can be extended by simply spreading the incision, using lateral and upward pressure applied

with each index finger (Fig. 25–8). Although Rodriguez and associates (1994) reported that blunt and sharp extensions of the initial

uterine incision are equivalent in terms of safety and postoperative complications, Magann and colleagues (2002) reported that

sharp dissection increased blood loss and the need for transfusion. It is very important to make the uterine incision large

enough to allow delivery of the head and trunk of the fetus without either tearing into or having to cut into the

uterine arteries and veins that course through the lateral margins of the uterus. If the placenta is encountered in the line

of incision, it must be either detached or incised. When the placenta is incised, fetal hemorrhage may be severe; thus, delivery and

cord clamping should be performed as soon as possible in such cases.

Figure 25–7.



The myometrium is incised carefully to avoid cutting the fetal head.

Figure 25–8.

After entering the uterine cavity, the incision is extended laterally with bandage scissors (A) or with the fingers, as shown in B.

Delivery of the Infant

In a cephalic presentation, a hand is slipped into the uterine cavity between the symphysis and fetal head, and the head is elevated

gently with the fingers and palm through the incision, aided by modest transabdominal fundal pressure (Fig. 25–9). After a long

labor with cephalopelvic disproportion, the fetal head may be tightly wedged in the birth canal. Upward pressure exerted by a hand

in the vagina by an assistant will help to dislodge the head and allow its delivery above the symphysis. To minimize fetal aspiration

of amnionic fluid, exposed nares and mouth are aspirated with a bulb syringe before the thorax is delivered. The shoulders then are

delivered using gentle traction plus fundal pressure (Fig. 25–10). The rest of the body readily follows.

Figure 25–9.



A. Immediately after incising the uterus and rupturing the fetal membranes, the fingers are insinuated between the symphysis pubis and the

fetal head until the posterior surface is reached. The head is lifted carefully anteriorly and, as necessary, superiorly to bring it from beneath

the symphysis forward through the uterine and abdominal incisions. B. As the fetal head is lifted through the incision, pressure usually is

applied to the uterine fundus through the abdominal wall to help expel the fetus.

Figure 25–10.

The shoulders are delivered, and oxytocin infusion is begun.

After the shoulders are delivered, an intravenous infusion containing about two ampules or 20 units of oxytocin per liter of

crystalloid is infused at 10 mL/min until the uterus contracts satisfactorily, after which the rate can be reduced. Bolus doses of 5 to

10 units are avoided because of associated hypotension. Munn and colleagues (2001) studied a much higher initial concentration

using a solution of 80 units of oxytocin in 500 mL of crystalloid, which was infused at about 17 mL/min. They reported that this

approach significantly reduced the need for additional uterotonic agents.

The cord is clamped, and the infant is given to the team member who will conduct resuscitative efforts as needed. The uterine

incision is observed for any vigorously bleeding sites. These should be promptly clamped with Pennington or ring forceps, or similar

instruments. The placenta is then delivered unless it has already done so spontaneously. Many surgeons prefer manual removal,

but spontaneous delivery with some cord traction (Fig. 25–11) has been shown to reduce the risk of puerperal metritis (Atkinson

and colleagues, 1996; Lasley and associates, 1997). Fundal massage, begun as soon as the fetus is delivered, reduces bleeding

and hastens placental delivery.

Figure 25–11.



Placenta bulging through the uterine incision as the uterus contracts.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2002) recommend that "a

qualified person who is skilled in neonatal resuscitation should be in the operative delivery room, with all equipment needed for

neonatal resuscitation, to care for the neonate." Based on their comparison of 834 cesarean deliveries with 834 low-risk vaginal

deliveries, Jacob and Phenninger (1997) reported that, with regional analgesia, there is rarely a need for vigorous infant

resuscitation after elective repeat cesarean delivery or cesarean delivery for dystocia without fetal heart rate abnormalities, and

that a pediatrician may not be necessary at such deliveries. At Parkland Hospital, pediatric nurse practitioners attend

uncomplicated, scheduled cesarean deliveries.

Repair of the Uterus

After delivery of the placenta, the uterus may be lifted through the incision onto the draped abdominal wall and the fundus covered

with a moistened laparotomy pack. Although some clinicians prefer to avoid it, uterine exteriorization often has advantages that

outweigh any disadvantages. For example, the relaxed, atonic uterus can be recognized quickly and massage applied. The incision

and bleeding points are visualized more easily and repaired, especially if there have been extensions laterally. Adnexal exposure is

superior, and thus tubal sterilization is easier. The principal disadvantage is from discomfort and vomiting caused by traction in

cesarean deliveries performed under regional analgesia. Neither febrile morbidity nor blood loss appears to be increased in women

undergoing uterine exteriorization prior to repair (Hershey and Quilligan, 1978; Wahab and co-workers, 1999).

Immediately after delivery and inspection of the placenta, the uterine cavity is inspected and either suctioned or wiped out with a

gauze pack to remove avulsed membranes, vernix, clots, and other debris. The upper and lower cut edges and each lateral angle of

the uterine incision are examined carefully for bleeding. Individually clamped large vessels are best ligated with a suture ligature.

Concern has been expressed by some clinicians that sutures through the decidua may lead to endometriosis in the hysterotomy



scar, but this is a rare.

The uterine incision is then closed with one or two layers of continuous 0 or number 1 absorbable suture. Chromic suture is used by

most surgeons, but some prefer synthetic nonabsorbable sutures. Hauth and colleagues (1992) randomized 906 women to either

one- or two-layer closure using 1-0 chromic gut. A continuous locking one-layer closure required less operative time and fewer

additional hemostatic sutures. In a follow-up report of 164 women delivered subsequently, the type of uterine closure did not

significantly affect several maternal and fetal complications in the next pregnancy (Chapman and associates, 1997). Similarly,

Durnwald and Mercer (2003) reported no uterine ruptures in 182 women who underwent a trial of labor after single-layer closure

compared with four ruptures in 340 women (1.2 percent) after double-layer closure. By contrast, Bujold and associates (2002)

reported that single-layer closure was associated with a fourfold increased risk of uterine rupture during a subsequent trial of labor.

Further study of this issue is needed (see Chap. 26, Closure of Prior Incision).

The initial suture is placed just beyond one angle of the uterine incision. A running-lock suture is then carried out, with each suture

penetrating the full thickness of the myometrium (Fig. 25–12). It is important to select carefully the site of each stitch and to avoid

withdrawing the needle once it penetrates the myometrium. This minimizes the perforation of unligated vessels and subsequent

bleeding. The running-lock suture is continued just beyond the opposite incision angle. Especially when the lower segment is thin,

satisfactory approximation of the cut edges usually can be obtained with one layer of suture. If approximation is not satisfactory

after a single-layer continuous closure, or if bleeding sites persist, then more sutures are required. Either another layer of sutures

may be placed so as to achieve approximation and hemostasis, or individual bleeding sites can be secured with figure-of-eight or

mattress sutures.

Figure 25–12.



The cut edges of the uterine incision are approximated with a running-lock suture.

Traditionally, serosal edges overlying the uterus and bladder have been approximated with a continuous 2-0 chromic catgut suture.

Multiple randomized trials suggest that omission of this step causes no postoperative complications (Grundsell, 1998; Hull and

Varner, 1991; Irion, 1996; Nagele, 1996; Pietrantoni, 1991, and all their associates). Specifically, not approximating the bladder

flap is unlikely to increase adhesion formation or long-term morbidity (Roset and colleagues, 2003; Tulandi and Al-Jaroudi, 2003).

Data are conflicting as to whether nonclosure of peritoneum decreases postoperative discomfort and need for analgesia

(Chanrachakul and colleagues, 2002; Rafique and colleagues, 2002).

If tubal sterilization is to be performed, it is now done as described in Chapter 33 (see Female Sterilization).

Abdominal Closure

All packs are removed, and the paracolic gutters and cul-de-sac are emptied of blood and amnionic fluid using gentle suction. Some

surgeons irrigate the gutters and cul-de-sac, especially in the presence of infection or meconium. A small randomized trial by

Harrigill and colleagues (2003) supports that this step is not necessary in low-risk women who undergo cesarean delivery in the

absence of amnionitis. After the sponge and instrument counts are found to be correct, the abdominal incision is closed in layers.

As previously discussed, many surgeons omit the parietal peritoneal closure because it serves little purpose. If there is distended

bowel in the incision site, however, we find that peritoneal closure may help to protect the bowel when fascial sutures are placed.

As each layer is closed, bleeding sites are located, clamped, and ligated. The rectus muscles are allowed to fall into place, and the

subfascial space is meticulously checked for hemostasis. With significant diastasis, the rectus muscles may be approximated with

one or two figure-of-eight sutures of 0 or number 1 chromic. The overlying rectus fascia is closed either with interrupted 0

nonabsorbable sutures that are placed lateral to the fascial edges and no more than 1 cm apart, or by continuous, nonlocking

suture of a long-lasting absorbable or permanent type.

The subcutaneous tissue usually need not be closed separately if it is less than 2 cm in thickness, and the skin is closed with

vertical mattress sutures of 3-0 or 4-0 silk or equivalent suture, with a running 4-0 subcuticular stitch using semipermanent suture,

or with skin clips. If the subcutaneous tissue is at least 2 cm thick, it should be closed. In a randomized prospective study of more

than 1400 women undergoing cesarean delivery, Bohman and colleagues (1992) reported a significantly decreased frequency of

superficial wound disruption when the subcutaneous layer was approximated. Based on their systematic review of six studies,

Chelmow and colleagues (2004) concluded that suturing the subcutaneous tissue at cesarean delivery decreases the risk of wound

disruption by 34 percent in women with fat thickness greater than 2 cm.

Technique for Classical Cesarean Incision

Occasionally it is necessary to use a classical incision for delivery. Some indications are:

1. Difficulty in exposing or safely entering the lower uterine segment because the bladder is densely adherent from previous

surgery, a myoma occupies the lower uterine segment, or the cervix has been invaded by cancer.

2. Transverse lie of a large fetus, especially if the membranes are ruptured and the shoulder is impacted in the birth canal. A

fetus presenting as a back-down transverse lie may be particularly difficult to deliver through a transverse incision.

3. Some cases of placenta previa with anterior implantation, especially in the case where the placenta has grown through a

prior uterine incision (placenta percreta).

4. Certain cases in which the fetus is very small, especially if breech, and the lower uterine segment is not thinned out.

5. Massive maternal obesity precluding safe access to the lower uterine segment.

Uterine Incision

A vertical uterine incision is initiated with a scalpel beginning as low as possible, depending on how well the lower segment is

thinned out. If adhesions, insufficient exposure, a tumor, or placenta percreta preclude development of a bladder flap, then the

incision is made above the level of the bladder. Once uterine entry is made with the scalpel, the incision is extended cephalad with



bandage scissors until it is sufficiently long to permit delivery of the fetus. Numerous large vessels that bleed profusely are

commonly encountered within the myometrium.

Uterine Repair

One method employs a layer of continuous 0 or 1-0 chromic catgut to approximate the deeper halves of the incision. The outer half

of the uterine incision is then closed with similar suture, using either a continuous stitch or figure-of-eight sutures. No unnecessary

needle tracts should be made lest myometrial vessels are perforated with subsequent hemorrhage or hematomas. To achieve good

approximation and to prevent the suture from tearing through the myometrium, it is helpful to have an assistant compress the

uterus on each side of the wound toward the midline as each suture is placed and tied. The edges of the uterine serosa, if not

already so, are approximated with continuous 2-0 chromic catgut. The operation is completed as described earlier.

Postmortem Cesarean Delivery

At times, cesarean delivery is performed on a woman who has just died, or who is expected to do so momentarily. The issue of

cesarean delivery to aid in cardiopulmonary resuscitation of the mother is further discussed in Chapter 42 (see Cardiopulmonary

Resuscitation).

Peripartum Hysterectomy

Hysterectomy performed at or following delivery may be lifesaving if there is severe obstetrical hemorrhage. It can be carried out in

conjunction with cesarean delivery or following vaginal delivery. One measure of its incidence is from the Maternal–Fetal Medicine

Units Network centers. In that study of almost 29,000 cesarean deliveries, Shellhaas and colleagues (2001) reported that

hysterectomy was performed in 1 in every 200 cesarean deliveries. Overall, hysterectomy was performed in 1 in every 950

deliveries. During the 9-year period ending with 2002, during which there were almost 129,500 deliveries at Parkland Hospital,

peripartum hysterectomy was performed once in every 500 deliveries. The incidence was 1 in 135 for 26,700 cesarean deliveries

and about 1 in 1850 for vaginal deliveries. These numbers are similar to those of Kastner and co-workers (2002), who reported an

overall rate of peripartum hysterectomy of 1.4 per 1000 deliveries. Similarly, Forna and associates (2004) cited a rate of 0.8 per

1000 deliveries at Grady Hospital.

