Tubal sterilization is a sample addition to cesarean section, but the operation should never be performed expressly for this purpose. The tubes should first be identified by tracing their distal ends until the fimbriae are visible, in order to avoid mistaken ligation of the round ligaments, with which they are easily confused. The tube is then grasped and elevated in its id-portion with the mucosal or appendix clamp, a 3-4 c knuckle raised, and its base ligated with plain catgut.
The mesosalpinx within the knuckle is destroyed by protruding the points of a scissors or clamp inside the loop and opening them. The loop of the knuckle is amputated above the suture, leaving the tubal stumps pointing in opposite directions. Plain catgut is preferable to chromic for ligation, for the former is absorbed more rapidly, allowing retraction within a few days and separation of the severed ends of the tube fro each other, with less danger of subsequent anastomosis and recanalization.
When sterilization at cesarean section is indicated for patients in the older age group, or in patients with uterine fibroids or a previous history of troublesome functional bleeding or a multiparas with placenta previa, cesarean hysterectomy should be considered as an alternate, and perhaps preferable, method of sterilization, if the termination of menstruation is acceptable to the patient. Myomectomy is usually inadvisable at cesarean section unless the tumors are pedunculated and easily removable.
Enucleation of intramural myomas is complicated by excessive bleeding, and if the rumors are multiple and widespread, thorough removal ay be dangerous. Furthermore, obliteration of the defects left in the myometrium may be difficult, with intramural collection of blood or serum resulting. Tumors with a broad subserous base often leave a gaping defect in the serosal surface of the uterus making closure without tension difficult because of myometrial detraction.
Extensive myomectoy is therefore best deferred until puerperal involution of the uterus is complete. Routine prophylactic appendectomy at the time of cesarean section has been recommended by a few obstetricians but has not received widespread acceptance and we have no experience with it. The postoperative care for cesarean section patients is similar to that following other lower abdominal operations or pelvic laparotomities. Immediate postoperative care requires attention to intravenous fluids, blood replacement if necessary and analgesics.
Demerol in doses of 50 to 100 mg or morphine 10 to 16 mg may be given as often as every 4 hours for the first 24 to 48 hours following operation. If the patient is unable to void she should be catheterized every 6 to 8 hours. Early ambulation helps the return of bladder and bowel function and may decrease the incidence of postoperative phlebothrombosis. We encourage our patients to move about freely in bed as soon as possible after operation and to get up for a brief period in the following day, with daily progressive increase in ambulation.
The patient is offered a regular diet on the first day of puerperium and encourages drinking liberal quantities of fluids. If this is difficult because of nausea or early postoperative vomiting, fluids should be administered intravenously in the form of 5 percent glucose solution. Vomiting that persists more than 24 hours after operation or recurs later in the puerperium may be due to gastric dilatation or paralytic ileus,but should arouse suspicion of intestinal obstruction.
Prostigmine may be effectively employed to combat distention resulting from paralytic ileus, and if this fails, nasogastric suction is resorted to. If a spontaneous bowel movement has not occurred an enema is given on the third or fourth postoperative day. Cesarean section probably originated as a producer to be carried out on undelivered pregnant women immediately after death. During the reign of Numa Pompilius of Rome (715-673 B. C.), a law was actually enacted, known at first as the Lex Regia and later as the Lex Caesare, requiring excision of the unborn babe from the womb of its dead mother.
Postmortem cesarean section may be carried out, as the request or insistence of the family, if the fetal heartbeat is still audible after the other’s demise. The need for haste is great, however, and in most postmortem sections the fetus is so compromised by hypoxia resulting fro the failing maternal circulation that it dies soon after delivery.
Cesarean section ay occasionally be performed in anticipation of the death of the mother. During the same period that parents’ expectations of childbirth have altered, there has been a steady rise in the cesarean section rate-especially in the numbers of women having a first (primary) emergency section performed. This is important because if women are delivered by cesarean section, they are much ore likely to have this type of delivery in the subsequent pregnancy (repeat cesarean.).
Few women, unless altered by obstetricians, or by their previous obstetric history, seriously consider the possibility that they will require a cesarean section. As women have become increasingly actively involve in their pregnancies by reading more about childbirth and attending antenatal preparation classes, their expectations are channeled towards a natural outcome of labour, where the mother is in control throughout the experiences as a fulfillment at the time of birth.
The inevitable corollary to this is a parallel increase in disappointment if the birth events do not go as planned. To date very little research has been carried out that has attempted to evaluate the psychosocial effects of cesarean delivery. This ay be because until recently, both parents and professionals accepted that cesarean section was only carried out as a life saving procedure. Few women doubt that the operation is only carried out in cases of real need when there is a risk for either the mother or the baby.
If it is suggested to a woman that cesarean section is the best option for either herself or more significantly her baby, then, not surprisingly she will be glad to have the operation. Certainly, in Hillan’s study, none of the women are delivered by emergency cesarean section who were intervened questioned the need for the operation, although many wanted more information about the events that had led up to it.
One of the worrying findings of this study was that 13 percent of the women did not know or gave completely wrong explanations for the performance in cesarean section and a further 14 percent were only partially right in their comprehension.
Works Cited
Whitridge,Williams J. “Williams Obstetrics 18th Edition”. Appleton & Lange: Publishing Division of Prentice Hall. 1985 Niven, Catherine A. “Conception, Pregnancy and Birth”. Reed Educational Professional Publishing. Linacre House, Jordan Hill, Oxford. 1996