O&G: Operating Theatre – Life and Death

J. was recently posted to the OT to watch and hopefully to scrub up and assist. Two operations seen had vastly different implications.

In the first, the start of a new human’s life in the external world began. In the second, any potential for growth or life was detroyed.

Life
The first was an elective lower segment caesarean section (LSCS) done at 38 weeks gestation for a patient with gestational diabetes mellitus. The indication was a previous LCSC done for the patient’s [now] 2-year-old child. A previous caesarean section is not an absolute contraindication to normal vaginal delivery, as there is this entity known as Vaginal Birth After Caesarean Section (VBAC).

The consultant made a transverse incision roughly above the bladder, slowly dissected through the fat layer, rectus sheathe and uterine wall. A gush of liquor followed the rupture of the membranes.

She then proceeded to deliver the child in vertex presentation while the medical officer pushed down on the uterus from above. The baby looked slightly bluish at the start and was covered in vernix caseosa. The neonatologist took care of the neonate and eventually it began to cry, though not as strongly as a normal vaginal delivery full-term neonate. The rest of the surgery involved closing up the uterus in two layers, followed by the rectus sheath and finally the skin (via subcuticular stitch).

Considering most surgeries involve removal of an undesirable part (e.g. surgical oncology, cyst removal, appendectomy), repair of an organ/part (e.g. perforated viscus), or creation of new channels (e.g. creation of arterovenous shunt, triple bypass, CABG), this was a new experience, to bring out life under the surgeon’s knife.

Death
The second was a termination of pregnancy (TOP), also known as an abortion. This patient, a 30+ year old Malay lady, had completed her family (3 children) and did not want any more children, hence the abortion. As the gestational age was about 8 weeks (i.e. first trimester, less than 12 weeks), surgical evacuation of the uterus via suction curettage was performed.

After anaesthesia, the patient was placed in the lithotomy position. After controlling the cervix, the cervix was dilated using Hegar dilators. A suction catheter was introduced to remove all trophoblastic and fetal tissue from the uterus, following which the uterus was scraped until a gritty sensation was felt. This attempts to ensure that all undesired tissue has been removed.

Afterwards, the removed tissue was sent was histology. J. is not sure why, but speculates that it is to confirm the tissue removed and to definitively exclude the possibility of gestational trophoblastic neoplasia.

The nature of the operation made a couple of J.’s colleagues uncomfortable, but it wasn’t a particularly gruesome affair. Perhaps, the ladies are commiserating with the painful-looking nature of the operation (dilating the cervix! scraping the uterus!). It was an interesting operation to watch for exposure, but it wasn’t fun.

J. does not look forward to seeing mid-trimester abortions.

P.S. Unlike in the United States, in Singapore there are not strong “Pro-Life” or “Pro-Choice” camps. Doctors can opt to be “conscientious objectors” and refuse to perform abortions, even though they are legal. J. thinks that legalised abortions are a necessity and would willingly perform them or refer patients to someone who would, in the future, if need be.

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