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Caeserean Delivery

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The term CAESEREAN (also spelt Cesarean) was derived from the Latin verb Caedere which means to cut so Caesarean section is sort of a tautology.

One of the most performed surgical procedures in obstetrics.

Incidence varies across the globe.

History

Origin has generated much debate & shrouded in myth. 3 explanations

  • Birth of Julius Caesar 100BC
  • From Latin word Caedere (Middle Ages)
  • Roman law –”Lex cesarea” (8th century BC)

Earliest report of infant surviving-508BC (Birth of georgias in Sicily)

1500- Mother and infant survival (Jacob Nufer)

Definition

Delivery of fetus through a surgical incision in the abdominal wall and uterine wall after 28wks of gestation.

Exclusion – removal of fetus in case of ruptured uterus or abdominal pregnancy. For example, a ruptured uterus following obstructed labor or extrauterine pregnancy where the fetus already lie in the abdominal cavity.

CS rate varies between and within countries

Recommended rate by WHO 10-15%

  • Britain 25%
  • USA >31%
  • Ghana 13%
  • Nigeria 2.1%

Trend has been that of progressive increase

Factors responsible for this increase include

Increasing maternal age

Electronic fetal monitoring

High incidence of CPD

Low tolerance for risk/litigation.

Convenience of physician

Repeat caesarean delivery

Elective caesarean delivery in HIV patients

Patient’s request- patient’s Autonomy

ART

Recommended to prevent maternal and or fetal morbidity when a contraindication to labor is present or vaginal delivery unsafe. The indications can be—

  • Absolute or Relative
  • Recurrent or Non recurrent
  • Fetal/Maternal/Combined

Maternal

Severe pre-eclampsia with unfavorable cervix

Previous classical scar

Previous extensive uterine surgery- myomectomy

Obstructive pelvic tumors - Fibroids

Previous third degree perineal tear and repair

Previous reconstructive vaginal surgery- VVF, colporrhaphy

Large vulval condylomata

Cervical incompetence with abdominal cerclage

HIV infection- low CD4, high viral titers

Fetal indications

Fetal distress before or in first stage of labor (in the later part of labor, a vacuum extraction or forceps delivery should be performed).

Abnormal presentations that persists after ECV-transverse, oblique

Face presentation in mento-posterior presentation

Multiple gestation with malpresentation of leading fetus

Fetal macrosomia >4.5kg

Very low birth weight<1.5kg

Fetal abnormality

Conjoint twins

Cord prolapse with live fetus.

Feto-maternal indications

Cephalo-pelvic disproportion

Failure to progress

Abnormal placentation- praevia

Abruptio placenta with live fetus

Absolute pelvic disproportion- contracted pelvis

Based on timing, may be divided into:

  • Elective
  • Emergency

Classification of caesarean urgency

Emergent-immediate threat to life of mother or baby (category 1). Should be started under 30 minutes.

Urgent-distress not immediately life threatening (category 2). Should be started under 75 minutes.

Scheduled-needing early delivery but no distress (category 3). Should be started under 72 hours.

Elective-at a time to suit the patient and labor ward team (category 4).

Involves obtaining the patients consent

For elective cases, the patient should fast at least 8 hours

IV line access with Normal Saline solution

PCV, Group and cross match blood

Urethral catheterization

Anesthetist review

Neonatologist review

Skin incisions

  • Midline subumbilical or infraumbilical
  • Pfannenstiel incision
  • Cohen incision
  • Maylard
  • Paramedian Incision
Skin incisions

A minimum length of 15cm is required

Allis forceps ~ 15cm in length can be used as a guide

Excision of previous scar is essential for better healing and cosmetic results

1. Midline Subumbilical Incision

Incision of choice in emergency situation.

If other operative procedure have to be combined.

