Caesarean Section with Acute Appendix.

By MARY A. CHAMPTALOUP, M.B.

NZMJ, 1925

The following case, operated on by Dr. C. North, Assistant-Gynæcologist, Dunedin Hospital, shows the value of the extraperitoneal method of a Cæsarean section.

Mrs H., æt. 21, admitted to Dunedin Hospital, 1st March, 1925. Liquor amnii began to escape 14 days previous. Labour pains present seven days, and were severe for last four days. On the day before admission she was seized with a sharp stabbing pain in right iliac region, continuous between the labour pains, and accompanied by vomiting. She had then a two finger dilation of the os, and the fœtal head was free above the pelvic brim. The fœtal heart sounds were good.

On admission her temperature was 96deg., pulse 54. She was intensely tender in the right lower abdomen, and operation was decided on. The abdomen was opened by a right rectus incision. It contained free fluid with a B. coli odour. The uterus was pulled over to the left, the abdominal cavity packed off, and an acutely inflamed appendix, covered with fibrinous exudate removed with considerable difficulty. The appendix region was swabbed out with warm ether, and the peritoneum carefully closed.

The skin wound was then extended 1½ in. downwards, the bladder and lower peritoneal reflection defined, and displaced respectively medially and upwards, thus laying bare the lower uterine segment. This was incised somewhat obliquely and the fœtal head was speedily delivered by uterine contraction. The placenta and membranes were removed in the usual way, and the uterine wound closed by three layers of catgut sutures. An extraperitoneal cigarette drain was inserted in the lower angle of the wound and removed after 24 hours.

As far as the uterine condition was concerned her recovery was uneventful. On the twelfth day involution was normal, the os quite closed, and no tenderness present in the fornices. The only trouble arose from some infection of the upper angle of the wound with B. coli pus formation.

Küstner advocates Trendelenburg position for this operation, but no difficulty was experienced with the patient lying flat. He also fills the bladder with saline to aid in its identification. The reflection of bladder and peritoneum was easily performed owing to the laxity of the connective tissue planes during pregnancy.