Indications

The majority of procedures are performed to arrest hemorrhage from intractable uterine atony, lower-segment bleeding associated

with the uterine incision or placental implantation, or a laceration of major uterine vessels. Placenta accreta, often in association

with repeat cesarean delivery, and uterine atony are the most common indications today for cesarean or postpartum hysterectomy

(Kastner and associates, 2002; Shellhaas and colleagues, 2001). These conditions are discussed in Chapter 35. Large myomas may

preclude satisfactory hysterotomy closure and thus necessitate hysterectomy. Elective indications for peripartum hysterectomy

include large or symptomatic myomas and severe cervical dysplasia or carcinoma in situ.

Major complications of peripartum hysterectomy are increased blood loss and the possibility of urinary tract damage. An important

factor affecting the complication rate is whether the operation is performed as an elective procedure or as an emergency. As shown

in Table 25–3, morbidity associated with emergency hysterectomy is substantively increased. Seago and associates (1999)

reported that the rate of intraoperative and postoperative complications among 100 women who underwent planned cesarean

hysterectomy was not increased when compared with that of a control group of 37 women who underwent cesarean delivery

followed by hysterectomy performed within 6 months.

Table 25–3. Comparison of Morbidity with Elective Versus Emergency Peripartum Hysterectomy



Complications (%) with Peripartum Hysterectomy

Complications Electivea (n = 189) Emergencyb (n = 231)

Blood transfusions 18 90

Bladder injury 1.5 5

Ureteral injury 0 1.3

Surgical infection 22 30

Death 0 1.3 aData from Plauche (1995).

bData from Kastner (2002), Zelop (1993), Zorlu (1998), and all their colleagues.

Although pelvic vessels are appreciably hypertrophied, hysterectomy usually is facilitated by the ease of development of tissue

planes in pregnant women. Blood loss is usually appreciable because hysterectomy performed for hemorrhage almost always is

torrential. Indeed, as shown in Table 25–3, 90 percent of women undergoing emergency peripartum hysterectomy required

transfusions.

Technique for Peripartum Hysterectomy

Supracervical or total hysterectomy is performed using standard operative techniques. Initially, placement of a self-retaining

retractor such as a Balfour is not necessary. Satisfactory exposure is best obtained with cephalad traction on the uterus by an

assistant, along with hand-held retractors such as a Richardson or Deaver. The bladder flap is deflected downward to the level of

the cervix if possible. After cesarean delivery and placental removal, if the hysterotomy is bleeding appreciably, either it can be

sutured, or Pennington or sponge-forceps can be applied for hemostasis. If bleeding is minimal, neither maneuver is necessary.

The round ligaments close to the uterus are divided between Heaney or Kocher clamps and doubly ligated. Either 0 or number 1

sutures can be used. The incision in the vesicouterine serosa that was made to mobilize the bladder is extended laterally and

upward through the anterior leaf of the broad ligament to reach the incised round ligaments (Fig. 25–13). The posterior leaf of the

broad ligament adjacent to the uterus is perforated just beneath the fallopian tubes, utero-ovarian ligaments, and ovarian vessels

(Fig. 25–14A). These vessels then are doubly clamped close to the uterus and divided, and the lateral pedicle is doubly ligated (Fig.

25–14B). The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligaments (Fig. 25–15). Next, the

bladder and attached peritoneal flap are again deflected and dissected from the lower uterine segment and retracted out of the

operative field (Fig. 25–16). If the bladder flap is unusually adherent, as it may be after previous cesarean incisions, careful sharp

dissection may be necessary.

Figure 25–13.



The incision in the vesicouterine serosa is extended laterally and upward through the anterior leaf of the broad ligament to reach the incised

round ligaments.

Figure 25–14.



A. The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tube, utero-ovarian ligaments, and

ovarian vessels. B. These then are doubly clamped close to the uterus and divided.

Figure 25–15.



The posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligament.

Figure 25–16.



The bladder is further dissected from the lower uterine segment by blunt dissection with pressure directed toward the lower segment and not

the bladder. Sharp dissection may be necessary.

Special care is necessary from this point on to avoid injury to the ureters, which pass beneath the uterine arteries. To help

accomplish this, the assistant places constant traction on the uterus in the direction away from the side on which the uterine

vessels are being ligated. The ascending uterine artery and veins on either side are identified near their origin. These pedicles are

then doubly clamped immediately adjacent to the uterus, divided, and doubly suture ligated. As shown in Figure 25–17, we prefer

to use three heavy clamps, incise the tissue between the most medial and two lateral clamps, and then ligate the two pedicles in

the clamps lateral to the uterus.

Figure 25–17.



A. The uterine artery and veins on either side are doubly clamped immediately adjacent to the uterus and divided. B, C. The vascular pedicle

is doubly suture ligated.

In cases of profuse hemorrhage, it may be more advantageous to rapidly double clamp and divide all of the vascular pedicles

between clamps to gain hemostasis and then return to suture ligate all of the pedicles.

Supracervical Hysterectomy

To perform a subtotal hysterectomy, it is necessary only to amputate the body of the uterus at this level. The cervical stump may

be closed with continuous or interrupted chromic sutures. Subtotal hysterectomy is often all that is necessary to stop hemorrhage

and may be the more prudent operation for selected women (Jones, 1999; Kastner, 2002; Learman, 2003; Munro, 1997, and their

associates).

Total Hysterectomy

Even if total hysterectomy is planned, we find it in many cases technically easier to finish the operation after amputating the

uterine fundus and placing Ochsner or Kocher clamps on the stump for traction and hemostasis. Self-retaining retractors also are

placed at this time. To remove the cervix, it is necessary to mobilize the bladder much more extensively in the midline and

laterally. This will help carry the ureters caudad as the bladder is retracted beneath the symphysis and also will prevent laceration

or suturing of the bladder during cervical excision and vaginal cuff closure. Before cesarean delivery, the bladder is dissected free

for about 2 cm below the lowest margin of the cervix to expose the uppermost part of the vagina. If the cervix is effaced and

dilated appreciably, after delivery the cervicovaginal junction may be identified by a vertical uterine incision made anteriorly in the

midline, either through the hysterotomy incision or through an incision made at the level of the ligated uterine vessels. A finger is

directed inferiorly through the incision to identify the free margin of the dilated, effaced cervix and the anterior vaginal fornix, and



the contaminated glove replaced. Another useful method to identify the cervical margins is to place four metal skin clips or brightly

colored sutures at 12, 3, 6, and 9 o'clock positions on the cervical edges prior to hysterectomy.

