b. Patient Preparation.
(1) The extent of preoperative planning and preparation will depend on the
urgency of the delivery and should be paced accordingly. Whole blood should be
available. When the patient arrives in surgery, she may or may not be in labor. The
circulator should auscultate the fetal heart tone with a fetuscope. The patient is
positioned supinely on the table, and restraints are applied; the patient is never left
unattended. A Foley retention catheter is inserted and connected to gravity drainage.
Choice of anesthetic agent is made by the anesthesiologist after reviewing the condition
of the mother and fetus.
(2) Adequate personnel should be available to individually care for the
mother and child, since simultaneous urgent needs may arise.
c. Operative Procedure (Low Cervical Method).
(1) A 12- to 15-cm long skin incision is made from below the umbilicus to
above the symphysis. As the incision is continued through the fascia and rectus
muscles to expose the lower portion of the cervix, blood vessels may be clamped with
Crile forceps and ligated with plain gut suture number 3-0.
(2) The exposed peritoneum is incised transversely with a scalpel and
Metzenbaum scissors between the two round ligaments. By blunt dissection, the
bladder is freed and retracted with the universal DeLee retractor to expose the lower
segment of the uterus.
(3) Using a new scalpel blade and bandage scissors, the uterus may be
opened either transversely in the manner of Kerr or longitudinally in the manner of
Kronig. Using the Kerr technique, a lunar incision is made through the myometrium
extending to within one inch of each uterine artery.
The membranes are ruptured and suction immediately applied.
(5) The fetal head is delivered by inserting a hand between the head and
the symphysis, rotating the face posteriorly, and exerting upward traction. With the
Kronig technique, the face is rotated anteriorly.
(6) The fetal body is delivered. The cord is double cross clamped with
Rochester-Pean forceps and cut with bandage scissors. The baby is given to the
The placenta and all membranes are manually removed from the uterus.
(8) The uterine edges are grasped with Pennington clamps and a layered
closure begun. A continuous suture of chromic gut number 0 or number 2-0 is placed
through the deep myometrium (and possibly endometrium). A second layer of similar