PREOPERATIVE DIAGNOSES:
1. A 37-week twin intrauterine pregnancy.
2. Prior cesarean section x1.
POSTOPERATIVE DIAGNOSES:
1. A 37-week twin intrauterine pregnancy.
2. Prior cesarean section x1.
OPERATION PERFORMED: Repeat low transverse cesarean section through a Pfannenstiel skin incision.
SURGEON: John Doe , MD
ASSISTANT: Jane Doe , MD
ANESTHESIA: Spinal with Duramorph.
ESTIMATED BLOOD LOSS: 800 mL.
COMPLICATIONS: None.
DRAINS: Foley catheter.
OPERATIVE FINDINGS:
1. Twin A 2750 grams female infant with Apgars of 8 and 9 in the vertex presentation.
2. Twin B 2195 grams female infant with Apgars of 8 and 9 in the vertex presentation,
3. Normal placenta, uterus, tubes, and ovaries.
DESCRIPTION OF OPERATION: The patient was taken to the operating suite. After appropriate level of spinal anesthesia with Duramorph, she was placed in the dorsal supine position with a left tilt. Foley catheter was inserted. She was then prepped and draped in sterile fashion. A Pfannenstiel skin incision was made through previous incision and it was extended out to the deeper layers with the second scalpel. Hemostasis was achieved with the Bovie. The fascia was incised horizontally from margin to margin. The rectus muscle was dissected off the fascia sharply, bluntly, inferiorly and superiorly. The rectus muscle was then bluntly and sharply dissected exposing the peritoneum below it and this layer was entered in its upper aspect and extended vertically avoiding the bladder inferiorly.
With appropriate retractors then put in place, the vesicouterine segment of the peritoneum was incised and the midline extended on either side. This layer was dissected off the lower uterine segment. A low transverse uterine incision was then made with the scalpel. The incision was extended with the operator's fingers and membranes of baby A were ruptured with clear fluid. The baby was delivered from the vertex presentation without difficulty. Mouth and nose were suctioned and the baby cried spontaneously. The cord was clamped and cut. The baby was handed off to the nurse after being shown to the parents. The baby was in good condition.
The second baby was also in the vertex presentation, followed easily after the first, and membranes on that sac were ruptured of clear fluid. The baby was delivered with fundal pressure without difficulty. The baby was obviously smaller, but did cry spontaneously after the mouth and nose were suctioned of clear fluid with bulb. The baby's cord was clamped and cut. The baby was shown to the parents after crying vigorously. After appropriate cord bloods were obtained from each placenta, the placenta was manually extracted from the uterus teasing the membranes with the Kelly clamp, exteriorizing the uterus while it was closed. The inside of the uterus was wiped clean with a dry lap.
The uterine incision was closed in two layers, first was a running interlocking 0 chromic. Hemostasis was deemed to be adequate; therefore, the vesicouterine segment of the peritoneum was closed with 2-0 Vicryl running sutures. Irrigation of the gutters was performed to remove blood and clots. The uterus was placed back into the abdominal cavity and contracted well. The inside of the uterus was wiped clean with a dry lap. The edges of the peritoneum were grasped and then this layer was closed with 0 Vicryl running sutures. A piece of Seprafilm was placed over the lower uterine segment peritoneum. The parietal peritoneum was closed with 0 Vicryl running sutures. Rectus muscle closed with 0 Vicryl interrupted sutures.
An On-Q pain buster with double lumen was placed. The first puncture site was used to place one just above the peritoneum and below the muscle and the second puncture site was used to place an Angiocath just above the muscle, below the fascia. After the rectus muscle was reapproximated, irrigation in the area was performed. The irrigant was removed and the fascia was then closed with 0 Vicryl running suture, one from either side, hanging to the midline. Subcutaneous fat layer was closed with 3-0 Vicryl running suture and the skin was closed with staples. The On-Q pain buster was steri-stripped and dressing placed and another dry sterile gauze dressing was applied to the incision proper. The uterus was expressed of a small amount of blood. Sponge, lap, and needle counts were correct x2. The patient was then transferred to the recovery room, again with her twin girls in good condition.