Gives good exposure of the abdominal and pelvic organs

Less vascular

Note

  • Prone to incisional hernia

2. Pfannenstiel Incision

Introduced in 1900

Widely used because of it excellent cosmetic results

Important when operating on the extremely obese patients often the thinnest part of the abdomen

Incision is made in the line – delineating the pelvic grove ~ 2 – 3cm above the symphysis pubis

Note

  • Takes a longer time to perform and more vascular than subumbilical
  • Associated with increased blood loss
  • Limits the view of the upper abdomen.
  • Damage to ilioinguinal and iliohypogastric nerves

3. Cohen Incision

Originally introduced for abdominal hysterectomy in 1954.

Can be used for C/S

A straight transverse incision placed slightly higher than pfannenstiel

Anterior rectus sheath is incised in the midline

Peritoneum is bluntly opened in a transverse direction

Note

Associated with:

  • Less post-operative febrile morbidity
  • Shorter duration of surgery

4. Maylard incision

Also a transverse incision above the symphysis pubis

Involves cutting the rectus sheath transversely and ligating the inferior epigastric artery

Provides better access to the pelvis than pfannenstiel

5. Paramedian Incision

Used if classical C/S is contemplated

1/3rd of its length is above the umbilicus

2/3rd of the length is below the umbilicus

Uterine Incision

Type of uterine incision based on:

  • Fetal presentation
  • Gestational age
  • Placenta location
  • Developed lower segment

It is classified broadly into–

  1. Transverse - low transverse (lower segment)
  2. Vertical:
    • Classical— upper uterine segment
    • Low vertical (De lee)-lower uterine segment

Uterine Incisions and their sites

  • Low transverse (Kerr) – LUS (lower uterine segment)
  • Low Vertical (De Lee) – LUS
  • U – Shaped– LUS
  • J – shaped – LUS + UUS (upper uterine segment)
  • Inverted T– LUS +UUS
  • Classical– UUS
Uterine incisions

(A) Low Transverse (Kerr) Incision

Employed in more than 95% of all CS

Popularized by Kerr 1926

Less bladder dissection

Less blood loss

Open the Uterus 2-3 cm length centrally

Bulging membranes should be left intact

Cut with Mc indole scissors or insert the index fingers to extend the incision laterally

Fingers push the uterine vessels to one side rather than cut them

(B) Low Vertical Incision (De Lee)

Indicated in poorly formed LUS (Preterm delivery)

Avoid the large uterine vessels bilaterally

Studies have shown and attest to its safety alternative to (A).

Requires extensive bladder dissection to keep the vertical incision (10-12cm) in the LUS.

Note

  • Unwanted extension of the incision is usually down toward the bladder

(C) U – Shaped Incision

Indicated in the delivery of the impacted fetal head.

A U- Shaped incisions with a broad base with the convexity of the incision pointing toward the pelvis

U – Bucket handle incision.

(D) J – Shaped Incision

Used in difficult situation that might require an extension of a transverse incision to a J – shaped incision with the extension into the upper segment of the most accessible side.

Better than the inverted T – Incision

(E) Inverted T - Incision

Both (D) & (E) have been shown to be frequently associated with

  • Intra operative complications
  • Prolonged hospital stay

(F) Classical Incision

Indications

Extreme prematurity before the formation of the LUS.

Preterm breech presentation with rupture membranes.

Transverse lie and ruptured membranes + hand prolapsed

Large cervical fibroids/pelvic mass in the LUS

Cancer of the Cervix /CIN

Preliminary to caesarean hysterectomy

Previous classical scar

Dense adhesion/abnormal vascularization of the LUS

?? Placental Praevia e.g. with large vessels in the lower uterine segment

Postmortem CS

Incisions in classical C/S

Midline infraumbilical incision/Paramedian incision.

