Kawei also encountered placental adhesion and implantation before crossing, and even penetrating implantation was not unheard of[1]. Some laborers went into the delivery room to give birth naturally, and as soon as the baby came out, they encountered implantation and directly entered the uterine cavity with bare hands to perform dissection in the delivery room.
Of course, most implants with placenta previa require on-stage surgery. Obstetric problems must be handled by obstetricians, and Kawei cannot perform the surgery.
If you can't be the chief surgeon, an ordinary assistant can still do it. Anyway, the purpose of abdominal surgery is the same. Moreover, the obstetrics department is often short of manpower. When I was young, the distinction between departments was not so clear, so I was often dragged into being a young man. Over time, I developed the habit of being a firefighter at any time.
Faced with the placenta tissue that has invaded the myometrium, massive bleeding will occur whether it is peeled off or not, so the risk of placenta implantation is very high. Even in modern times, it needs to be transferred to a capable higher-level hospital and handled by experienced obstetricians. In the 19th century, there were no such conditions.
Kawei's oxytocin can only be used to contract the uterus and rely on the uterus itself to compress the blood sinusoids to stop bleeding, but it has little effect on placenta implantation.
Once this kind of placenta accreta is peeled off, the uterus will form a large-scale wound deep into the muscle layer, and the blood sinuses will open in large quantities and the amount of bleeding will be staggering. It is difficult to stop the bleeding by the contraction of the uterus alone. What's more, Kawei's oxytocin has not been further purified and has a very strong blood pressure boosting effect, with limited effects and limited usage.
In the absence of hemostatic drugs, the effect of oxytocin is limited. If major bleeding occurs again, the only clinical treatment available is fluid rehydration and blood transfusion.
Kawei is already doing the rehydration, but there are too many difficulties in blood transfusion, because whether it is temporary blood type matching, selecting people to draw blood, and storing the blood after it is separated from the body, all of them need to be solved one by one. Moreover, allogeneic blood transfusion will cause many other problems. Severe 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], Kawei had to overturn his opinion before entering the abdomen and choose carefully, because once the operation was performed, it would be a race against time.
"These purple-black blood vessels are all over Brenda's uterine myometrium. I first want to explore whether this highly invasive placenta has the possibility of implanting into the surrounding tissue..." Kawei rummaged through the bottom of the bladder and other organs in the abdominal cavity. "Fortunately, the implantation was limited to the uterus and did not extend to other places."
This is good news. At least Brenda's survival probability has increased from 90% to 70% as he had previously judged.
After checking the surrounding tissue, the second thing Kawi had to face was the choice of incision location.
In the eyes of the audience, he avoided placenta previa and still chose the common uterine body incision. But in Kawei's own eyes, there are many trade-offs involved in this decision, which cannot be summed up in a simple sentence and according to convention.
The incision location of classical cesarean section is in the uterus. The reason why this location is chosen is that it can easily expand the field of view and facilitate fetal removal.
However, incision in the uterine body will increase the risk of uterine rupture during another pregnancy. No matter how you look at it, the possibility of another pregnancy in this era is much higher than in modern times. And raising the incision may not necessarily avoid placenta previa, so Kawei decided to use a new lower uterine segment incision from the beginning.
However, the location of placenta implantation just covers the lower segment of the front wall of the uterus, and the area exceeds 5*5. The amount of bleeding caused by the incision here will be very large.
After combining these factors, Kawei still put the scalpel back into the uterus: "We avoided these blood vessels and directly chose to make a transverse incision above the implantation area. My two assistants and I must be fast, and we must be quick when heavy bleeding breaks out. Take out the child before..."
The operating theater was completely silent due to the appearance of this strange uterus.
Everyone restrained their curiosity about placenta implantation and stared at the operating table in the center of the theater with bated breath. Such a uterus has opened everyone's eyes, and the subsequent surgical process must be an area that no one has touched before, which means that every step that follows is a point of knowledge.
General audiences don’t want to miss it, and doctors and students who are proficient in medicine don’t want to miss it even more.
Even doctors like Ignatz and Waterman took out their usual notebooks and wanted to record the entire process.
"We first cut open the body of the uterus and make an incision of about 5cm."
