Nineteenth Century Medical Guide

Chapter 127 124. Every next step is a knowledge point
Carvey also encountered placental adhesion and implantation before crossing, and even penetrating implantation is not unheard of【1】.Some laborers went to the delivery room for natural delivery, and the baby just came out, but when it encountered implantation, it went directly into the uterine cavity in the delivery room for peeling.

Of course, the vast majority of implants have placenta previa and need to be operated on stage. Obstetric problems must be performed by obstetricians, and Kawei has no way to perform the surgery.

If you can't be the chief surgeon, ordinary assistants can still do it. Anyway, the purpose of abdominal surgery is the same.Moreover, the obstetrics department has been short of manpower all year round. When I was young, the division between departments was not so clear, and I was often pulled to be a strong man. Over time, I developed the habit of being a firefighter at any time.

Faced with the placental tissue invading the myometrium, peeling or not peeling will cause a lot of bleeding, so the risk of placenta accreta is very high.Even in modern times, it needs to be transferred to a powerful higher-level hospital, and experienced obstetricians can take over to handle it. There was no such condition in the 19th century.

Carvey's oxytocin can only be used to contract the uterus, and the uterus itself compresses the blood sinuses to stop bleeding, but it has little effect on placenta accreta.

Once this kind of placenta accreta is stripped, the uterus will form a large-scale wound that penetrates into the muscle layer, and the sinusoids will open up in a large amount, and the amount of bleeding will be astonishing. It is difficult to stop the bleeding by contracting the uterus alone.What's more, Kavey's oxytocin has not been further purified, it has a very strong boosting effect, the effect is limited, and the amount of use is also limited.

There is a lack of hemostatic drugs, and the effect of oxytocin is limited. If there is a massive bleeding again, the only clinical option is fluid transfusion.

Kavi is already doing fluid rehydration, but there are too many difficulties in blood transfusion, because whether it is temporary blood type matching, selection of blood, and storage of blood after isolation, all problems need to be solved one by one.Moreover, allogeneic blood transfusion will bring many other problems. Severe blood transfusion reactions such as allergies were more difficult to deal with than blood loss in the 19th century.

Looking at such a troublesome uterus【2】, Kavey had to overthrow the idea of ​​entering the abdomen and choose carefully, because once the knife is cut, it will be against time.

"These purple-black blood vessels are all over Brenda's uterine myometrium. First, I want to check whether this extremely aggressive placenta has the possibility of implanting into the surrounding tissue." Carvey searched for the lower bladder and other organs in the abdominal cavity. Organs, "Fortunately, the implantation is limited to the uterus and has not expanded to other places."

This is good news, at least Brenda's chances of survival have gone from 90% to 70% which he judged before.

After checking the surrounding tissues, the second thing Carvey has to face is the choice of incision location.

In the eyes of the audience, he avoided placenta previa and still chose the common uterine corpus incision.But in Carvey's own eyes, there are many trade-offs in this decision, which cannot be summed up in a simple sentence according to the rules.

The incision of the classical cesarean section is in the uterus. The reason why this place is chosen is that it is easy to expand the field of view and facilitate fetal extraction.

However, the incision of the uterine body will increase the risk of uterine rupture in another pregnancy. No matter how you look at it, the possibility of another pregnancy in this era is much higher than in modern times.Moreover, raising the incision may not necessarily avoid the placenta previa, so Carvey decided to use a new lower uterine incision from the beginning.

However, the position of placenta accreta just covers the lower part of the anterior wall of the uterus, with an area exceeding 5*5, and the amount of incision bleeding here will be very large.

After combining these factors, Carvey returned the scalpel to the uterine body: "We avoided these blood vessels, and directly chose to make a transverse incision above the implanted area. My two assistants and I must be fast. Take out the child before"

Because of the appearance of this strange uterus, the operation theater completely lost its sound.

Everyone suppressed their curiosity about placenta accreta and stared at the operating table in the center of the theater with breathless concentration.Such a uterus has opened everyone's eyes, and the following surgical procedure must be an area that no one has touched before, which means that every next step is a knowledge point.

Ordinary audiences don't want to miss it, and doctors and students who are good at medicine don't want to miss it.

Even doctors like Ignatz and Waterman took out their usual notebooks and wanted to record the whole process.

"We first cut open the uterus and make an incision of about 5cm."

