DESCRIPTION OF OPERATION: The patient was brought to the labor and delivery operating room and placed in a seated position. Spinal with Duramorph was performed. She was then placed in a supine position with left lateral tilt. Once an adequate level was obtained, she was placed in dorsal supine position and prepped and draped in a sterile fashion with Foley catheter inserted into the bladder. A Pfannenstiel incision was made with a knife through the skin and carried down to the fascia. The patient had a very deep pannus, approximately 6 plus cm in depth. This was carried down to the level of the fascia, nicked with the knife, and extended to both sides laterally with Mayo scissors. The fascia was then dissected off the rectus muscle, inferiorly towards the symphysis and superiorly to the level of the umbilicus. The preperitoneal fat was then grasped with pickups and incised with Metzenbaums down to the level of the peritoneum, which was grasped with pickups and incised with Metzenbaums. The peritoneum was opened clearly with no evidence of internal adhesions and incised superiorly away from the bladder and somewhat laterally and then dissected down towards the level of the bladder, avoiding the bladder for limitation-of-injury purposes. The incision was stretched. A bladder blade was inserted and the vesicouterine peritoneum was grasped, incised with Metzenbaums, and extended to both sides laterally. This was dissected off of the lower uterine segment, which was noted to be paper-thin with fluid and hair visualized below. A knife was used to create a small incision in the lower uterine segment, and bandage scissors were used to extend the incision to the right and the left, to control the direction of the incision, given the thinness of the uterine scar. Fetal head was directed into the incision and given the prospective size of the baby, the vacuum was applied to the vertex of the fetal head, hand was removed, and the vertex was delivered with fundal pressure and traction from the vacuum. Nose and mouth were suctioned. Nuchal cord was noted. This was reduced over the head easily. Shoulders were then delivered with gentle traction and fundal pressure. Body was then delivered easily. Cord was doubly clamped and cut, and the baby was passed off to the awaiting neonatologist with suction of the nasopharynx and oropharynx performed with a bulb syringe. A segment of the cord was taken for arterial blood gas and cord blood was taken for ABO/Rh. The placenta was then removed manually from the anterior surface of the uterus. The uterus contracted well and was delivered from the abdomen. The incision was closed using #1 chromic in a running locking fashion from the right to the left with adequate hemostasis appreciated. The uterus was then placed back into the abdomen. Copious irrigation was performed. Ovaries and tubes appeared normal. The uterus was well contracted. The incision was hemostatic. No evidence of bladder injury was appreciated. Peritoneum around the bladder was evaluated with no evidence of bleeding. All lap counts were correct. The fascia was then closed using #1 Vicryl in a running fashion from the right to the midline and left to the midline. Two figure-of-eight sutures were placed across the area on the right midline, where the fascia appeared to the somewhat thin. Copious irrigation was then performed again to subcutaneous tissue. This was irrigated well and cauterized for hemostasis. Due to the depth of the subcutaneous tissue, a Jackson-Pratt drain was placed with the incision made in the left lower quadrant away from the C-section incision. A Kelly clamp was pushed up to the skin. The incision was made with a knife. The Kelly clamp was then pushed through the skin incision back into the corner of the cesarean section incision. The Jackson-Pratt was placed into the incision and the tubing was then pulled out through the incision of the skin. It was fixed using 3-0 silk suture and tied in place. The skin incision for the C-section was then closed using 4-0 Vicryl in a subcuticular fashion. Pressure bandage was applied to the incision. The bandage was tied around the Jackson-Pratt drain, and it was placed to bulb suction. The vagina was evacuated of all clots, and the patient was then taken awake and in stable condition to the recovery room. The Jackson-Pratt drain will remain in place until decreased drainage is noted. Serosanguinous drainage was noted at the end of the procedure. Good urine output was noted, and the patient was comfortable and taken to the recovery room. The patient received 2 grams of Ancef intraoperatively and IV fluids with Pitocin.
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