Peritonitis (6.2) may follow any obstructed labour, or an infected Caesarean section, and is common after rupture of the uterus. If a patient dies she will probably do so because you did not anticipate infection, or because you opened her abdomen much too late. She is likely to be infected: (1) If her labour is abnormally long, and the longer it lasts, the greater the risk. (2) If her baby is dead. (3) If her membranes rupture early and her liquor becomes infected. (4) If your sterile procedures are poor. In any of these conditions, anticipate infection and try to prevent it.
INFECTION [s8]AFTER CAESAREAN SECTION See also Section 6.6, 6.6a and 6.7. For vaginal bleeding due to infection (secondary PPH) see Sections 18.10 and 19.11b.
TRY TO ANTICIPATE INFECTION. If you expect that infection will follow Caesarean section: (1) Give the patient the perioperative antibiotic regime in Section 2.9, and (2) consider doing an extraperitoneal Caesarean section (18.13).
If you do not do an extraperitoneal operation, put a pack in each paracolic gutter, and one or two above the incision between her uterus and her abdominal wall. Make a small incision in her uterus first, and suck out her infected liquor and meconium. After delivering the placenta, mop out her uterus, and remove all remnants of membranes and some decidua. After closing her myometrium, and before closing her uterine peritoneum, wash out her pelvis 2 or 3 times with warm saline or water. Repair her peritoneum, control bleeding meticulously, remove the packs and clean up very, very carefully.
Alternatively, and probably less satisfactorily, after doing an ordinary lower segment operation, insert corrugated rubber drains, about 3 fingers width, in each of her paracolic gutters, and lead them out loosely through incisions in her abdominal wall. Cut her peritoneum round these drains, and don't merely stretch it. Insert another good wide drain suprapubically. Make sure there is no remaining amnion in her uterus to prevent free drainage through her cervix. Some surgeons insert insert a fourth drain through her cervix into her vagina.
After you have done the Caesarean section close her peritoneum and rectus sheath with a single layer of interrupted through-and-through sutures of stainless steel wire, or strong monofilament, 1 cm apart, taking 1.5 cm bites each side of the wound (9-21). Don't close her skin immediately; instead, close it by delayed suture (9.8).
CAUTION ! Watch carefully for the first signs of infection[md]fever, and a large soft tender uterus with tenderness deep in her flanks.
IF INFECTION OCCURS, it may take the following forms. It can also cause secondary haemorrhage (3.10), or sterility (15.2). If you left packs or swabs in her abdomen, low-grade peritonitis may follow and obstruct her gut. See also 6.6D.
If pus forms around the wound (9.12), it may discharge through the scar into the cavity of her uterus. Infection may resolve, or you may need to drain pus suprapubically.
If she develops a pelvic abscess, manage it as in Section 6.3.
If pus forms in her peritoneal cavity and spreads upwards, manage her as for peritonitis (6.2, 6.6). Continue intravenous fluids, and gastric suction. Open her abdominal wound, and suck pus from all the cracks and crevices. If her general condition is poor, do this under local anaesthesia. You will probably find that her uterus is totally disrupted, so it is hopeless to try to repair it, and almost certainly fatal to try to remove it. If you do decide to do a hysterectomy, a subtotal operation will usually be enough[md]commonly with the removal of both adnexa, but retain one if you can.
Wash out her abdomen and instil tetracycline (6.2). Consider inserting four drains, one in each paracolic gutter, one down to the wound, and one through her cervix into her vagina, making sure that this last is not occluded by amnion. Close her abdomen with interrupted wire sutures and leave her skin wound open.
If she has a tender suprapubic mass, make a 5 cm muscle-splitting incision over it, as for appendicectomy. Open her peritoneum, insert a sump sucker, and sweep your finger round the inside of her peritoneum as far as you can reach. A litre of thin pus may escape. Stitch in a large drainage tube.
If she has signs of ''pus somewhere' (a hectic fever, malaise, and anorexia), but there are no obvious signs of it, suspect that she has a subphrenic abscess. This is a common late complication, and is likely to kill her if you don't drain it (6.4); so may multiple abscesses between loops of her gut (6.3).
If her abdominal wall bursts, and exposes her uterus, repair it.
If her fever recurs, and there are signs that more pus is collecting, do another drainage operation.
7 Pus in muscles, bones, and joints