As soon as Kawei finished speaking, the scalpel blade had already scratched the uterus lightly.Because the uterus is fully inflated, a simple incision can only be made with a knife, but no one knows whether the endometrium or the placenta is underneath, so the scalpel needs to be gentle enough to cut the serosa layer.

One knife, two knife, three knife
Blood gushed out directly, and the field of vision was blood red.

The most troublesome thing happened to Carvey. He didn't need to try to stop the bleeding. He could guess that the placenta was not the endometrium under the incision.Even for the most accurate surgeon, the scalpel will touch the placenta to some extent, so bleeding will definitely follow, and it will be massive.

He frowned and quickly made a simple probe around the incision with his fingers, but he couldn't touch the edge of the placenta, and all the gaps were blocked.

"Aspirator, stop the bleeding!"

Herman still couldn't stabilize his mind, and wanted to use gauze and suction, but was immediately rejected by Kawei: "I said before, the bleeding in this situation will definitely not stop, and the child must be taken out first." , and then remove the placenta."

This sentence is easy to say, but there is a pile of placenta under the incision, and the child cannot be seen at all. How to remove the fetus in the face of the blood that is constantly pouring out?

"Mellen, take a basin to catch the blood."

"it is good."

Because the entire operating table is temporarily head high and feet low, blood can flow down directly from the surgical incision, which is much more convenient than a suction device.And Carvey did not change the incision as others thought, or chose to strip the placenta first, but continued to make incisions directly on the placenta more roughly.

"The original purpose of cesarean section is not to let the mother live, but to let the child live, so we continue to rush forward regardless of the placenta" [3]

He speaks fast and his hands are faster.The audience didn't have time to react, the scalpel was already in the pool of blood and slid twice, the dark red blood suddenly faded: "Okay, the membrane is ruptured!"

Carvey quickly threw away the scalpel, and called the two midwives who were already on the stage to help: "Help get the fetus!"

The only cesarean section that followed Kavey's pace was the position of the fetus, the truly perfect head position, that is, the top of the fetal head facing the birth canal.This is the best position for a normal delivery, but now it is a cesarean section, and it is forced to choose a cesarean section with an incision in the uterine body.

When the incision was made, what he saw was not the fetal head, but his arm. 【4】

Caesarean section fetal extraction is to block the child's head, and then pull out the uterus all at once.Because the head of the child is the widest in the whole body, as long as the head can come out, the limbs and trunk can come out together.

But if the arm is pulled out first, the head will be stuck in the lower part of the uterus, and the torso will be stuck in the upper part.Even if the baby does get out of the mother's womb by chance, pulling the shoulder and neck forcibly can cause damage to the brachial plexus. 【5】

Now the arm is in front of me, and the difficulty has increased to a higher level.

He had to find the baby's head before Brenda's blood ran dry.In order to gain time for himself, he moved up the tentative oxytocin injection time to now: "Sals, give her an injection first."

"it is good."

"Have you got forceps?"

"Bring it!"

One of the midwives was already on the operating table, holding forceps tightly in her hand. 【6】

Carvey has never seen such a cephalic fetus with uterine body incision, because this kind of situation is too rare.But because the palpation done in advance had already clarified the position of the fetus, so when deciding on the incision of the uterine body, a solution was thought of:
"I lifted the child by the shoulders first, exposing the fetal head as much as possible, and clamped him out once I saw the fetal head!"【7】

Before Kavey finished speaking, his hand had already reached into the pool of blood in the uterus.The obstetric forceps on the side also followed the gap he pulled up and went straight in.

Everyone's eyes were bright red, and the only thing they could see was Carvey's hand and the black pliers.They hoped to see the baby appear, but things didn't go well.

"Not enough, the fetal head is still below, I can't reach it!"

After all, midwives are not surgeons. No matter how rough their movements are during normal delivery, they will subconsciously reduce their strength when seeing such a scene of bleeding.

This is of course a good thing, because it is dangerous to treat the incision violently, and below the incision is the swollen blood vessels in the myometrium. Once the incision is torn, the consequences will be unimaginable.

Kawei can't wait that long, the child will suffocate in the pool of blood at any time, there is no time to wait any longer: "One more person, push up from below!"【8】

under?

What's down there?
When the assistant was still in a daze and most of the audience's thoughts were out of touch with the operating table, another midwife immediately understood, quickly got under the blood basin, and stretched his hand in.

Lifting the shoulders at the top and pushing up the head at the bottom, the forceps finally clamped the child's head.