The cardinal ligaments, uterosacral ligaments, and the many large vessels these ligaments contain are doubly clamped

systematically with Heaney-type curved clamps, Ochsner-type straight clamps, or similar instruments (Fig. 25–18). The clamps are

placed as close to the cervix as possible, taking care not to include excessive tissue in each clamp. The tissue between the pair of

clamps is incised and the distal pedicle suture ligated. These steps are repeated until the level of the lateral vaginal fornix is

reached. In this way, the descending branches of the uterine vessels are clamped, cut, and ligated as the cervix is dissected from

the cardinal ligaments posteriorly.

Figure 25–18.

The cardinal ligaments are clamped, incised, and ligated.

Immediately below the level of the cervix, a curved clamp is placed across the lateral vaginal fornix, and the tissue is incised

medially to the clamp (Fig. 25–19). The excised lateral vaginal fornix can be simultaneously doubly ligated and sutured to the

stump of the cardinal ligament. The entire cervix is then excised from the vagina. The cervix is inspected to ensure that it has been

completely removed, and the vagina is then repaired. Each of the angles of the lateral vaginal fornix is secured to the cardinal and

uterosacral ligaments (Fig. 25–20). Following this step, some surgeons prefer to close the vagina using figure-of-eight chromic



catgut sutures. Others achieve hemostasis by using a running-lock stitch of chromic catgut suture placed through the mucosa and

adjacent endopelvic fascia around the circumference of the vaginal cuff (Fig. 25–21). The open vagina may promote drainage of

fluids that would otherwise accumulate and contribute to hematoma formation and infection.

Figure 25–19.

A curved clamp is placed across the lateral vaginal fornix below the level of the cervix and the tissue incised medially to the point of the clamp.

Figure 25–20.



The lateral angles of the vaginal cuff are secured to the cardinal and uterosacral ligaments.

Figure 25–21.

A running-lock suture is placed through the edge of the vaginal mucosa, circumferentially.

If a self-retaining retractor has not already been placed, some clinicians choose to insert the instrument at this point. The bowel is

then packed out of the field and all sites of incision are examined carefully for bleeding. One technique is to perform a systematic

bilateral survey from the fallopian tube and ovarian ligament pedicles to the vaginal vault and bladder flap. Bleeding sites are

ligated with care to avoid the ureters.

Some clinicians choose to reperitonealize the pelvis. One method employs a continuous chromic suture starting with the tip of the



ligated pedicle of fallopian tube and ovarian ligament, which is inverted retroperitoneally. Sutures are then placed continuously to

approximate the leaves of the broad ligament, bury the stump of the round ligament, and to join the cut edge of the vesicouterine

peritoneum over the vaginal vault posteriorly to the cut edge of peritoneum above the cul-de-sac. This action is then repeated on

the other side. The abdominal wall normally is closed in layers, as previously described.

Oophorectomy

Most studies indicate that in 5 percent of postpartum hysterectomies, one adnexum will have to be removed to stop bleeding

(Plauche, 1995). That said, during any hysterectomy, a decision as to the fate of the ovaries must be made. For women who are

approaching menopause, the decision is not difficult, but few women who undergo cesarean hysterectomy are of this age.

Peripartum Management

Preoperative Care

If cesarean delivery is planned, a sedative, such as secobarbital, 100 mg, may be given at bedtime the night before the operation.

In general, no other sedatives, narcotics, or tranquilizers are administered until after the infant is born. Oral intake is stopped at

least 8 hours before surgery. The woman scheduled for repeat cesarean delivery typically is admitted the day of surgery and

evaluated by the obstetrician and the anesthesiologist. The hematocrit is rechecked, as is the indirect Coombs test. If the latter is

positive, then availability of compatible blood must be assured. An antacid, such as Bicitra, 30 mL, is given shortly before

placement of conduction analgesia or induction with general anesthesia. This minimizes the risk of lung injury from gastric acid

should aspiration occur (see Chap. 19, Aspiration). An indwelling bladder catheter is placed. If hair obscures the operative field it

should be removed the day of surgery by clipping or shaving. If shaving is performed the night before surgery, the risk of wound

infection is increased.

Intravenous Fluids

Requirements for intravenous fluids, including blood during and after cesarean delivery, can vary considerably. The woman of

average size with a hematocrit of 30 percent or more and a normally expanded blood and extracellular fluid volume most often will

tolerate blood loss up to 2000 mL without difficulty. Unappreciated bleeding through the vagina during the procedure, bleeding

concealed in the uterus after its closure, or both, commonly lead to underestimation. Although blood loss averages about 1500 mL

with elective cesarean hysterectomy, it is quite variable (Pritchard, 1965). Intravenously administered fluids consist of either

lactated Ringer solution or a similar crystalloid solution with 5 percent dextrose. Typically, 1 to 2 L are infused during and

immediately after the operation. Throughout the procedure, and subsequently while in the recovery area, the blood pressure and

urine flow are monitored closely.

Prevention of Postoperative Infection

Febrile morbidity is frequent after cesarean delivery. A large number of randomized trials have demonstrated that a single dose of

an antimicrobial agent given at the time of cesarean delivery will serve to decrease infection morbidity significantly. This is true of

high-risk laboring patients as well as those undergoing elective cesarean delivery (American College of Obstetricians and

Gynecologists, 2003). For women in labor or with ruptured membranes, most clinicians recommend a single 2-g dose of a -lactam

drug—either a cephalosporin or an extended-spectrum penicillin—after delivery of the infant. Postoperative pelvic infection is the

most frequent cause of febrile morbidity and develops in up to 20 percent of these women despite peripartum prophylactic

antimicrobials (Goepfert and associates, 2001). In general, infection rates are higher among government-funded and indigent

patients. Treatment of uterine infection and its complications are discussed in Chapter 31.

Recovery Suite

Postoperatively, the amount of bleeding from the vagina must be monitored closely, and the uterine fundus must be identified

frequently by palpation to assure that the uterus is remaining firmly contracted. Unfortunately, as conduction analgesia fades or the

woman awakens from general anesthesia, palpation of the abdomen is likely to produce considerable discomfort. This can be made

more tolerable by giving an effective analgesic intravenously, such as meperidine, 75 to 100 mg, or morphine, 10 to 15 mg. A thick

dressing with an abundance of adhesive tape over the abdomen interferes with fundal palpation and massage and later causes



discomfort as the tape is removed. Deep breathing and coughing are encouraged. Once the mother is fully awake, bleeding is

minimal, blood pressure is satisfactory, and urine flow is at least 30 mL/hr, she may be sent to her room.

