![]() There are no true medical contraindications to the cesarean section. In the 2011 article “Safe Prevention of the Primary Cesarean Delivery,” authors addressed the most commonly documented indications for first-time cesarean deliveries (labor dystocia, abnormal fetal heart rate pattern, malpresentation of the fetus, multiple gestations, and suspected fetal macrosomia) and mitigation of how these factors. For example, if that patient has an unfavorable cervix at term, cervical ripening with medications such as misoprostol is not recommended due to an increased risk of uterine rupture with those agents. She may choose another cesarean for various reasons, or she may not be a candidate for a subsequent vaginal birth. There has been an emphasis on decreasing the number of first-time cesareans, as many women who have one cesarean delivery will ultimately have the remainder of their children via cesarean. However, due to the potential complications of cesarean delivery (see below), much study has been done looking for ways to reduce the cesarean rate. For example, a cesarean delivery is often the recommended approach if the patient has had a prior classical cesarean scar or previous uterine rupture. Some of these indications are inflexible, as a vaginal birth would be dangerous in certain clinical scenarios. There are various reasons why a fetus cannot, or should not, be delivered vaginally. The cervix, located at the lower portion of the uterus, is not routinely visible, nor is the vagina. The medial leaf of the broad ligament, if opened, is also where one may find the ureter coursing. This structure consists of two leaves of the peritoneum and attaches the uterus to the pelvic sidewalls. The surgeon may appreciate the Fallopian tubes and ovaries, and performing a tubal ligation is possible if the patient has previously expressed a desire and has given informed consent for this form of contraception. However, after delivery of the fetus, other structures may become visible, which is especially the case if the surgeon exteriorizes the uterus for repair. The gravid uterus often obscures the remainder of the female reproductive anatomy. It is at this point that the fetus is delivered, achieving the primary goal of the cesarean section. The amniotic sac, if present, would be the last layer between the surgeon and the fetus. ![]() The amniotic sac consists of two layers, the chorion, and the amnion, which fuse early in pregnancy. ![]() The uterine arteries anastomose in the broad ligament with the ovarian arteries, which arise from the abdominal aorta.ĭepending on the status of the patient’s amniotic membranes (if her “water is broken” or intact), the surgeon could encounter that amniotic sac upon incision of the uterus. The uterine arteries cross the ureters anteriorly and enter the uterus at the cardinal ligament. The blood flow through these arteries is eight times faster during pregnancy, with a unilateral flow of over 300 milliliters per minute at 36 weeks. It is important to recall that the uterine vessels run along with the lateral aspects of the uterus on both sides, and care must be taken to avoid damaging these blood vessels when the uterine incision is either made or extended - the uterine arteries branch from the anterior division of the internal iliac artery. All three of these layers are incised to make the uterine incision or hysterotomy. The uterus consists of the serosal outer layer (perimetrium), the muscle layer (myometrium), and the inside mucosal layer (endometrium). In a patient with prior cesarean sections, the bladder may become difficult to separate from the uterus. If the surgeon desires to make a bladder flap, he or she must incise the vesicouterine peritoneum. Upon identifying the uterus, the surgeon can then identify the vesicouterine peritoneum, or vesicouterine serosa, that connects the bladder and the uterus. If the patient has an adhesive disease from prior surgeries, the surgeon may encounter adhesions involving such structures as the omentum, the bowel, the anterior abdominal wall, the bladder, and the anterior aspect of the uterus. In a gravid woman, unlike in a nongravid patient, the uterus is often encountered at this point immediately upon entry into the abdomen. After separating the rectus muscles, which run from cephalad to caudal, the surgeon enters the abdominal cavity through the parietal peritoneum. One is composed of aponeurosis from the external oblique rectus muscle, and the other is a fused layer that contains the aponeuroses of the transverse abdominis and internal oblique muscles. The anterior abdominal fascia usually consists of two layers. The next layer is the fascia overlying the rectus abdominis muscles. First, the skin is incised, followed by the subcutaneous tissues. To achieve a cesarean delivery, the surgeon must traverse all the layers that separate him/her from the fetus.
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