A woman's journey from pregnancy to delivery is like riding a roller coaster. The first ten months of pregnancy were an uphill climb of slowly accumulating atmosphere, but when it comes to delivery, it's a downhill slope of releasing adrenaline from top to bottom. If normal childbirth is a progressive process for the gap, then cesarean section takes this stimulation to the extreme and compresses it to explode in just half an hour.
Compared with a normal birth that often takes more than ten hours, a cesarean section is really fast. From the time the skin is incised to the time the baby leaves the mother's body, it usually takes no more than 10 minutes, and it can come out in a minute or two.
What was originally a relatively mild change was suddenly accelerated, avoiding common birth problems such as episiotomy and pelvic floor dysfunction [1], and will definitely bring about other new problems.
One of the more important ones is hemodynamics. 【2】
The enlarged uterus suddenly shrinks and is pulled out of the abdominal cavity by Cavite, which causes the inferior vena cava that was originally compressed to rebound, and blood from the lower body begins to flow back into the heart. Coupled with changes in position on the operating table, this reflux should become more severe.
In modern times, it is the anesthetist's responsibility to ensure that the mother goes through the operation smoothly.
But now, the only person on stage who can judge Brenda's physical condition is Kawei himself.
Whether it is excessive blood loss or increased blood return to the heart, the heart rate will increase [3]. But if we only use the "increased heart rate" to reversely determine whether Brenda is suffering from excessive blood loss or heart failure due to increased blood return, then we need to add another variable as a basis for judgment.
Because the treatment of the two is completely different, if it is really just a transient increase in the amount of blood returned to the heart, immediately increasing the rehydration at this time will only further increase the load on the heart, causing Brenda to die on the operating table.
So even though the bleeding volume has now reached nearly 1000ml, without the help of a sphygmomanometer [4], Kawei still tried to stabilize himself. While watching them prepare to add medicine to the blood basin, he checked Brenda's Body.
His breathing was fine, his pulse was a little weak, and his face was pale.
Looking at the still bleeding uterus, Kawei made a decision: "Take a wide-mouth bottle from my box, cover the mouth of the bottle with gauze to make a funnel, and then pour the medicine-added blood into the bottle. "
This is the anticoagulant-sodium citrate, also known as sodium citrate, that Kawei obtained after going back and forth between the University of Vienna Medical School and the chemical factory.
Compared with modern common heparin, the preparation of sodium citrate is much simpler. The most important raw material is citric acid, which is citric acid. 【5】
Since it is a new drug different from oxytocin, Kawei needs to explain: "My second hometown, Italy, is the best citric acid producer in the world. Once my father's experiment went wrong, and the Citric acid and sodium hydroxide are mixed together, which gives us this new thing, sodium citrate.
It effectively relieves blood clotting and is used at a dose of 2.5 grams per liter of blood, as they are doing now. "
From the moment he used a basin to collect blood, many people in the audience felt strange. Now after hearing him describe the effect of sodium citrate, many people have realized what Kawei is going to do next: "You Do you want to put the blood that has left Brenda's body back into her body?"
"Yes, I am doing autotransfusion."[6]
Another brand-new concept, a brand-new rescue idea, some people in the audience could not help but start discussing the feasibility of this approach. But for more other viewers, this step-by-step operation is crushing their common sense and ravaging their brains.
Once they couldn't keep up with their thoughts, after seeing these dazzling things, they were left with admiration.
As for the applause, just wait until Kawei completely completes the operation before taking it out.
The blood was filtered through eight layers of gauze, slowly flowed into the jar, then poured into the infusion bottle, and returned to Brenda's blood vessels through the rubber tube. Non-washed autologous reinfusion has a very high collection rate. 1L of blood can leave 600-700ml after anticoagulation and filtration, which is enough to maintain Brenda's life.
"The bleeding hasn't stopped yet. If the basin is empty, take it over and continue collecting blood."
Kawei cleaned the uterine cavity again, Herman kept rubbing the fundus of the uterus with both hands, and Berget helped pull the incisions on both sides of the uterus. The bleeding in the implantation area continued: "The uterine cavity has been cleaned, I still choose to do it before. Spiral suturing is used to sew the separated surface of the placenta to stop bleeding."
This stitching itself is also a product of experience.
