DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. A 39 week pregnancy.
2. Previous cesarean section x1.
POSTOPERATIVE DIAGNOSES:
1. A 39 week pregnancy.
2. Previous cesarean section x1.
OPERATION PERFORMED: Repeat low transverse cesarean section via Pfannenstiel incision.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: Spinal.
ESTIMATED BLOOD LOSS: 600 mL.
DRAINS: Foley urinary catheter.
OPERATIVE FINDINGS:
1. Delivery of a healthy 6 pound and 4 ounce male infant with Apgars of 8 and 9.
2. Clear amniotic fluid.
3. Normal tubes, uterus and ovaries.
4. Nuchal cord x1.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic female, gravida 2, now para 2. Her first delivery ended in primary cesarean section. This pregnancy she has requested repeat cesarean delivery at term. Late in the pregnancy, she was measuring a size less than 8 and had serial ultrasound exams following fetal growth and amniotic fluid index. There was no evidence of intrauterine growth restriction; however, serial testing was continued and remained normal. She is now admitted at 39 weeks’ gestation in early labor. Fetal heart rate was reactive with good variability, and there were no decelerations. The cervix was thick and closed. The risks, benefits and complications of repeat cesarean delivery were discussed with the patient and her husband, and they agreed to proceed as planned.
DESCRIPTION OF OPERATION: The patient was brought to the operating room under an adequate level of spinal anesthetic without complication. She was placed in the supine position with left lateral tilt, and a Foley catheter was inserted. The lower abdomen was shaved, prepped with chlorhexidine and alcohol and draped in the usual sterile fashion using an Ioban steri-drape.
The previous Pfannenstiel scar was excised and the incision carried through the small amount of subcutaneous tissue where hemostasis was achieved with the Bovie. The fascia was incised and extended bilaterally in a curvilinear fashion. The fascia was elevated and bluntly and sharply dissected off the underlying pyramidalis and rectus muscles below. There was minimal scarring noted from the previous cesarean delivery.
The muscles were carefully split in the midline, and the peritoneum was identified. The peritoneum was opened first superiorly taking care not to injure bowel and then inferiorly taking care not to injure the bladder. A bladder blade was placed. The vesicouterine peritoneum was opened bilaterally in a curvilinear fashion. Blunt and sharp dissection was used to create a bladder flap and the bladder blade was replaced. Moist laparotomy sponges were used to pack the gutters bilaterally.
A transverse incision was made in the lower uterine segment, which was noted to be slightly thin and was extended bilaterally in a curvilinear fashion. Amniotomy revealed clear amniotic fluid, and all instruments were removed from the field. With the operator’s hand in the endometrial cavity, the infant’s head was easily delivered and mouth and nose were well suctioned. Nuchal cord x1 was reduced. Once again, suction was performed after the remainder of the infant was delivered, the cord doubly clamped and cut and the infant passed to the neonatal nurse practitioner who was present. Appropriate cord bloods were obtained, and the placenta was extracted intact.
The uterus was exteriorized and the endometrial cavity wiped free of remaining blood and clots with a dry laparotomy sponge. The uterus was closed in two layers using a running interlocking 0 chromic suture, the second layer imbricating the first. Hemostasis was completed after the second layer of closure. This effected excellent closure of the uterine musculature. On inspection, the uterus, tubes and ovaries were all completely normal.
The uterus was replaced into the abdominal cavity and both gutters well irrigated with warm normal saline after removal of the laparotomy sponges. The peritoneum was then closed in the midline using a running 2-0 Vicryl suture. Interrupted 0 Vicryl was used to close the muscle in the midline. Once again, irrigation was performed and hemostasis achieved with the Bovie. The fascia was closed using running 0 PDS suture beginning bilaterally and meeting in the midline. Once again, irrigation was performed and hemostasis achieved with the Bovie. Interrupted 3-0 Vicryl was used to close the small subcutaneous layer. A running 4-0 Monocryl suture was used to close the skin in a subcuticular fashion.
Sponge and needle counts were verified correct x3 by the scrub nurses. Steri-Strips and a dry sterile dressing were applied. The patient tolerated the procedure well and was sent to the recovery room in satisfactory condition with Foley catheter draining clear yellow urine. The infant was taken to the recovery room with the parents in satisfactory condition.