About 10cm long incision in the anterior surface of the uterus

Should be made quickly (hemorrhage)

Bleeding may be enhanced if the placenta is anterior

Risk of cutting the fetus is greater than (A)

Delivery of the fetus is usually by the breech

Advantages of Classical Incision

Rapid entry to the uterus

No lateral extension into the vessels of the broad ligaments

Easy entry into the uterus when there is fibroids in the LUS

Disadvantages of the Classical Incision

Increase intra operation blood loss

High risk of adhesion formation

High risk of uterine rupture in subsequent pregnancy

Less chance of VBAC

Low Uterine Segment Incision

The lower part of the anterior uterine wall which is covered by the loose peritoneum of the uterovesical sulcus or pouch

Has become accepted as the standard approach

Less vascular than the upper part of the uterus

Has less contractile tissue than the upper segment

Hemostasis is easily achieved

Healing occurs readily (inactive part of the uterus)

Reduced the risk of contamination of peritoneal cavity

VBAC is possible

Less postoperative complications.

  • Paralytic ileus
  • Peritonitis
  • Adhesions
  • Obstruction

Reduced risk of rupture of uterine scar in subsequent pregnancies.

Risk of rupture

Delivery of the Presenting Part (Baby)

When the incision in the LUS is complete the Doyen retractor is removed and the presenting part is delivered.

Cephalic Presentation

Insert the hand below the head to disimpact from the pelvis

While the assistant applied fundal pressure when the head is brought into the incision to deliver the fetal head.

Clear the airways

Delivery of a Deeply Engaged Head

Disimpact form below by a 3rd assistance

Use of one half of Wrigley’s forceps to disimpact the head from the pelvis

Breech delivery / extraction

A high mobile head at a repeat elective CS

Employ fundal pressure

Wrigley’s forceps to assist the delivery

Breech Presentation

If the presentation is breech the lower limbs are delivered and then the breech

Oxytocic is then given

Deliver the arms

Deliver the head (well flexed)

Care should be taken to maintain flexion of the head.

Transvers Lie ± Membranes Intact

Convert to cephalic presentation OR

Effect breech delivery

Transverse Lie + Hand Prolapse

Breech delivery via classical caesarean section

Delivery of Placenta

  1. Cord traction
  2. Manually
  3. Spontaneous expulsion
    • Reduces blood loss by 300ml
    • Decreases feto-maternal hemorrhage.
    • Decreases risk of maternal isoimmunization.

Repair of LUS

Traditionally repaired in two layers

First layer by continuous locking suture

Second imbricating layer is then applied

However a continuous locking single layer is optimal for uterine closure

  • Safe and prudent
  • Provides the best anatomical result and a strong uterine scar
  • Reduces the risk of endometritis
  • Decreases operating time
  • Reduces the number of suture materials used
  • No increased risk of dehiscence in subsequent pregnancy.

Repair of Classical Incision

Repair is in 3 layers

First layer of interrupted sutures

Second layer of continuous suture

Third layer of continuous suture to approximate the edges of the uterine serosa

Repair of Anterior Abdominal Wall

Rectus fascia is repaired with either interrupted or continuous non-locking absorbable or non-absorbable sutures

Subcutaneous tissue is closed with interrupted sutures if the space is >2cm

Closure of Campers fascia- reduces risk of hematoma formation

Skin Closure

The best cosmetic outcome is a subcutaneous rather than a percutaneous closure

Remove non-absorbable suture early in the post-operative period

Hemorrhage

Infections- wound/urinary tract/Necrotizing fasciitis, Genital sepsis

Thromboembolism

Injury to internal organs

  • Bladder
  • Ureters
  • Bowels

Injury to neonate

  • Lacerations
  • Fractures- humerus/femur

These will include

  • Stringent requirement for a second opinion
  • Objective criteria for the 4 most common indications for C/S
  • A detailed review of
    • All caesarean sections
    • Individual physicians C/S rate

Strategies

Keep accurate statistics

Allow VBAC

Attend to poor progress in labor

Focus labor management on reducing the primary C/S in primigravida

Induction of labor for specific indications after cervical ripening

Certainty of diagnosis of fetal distress

Management of breech presentation at term

Experienced Obstetrician for:

  • Assisted delivery
  • Twin delivery

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