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CESAREAN DELIVERY AND PERIPARTUM HYSTERECTOMY Prof. Dr. Daulat H. Sibuea, SpOG(K)DEPARTEMEN OBSTETRI & GINEKOLOGIFK-USU/RSHAM-RSPM2007CESAREAN DELIVERY AND PERIPARTUM HYSTERECTOMY

CESAREAN DELIVERY THE BIRTH OF A FETUS THROUGH INCISIONS IN THE ABDOMINAL WALL (LAPAROTOMI) AND UTERINE WALL (HYSTEROTOMY).

THE DERIVATION OF THE TERM IS MORE LIKELY FROM THE LATIN WORD CAEDO MEANING TO CUTPERIPARTUM HYSTERECTOMY CONSIST OF ; 1. CESAREAN HYSTERECTOMY, IS A ABDOMINAL HYSTERECTOMY, PERFORMED AT THE TIME OF CESAREAN DELIVERY. 2. POSTPARTUM HYSTERECTOMY IS A ABDOMINAL HYSTERECTOMY, PERFORMED WITHIN A SHORT TIME AFTER VAGINAL DELIVERY.

TYPE OF CESAREAN SECTION (CS) 1. ELECTIVE CESAREAN SECTION (CESAREAN DELIVERY IS PLANNED). THESE WOMEN HAVE TIME FOR PHYSICAL AND PSYCHOLOGIC PREOPERATIVE PREPARATION2. EMERGENCY CESAREAN SECTION (CESAREAN DELIVERY IS UNPLANNED) EMERGENCY CS - ALL PREOPERATIVE PROCEDURES MUST BE DONE QUICKLY AND COMPETENTLY THE WOMAN APPROACHES SURGERY USUALLY TIRED AND DISCOUROGED AFTER A FRUITLESS LABOR. SHE IS WORRIED AND FRETFUL ABOUT HER OWN, AND THE CHILD CONDITION. - SHE MAY BE DEHYDRATED, WITH LOW GLYCOGEN RESERVES. CESAREAN SECTION (CS) RATES THE RATE FOR CS HAS INCREASED DRAMATICALLY.CS RATE IN THE USA. FROM THE MID 1960 LESS 5%, MORE THAN 15% IN THE EARLY-1980, AND MORE THAN 25% OF DELIVERIES IN THE 2002.

