C-section

Question 1

Intra-op mx of unexpected ovarian cyst

Scenario 1 - 28yo G2P1 emCS for malpresentation, incidental intra-op ovarian cyst

Answer 1

DDx
- benign ovarian tumor (e.g. dermoid)
- endometrioma
- ovarian ca

• ax/describe
• inform team/pt
• verify consent
• +/- GONC for 2nd opinion
• +/- frozen section
• ax ipsilateral FT & contralateral FT/Ov
• ax peritoneum, LN palpation
• cystectomy or USO +/- omental bx

Question 2

Mx of impacted head at emCS

Answer 2

Principles
- have experienced obs as backup
- stand on a step or lower operating table
- table tilted with head down
- wait for contraction to cease
- hand below presenting part
- GTN/subcut tertubaline for uterine relaxation
- extend LUS incision - inverted T or J to make space
- turn to OT where possible
- deliver with non-dominant hand

3 maneuvers

1. Push
   - Push from below, assistant vs fetal pillow
   - Deliver head through LUS incision
2. Reverse breech
   - OA - arms/trunk-hips/pull hips + fundal pressure to extract body/delivery of head by screwing on body/shoulders (i.e. putting head into OT)
   - OP - arm & feet out/pull legs to extract body/delivery of head by screwing on body/shoulders
3. Torso delivery
   - Deliver both shoulders through incision -> trunk -> breech -> head

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2253-3

Question 3

Intra-op interventions to facilitate delivery in emCS

Scenario 1 - preterm, breech, abruption, anhydramnios

Answer 3

• senior colleague support
• adequate skin incision +/- midline
• uterine incision - classical or T-incision
• uterine relaxant
• Lovset/MSV +/- forceps after coming

Question 4

Intra-op mx of unexpected PAD

Scenario 1 - unexpected PAD at CS c/b excess blood loss

Scenario 2 - unexpected PAD at not bleeding.

Answer 4

Undiagnosed PAD on entry at elCS
- if mother/baby stable
- CS delayed till appropriate staff/resource/blood products available
+/- close abdo -> transfer to tert

Undiagnosed PAD after birth of baby
- inform OT team
- summon assistance - senior, gonc, urology
- cell saver/haem/products - PRBC/FFP…
- placenta left in-situ
- emergency hysterectomy

Alternative
- attempt to remove placenta
- tamponade post removal -> Bakri etc…
- only at facilities with expertise & capacity to perform emergency hysterectomy & transfusion

Conservative
- leave in-situ, close, treat with MTX

• don’t forget to mention all the postop spiel if still left with time

Question 5

MRCS counsel principles

Answer 5

• acknowledge
• explore reason
  (understanding of pros/cons, fear of labor, previous experience)
• practical factors
  (age, family size, locality)
• shared decision making

Question 6

MRCS counsel - benefit of planned CS

Scenario 1 - requesting CS to prevent POP/incontinence

Answer 6

Benefit of planned CS

Planned CS may reduce risk
(multifactorial, limited evidence)
- for surgery for POP
- for surgery for incontinence
- anal sphincter injury
- fecal incontinence

Others
- reduce perinatal mort of preg till 41+
- less HIE/CP/Erb’s palsy
- cx rate less cf emCS/assisted del

Question 7

MRCS counsel - risks of planned CS

Answer 7

Risks of a planned CS

Maternal - increase risk of
- postpartum hysterectomy
- maternal death
- endometritis
- wound infection
- uterine rupture
- PAS <1% (1-3), 2% (4-5th), 7%

Neonatal - increase risk of
- breastfeeding/TTN
- NND
- Resp/GI infection req hospitalization
- Diabetes
- Asthma