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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
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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–
- Transverse - low transverse (lower segment)
- 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
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(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.
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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
- Cord traction
- Manually
- 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
Practice Questions
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