Subsequent Care

Analgesia

For the woman of average size, meperidine, 75 to 100 mg, is given intramuscularly as often as every 3 hours as needed for

discomfort, or morphine sulfate, 10 to 15 mg, is similarly administered. An antiemetic, such as promethazine, 25 mg, usually is

given along with the narcotic. Intravenous meperidine or morphine via a patient-controlled pump is an even more effective

alternative to bolus therapy in the immediate postoperative period. The pump typically is programmed to deliver a continuous

infusion of drug, which the woman can supplement with intermittent boluses, the frequency of which are determined by the "lock-

out" interval (Table 25–4). In a recent trial at Parkland Hospital (Yost and colleagues, 2004), morphine provided superior pain relief

to meperidine and was associated with significantly higher rates of breast feeding continuation and infant rooming-in.

Table 25–4. Typical Settings for Administration of Intravenous Opioids Via a Patient-Controlled

Analgesia Pump

Opioid Bolus Dose (mg) Lock-Out Interval (min) Continuous Infusion (mg/hr)

Meperidine 5–15 5–15 5 – 40

Morphine 0.5–3.0 5–20 1–10

Modified from Lubenow and colleagues (1997), with permission.

Vital Signs

After transfer to her room, the patient is assessed at least hourly for 4 hours and thereafter, at intervals of 4 hours. Blood

pressure, pulse, temperature, uterine tone, urine output, and amount of bleeding are evaluated.

Fluid Therapy and Diet

Unless there has been pathological constriction of the extracellular fluid compartment from severe preeclampsia, vomiting, fever, or

prolonged labor without adequate fluid intake, or there is sepsis or significant blood loss, the puerperium is characterized by

excretion of fluid that was retained during pregnancy. Moreover, with the typical cesarean delivery, significant extracellular fluid

sequestration in bowel wall and lumen does not occur, unless it was necessary to pack the bowel away from the operative field or

peritonitis develops. Thus, the woman who undergoes cesarean delivery rarely develops fluid sequestration in the so-called third

space. Quite the contrary, she normally begins surgery with a physiologically enlarged extravascular volume acquired during

pregnancy that she mobilizes and excretes after delivery. Therefore, large volumes of intravenous fluids during and subsequent to

surgery are not needed to replace sequestered extracellular fluid. As a generalization, 3 L of fluid should prove adequate during the

first 24 hours after surgery. If urine output falls below 30 mL/hr, however, then the woman should be reevaluated promptly. The

cause of the oliguria may range from unrecognized blood loss to an antidiuretic effect from infused oxytocin.

Bladder and Bowel Function

The bladder catheter most often can be removed by 12 hours postoperatively or, more conveniently, the morning after surgery.

Subsequent ability to empty the bladder before overdistention develops must be monitored as with vaginal delivery.

In uncomplicated cases, solid food may be offered within 8 hours of surgery (Burrows and associates, 1995; Kramer and

colleagues, 1996). Although some degree of adynamic ileus follows virtually every abdominal operation, in most cases of cesarean

delivery, it is negligible. Symptoms include abdominal distention and gas pains, and an inability to pass flatus or stool. The

pathophysiology of postoperative ileus is complex and involves hormonal, neural, and local factors that are incompletely

understood (Livingston and Passaro, 1990). If associated with otherwise unexplained fever, an unrecognized bowel injury may be

responsible. Treatment for ileus has changed little over the past several decades and involves intravenous fluid and electrolyte

supplementation. If severe, nasogastric decompression is necessary. Frequently, a 10-mg bisacodyl rectal suppository provides

appreciable relief.



Ambulation

In most instances, by the day after surgery, the woman should get briefly out of bed with assistance at least twice. Ambulation can

be timed so that a recently administered analgesic will minimize the discomfort. By the second day she may walk without

assistance. Early ambulation lowers the risk of venous thrombosis and pulmonary embolism (see Chap. 47).

Wound Care

The incision is inspected each day, and the skin sutures or clips often can be removed on the fourth day after surgery. However, if

there is concern for superficial wound separation, as in the obese patient, the suture or clips should remain in place for 7 to 10

days if they are not causing appreciable skin irritation. By the third postpartum day, bathing by shower is not harmful to the

incision. In addition to increasing the risk of wound separation, thick subcutaneous tissue—greater than 3 cm—increases the risk of

wound infection (Vermillion and associates, 2000).

Laboratory

The hematocrit is routinely measured the morning after surgery. It is checked sooner when there was unusual blood loss or when

there is oliguria or other evidence to suggest hypovolemia. If the hematocrit is decreased significantly from the preoperative level,

the measurement is repeated and a search is instituted to identify the cause of the decline. If the hematocrit stabilizes, the mother

can ambulate without any difficulty, and if there is little likelihood of further blood loss, iron therapy is preferred to transfusion.

Breast Care

Breast feeding can be initiated the day of surgery. If the mother elects not to breast feed, a binder that supports the breasts

without marked compression usually will minimize discomfort (see Chap. 30, Breast Feeding).

Hospital Discharge

Unless there are complications during the puerperium, the mother generally is discharged on the third or fourth postpartum day

(see Chap. 30, Time of Discharge). Strong and associates (1993) have presented data suggesting that discharge on day 2 may be

appropriate for properly selected and motivated women. The mother's activities during the first week should be restricted to self-

care and care of her baby with assistance. Brooten and colleagues (1994) successfully combined early discharge with nurse

specialist transitional home care. In many cases, it may be advantageous to perform an initial postpartum evaluation during the

first to third week after delivery to search for puerperal complications discussed in Chapter 30 and Chapter 32.

References

Alexander JM for the NICHD MFMU Network: The MFMU Units Cesarean Registry: Fetal injury associated with cesarean delivery.