As soon as Kawei finished speaking, the scalpel blade had already lightly scratched the uterus. Because the uterus has been fully expanded, a simple incision can only be made with a knife, but no one knows whether it is the endometrium or the placenta underneath, so the scalpel needs to be gentle enough while cutting through the serosa layer.
One sword, two swords, three swords...
Blood gushed out directly, and the vision was blood red.
The most troublesome thing for Kawei happened. He didn't need to try to stop the bleeding. He could guess that the placenta was not the endometrium under the incision. Even if the surgeon is the most precise, the scalpel will touch the placenta to some extent, so bleeding will definitely follow, and it will be heavy bleeding.
He frowned and quickly used his fingers to do a simple exploration around the incision. He couldn't touch the edge of the placenta, and all the gaps were blocked.
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"Suction device, stop the bleeding quickly!"
Herman still couldn't calm down and wanted to use gauze and a suction device, but was immediately rejected by Kawei: "I have said before, the bleeding in this case will definitely not stop, and the child must be taken out first. , and then remove the placenta.”
This sentence is said lightly, 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 constant flow of blood?
"Mellen, take a basin to catch the blood."
"good."
Because the entire operating table is temporarily raised from head to foot, blood can flow directly downward from the surgical incision, which is much more convenient than a suction device. Kawei did not change the incision as others thought, or choose to remove the placenta first, but continued to make incisions directly on the placenta more roughly.
“The initial purpose of cesarean section is not to let the mother live, but to let the child live, so we ignore the placenta and continue to move forward..." [3]
He spoke quickly and his hand speed was even faster. The audience had no time to react. The scalpel had already been submerged in the pool of blood and he gently slid it twice. The dark red blood suddenly became lighter: "Okay, the membrane is ruptured!"
Kawei quickly threw away the scalpel and called to the two midwives who were already at the table for help: "Help take out the fetus!"
The only thing that Kawei followed during this cesarean section was the position of the fetus, which was the truly perfect head position, that is, the top of the fetal head was facing the birth canal. This is the best position for a normal delivery, but now it is a cesarean section, and it is a cesarean section that is forced to choose a uterine body incision.
What you see after the incision is not the fetal head, but his arms. 【4】
During cesarean section, the baby's head is stuck and then the uterus is pulled out in one go. Because the child's head is the widest in the whole body, as long as the head can come out, the rear limbs and trunk can come out together.
But if the arms were pulled out first, the head would be stuck in the lower part of the uterus, and the torso would be stuck in the upper part. Even if the child is lucky enough to leave the mother's body alive, forcibly pulling the shoulder and neck can cause damage to the brachial plexus. 【5】
What's in front of you now is the arm, and the difficulty has reached another level.
He had to find the child's head before Brenda's blood drained out. In order to buy himself time, he moved the previously tentative time for oxytocin injection to now: "Sars, give her an injection first."
"good."
"Did you wear forceps?"
"Bring it!"
One of the midwives was already on the operating table, holding a forceps tightly in her hand. 【6】
Kawei has never seen a cephalic fetus with this kind of uterine incision, because this situation is so rare. But because the position of the fetus had already been clarified by palpation in advance, we thought of a way when deciding on the incision of the uterine body:
"I first lift the child's shoulders to expose the fetal head as much as possible. Once I see the head raised, I will pinch him out!" [7]
Before Kawei finished speaking, his hand had already reached into the pool of blood in the womb. The forceps on the side also followed the gap he made by pulling up, and went straight in.
Everyone's eyes were bright red, and the only thing that could be seen was one of Kawei's hands and the dark pliers. They hoped to see the child appear, but things did not develop smoothly.
"It's not enough, the fetal head is still underneath and I can't reach it!"
After all, midwives are not surgeons. No matter how rough their movements are during normal delivery, they will still subconsciously reduce their intensity when they see such bleeding.
This is of course a good thing, because violent treatment of the incision is inherently dangerous, and underneath the incision are the dilated blood vessels in the myometrium. Once the incision is torn, the consequences are unimaginable.
Kaweike couldn't wait that long. The child would suffocate at any time in the pool of blood. He had no time to wait any longer: "Here comes another person, push it up from below!" [8]
under?
What's underneath?