Although suturing can stop bleeding, it itself is a traumatic intervention, so the operation determines the quality of the suture: "Because the area where the placenta is implanted has become thinner, I chose to directly penetrate the uterus, increase the thickness of the suture, and reduce the suture line. Tearing at the peeling surface.”
However, even if Kawei maximizes his operation, he is still limited by the weakness of the material.
The catgut could not withstand the force of the ligation and was broken three times in a row. It was not until a tougher silver thread was replaced that the wound was sutured...
...But it was just stitched on, and it didn't really stop the bleeding.
Brenda's uterus was weak in contraction. After incising the uterus, Sarson injected six injections into the uterine muscles, which exceeded the dose that Nora had received. Now Kawei encountered a second fork in the road, whether to continue injecting oxytocin or choose to stop.
Continuing to inject oxytocin will significantly increase Brenda's blood pressure, which may not be visible now, but will change when the blood is returned. All the changes produced by the body's various stress reactions will converge in her body, creating a situation where judgment cannot be made by just guessing.
The lack of a blood pressure monitor was definitely the biggest challenge for Carvey.
Looking at the sutured surface that was constantly seeping blood, he didn't have much time to waste: "Keep fighting."
"good."
Those who don’t know are fearless. Sarson who was taking oxytocin, Hermann who was doing uterine massage, Bergert who was retracting the hook, and Mellen who was performing blood filtration on the side all felt that the operation reached this step was all calculated by Kawei, and they didn’t know There are risks behind every decision.
They were very excited because the operation had actually been considered successful at this stage. Previous reported cesarean sections with placenta previa ended in the death of both mother and child.
As witnesses of the operation, they felt sincerely proud.
The audience on the stage was even more excited, because this operation was completely worth the ticket price. The new operating table, infusion, placenta implantation, rapid fetal retrieval, blood anticoagulation, and autologous reinfusion were every detail in the Austrian surgical theater. first appearance.
"The Great Luo of All Worlds"
The most typical one among them is none other than Varela, who knows something about surgery and belongs to the audience.
He had always scorned the conservative Austrian surgery, and only praised Ignatz's speed in surgery. He has always hoped that his country's surgical operations can be innovative, so that he can join the ranks of surgical powers and at the same time make his job more stable.
Previously, Varela only regarded Kawi as a rising surgical star with surgical experience, great luck, and not bad operations.
He had expectations but not much confidence, especially after Kawei chose to use a cleaner and more time-consuming amputation. He increasingly felt that Kawei would ruin his work. Several negative reports in daily newspapers were written by him, with the purpose of suppressing Kawei and further maintaining the aesthetic value of surgery.
However, today, Kawei’s series of arrangements completely shattered Varela’s long-standing understanding of “spectability”.
Kawei, who performs delicate operations on surgical incisions, can also become rough enough, and his speed is not slow at all. At the same time, it also tells the world that the appreciation of surgery is not limited to blood splashing and fast operations, but also the innovation that Varela hopes.
It had only been half an hour since the operation, and the senior surgical reporter had already mobilized all his brain cells to understand as much as possible what he saw. But even if I spend 120% of my efforts, I can only hear clearly what Kawei said, and there is still a long way to go before truly understanding it.
In fact, not to mention Varela, even surgical experts such as Ignatz, Waterman, Orji and Massimov sitting in the front row could only partially understand.
They could only choose to temporarily skip many details that were mentioned briefly. After all, in a fast-paced cesarean section, keeping up with the pace is the most important thing.
"This is already the 10th dose of oxytocin."
"Let's stop for a moment."
"Heart rate?"
"108."
The large amounts of oxytocin were finally having some effect, the size of the uterus had begun to shrink, and the bleeding seemed to have stopped. However, Kawei's face was still stern. He looked at Bergt beside him and said, "Loosen the blocking band on the lower part of the uterus."
"good."
The blocking band cuts off a lot of blood flow in the uterus. If there is still no active bleeding after being loosened, it can prove that the bleeding has been successfully stopped. In fact, the peeled surface was still bleeding after suturing. This feeling of powerlessness that could not be changed by all means made other people on the operating table have other ideas.
"How about cutting out the uterus."
"Well, if you cut off the obstructive uterus, there will be no bleeding."