"Out!"

"Crowbeak forceps" Carvey took the two forceps from Bergett and cut them with a scalpel, "Take it away, the placenta is next! Take the blocking tape!"

Bergett quickly pulled out the thick rope at hand, and the uterus that was still inside Brenda was completely pulled out of the body by Kawei.This is a surgical operation that Cavet asked Bergt to practice after taking over the cesarean section. After several days of hard work, the proficiency is already very high.

The rope in his hand was looped around the lower part of the uterus and knotted directly blocking most of the blood flow.And Herman freed up one hand to firmly press the bottom of the uterus, which relieved the bleeding from the placental tear.

"Nurse, heart rate?"

"118."

Carvey nodded, realizing that simple tying would not be enough.The implant wound is very large, and more careful hemostasis and coping work is required before peeling off.

Now that the blood receiving basin under Brenda's body is half full, Carvey took the needle and thread from the nurse and shouted: "Assistants, here are two assistants, help adjust the operating table so that the head is low and the feet are high." .”

The countertop, which had fallen to the right, fell to the left, and the blood volume accumulated in Brenda's lower limbs began to flow into her torso.

"Everyone, the first difficulty of cesarean section has passed."

Carvey touched the pulse of the artery on one side of the uterus with his fingers: "But there are two difficulties to face next, one is the separation of the placenta. Such a placenta separation will definitely cause massive bleeding. The ascending blocking method proposed by Dr. Card ligates the ascending arteries on both sides of the uterus.

The needle thread in my hand is inserted from the front of the side wall of the uterus, passed around the back, and then passed through the front to complete the ligation.”【9】

During the time of speaking, one side has been ligated.

Lockard was in the auditorium with Olgi next to him. He did not expect that the hemostasis method he used for amputation was transferred by Kawei to the cesarean section, and achieved very good results.

Carvey didn't lie. From the beginning of the operation to the present, every step he took was the knowledge blind spot of those surgeons.These important knowledge points were forcibly compressed by him into just 10 minutes.

Can't understand?
Too late to hear it all?
It didn't matter, as long as he mechanically followed what he said, the mother could live. Now Brenda's heart rate and the decrease in bleeding visible to the naked eye are the best evidence.

Carvey's suturing technique was naturally impeccable. Within 2 minutes, the bilateral ascending uterine arteries were ligated. 【10】

"Continue to inject oxytocin to speed up the contraction of the uterus." Carvey asked Sarson to continue his work, and began to strip the placenta by himself, "Fortunately, the implantation of the placenta this time is not too deep and did not penetrate the muscle layer , just strip the placenta directly. It’s just that there will be more bleeding.”【11】

Kavi hasn't given up on keeping Brenda's uterus.

But the reality will not develop according to his wishes. Even if the lower uterine segment is tied up and the two arteries are ligated, the uterine bleeding still exists.However, the bleeding at this time still cannot be dealt with by frontal hemostasis, and it can only be endured until the placenta and residues are cleaned up.

"Gauze forceps!" Kavey said as he worked, "In the face of subsequent bleeding, you still can't be impatient. You need to remove the residual tissue in the uterine cavity first. Pay special attention to the implanted tissue in the lower part of the uterus. The residue here will be very serious. Clean it up!"

The gauze was repeatedly passed in and out of the uterus, bringing out some debris and debris.

At the same time, there was unstoppable blood.

The implantation wound left after extensive peeling began to ooze blood continuously, and the amount of bleeding was not less than when the uterus was cut.

"The contraction of the uterus is too bad!" Carvey knocked on Herman's hand, "Stop being an assistant, you two hands together, tightly pinch the fundus of the uterus!"

"it is good."

"Get the suture needle!" Carvey said, "If the uterus is not contracted when the wound is bleeding, we need to suture the area as soon as possible, using spiral sutures, and suturing the entire wound at one time."

Before he finished speaking, the nurse on the side suddenly said, "Dr. Carvey, your heart rate has increased!"

"How many?"

"132."

"So fast?" Kavi didn't have time to hesitate, "Where's my medicine bottle, pour it into the blood basin just now, and prepare gauze for filtration!"

At this time, with a loud cry, the child was declared alive in the midwife's report, and the cesarean section was half successful.And the other half is lying on the operating table, both ends are still pinched by Kawei and Reaper in their respective hands, I don't know who will die in the end.

(End of this chapter)