Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201o7.) it is helpul to have an assistant compress the uterus on each side of the wound toward the midline as each stitch is placed.
Hysterectomy is most commonly performed to arrest or prevent hemorrhage from intractable uterine atony or abnormal placentation (Bateman, 2012; Hernandez, 2012; Owolabi, 2013). It is more often completed during or after cesarean delivery but may be needed following vaginal birth. If all deliveries are considered, the peripartum hysterectomy rate in the United States approximates 1 per 1000 births and has risen signiicantly during the past few decades (Bateman, 2012; Govindappagari, 2016). During a 25-year period, the rate of peripartum hysterectomy at Parkland Hospital was 1.7 per 1000 births (Hernandez, 2012). Most of this rise is attributed to the increasing rates of cesarean delivery and its associated complications in subsequent pregnancy (Bateman, 2012; Bodelon, 2009; Flood, 2009; Orbach, 2011). Of hysterectomies, approximately one half to two thirds are total, whereas the remaining cases are supracervical (Rossi, 2010; Shellhaas, 2009).
Major complications of peripartum hysterectomy include greater blood loss and risk of urinary tract damage. Blood loss is usually appreciable because hysterectomy is being performed for hemorrhage that frequently is torrential, and the procedure itself is associated with substantial bleeding. lthough many cases with hemorrhage cannot be anticipated, those with abnormal implantation are oten identiied antepartum. Preoperative preparations for placenta accreta are discussed in Chapter 41 (p. 781) and have also been outlined by the Society for Maternal-Fetal
FIGURE 30-14 The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tube, uteroovarian ligaments, and ovarian vessels.
FIGURE 30-13 The round ligaments are clamped, doubly ligated, FIGURE 30-15 The uteroovarian ligament and fallopian tube are and transected bilaterally. clamped and cut. The lateral pedicle is doubly ligated.
Medicine (2010) and American College of Obste tricians and Gynecologists (2017 c).
An important factor afecting the cesarean hysterectomy complication rate is whether the operation is performed electively or emergently.
tomy, rates of blood loss, blood transfusion, and urinary tract complications are lower that with emergent procedures (Briery, 2007; Glaze, 2008).
Total or supracervical hysterectomy is performed using standard operative techniques. Adequate exposure is essential, but initially, placement of a self-retaining retractor such as a Balfour is not necessary. Rather, satisfactory exposure is obtained with cephalad traction on the uterus by an assistant, along with handheld Richardson or Deaver retractors. he bladder lap is deflected downward to the level of the cervix if possible to permit total hysterectomy. In cases in which cesarean hysterectomy is planned or strongly suspected, extended bladder flap dissection is ideally completed before initial hysterotomy. Later attempts at bladder dissection may be obscured by bleeding, or excess blood may be lost while this dissection is performed.