Delivey of the Placenta. he uterine incision is observed for any vigorously bleeding sites. These should be quickly clamped with Pennington or ring forceps. Although some surgeons may prefer , manual removal of the placenta, spontaneous delivery prompted by some cord traction may reduce the risk of operative blood loss and infection (Anorlu, 2008; Baksu, 2005). Fundal massage may
FIGURE 30-8 The anterior (A) and then the posterior (B) shoulder are delivered.
begin as soon as the fetus is delivered to hasten placental separation and delivery (Fig. 30-9).
Immediately after delivery and quick gross inspection of the placenta, the uterine cavity is suctioned and wiped out with a gauze sponge to remove avulsed membranes, vernix, and clots. In the past, double-gloved fingers or ring forceps placed through the hysterotomy incision were used to dilate an ostensibly closed cervix. his practice does not reduce infection rates from potential hematometra and is not recommended (Kirscht, 2017; Liabsuetrakul, 2011).
Uterine Repair. Ater placental delivery, the uterus is lited through the incision and onto the draped abdominal wall, and the fundus is covered with a moistened laparotomy sponge. We favor this and believe a relaxed, atonic uterus can be recognized quickly and massage applied. Incision and bleeding points are more easily visualized and repaired, especially if there have been extensions. Adnexal exposure is superior, and thus, tubal sterilization is easier. Instead, some clinicians prefer to close the hysterotomy with the uterus in situ. Comparing these two approaches, febrile morbidity, pain, and blood loss are not signiicantly diferent (Walsh, 2009; Zaphiratos, 2015).
Before hysterotomy closure, previously clamped large vessels may be ligated separately or incorporated within the running incision closure. IUD insertion, if planned, is completed prior to hysterotomy closure (Chap. 38, p. 685). One angle of the uterine incision is grasped to stabilize and maneuver the incision. he uterine incision is then closed with one or two layers of continuous 0-or no. 1 absorbable suture (Fig. 30-10). Chromic catgut suture is used by many, but some prefer synthetic delayed-absorbable polyglactin 910 (Vicryl). In subsequent pregnancy, neither suture type has been shown superior by mitigating against greater rates of adverse pregnancy outcomes such as uterine incision rupture (CORONIS Collaborative Group, 2016). Single-layer closure is typically faster and is not associated with higher rates of infection or transfusion (CAESAR Study Collaborative Group, 2010; Dodd, 2014; Roberge, 2014). Moreover, most studies observed that the number of layers does not significantly afect complication rates in the next pregnancy (Chapman, 1997; CORONIS Collaborative Group, 2016; Durnwald, 2003; Roberge, 2011).
At Parkland Hospital, we use a one-layer uterine closure with chromic catgut. he initial suture is placed just beyond one angle of the uterine incision. A continuous, locking suture line for hemostasis is then performed, with each suture penetrating the full thickness of the myometrium. he suture line then extends to a point just beyond the opposite incision angle. If approximation is not satisfactory after a single layer or if bleeding sites persist, then more sutures are required. Either another layer of running suture is placed to achieve approximation and hemostasis, or individual bleeding sites can be secured with targeted figure-of-eight or mattress stitches.