Presented at the 25th Annual Meeting of the Society for Maternal-Fetal Medicine, Reno/Lake Tahoe NV, 7–12 Feb 2005

Al-Mufti R, McCarthy A, Fisk NM: Survey of obstetricians' personal preference and discretionary practice. Eur J Obstet Gynecol

Reprod Biol 73:1, 1997 [PMID: 9175681] [Full Text]

Althabe F, Beliz‡n JM, Villar J, et al: Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America:

a cluster randomised controlled trial. Lancet. 12;363:1934, 2004

American Academy of Pediatrics and American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 5th ed. Elk

Grove, Ill, American Academy of Pediatrics, 2002

American College of Obstetricians and Gynecologists: Prophylactic antibiotics in labor and delivery. Practice Bulletin No. 47, October

2003

American College of Obstetricians and Gynecologists, Task Force on Cesarean Delivery Rates: Evaluation of cesarean delivery. June

2000

Atkinson MW, Owen J, Wren A, et al: The effect of manual removal of the placenta on post-cesarean endometritis. Obstet Gynecol

87:99, 1996 [PMID: 8532276] [Full Text]



Ayers JWT, Morley GW: Surgical incision for cesarean section. Obstet Gynecol 70:706, 1987 [PMID: 2958727] [Full Text]

Beck AC: Observations on a series of cases of cesarean section done at the Long Island College Hospital during the past six years.

Am J Obstet Gynecol 79:197, 1919

Bewley S, Cockburn J: The unethics of `request' caesarean section [commentary]. Br J Obstet Gynaecol 109:593, 2002a

Bewley S, Cockburn J: The unfacts of `request' caesarean section [commentary]. Br J Obstet Gynaecol 109:597, 2002b

Bloom SL for the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Cesarean Registry:

Decision to incision times and infant outcome. Am J Obstet Gynecol 185:S121, 2001

Bohman VR, Gilstrap L, Leveno K, et al: Subcutaneous tissue: To close or not to close at cesarean section. Am J Obstet Gynecol

166:407, 1992

Boley JP: The history of cesarean section. Can Med Assoc J 145:319, 1991 [PMID: 1873766] [Full Text]

Brooten D, Roncoli M, Finkler S, et al: A randomized trial of early hospital discharge and home follow-up of women having cesarean

birth. Obstet Gynecol 84:832, 1994 [PMID: 7936522] [Full Text]

Bujold E, Bujold C, Hamilton EF, et al: The impact of a single-layer or double-layer closure on uterine rupture. Am J Obstet Gynecol

186:1326, 2002 [PMID: 12066117] [Full Text]

Burrows LJ, Meyn LA, Weber AM: Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol. 103:907,

2004 [PMID: 15121564] [Full Text]

Burrows WR, Gingo AJ Jr, Rose SM, et al: Safety and efficacy of early postoperative solid food consumption after cesarean section. J

Reprod Med 40:463, 1995 [PMID: 7650662] [Full Text]

Chanrachakul B, Hamontri S, Herabutya Y: A randomized comparison of postcesarean pain between closure and nonclosure of

peritoneum. Eur J Obstet Gynecol Reprod Biol 101:31, 2002 [PMID: 11803097] [Full Text]

Chapman SJ, Owen J, Hauth JC: One versus two-layer closure of a low transverse cesarean: The next pregnancy. Obstet Gynecol

89:16, 1997 [PMID: 8990429] [Full Text]

Chauhan SP, Roach H, Naef RW, et al: Cesarean section for suspected fetal distress: Does the decision-incision time make a

difference? J Reprod Med 42:347, 1997 [PMID: 9219122] [Full Text]

Chelmow D, Rodriguez EJ, Sabatini MM: Suture closure of subcutaneous fat and wound disruption after cesarean delivery: A meta-

analysis. Obstet Gynecol. 103:974, 2004 [PMID: 15121573] [Full Text]

DeLee JB, Cornell EL: Low cervical cesarean section (laparotrachelotomy). JAMA 79:109, 1922

DeMott RK, Sandmire HF: The Green Bay cesarean section study, 1. The physician factor as a determinant of cesarean birth rates.

Am J Obstet Gynecol 162:1593, 1990 [PMID: 2360593] [Full Text]

DeMuylder X, Thiery M: The cesarean delivery rate can be safely reduced in a developing country. Obstet Gynecol 75:60, 1990

Durnwald C, Mercer B: Uterine rupture, perioperative and perinatal morbidity after single-layer and double-layer closure at

cesarean delivery. Am J Obstet Gynecol 189:925, 2003 [PMID: 14586327] [Full Text]

Eastman NJ: The role of frontier America in the development of cesarean section. Am J Obstet Gynecol 24:919, 1932

Fasbender H: Geschichte der Geburtshilfe. Jena, 1906, p 979

Foley M, Alarab M, O'Herlighy C: Neonatal seizures and peripartum deaths: Lack of correlation with cesarean rate [abstract]. Am J

Obstet Gynecol 187:S102, 2002



Forna F, Miles AM, Jamieson DJ: Emergency peripartum hysterectomy: A comparison of cesarean and postpartum hysterectomy.

Am J Obstet Gynecol 190:1440, 2004 [PMID: 15167863] [Full Text]

Frank F: Suprasymphysial delivery and its relation to other operations in the presence of contracted pelvis. Arch Gynaekol 81:46,

1907

Friedman EA: Labor, Clinical Evaluation and Management. New York, Appleton, 1978

Frigoletto FD Jr, Ryan KJ, Phillippe M: Maternal mortality rate associated with cesarean section: An appraisal. Am J Obstet Gynecol

136:969, 1980 [PMID: 7361846] [Full Text]

Giacalone PL, Daures JP, Vignal J, et al: Pfannenstiel versus Maylard incision for cesarean delivery: A randomized controlled trial.

Obstet Gynecol 99:745, 2002 [PMID: 11978282] [Full Text]

Goepfert A for the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network: The MFMU

Cesarean Registry: Infectious morbidity following primary cesarean section. Am J Obstet Gynecol 185:S192, 2001

Grundsell HS, Rizk DE, Kumar RM: Randomized study of non-closure of peritoneum in lower segment cesarean section. Acta Obstet

Gynecol Scand 77:110, 1998 [PMID: 9492730] [Full Text]

Hall MH, Bewley S: Maternal mortality and mode of delivery. Lancet 354:776, 1999 [PMID: 10475219] [Full Text]

Hamilton BE, Martin JA, Sutton PD: Births: Preliminary data for 2002. National Vital Statistics Reports, Vol 51, No.1. Hyattsville,

Md, National Center for Health Statistics, 2003

Harer W: Patient choice caesarean. Am Coll Obstet Gynecol Clin Rev 5:2, 2000

Harper MA, Byington RP, Espeland MA, et al: Pregnancy-related death and health care services. Obstet Gynecol 102:273, 2003

[PMID: 12907099] [Full Text]

Harrigill KM, Miller HS, Haynes DE: The effect of intraabdominal irrigation at cesarean delivery on maternal morbidity: A

randomized trial. Obstet Gynecol 101:80, 2003 [PMID: 12517650] [Full Text]

Harris RP: Lessons from a study of the cesarean operation in the city and state of New York. Am J Obstet Gynecol 12:82, 1879

Hauth JC, Owen J, Davis RO, et al: Transverse uterine incision closure: One versus two layers. Am J Obstet Gynecol 167:1108,

1992 [PMID: 1415400] [Full Text]

Henderson J, McCandlish R, Kumiega L, et al: Systematic review of economic aspects of alternative modes of delivery. Br J Obstet

Gynaecol 108:149, 2001 [PMID: 11236114] [Full Text]

Hendrix SL, Schimp V, Martin J, et al: The legendary superior strength of the Pfannenstiel incision: A myth? Am J Obstet Gynecol

182:1446, 2000 [PMID: 10871464] [Full Text]

Hershey DW, Quilligan EJ: Extraabdominal uterine exteriorization at cesarean section. Obstet Gynecol 52:189, 1978 [PMID:

683658] [Full Text]

Hull DB, Varner MW: A randomized study of closure of the peritoneum at cesarean delivery. Obstet Gynecol 77:818, 1991 [PMID:

2030849] [Full Text]

ICD-9-CM Professional, 6th ed. 2003 ICD-9-CM Vol 1 (October 2002). Salt Lake City, Utah, St. Anthony Publishing, 2003, p 182

Irion O, Luzuy F, Beguin F: Nonclosure of the visceral and parietal peritoneum at caesarean section: A randomised controlled trial.

Br J Obstet Gynaecol 103:690, 1996 [PMID: 8688397] [Full Text]



Jacob J, Phenninger J: Cesarean deliveries: When is a pediatrician necessary? Obstet Gynecol 89:217, 1997 [PMID: 9015023] [Full

Text]

Jones DE, Shackelford DP, Brame RG: Supracervical hysterectomy: Back to the future? Am J Obstet Gynecol 180:513, 1999 [PMID:

10076119] [Full Text]

Kastner ES, Figueroa R, Garry D, et al: Emergency peripartum hysterectomy: Experience at a community teaching hospital. Obstet

Gynecol 99:971, 2002 [PMID: 12052583] [Full Text]

Kerr JMM: The technic of cesarean section with special reference to the lower uterine segment incision. Am J Obstet Gynecol

12:729, 1926

Kramer R, Van Someren J, Qualls C, et al: Postoperative management of cesarean section patients: The effect of immediate feeding

on the incidence of ileus. Obstet Gynecol 88:29, 1996 [PMID: 8684757] [Full Text]

Krönig B: Transperitonealer cervikaler Kaiserschnitt. In Doderlein A, Krönig B (eds): Operative Gynakologie. 1912, p 879

Landon MB, Hauth JC, Leveno KJ, et al: Maternal and perinatal outcomes associated with a trial of labor after prior cesarean

delivery. N Engl J Med 351:25, 2004

Lasley DS, Eblen A, Yancey MK, et al: The effect of placental removal method on the incidence of postcesarean infections. Am J


Latzko W: Ueber den extraperitonealen Kaiserschnitt. Zentralbl Gynaekol 33:275, 1909

Learman LA, Summitt RL, Varner RE, McNeeley SG, et al: A randomized comparison of total or supracervical hysterectomy: Surgical

complications and clinical outcomes. Obstet Gynecol 102:453, 2003 [PMID: 12962924] [Full Text]

Lien JM, Towers CV, Quilligan EJ, et al: Term early-onset neonatal seizures: Obstetric characteristics, etiologic classifications, and

perinatal care. Obstet Gynecol 85:163, 1995 [PMID: 7824225] [Full Text]

Livingston EH, Passaro EP: Postoperative ileus. Dig Dis Sci 35:21, 1990

Lubenow TR, Ivankovich AD, McCarthy RJ: Management of acute postoperative pain. In Barash PG, Cullen BF, Stoelting RK (eds):

Clinical Anesthesia, 3rd ed. Philadelphia, JB Lippincott-Raven, 1997, p 1320

Lydon-Rochelle M, Holt VL, Martin DP, et al: Association between method of delivery and maternal rehospitalization. JAMA

283:2411, 2000 [PMID: 10815084] [Full Text]

MacKenzie IZ, Cooke I: What is a reasonable time from decision-to-delivery by caesarean section? Evidence from 415 deliveries. Br

J Obstet Gynaecol 109:498, 2002 [PMID: 12066937] [Full Text]

Magann EF, Chauhan SP, Bufkin L, et al: Intra-operative haemorrhage by blunt versus sharp expansion of the uterine incision at

caesarean delivery: A randomised clinical trial. Br J Obstet Gynaecol 109:448, 2002 [PMID: 12013167] [Full Text]

Martin JA, Hamilton BE, Sutton PD, et al: Births: Final data for 2002. National Vital Statistics Reports, Vol 52, No. 10. Hyattsville,

Md, National Center for Health Statistics, 2002

Minkoff H, Chervenak FA: Elective primary cesarean delivery. N Engl J Med 348:946, 2003 [PMID: 12621140] [Full Text]

Minkoff H, Powderly KR, Chervenak F, et al: Ethical dimensions of elective primary cesarean delivery. Obstet Gynecol. 103(2):387,

2004

Munn MB, Owen J, Vincent R, et al: Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: A

randomized controlled trial. Obstet Gynecol 98:386, 2001 [PMID: 11530117] [Full Text]



Munro MG: Supracervical hysterectomy: A time for reappraisal. Obstet Gynecol 89:133, 1997 [PMID: 8990455] [Full Text]

Nagele F, Karas H, Spitzer D, et al: Closure or nonclosure of the visceral peritoneum at cesarean delivery. Am J Obstet Gynecol

174:1366, 1996 [PMID: 8623871] [Full Text]

Naumann RW, Hauth JC, Owen J, et al: Subcutaneous tissue approximation in relation to wound disruption after cesarean delivery

in obese women. Obstet Gynecol 85:412, 1995 [PMID: 7862382] [Full Text]

Niemann JT: Cardiopulmonary resuscitation. N Engl J Med 327:1085, 1992

Notzon FC, Cnattingius S, Bergsjo P, et al: Cesarean section delivery in the 1980s: International comparison by indication. Am J


Nygaard I, Cruikshank DP: Should all women be offered elective cesarean delivery? Obstet Gynecol 102:217, 2003 [PMID:

12907089] [Full Text]

Parrish K, Holt VL, Easterling TR, et al: Effect of changes in maternal age, parity and birth weight distribution on primary cesarean

delivery rates. JAMA 271:443, 1994 [PMID: 8295319] [Full Text]

Physicians Insurance Association of America: Data Sharing System, Report No. 4. Pennington, NJ, PIAA, 1992

Physicians Insurance Association of America: Risk Management Review, Obstetrics 2002, Rockville, Md. Available at: http://www.

thepiaa.org.