TABLE 1 . CONTRIBUTION BY INDICATION TO OVERALL CESAREAN DELIVERY RATE IN FOUR COUNTRIES DURING 1990INDICATIONS CESAREAN DELIVERY RATE PER 100 TOTAL DELIVERIES NorwayScotlandSwedenUnited StatesPrevious Cesarean Breech Dystocia Fetal distress Other 1,32,13,62,03,73,12,04,02,42,73,11,81,71,62,48,52,67,12,33,2Overall CS Rate 12,714,210,623,7MODIFIED FROM NOTZON AND COLLEAGUES (1994) TABLE 2 : INDICATIONS FOR CS AND MATERNAL AND FETAL EFFECTS (MATERNITY AND GYNAECOLOGIC CARE 2. THE NURSE AND THE FAMILY 1989INDICATIONS FOR CSEFFECT OF CSMeternal : Feto Pelvic Disproportion Previous CSBreech Presentation Medical Complication (PIH)Placental Abnormalities (placenta previa, abruptio placenta)6. Infection ( Herpes Virus type 2) 7. Trauma To The Pelvis Maternal : Mortality ( 1:1000 ) From : - Anesthesia - Severe Sepsis - Thromboembolic Episode 2. Morbidity Higher Than With Vaginal Delivery Because Of : - Infection - Injury To The Urinary TractINDICATIONS FOR CS EFFECT OF CSFetal : Fetal Hypoxia Prolapse Of The Cord Breech Presentation Malpresentation ( Shoulder) Fetal Anomalies (Hydrocephalus) Fetal : Mortality Has Declined Where CS Is Used In Conjunction With Improved Perinatal Care.2. Morbidity - Birth Trauma Is Reduced - Reduced Morbidity In Breech Deliveries, Transverse Lie Of The Fetus, And Placen -ta Previa. TABLE 3 CS RATE PER 100 DELIVERIES IN 9 SELECTED COUNTRIES 1980. (DATA FROM; CESAREAN SECTION GUIDELINES FOR APROPRIATE UTILIZATION ). COUNTRY CS RATE PE 100 DELIVERIES YEAR 1980CANADANETHERLANDS BELGIUM FRANCE ENGLAND SAUDI ARABIA SWEDENAUSTRALIA USA15,0%4,77,410,99,05,412,111,216,5CS Rate Per 100 Deliveries At Dr. Pirngadi General Hospital Medan Year: 1958: 1,42%Year 1973: 7,1% 1960: 5,32%1980: 10,8% 1970: 6,2 % TABLE 4 REASON FOR DIFFERENCE IN RATE OF CS Medical Non Medical Previous CS Breech Presentation Cephalopelvic DisproportionFetal Distress Dystocia Very Low Birth Weight ( < 1500 gr)Preterm Delivery ( 35 Years Old, CS Rate .Socio Economic Factors (CS Rate With Women Of Higher Social Class) Cultural reasours (Culntural factors can influence CS Rate) Hospital Reasons (CS Rate At Teaching Hospital )Private Practice. Financial Consideration Certainly Play An Important RoleGeographical Location CS Rate If The Location Of Hospital And The Proximity To The Community) Litigation (Litigation Is An Important Factor In CS Rate)Physician Factor In Any Given Case, Some May Decided That CS Is Necessary, While Others May Not THE REASONS WHY THE CS RATE INCREASED 1. WOMEN HAVING FEWER CHILDREN 2. THE AVERAGE MATERNAL AGE IS RISING 3. THE USE OF ELECTRONIC FETAL MONITORING IS WIDESPREAD 4. THE VAST MAJORITY OF FETUSES PRESENTING AS BREECH ARE NOW DELIVERED BY CESAREAN 5. THE INCIDENCE OF MIDPELVIC FORCEPS AND VACUM DELIVERIES HAS DECREASED.6. RATE OF LABOR INDUCTION CONTINUE TO RISE. INDUCED LABOR ESPECIALLY AMONG NULLIPARAS, INCREASES THE RISK OF CESAREAN DELIVERY. 7. THE PREVALENCE OF OBESITY HAS RISEN DRAMATICALLY, AND OBESITY ALSO INCREASES THE RISK OF CS. 8. CONCERN FOR MALPRACTICE LITIGATION HAS CONTRIBUTED SIGNIFICANTLY TO THE PRESENT CS RATE 9. SOME ELECTIVE CS ARE NOW PERFORMED DUE TO CONCERN OVER PELVIC FLOOR INJURY ASSOCIATED WITH VAGINAL BIRTH ( MATERNAL REQUEST ) METHODS TO DECREASE CS RATE 1. EDUCATING PHYSICIANS, MIDWIVE, AND WOMEN 2. PEER GROUP REVIEWING ENCOURAGING A TRIAL OF LABOR AFTER PRIOR TRANSVERS CESAREAN DELIVERY RESTRICTING CS FOR DYSTOCIA ONLY TO WOMEN WHO MEET STRICTLY DEFINED CRITERIA A MANDATORY SECOND OPINION MATERNAL MORTALITY

HALL & BEWLY (1999) SHOWED IN THE UNITED KINGDOM FROM 1994 THROUGH 1996, THAT WHEREAS EMERGENCY CS WAS ASSOCIATED WITH AN ALMOST NINEFOLD RISK OF MATERNAL DEATH RELATIVE TO THAT OF VAGINAL DELIVERY, EVEN ELECTIVE CS WAS ASSOCIATED WITH AN ALMOST THREEFOLD RISK OF MATERNAL DEATH RELATIVE TO THAT OF VAGINAL DELIVERY.

TABLE 5 : DIRECT DEATH RATES BY MODE OF DELIVERY IN THE UNITED KINGDOM 1994-1996

MODE OF DELIVERYTOTAL BIRTHSTOTAL DEATHSDEATH RATE (PER 100.000)VAGINAL ELECTIVE CAESAREAN EMERGENCY CAESAREAN 1.845.957153.829197.781389362,15,918,2TECHNIQUE FOR CESAREAN DELIVERY

* TYPE OF SKIN ( ABDOMINAL INCISION ). 1. AN INFRAUMBILICAL MIDLINE VERTICAL INCISION

2. TRANSVERSE INCISIONS, - A: PFANNENSTIEL INCISION, - B: MAYLARD INCISION, - C: COHENS INCISION.

* TYPE OF UTERINE INCISION 1. INCISION IS MAKE IN THE LOWER UTERINE SEGMENT TRANSVERSELY ( AS DESCRIBED BY MUNRO-KERR IN 1926 ). 2. A LOW SEGMENT VERTICAL INCISION (AS DESCRIBED BY KRONIG IN 1912) 3. A VERTICAL INTO THE BODY OF THE UTERUS ( ABOVE THE LOWER UTERINE SEGMENT AND REACHING THE UTERINE FUNDUS) , OR CLASSICAL INCISION)

* THE ADVANTAGE AND DISADVANTAGE OF THE TRANSVERSE SKIN INCISION THE COSMETIC ADVANTAGE OF THE TRANVERSE SKIN INCISION. THE TRANSVERSE SKIN INCISION IS STRONGER AND LESS LIKELY TO UNDERGO DEHISCENCE. EXPOSURE IN SOME WOMEN IS NOT AS OPTIMAL AS WITH A VERTICAL INCISION WITH REPEAT CS, REENTRY THROUGH A PFANNENSTIEL INCISION USUALLY IS MORE TIME CONSUMING AND DIFFICULT BECAUSE OF SCARRING. FOR MOST CS, THE LOWER UTERINE SEGMENT TRANSVERSE INCISION IS THE OPERATION OF CHOICE ; ITS ADVANTAGES ARE THAT IT :IS EASIER TO REPAIR. IS LOCATED AT A SITE LEAST LIKELY TO RUPTURE DURING A SUBSEQUENT PREGNANCY.DOES NOT PROMOTE ADHERENCE OF BOWEL OR OMENTUM TO THE INCISIONAL LINE . A LOWER SEGMEN VERTICAL OR EVEN A CLASSICAL INCISION MAY, AT TIMES, PROVE TO BE ADVANTAGEOUS, IF :1. THE FETUS IS NOT PRESENTING BY THE VERTEX 2. THERE ARE MULTIPLE FETUSES3. THE FETUS IS VERY IMMATURE AND THE WOMEN HAS HAD NO LABOR4. PRETERM DELIVERY WITH POORLY FORMED LOWER SEGMENT 5. PREMATURE RUPTURE OF MEMBRANES, POOR LOWER SEGMENT AND TRANSVERSE THE6. TRANSVERSE LIE WITH BACK INFERIOR 7. LARGE CERVICAL FIBROID 8. SEVERE ADHESIONS IN LOWER SEGMENT 9. POST MORTEM CESAREAN SECTION 10. PLASENTA PREVIA WITH LARGE VESSELS IN LOWER SEGMENT

ELECTIVE CESAREAN DELIVERY PREPARATION

* A SEDATIVE, SUCH AS SECOBARBITAL 100 MG, MAY BE GIVEN AT BEDTIME THE NIGHT BEFORE THE OPERATION. * ORAL INTAKE IS STOPPED AT LEAST 8 HOURS BEFORE SURGERY

CASEREAN DELIVERY PREOPERATIVE NURSING ACTIONS : THE ABDOMEN IS SHAVED AND DOWN TO THE PUBIC AREAINSERT A RETENTION CATHETER ( FOLEY )ADMINISTER PREOPERATIVE MEDICTION ANALGESIA TO PROMATE RELAXATION BEFORE SURGERY ATROPIN TO MINIMIZE AMOUNT OF SECRETIONS IN BRONCHIAL TREE ANTACID TO PREVENT IRRITAVIVE PNEUMONIA IF ASPIRATION OF GASTRIC JUICE FROM STOMACH OCCURS IF SPINAL OR EPIDURAL ANESTHESIA IS USED, AN ANTACID MAY BE THE MEDICATION ADMINISTERED. BEGIN IV INFUSION, 1000 ML RINGERS LACTATE SOLUTION, OR 5% DEXTOSE IN WATER OR SALINE, TO MAINTAIN HYDRATION SEND BLOOD FOR TYPING AND CROSS-MATCHING. TWO UNITS OF MATCHED BLOOD ARE KEPT IN RESERVE FOR 48 HOURS AFTER SURGERY. SEND URINE FOR ROUTINE ANALYSIS SEND BLOOD FOR CBC AND CHEMISTRY TAKE AND RECORD VITAL SIGNS, BLOOD PRESSURE, FHR COMPLETE PRE OPERATIVE CARE INCLUDING REMOVAL OF DENTURES, CONTACT LENSES, RINGS, AND FINGERNAIL POLISH. VALUABLE ARE GIVEN TO SUPPORT PERSON OR PUT INTO SAFEKEEPING. READY THE WOMENS CHART FOR USE IN SURGERY AND TO SEE WETHER PERMISSION FORMS FOR CARE OF THE MOTHER AND INFANT ARE SIGNED. IF THE WOMAN HAS RECEIVED AN ANALGESIC OR ANAESTHETIC, THE RESPONSIBLE ADULT ACCOMPANYING THE WOMAN SIGNS THE NECESSARY FORMS. PROVIDE AS MUCH INFORMATION AS POSSIBLE TO THE WOMAN AND HER FAMILY WHILE CARRYING OUT THE NECESSARY CARE. THE PRERATION OF THE WOMEN FOR CS IS THE SAME FOR EITHER ELECTIVE OR EMERGENCY SURGERY THE OBSTETRICIAN DISCUSSES THE NEED FOR THE CESAREAN DELIVERY AND THE PROGNOSIS FOR MOTHER AND INFANT WITH THE WOMAN AND HER FAMILY THE ANESTHESIOLOGIST ASSESSES THE WOMANS CARDIO-PULMONARY SYSTEM AND PRESENTS THE OPTION FOR ANESTHESIA INFORM CONSENT IS OBTAINED FOR THE PROCEDURES.

