ACOG Practice bulletin: # 171

PTL or TPTL:  Preterm <37wks, cervical change

Evaluation:

SSE first: Collect GC/CT cultures, FFN (no gel, blood or semen), GBS, eval for rupture if needed

SVE:

Cervical change–can dilation or effacement changes

FFN: Fetal fibronectin

If tPTL:

PPROM: Preterm <37wks, Ruptured membranes

SSE: Confirm rupture with Pooling, nitrazine ferning. Collect GC/CT and GBS.

If PPROM: Delivery at 34wks or at diagnosis if chorio or 34+wks

Resources:

https://www.bedsider.org/methods

Table:

http://www.womenscommunityclinic.org/wp-content/uploads/Bedsider-Birth-Control-Effectiveness-Poster.jpg

http://s3.amazonaws.com/providers/images/images/000/000/032/center/Spanish_tiers_of_effectiveness.png?1464661802

What approach: Abdominal, laparoscopic, vaginal or combination

If it’s laparoscopic–listen to the LSC podcast for more details on the approach

Let’s talk about important steps:

Review anatomy– you’ll be able to see well!

What case are you doing and why?

Saying hi to the patient first

Abx: If entering uterus or vagina ie hyst

Let resident/attending drape unless asked.

Abdomen:

Port placement: Typically middle ⅓ of distance between ASIS and umbilicus. Avoid obvious superficial vessels and inferior epigastric –watch from below

Common procedures:

Closing ports: Close fascia on ports >5mm due to increased risk of hernia

Post-op checks: Many LSC cases are same-day, meaning patients go home

Hypertension in Pregnancy — One large spectrum

Mild range: 140/90

CHTN → SIPE

BP meds: Methyldopa, labetalol, hydralazine, nifedipine

Severe features:

HELLP

Eclampsia — Seizures

Why?

Scheduled: Repeat cesarean, hx of uterine surgery, abnormal placentation (placenta previa, vasa previa, accrete, etc) malpresentation (not cephalic), multiple gestation

In labor: arrest of dilation, arrest of descent, nonreassuring fetal heart tones, elective

Anatomy: Layers of anterior abdominal wall: skin, subcutaneous tissue, superficial fascia (Campers, scarpa’s), external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum. Nerves, blood vessels, and lymphatics are present throughout.

Now you’re at the uterus — or should be. Clear the surgical field, take down adhesions, bladder flap if needed.

Hysterotomy — lower uterine segment, lateral uterine vessels to avoid

Delivery baby — delay cord clamp, placenta

Likely lots of bleeding — same atony meds as vaginal delivery

Clean inside of uterus to remove all membranes etc.

Possibly exteriorize uterus to see better — depends on scaring

How can you be helpful — visualization! Bladder blade back in, suction or clean with lap between when surgeon placing sutures.

Two layers to hysterotomy if they might ever want to labor again or if needed for hemostasis.

Clean up the abdomen–irrigation vs moist laps vs suction

Now to close:

Peritoneium — either way, close or not– no evidence either way

Closing Fascia:

Nerves at the lateral edges of the fascial incision are ilioingiunal, iliohypogastric

Subcutaneous fat — if >2cm depth, close to reduce risk of seroma/hematoma/infection

Skin closure — stables, suture, absorbable stables