Pickrell K: An inquiry into the history of cesarean section. Bull Soc Med Hist (Chicago) 4:414, 1935

Pietrantoni M, Parsons MT, O'Brien WF, et al: Peritoneal closure or non-closure at cesarean. Obstet Gynecol 77:293, 1991 [PMID:


Plauche WC: Obstetric hysterectomy. In Hankins GDV, Clark SL, Cunningham FG, et al (eds): Operative Obstetrics. Norwalk, Conn,

Appleton & Lange, 1995, p 333

Pliny the Elder: Natural History, book VII, chap IX. Rackham H, trans. Cambridge, Harvard University Press, 1942

Porreco RP: Meeting the challenge of the rising cesarean birth rate. Obstet Gynecol 75:133, 1990 [PMID: 2296410] [Full Text]

Porro E: Della Amputazione Utero-ovarica. Milan, 1876

Pridijian G, Hibbard JU, Moawad AH: Cesarean: Changing the trends. Obstet Gynecol 77:195, 1991

Pritchard JA: Changes in the blood volume during pregnancy and delivery. Anesthesiology 26:393, 1965 [PMID: 14313451] [Full

Text]

Rafique Z, Shibli KU, Russell IF, et al: A randomised controlled trial of the closure or non-closure of peritoneum at caesarean

section: Effect on post-operative pain. Br J Obstet Gynaecol 109:694, 2002 [PMID: 12118650] [Full Text]

Rajasekar D, Hall M: Urinary tract injuries during obstetric intervention. Br J Obstet Gynaecol 104:731, 1997 [PMID: 9197879]

[Full Text]

Rodriguez AI, Porter KB, O'Brien WF: Blunt versus sharp expansion of the uterine incision in low-segment transverse cesarean

section. Am J Obstet Gynecol 171:1022, 1994 [PMID: 7943065] [Full Text]

Roset E, Boulvain M, Irion O: Nonclosure of the peritoneum during cesarean section: Long-term follow-up of a randomized

controlled trial. Eur J Obstet Gynecol Reprod Biol 108:40, 2003 [PMID: 12694968] [Full Text]

Rousset F: Traité Nouveau de l'Hystérotomotokie ou l'Enfantement Césaerien. Paris, Denys deVal, 1581



Sachs BP, Yeh J, Acker D, et al: Cesarean section-related maternal mortality in Massachusetts, 1954–1985. Obstet Gynecol 71:385,

1988 [PMID: 3347424] [Full Text]

Sanchez-Ramos L, Kaunitz AM, Peterson HB, et al: Reducing cesarean sections at a teaching hospital. Am J Obstet Gynecol

163:1081, 1990 [PMID: 2403133] [Full Text]

Sänger M: Der Kaiserschnitt bei Uterusfibromen. Leipzig, 1882

Scheller JM, Nelson KB: Does cesarean delivery prevent cerebral palsy or other neurologic problems of childhood? Obstet Gynecol

83:624, 1994 [PMID: 8134078] [Full Text]

Seago DP, Roberts WE, Johnson VK, et al: Planned cesarean hysterectomy: A preferred alternative to separate operations. Am J


Sewell JE: Cesarean section—a brief history. Washington, DC, American College of Obstetricians and Gynecologists, 1993

Shellhaas C for the National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network: The MFMU

Cesarean Registry: Cesarean hysterectomy—its indications, morbidities, and mortality. Am J Obstet Gynecol 185:S123, 2001

Smith W: A Profile of Health and Disease in America: Obstetrics, Gynecology, and Infant Mortality. New York, Facts on File

Publications, 1987, p 82

Strong TH, Brown WL Jr, Brown WL, et al: Experience with early postcesarean hospital dismissal. Am J Obstet Gynecol 169:116,

1993 [PMID: 8333434] [Full Text]

Thacker SB, Stroup D, Chang M: Continuous electronic heart rate monitoring for fetal assessment during labor. Cochrane Database

of Systematic Reviews 2:CD000063, 2001

Tulandi T, Al-Jaroudi D: Nonclosure of peritoneum: A reappraisal. Am J Obstet Gynecol 189:609, 2003 [PMID: 14520243] [Full

Text]

U.S. Department of Health and Human Services: Healthy People 2010, 2nd ed. With Understanding and Improving Health and

Objectives for Improving Health. 2 vols. Washington, DC, U.S. Government Printing Office, November 2000

U.S. Public Health Service: Maternal and Child Health Bureau. Washington, DC, Department of Health and Human Services, 1991.

Publication No. HRSA-M-CH 91-2

Vermillion ST, Lamoutte C, Soper DE, et al: Wound infection after cesarean: Effect of subcutaneous tissue thickness. Obstet

Gynecol 95:923, 2000 [PMID: 10831993] [Full Text]

Wagner M: Choosing caesarean section. Lancet 356:1677, 2000 [PMID: 11089840] [Full Text]

Wahab MA, Karantziz P, Eccersley PS, et al: A randomized, controlled study of uterine exteriorization and repair at cesarean

section. Br J Obstet Gynaecol 106:913, 1999 [PMID: 10492101] [Full Text]

Waters EG: Supravesical extraperitoneal cesarean section: Presentation of a new technique. Am J Obstet Gynecol 39:423, 1940

Yost NP, Bloom SL, Sibley MK, Lo JY, et al: A hospital-sponsored quality improvement study of pain management after cesarean

delivery. Am J Obstet Gynecol 190:1341, 2004 [PMID: 15167840] [Full Text]

Zelop CM, Harlow BL, Frigoletto FD Jr, et al: Emergency peripartum hysterectomy. Am J Obstet Gynecol 168:1443, 1993 [PMID:


Zorlu CG, Turan C, Isik AZ, et al: Emergency hysterectomy in modern obstetric practice. Changing clinical perspective in time. Acta

Obstet Gynecol Scand 77:186, 1998 [PMID: 9512325] [Full Text]



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