ONCE THE WOMEN HAS BEEN TAKEN TO SURGERY HER CARE BECOMES THE RESPONSIBILITY OF THE : - OBSTETRIC TEAM - SURGEON - ANESTHESIOLOGIST - PEDIATRICIAN - NURSING STAFF CARE OF THE INFANT IS DELEGATED TO A PEDIATRICIAN AND A NURSE BECAUSE THESE INFANTS ARE CONSIDERED TO BE AT RISK UNTIL THERE IS EVIDENCE OF PHYSIOLOGIC STABILITY AFTER DELIVERY. THOSE RESPONSIBLE FOR CARE ARE EXPERT IN RESUSCITATIVE TECHNIQUES, AS WELL AS IN OBSERVATIONAL SKILLS FOR DETECTING NORMAL INFANT RESPONSES

AFTER BIRTH, IF THE INFANTS CONDITION PERMITS, SHE OR HE IS GIVEN TO THE FATHER TO HOLD AND TO SHOW TO THE MOTHER

. INDICATION FOR CESAREAN SECTION DIFFICULT LABOUR OR DYSTOCIA FETAL DISTRESS PREVIOUS CESAREAN SECTION BREECH PRESENTATION PREMATURE FETUS. ANTEPARTUM HAEMORRHAGE - SOLUSIO PLACENTA - PLACENTA PREVIA - VASA PREVIA TWINS PREGNANCY CORD PROLAPSE MATERNAL DISEASES DIABETES MELLITUS INDIOPATHIC THROMBOCYTOPENIA PURPURA OBSTETRIC CHOLESTASIS PREECLAMPSIA OVARIAN AND CERVICAL MALIGNANCY HERPES SIMPLEX

FETAL CONDITIONS FETAL MACROSOMIA TRANSVERSE LIE FETAL ANOMALIES HYDROPCEPHALUS MATERNAL REQUEST TECHIQUES FOR PERFORMING CESAREAN SECTION PRECAUTION ARE IMPORTANT TO AVOID RISK ASSOCIATED WITH EXPOSURE TO, OR INOCULATION OF BODY FLUIDS (e.g, HIV, HEPATITIS B) POSITION OF THE PATIENT WITH LEFT LATERNAL TILT OF 10 TO 15 CATHETERIZATION THE USE OF AN INDWELLING CATHETER AFTER CESAREAN SECTION UNDER EPIDURAL IS THOUGHT TO LESSEN THE RISK OF URINARY RETENTION AND THE NEED FOR REPEAT CATHETERIZATION4. THE OPTION FOR ANESTHESIA IS : GENERAL ANESTHESIA , OR REGIONAL ANESTHESIA ( SPINAL, OR EPIDURAL ANESTHESIA ).5. PREPARTION OF THE SKIN POVIDONE IODINE AND TINCTURE OF CHLORHEXIDINE GLUCONATE ( 0,5% IN 70% ISOPROPYL ALCOHOL ) ARE USUALLY RECOMMENDED.