This is indeed a good solution once and for all. It not only ensures Brenda's life, but also brings Kawei's operation to a successful conclusion. For such a dangerous cesarean section with placenta previa, the mother and child could be safe. This is already a pioneering achievement that can be shown off to the world.
However, Kawei's thinking was completely different from theirs: "Don't think about whether these are available..."
"But the bleeding is too serious." As the second assistant and a friend of his generation, Bergt still hopes that Kawei will stop the loss in time and retain this hard-won victory. "If we continue to let it bleed, maybe. .....”
"Well, please stop for a moment." Kawei immersed himself in checking the bleeding situation of the wound, and suddenly asked suddenly, "Who is the chief surgeon?"
Berget immediately realized the change in his friend's attitude, swallowed, and replied: "...It's you."
"Then who has the final say on the operating table?"
"Chief surgeon."
"So you are giving orders to the surgeon?"
"I just......"
Berget wanted to say something else, but he felt his calf was kicked and had to stop there.
The one who kicked him was Herman, who was standing aside and concentrating on uterine compressions.
He knew very well that Kawei, like Ignatz, was the same kind of person who was self-absorbed when he stood on the operating table and could not listen to advice at all. Not to mention him, Berget, even Hills, who had been working in clinical practice for several years, was kicked out by Kawei.
"I'm sorry." Bergt immediately surrendered. Kawi's current abilities were definitely not something he could question casually.
Kawei rolled his eyes at him, used a large amount of gauze at hand to perform intrauterine packing, and then slowly introduced the current situation: "I have performed ligation of both ascending arteries of the uterus after blocking the lower segment of the uterus. The hemostatic effect was not good, so I had to choose to continue ligating the descending uterine artery."
He had no room for hesitation. Continuing the operation would increase the risk of infection, and he had to choose a more aggressive hemostasis strategy to end the operation as soon as possible.
The descending uterine artery is in the lower segment of the uterus. If you want to perform suturing, you must perform anatomical separation of the lower segment of the uterus. The most important thing is to separate the bladder [7]: "Don't worry about the blood supply, because the blood supply of the uterus is not only the arteries on both sides, but also the blood supply of the uterus." There are other small blood vessels.
We push down on the bladder to fully expose the descending branches of the arteries in the lower uterine segment. Note that you must use a scalpel to slowly cut and separate here. Never use your fingers, because it will cause irreparable damage to the bladder... After suturing and ligation, you need to check whether there is any accidental injury on the rear... ..Finally check the bleeding inside the uterus..."
This was the last card Kawei could play. If this method could not stop the bleeding, Kawei would have no choice but to have a hysterectomy.
Fortunately, the effect of the upper and lower ligation was good, and the bleeding from the newly sutured wound in the uterus finally stopped.
"Heart rate?"
"101."
"breathe?"
"It's still the same as before."
Kawei glanced at Brenda, who looked pretty well, and finally breathed a sigh of relief, and brought the final result of the operation to the audience: "Because both uterine arteries were completely ligated, the bleeding has stopped now. The child is alive, Brenda The lady is also alive and I declare this cesarean section a success.”
...
This kind of "success" is just the result of compromise under the current understanding of surgery. The real test lies in postoperative care.
But for a broad audience, this success was enough to rewrite the outcome of obstetrics. Both operations ended successfully. Kawei single-handedly moved the cesarean section onto the operating table, telling the world that mothers do not need to die when they encounter difficult labor, and they have other options.
Many people in the stadium even ignored that the surgery was still being completed and had already started cheering Kawhi's name.
But the young surgeon didn't care. Cheering would not make Brenda fully recover, and she would still have to arrange nursing tasks.
"Beget, put the remaining oxytocin into the salt water and continue to infuse it slowly through the infusion bottle." Kawei handed the suture needle to Herman, "You sew the skin, be sure to sew it tightly to prevent the stitches from collapsing. .”
"Ok, I know."
"Sarson, go find the sandbag. Her uterine contractions are too poor, and there is no good way to continue relying on oxytocin. It must be pressurized."
"good."
"The two midwives went back and told the nurses to perform abdominal compressions every once in a while to expel all the blood clots."
"good."
"Meren, I'll leave the rest of the blood to you. After filtering, continue to inject it into her body as before."
"Um."
Kawei bowed to the audience behind him: "The operation is over."
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