Cell salvage with an experienced transfusionist
Fundal incision in an exteriorised uterus
It is important to have very senior and experienced scrub staff as the equipment required is considerably more than for a standard caesarean hysterectomy usually undertaken for uterine atony
All women should be consented by a senior consultant with expertise in PAS who will be part of the team undertaking the surgery.
The discussion covers the intended plan of management (primary hysterectomy, conservative management or partial resection) and what else the surgeons might do if they are unable to follow the original plan e.g. if the findings are different to those anticipated.
Specific items which should be discussed and documented on the consent form:
* Massive obstetric haemorrhage (+/- need for blood transfusion)
* Use of cell salvage
* Risk of venous thrombo-embolism
* Intentional or accidental cystotomy (+/- bladder repair: +/- ureteric stenting if trauma is near to the ureteric orifice)
* Risk of damage to other viscera including bowel (+/- potential risk of colostomy)
* Major vessel injury &/or ligation (prophylactic or indicated)
* Risk of pressure sores from prolonged surgery
* Risk of trauma to baby at delivery (e.g. cut to bottom)
* Risk of transient tachyopnoea of the newborn
* Risks associated with prematurity (tailored to gestation at time of delivery)
* Type of incision (midline vs transverse) with risk of inverted 'T' incision if transverse is opted for but greater access is needed in an emergency
* Type of uterine incision (Classical/Fundal)
* Prophylactic salpingectomy if hysterectomy (to decrease risk of neoplasia)
* Oophorectomy (only if necessary due to invasion or bleeding or the woman >50yrs old)
* Risk of post-operative Ileus (+/- Ogilvie syndrome)
* Potential risks from positioning (compartment syndrome and nerve injury)
* Earlier-onset menopause from hysterectomy
* Delayed ischaemic organ injury from hypovolaemia
If appropriate to do so consent should be obtained to record video and images of all procedures for educational or research purposes.
Bilateral salpingectomy should also be discussed as a form of contraception in the event of conservative management either as the woman's first choice of management or if it is deemed by the operating team to be the safest option at point of delivery.
All the details of the discussion should be documented in the medical records and the woman provided with a copy of the consent form.