1. HISTORY: The patient is a 28-year-old, gravida 2, para 1, with complete/total placenta previa with hemorrhage in four bleeding episodes was admitted to the hospital. She has a previous cesarean section for her first child. The patient has received steroids and has consented for a repeat preterm cesarean delivery because of the placenta previa and the threat-to-life hemorrhage that could occur again as the pregnancy continued or during a vaginal delivery. The patient is aware that a hysterectomy may need to be performed if the placenta cannot be removed but will be avoided if at all possible. The patient also is known to have the baby in a double footling breech presentation and had gestational hypertension during this pregnancy. Labor was not allowed to occur in this patient. The patient is a 32 5/7 week gestation.

FINDINGS:

1. Complete placenta previa

2. Viable male infant in double footling breech presentation. Weight 5 pounds even. Apgar scores were 6 at one minute, 8 at five minutes, and 9 at ten minutes. The uterus did not have to be removed. There were normal-appearing tubes and ovaries. Of note: the pathologist reported on examination of the placenta that mild-to-moderate amnionitis was present in this mid third-trimester placenta.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, where a spinal anesthesia was found to be adequate. She was then prepped and draped in the normal, sterile fashion in the dorsal supine position with a leftward tilt. A Pfannenstiel skin incision was made along the site of the previous scar with the scalpel and carried through to the underlying layer of the fascia. The fascia was incised in the midline, and the incision extended laterally with the use of Mayo scissors. The superior aspect of the fascial incision was then grasped with the Kocher clamps, and the underlying rectus muscles were dissected with the Mayo scissors. Attention was then turned to the inferior aspect of this incision, which in a similar fashion was grasped with the pickups and entered, and the underlying rectus muscles were dissected with the Mayo scissors. The rectus muscle was spread in the midline, and the peritoneum was entered bluntly. The peritoneum was extended superiorly and inferiorly, with good visualization of the bladder, using the Metzenbaum scissors. The bladder blade was placed and the vesico-uterine peritoneum was identified, tented up, and entered sharply with the Metzenbaum scissors. A bladder flap was then created digitally, and the bladder blade was replaced. The uterine incision was made about a centimeter and a half higher than usual due to the placenta previa, and the incision was widened with blunt force. At this time we were able to reach past the placenta previa and were able to grab both feet. At this point, the bag seemed to rupture. The infant was delivered in double footling breech with the typical breech maneuvers. The head delivered atraumatically. The nose and mouth were bulb suctioned. The cord was doubly clamped and cut. The infant was handed off to the waiting pediatrician. Cord gases and blood were obtained. The placenta was removed. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was then repaired with a 0 Vicryl in a running, locked fashion, and a second layer of the same was used to ensure excellent hemostasis. The uterus was then replaced into the abdomen and the gutters were irrigated and cleared of all clots and debris. The peritoneum was repaired with a 2-0 Vicryl. The 0 Vicryl was then used to reapproximate the rectus muscle in the midline. The fascia was repaired with a 0 Vicryl in a running fashion. The subcutaneous layer was then closed with plain 2-0 silk on a GI needle. The skin was closed with staples. The sponge, lap, and needle counts were correct times two. The patient had been given a gram of Ancef at cord clamp. The patient was taken to the recovery room in stable condition.

Principal Diagnosis: