Or at least how I perform them! List inspiration: taking new 2nd year residents through C-sections. Warning: There is cutting of tissue and blood involved 😷
  1. β€’
    Skin incision
    Usually a 10cm low horizontal "Pfannenstiel" incision in the bikini line (2cm above the pubic bone) using a scalpel
  2. β€’
    Dissect through subcutaneous fat
    If the patient is really obese, it can take a while. For these patients, I will tape their pannus (overhanging belly) up and out of my way before I make the skin incision.
  3. β€’
    Open the fascia
    After nicking the fascia, It can be opened bluntly using fingers like during a STAT C-Section vs sharply with Mayo Scissors vs with cautery using the Bovie. Separate the fascia from the underlying rectus muscles.
  4. β€’
    Separate the rectus muscles
    Sorry, muscles! I'll try to put you back together later.
  5. β€’
    Make incision in the peritoneum and bluntly expand the opening
    This is accomplished by the primary and assistant surgeons putting both hands in the peritoneal opening and literally stretching it open by force. I usually warn the patient that she'll feel some pressure.
  6. β€’
    Dissect the bladder down and away from where the uterine incision will be
    The bladder sits in front of the uterus. It's every OB's fear that he/she will accidentally get into the bladder, though this is rare. So, I find the peritoneal plane between the uterus and the bladder, create a "bladder flap", and push the bladder down and away from where we want to cut. Then I protect the bladder with a retractor called a "bladder blade." Sounds scary, but it's not!
  7. β€’
    Feel for the rotation of the uterus
    Women are put in a leftward tilt using a "bump" under their right side to get the weight of the uterus off their major blood vessels. If I don't know the extent of the rotation of the uterus I may not be able to perfectly center the uterine incision.
  8. β€’
    Uterine incision
    We always announce when we're making the uterine incision with the scalpel so the time can be recorded. For the standard low transverse uterine incision, we make a smiley-shaped incision to avoid going too far to the sides and getting into the uterine vessels. Try to get all the way through the uterine layers without breaking the amniotic sac on the other side.
  9. β€’
    Expanding the uterine incision
    bluntly with hands or using the Bandage Scissors
  10. β€’
    Break the amniotic sac
    and call out if the fluid is clear it has meconium (fetal poop)
  11. β€’
    Ask the anesthesiologist to lower the operating bed/table
    so I can get in the optimal position to deliver the baby
  12. β€’
    Reach down with one hand and bring the baby's head up to the uterine incision
    If the baby is breech (bottom down) then I use different techniques to deliver the baby bottom first and the next couple steps are different.
  13. β€’
    Have the surgical assistant push on the top of the uterus and direct the pressure towards the uterine incision
    Warn the patient she'll feel a lot of pressure now. Hope my assistant ate Wheaties this morning! Rarely, the anesthesiologist helps from the other side of the surgical drape. @AlexandraLouise have you had to do this?
  14. β€’
    Deliver the baby's shoulders and body
    Welcome to the world!! πŸ‘ΆπŸ»πŸ˜
  15. β€’
    Dry and stimulate the baby
    and announce the sex of the baby! Hold up baby so dad can take a picture. πŸ“·
  16. β€’
    Delay cord clamping for 60 seconds
    as long as the newborn is doing ok. @sally Are your OBs doing this for term babies, too?
  17. β€’
    Clamp and cut the umbilical cord
    2 clamps--Yellow plastic clamp closer to baby and metal clamp on the placenta side. Cut in between.
  18. β€’
    Hand the newborn to the waiting pediatric team
    After baby has been assessed and dried, we put baby on mom's chest for skin to skin time while still in the OR if everything is going well 😊
  19. β€’
    Deliver the placenta
    Make sure not to leave any parts of the placenta or membrane behind.
  20. β€’
    Exteriorize the uterus
    Literally bring the uterus out through the abdominal incision to clean the uterine cavity out with a lap towel and also for better visualization while closing the uterine incision. Some OBs leave it in if they can see the incision fine and they have a good assistant retracting tissue for them.
  21. β€’
    2 layer closure of the uterine incision
    We would love for patients to have a safe and successful Trial of Labor After Cesarean (TOLAC) that results in a Vaginal Birth After Cesarean (VBAC)!
  22. β€’
    Make note of how both ovaries and Fallopian tubes look
  23. β€’
    Replace the uterus into the abdomen/pelvis
  24. β€’
    Clean out the abdomen
    Remove blood and blood clots from the "gutters" (paracolic gutters)
  25. β€’
    Check for any bleeders or oozing from the uterine incision
    Place additional Figure of 8 stitches as needed to stop any active bleeding
  26. β€’
    Close the peritoneum
    in hopes of minimizing intra-abdominal scarring that occurs after surgery
  27. β€’
    Approximate the rectus muscles
    Put a loose stitch across the rectus muscles to bring them back together. I feel bad when women have diastasis of the rectus (when the two vertical bands of muscles in your abs separate far apart.
  28. β€’
    Close the fascia
    Let the anesthesiologist know so he/she has an idea of how much longer it will be until I'm done. Decide on the final number for Estimated Blood Loss. (Less than 1,000cc is normal.) Scrub tech will start counting instruments.
  29. β€’
    Irrigate the subcutaneous fat space and check for bleeders that can disrupt wound healing.
    Close the subcutaneous layer with a running stitch if there is more than 2cm of fat
  30. β€’
    Close the skin
    I like to use a thin 4-0 Vicryl on a straight Keith needle. Some OBs use stiffer, but smoother 4-0 Monocryl on a curved needle. Others place a row of staples along the incision that are removed on post-op day 3 or 4. I'm really meticulous about my skin closure because that's what patients can see after surgery.
  31. β€’
    Cover incision with Telfa, gauze, and bandage tape
    Take down the surgical drape and tell mom "Congratulations!" 😊