Obstetrical Nursing / A Text-Book on the Nursing Care of the Expectant Mother, the Woman in Labor, the Young Mother and Her Baby

by Carolyn Conant Van Blarcom

There are three main types of Cæsarean section: conservative, radical and extraperitoneal.

The conservative operation consists of opening the abdomen in the mid-line; incising the uterus; extracting the child and placenta, and suturing both uterine and abdominal walls. This is the usual operation when there is a choice, but because of the danger of infection, it is ordinarily performed only before the onset of labor or in the early part of the first stage, and many obstetricians are loath to undertake it then if the patient has been examined vaginally, particularly if the technique of the examination was open to question.

In the radical operation the abdomen and uterus are incised; the child and placenta extracted and the uterus is amputated just above the cervix. This operation is usually performed when labor is well advanced and there is fear of infection.

In the extraperitoneal operation the incision in the abdomen is made low down on one side, the peritoneum is not incised but is peeled back from the bladder and lower part of the uterus. The uterus may thus be opened and the child and placenta extracted, without entering the peritoneal cavity, thereby greatly reducing the risk of infection, and also without necessitating the removal of the uterus as a safeguard against infection. This operation, also, is performed late in labor when infection is feared, but is considered very difficult and therefore is not common.

The nurse’s duties in connection with a Cæsarean section are the same as those in any abdominal operation plus preparations for receiving and reviving the baby.

A Ruptured Uterus is a splitting of the uterine wall at some point, usually in the lower uterine segment, that has become thinned or weakened and unable to stand the strain of further stretching incident to uterine contractions, and is accompanied by an extrusion of all or a part of the uterine contents into the abdominal cavity. The rupture of a uterus during labor is a very rare accident, occurring but once in from 500 to 1,000 cases and usually only in prolonged labors, obstructed labors or certain faulty presentations. It is also a very grave accident, since the baby nearly always dies and sometimes the mother as well.

The cause of a ruptured uterus may be found in scar tissue, following a Cæsarean section or an injury; inherent defects in the tissues comprising the uterine wall; contracted pelves; neglected transverse presentations and the accident may occur during a version. It is usually preceded by extreme tenderness in the lower uterine segment, the part that is being abnormally stretched. The common symptoms, after the rupture has occurred, are sudden and acute abdominal pain during a contraction, which the patient describes as being unlike anything she has ever felt and as though “something had given way” inside of her. There is immediate and complete cessation of labor pains because the torn uterus no longer contracts. Sooner or later the patient has symptoms of shock because of the hemorrhage, which is usually internal, though there may be vaginal bleeding as well. Her face becomes pale and drawn and covered with perspiration; her pulse is weak and rapid; she appears exhausted and collapsed and may complain of chilly sensations and air hunger.

Abdominal palpation shows that the lower uterine segment is even more sensitive than formerly and that the presenting part has slipped away from the superior strait while at the side of the fetus the contracted uterus, partly or entirely empty, may be felt as a hard mass. The symptoms of shock may be delayed for some time when they will be accompanied, as a rule, by abdominal distension, due to hemorrhage, and a slight elevation of temperature.

The prevention of this disaster lies in performing version and prompt extraction in transverse presentations, as soon as the cervix is dilated, and in interference if the presenting part does not engage after an hour of strong, second-stage pains.

The treatment of a ruptured uterus is influenced by many factors. Possibly the most frequent course followed is to open the abdominal cavity and repair or remove the uterus, after extracting the fetus and placenta, according to existing conditions and the judgment of the operator. Sometimes the fetus is removed through the vagina and the uterus repaired through that channel.