| 1 |
Give
a single dose of prophylactic antibiotics. |
| 2 |
If
there is uncontrollable haemorrhage following vaginal
delivery, keep in mind that speed is essential. To open
the abdomen:
| • |
Make
a midline vertical incision below the umbilicus
to the pubic hair, through the skin and to the level
of the fascia |
| • |
Make
a 2–3 cm vertical incision in the fascia |
| • |
Hold
the fascial edge with forceps and lengthen the
incision up and down using scissors |
| • |
Use
fingers or scissors to separate the rectus muscles
(abdominal wall muscles) |
| • |
Use
fingers to make an opening in the peritoneum near
the umbilicus.
Use scissors to lengthen the incision up and down in order to see the entire
uterus. Carefully, to prevent bladder injury, use scissors to separate layers
and open the lower part of the peritoneum |
| • |
Place
a bladder retractor over the pubic bone and place
self-retaining abdominal retractors. |
|
| 3 |
If
the delivery was by caesarean section, clamp the sites
of bleeding along the uterine incision: |
| 4 |
In
case of massive bleeding, have an assistant press fingers
over the aorta in the lower abdomen. This will reduce
intraperitoneal bleeding; |
| 5 |
Extend
the skin incision, if needed. |
| 1 |
Lift
the uterus out of the abdomen and gently pull to maintain
traction. |
| 2 |
Double-clamp
and cut the round ligaments with scissors (Figure
12.24).
Clamp and cut the pedicles, but ligate after the uterine arteries are secured to
save time. |
|
| 3 |
From
the edge of the cut round ligament, open the anterior
leaf of the broad ligament. Incise to the point where
the bladder peritoneum is reflected onto the lower uterine
surface in the midline or to the incised peritoneum at
a caesarean section. |
| 4 |
Use
two fingers to push the posterior leaf of the broad ligament
forward, just under the tube and ovary, near the uterine
edge. Make a hole the size of a finger in the broad ligament,
using scissors. Doubly clamp and cut the tube, the ovarian
ligament and the broad ligament through the hole in the
broad ligament (Figures 12.25,
12.26). |
The
ureters are close to the uterine vessels. The ureter
must be identified and exposed to avoid injuring it during
surgery or including it in a stitch.
|
|
|
| 5 |
Divide
the posterior leaf of the broad ligament downwards towards
the uterosacral ligaments, using scissors. |
| 6 |
Grasp
the edge of the bladder flap with forceps or a small
clamp. Using fingers or scissors, dissect the bladder
downwards from the lower uterine segment. Direct the
pressure downwards but inwards toward the cervix and the
lower uterine segment. |
| 7 |
Locate
the uterine artery and vein on each side of the uterus.
Feel for the junction of the uterus and cervix. |
| 8 |
Doubly
clamp across the uterine vessels at a 90° angle on
each side of the cervix. Cut and doubly ligate with 0
chromic non absorbable (or polyglycolic) suture (Figure
12.27). |
|
| 9 |
Observe
carefully for any further bleeding. If the uterine arteries
are ligated correctly, bleeding should stop and the uterus
should look pale. |
| 10 |
Return
to the clamped pedicles of the round ligaments and tubo-ovarian
ligaments and ligate them with 0 chromic non absorbable
(or polyglycolic) suture. |
| 11 |
Amputate
the uterus above the level where the uterine arteries
are ligated, using scissors (Figure
12.28). |
|
| 12 |
Close
the cervical stump with interrupted 2-0 or 3-0 chromic
non absorbable (or polyglycolic) sutures. |
| 13 |
Carefully
inspect the cervical stump, leaves of the broad ligament
and other pelvic floor structures for any bleeding. |
| 14 |
If
slight bleeding persists or a clotting disorder is suspected,
place a drain through the abdominal wall. Do not place
a drain through the cervical stump as this can cause postoperative
infection. |
| 15 |
Ensure
that there is no bleeding. Remove clots using a sponge. |
| 16 |
In
all cases, check for injury to the bladder. If a bladder
injury is identified, repair the injury. |
| 17 |
Close
the fascia with continuous 0 chromic non absorbable (or
polyglycolic) sutures. |
| 1 |
Push
the bladder down to free the top 2 cm of the vagina. |
| 2 |
Open
the posterior leaf of the broad ligament. |
| 3 |
Clamp,
ligate and cut the uterosacral ligaments. |
| 4 |
Clamp,
ligate and cut the cardinal ligaments, which contain
the descending branches of the uterine vessels. This is
the critical step in the operation:
| • |
Grasp
the ligament vertically with a large-toothed clamp
(e.g. Kocher) |
| • |
Place
the clamp 5 mm lateral to the cervix and cut the
ligament close to the cervix, leaving a stump medial
to the clamp for safety |
| • |
If
the cervix is long, repeat the step two or three
times as needed |
| • |
The
upper 2 cm of the vagina should now be free of
attachments |
| • |
Circumcise
the vagina as near to the cervix as possible, clamping bleeding
points as they appear. |
|
| 5 |
Place
haemostatic angle sutures, which include round, cardinal
and uterosacral ligaments. |
| 6 |
Place
continuous sutures on the vaginal cuff to stop haemorrhage. |
| 7 |
Close
the abdomen (as above) after placing a drain in the extraperitoneal space
near the stump of the cervix. |