6. THE LENGTH OF THE SKIN INCISION SHOULD BE ADEQUAT ( 15 CM ) # # TYPE OF SKIN INCISION : I. VERTICAL ( MIDLINE ) INCISION A VERTICAL INCISION HAS ADVANTAGES : A LESS VASCULAR RAPID ENTRY AND GOOD EXPOSURE OF BOTH THE ABDOMEN AND PELVIS THIS INCISION MAY BE INDICATED IN CASES OF URGENCY II. PFANNENSTIEL INCISION. A PANNENSTIEL INCISCION HAS ADVANTAGES : THIS INCISION IS EXTENSIVELY USED BECAUSE OF ITS EXCELLENT COSMETIC RESULTS; EARLY AMBULATION, AND LOW INCIDENCE OF WOUND DISRUPTION, DEHISCENCE AND HERNIA. PFANNENSTIEL INCISION HAS DISADVENTAGES, MAY RESULT INJURY TO THE ILIOINGUINAL AND ILIOHYPOGASTRIC NERVE; USE OF THIS INCISION LIMITS VIEWS OF THE UPPER ABDOMEN. III. OTHER JOEL COHEN`S INCISION MAYLARD INCISION 7. UTERINE INCISION * TYPE OF UTERINE INCISION. I. LOWER UTERINE SEGMENT TRANSVERSE INCISION (MUNRO-KERR) LOWER UTERINE SEGMEN VERTICAL INCISION ( KRONIG, DE LEE AND CORNELL ) BECAUSE OF THE RISK OF BLADDER EXTENSION, IT REMAINS ADVISABLE TO DO A LOWER SEGMENT TRANSVERSE INCISION WHENEVER THE LOWER SEGMENT IS WILL FORMED. II. CLASSICAL INCISION ( A VERTICAL INCISION IN TO THE BODY OF THE UTERUS ). III. LOWER UTERINE SEGMENT VERTICAL INCISION . A LOWER UTERINE SEGMENT VERTICAL INCISION OR EVEN A CLASSICAL INCISION MAY, AT TIMES, PROVE TO BE ADVANTAGEOUS, IF : THE FETUS IS NOT PRESENTING BY THE VERTEX THERE ARE MULTIPLE FETUSES THE FETUS IS VERY IMMATURE ( < 26 WEEKS ) AND THE WOMAN HAS HAD NO LABOR. PRETERM DELIVERY WITH POORLY FORMED LOWER SEGMENT PROLONGED RUPTURE OF THE MEMBRANE. POOR LOWER SEGMENT AND TRANSVERSE LIE THE LOWER SEGMENT IS INACCESSIBLE DUE TO : = A DENSE ADHESION OR LARGE FIBROIDS, OR PLACENTA PREVIA PERIMORTEM CESAREAN. THE CLASSICAL UPPER UTERINE SEGMENT VERTICAL INCISION IS THOUGHT TO BE ASSOCIATED WITH : EXCESSIVE BLOOD LOSS INFECTION POOR HEALING AN INCREASED RISK OF UTERINE RUPTURE IN SUBSEQUENT PREGNANCIES. 8. DELIVERY OF THE FETUS INDUCTION DELIVERY INTERVAL OF MORE THAN 8 MINUTS UNDER GENERAL ANESTESIA AND INCISION DELIVERY INTERVALS MORE THAN 3 MINUTS UNDER BOTH GENERAL OR SPINAL ANAESTHETIC WERE ASSOCIATED WITH INCREASED NUMBER OF LOW APGAR SCORES AND NEONATAL ACIDOSIS.9. DELIVERY OF THE PLACENTA THE METHODE USED TO REMOVED THE PLACENTA WITH CONTROLLED CORD TRACTION 10. CLOSURE . SUTURING OF THE UTERUS USING POLYGLACTIN ( VICRYL ), OR POLYGLYCOLIC ACID ( DEX ON ). PERITONEAL CLOSURE USING VICRYL, OR DEXON CLOSURE OF FASCIA USING VICRYL OR DEXON CLOSURE SUBCUTANEOUS SPACE USING VICRYL , OR DEXON. CLOSURE OF SKIN BY INTRA CUTANEOUS SUTURES, OR BY SUBCUTICULAR SUTURES USING VICRYL, OR DEXON..10. SKIN INCISION DRESSING WITH AN ABUNDANCE OF ADHESIC TAPE, THE SURGERY IS COMPLETED11.THE MOTHER IS TRANSFERRED TO RECOVERY ROOM FOR INTENSIVE CARE UNTIL HER CONDITION