While the assistant was still in a daze and most of the audience's thoughts were disconnected from the operating table, another midwife immediately understood and quickly got under the basin for collecting blood and put her hand in.
The upper part was used to lift the shoulders, and the lower part was used to push the head upward. The forceps finally clamped the child's head.
"Out!"
"Crow's beak forceps..." Kawei took the two forceps given by Berget and used a scalpel to cut. "Take them away. Next is the placenta! Get the blocking tape!"
Berget quickly pulled out the thick rope at hand, and the uterus that was still in Brenda's body was completely pulled out of the body by Kawei. This is the surgical operation that Cavite asked Beget to practice after receiving this cesarean section. After several days of hard work, his proficiency has become very high.
The rope in his hand went around the lower part of the uterus and tied directly into a knot, blocking most of the blood flow. And Herman freed up a hand to press firmly on the bottom of the uterus, which relieved the bleeding at the placental rupture.
"Nurse, heart rate?"
"118."
Kavi nodded, realizing that simple binding would definitely not be enough. The implant wound is very large, and more detailed hemostasis and response work are required before peeling off.
Now that the blood basin under Brenda's body was mostly full, Kawei took the needle and thread from the nurse and shouted: "Assistant, here are two assistants to help adjust the operating table so that the head is low and the feet are high. .”
The countertop that had originally tilted to the right tilted to the left, and the blood volume accumulated in Brenda's lower limbs began to pour into her trunk.
"Everyone, the first difficulty of cesarean section has passed."
Kawei felt the pulse of the artery on one side of the uterus with his fingers: "But we still have to face two difficulties. One is the separation of the placenta. Such separation of the placenta will definitely cause massive bleeding. I had to choose the place where I was at Graz Hospital." The ascending occlusion method proposed by Dr. Card involves ligating the ascending arteries on both sides of the uterus.
The needle and thread in my hand enter from the front of the uterine side wall, go around the back, and then pass out from the front to complete the ligation..." [9]
While he was talking, one side had already been ligated.
Lockard was in the audience with Orgi next to him. He did not expect that the method he used to stop bleeding for amputation would be used by Kawei for cesarean section, and achieved very good results.
Kawei did not lie. From the beginning of the operation to the present, every step he took was in 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 doesn't matter, you just need to do what he said mechanically to keep the mother alive. Now Brenda's heart rate and visible bleeding reduction are the best evidence.
Kawei's suturing skills were of course impeccable. Within two minutes, both ascending uterine arteries were ligated. 【10】
"Continue to inject oxytocin to speed up uterine contractions." Kawei asked Sarson to continue his work and began to remove the placenta. "Fortunately, the placenta implantation was not too deep this time and did not penetrate the muscle layer. , just remove the placenta directly. But... there will be more bleeding." [11]
Carvey hasn't given up on keeping Brenda's uterus.
But reality would not develop as he wished. Even if the lower segment of the uterus was tied and two arteries were tied off, the bleeding from the uterus would still exist. However, the bleeding at this time still cannot be treated by frontal hemostasis, and I can only endure it until the placenta and residue are cleaned up.
"Gauze forceps!" Kawei said as he was doing it. "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 segment of the uterus. The residual tissue here will be very serious. It will definitely Gotta clean it up!”
The gauze was repeatedly moved 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 a large area of dissection began to bleed continuously, and the amount of bleeding was no less than when the uterus was cut open.
"The contraction of the uterus is too bad!" Kawei knocked on Herman's hand, "Stop being an assistant, use both hands together and pinch the fundus of the uterus!"
"good."
"Get a suture needle!" Kawei said, "If the uterus contracts poorly when the wound bleeds, we need to suture this area as soon as possible. Use spiral sutures to sew the entire wound at one time..."
Before he finished speaking, the nurse on the side suddenly said: "Dr. Kawei, the heart rate has increased!"
"How many?"
"132."
"So fast?" Kawei didn't have time to hesitate, "Where's my medicine bottle? Pour it into the blood basin just now, and then prepare the gauze for filtering!"
At this time, with a loud cry, the child was declared alive in the midwife's report, and the cesarean section operation was half successful. The other half was lying on the operating table, with both ends still being held by Kawei and Death in their respective hands. I don’t know who will win in the end.