STABILIZER, THE PATENTS IS ASSESSED AT LEAST HOURLY FOR 4 HOURS AND THERE AFTER AT INTERVALS OF 4 HOURS. POST CESAREAN SECTION PHYSICIANS ORDERS ( THESE ORDERS DO NOT APPLY TO DIABETIC, HYPERTENSION OR PREECLAMPSIA / ECLAMPSIA ). PATIENTS WITH SPINAL OR EPIDURAL MUST BE ABLE TO MOVE LEGS BEFORE LEAVING RECOVERY ROOM BLOOD PRESSURE, PULSES, TEMPERATURE, FUNDAL CHECK; AND BLOOD LOSS ASSESSMENT; NOTIFY PHYSICIAN IF PULSE > 110; SYSTOLIC BP > 150 OR < 90 mmHg; DIASTOLIC BP > 100 mmHg; TEMPERATUR > 38C.PROPHYLACTIC ANTIBIOTIC HAVE BEEN SHOWN TO REDUCE THE INCIDENCE OF INFECTION. CLEAR LIQUID DIET; AND SOLID FOOD MAY BE OFFERED WITHIN 8 HOURS OF SURGERY 5. N0TIFY PHYSICIAN , IF URINE OUT PUT < 100 ML IN ANY 4 HOURS INTERVAL THE BLADDER CATHETER MOST OFTEN CAN BE REMOVED BY 12 HOURS POST OPERATIVELY. 6. EACH INTRAVENA TO RUN AT 125-150 ML/ HOUR ; DO NOT EXCEED 250 ML IN ANY HOURS. 1000 ML D5-RL WITH 10 IU OXYTOCIN ADDED. 7. NOTIFY PHYSICIAN , IF PAIN RELIEF INADEQUATE 8. NOTIFY PHYSICIAN , IF PROMETHAZINE 25 MGR, INTRA MUSCULAR, INADEQUATE9. ANTACID 30 ML PER ORAL 10. BISOCODYL SUPPOSITORIA11. CHECK Hb, NOTIFY PHYSICIAN, IF HB CONCENTRATION < 8 GR %, BLOOD TRANSFUSIONS SHOULD BE PRESCRIBED12. ROOMING IN, IF DESIRED13. AMBULATION IN MOST INSTANCES, BY THE DAY AFTER SURGERY, SHE MAY WALK WITHOUT ASSISTANCE14. THE INCISION INSPECTED EACH DAY, AND SKIN SUTURES OFTEN CAN BE REMOVED ON THE FOURTH DAY OF THE SURGERY. 15. BY THE THIRD POSTPARTUM DAY BATHING BY SHOWER IS NOT HARMFUL TO THE INCISION16. BREAST FEEDING CAN BE INITIATED THE DAY OF SURGERY 17. UNLESS THERE ARE COMPLICATIONS DURING THE PUERPERIUM, THE MOTHER GENERALLY IS DISCHARGED ON THE THIRD OR FOURTH POSTPARTUM DAY.COMPLICATIONS DURING CS DIFICULT DELIVERIES AF THE FETUS .HAEMORRHGE MATERNAL BLOOD LOSS IS REPORTED TO BE MORE WITH PRETERM CS, PROLONGED LABOR, SECOND STAGE CS, PLACENTA PREVIA, CHORIOAMNIONITIS, CLASSICAL INCISION, GENERAL ANAESTHESIA, ATONIA UTERI, COUVELAIRE UTERI, AND OBESITY. 3. SURGICAL INJURIES TO THE URINARY AND GASTRO-INTESTINAL TRACT DURING CS ARE INFREQUENT.PERIPARTUM AND POST PARTUM HYSTERECTOMY INCIDENCE PERIPARTUM HYSTRECTOMY : HYSTERECTOMY WAS PERFORMED 1 IN EVERY 200 CESAREAN DELIVERIES ( DATA FROM, MATERNAL FETAL MEDICINE UNITS NETWORK CENTERS, 2001).

INCIDENCE POST PARTUM HYSTERECTOMY; HYSTERECTOMY WAS PERFORMED 1 IN EVERY 500 VAGINAL DELIVERIES ( DATA FROM, PARKLAND HOSPITAL, USA, 2002 ).S INDICATION PERI AND POSTPARTUM HYSTERECTOMY : - ATONIA UTERI - COUVELAIRE UTERI WITH ATONIA UTERI - PLACENTA ACCRETA/ INCRETA / PERCRETA - LASERATION OF MAYOR UTERINE VESSELS- LARGE MYOMAS CERVICAL CARCINOMA INSITU.

SUPRACERVICAL HYSTERECTOMY, OR TOTAL HYSTERECTOMY IS PERFORMED USING STANDARD OPERATIVE TECHNIQUES. THANK YOU