Christopher R Graber, MDSalina Women’s Clinic

Jan 22, 2010

Outline History of cesareans Procedure overview Evidence-based techniques Avoiding trouble Consent for surgery

History of Cesareans Definition/origin: Latin

Caesus, plural of caedere “to cut” Not related to Julius Ceasar C-section vs. C-delivery

Caesarean in British English

History of Cesareans First deliveries

Roman Law, Lex Ceasarea, for maternal death

1500, 1580 – first documented1820 – first documented in British Empire

○ By James Miranda Stuart BarryCommon not to close uterus

○ 1876 – Italian Porro – hyst to control bleeding○ 1882 – German Sanger – wire sutures

Other: anesthesia, abx, blood products

Procedure Overview Skin incision Fascial incision Rectus muscle separation Peritoneal entry Bladder flap – optional Uterine incision Delivery – baby and placenta Closure

Procedure Details Skin incision

Pfannenstiel○ excellent cosmetics, limited exposure○ Transverse, slightly curved upward○ 2-3 cm superior to symphysis pubis

Cherney○ Transection of rectus muscles at symphysis

Maylard○ Transection of rectus muscles at midpoint

Midline – median vs. paramedian

Procedure Details Fascial incision

Nick fascia in midline with knife or cauteryExtension with scissors laterally

○ Usually a slight curve upward○ Undermining is an option○ Avoid muscles and superficial epigastric

vesselsFree fascia from rectus

○ Blunt vs. knife vs. scissors

Procedure Details Rectus muscle separation

More important for repeatsKnife vs. scissors

Procedure Details Peritoneal entry

Easier on primary○ Blunt vs. sharp○ Elevation of peritoneum○ Enter high if worried

Extension superior and inferior○ Blunt vs. sharp○ Watch out for bladder

Procedure Details Bladder flap

Optional stepEasy to create on primaryPick-up bladder at peritoneal reflection

○ Blunt vs. sharp developmentBladder blade

Procedure Details Uterine incision

ClassicalLow verticalLow transverse

○ Knife entry, 1-layer at a time○ Blunt vs. sharp extension○ AROM if necessary

Inverse-T extension○ If more room needed

Procedure Details Delivery

Hand under head, flex fingers to elevate○ Find occiput○ If complete – “Break the seal”, consider vaginal

assistFundal pressure, consider vacuum or forceps

PlacentaActive vs. passive

Prevention of atonyQuick closure, massage, pitocin, methergineUterine compression stitches, hysterectomy

Procedure Details Closures

Uterine – locking (0-chromic on a big needle)○ Exteriorized? 2nd layer?

Bladder flap – optionalPeritoneum – optional (2-0 vicryl or plain)Rectus muscles – optionalFascia – required (0 or 2-0 vicryl)Sub-cutaneous – optional (small vicryl or plain)Skin

Other Procedure Details Prophylactic antibiotics

If chorio – amp/gent then add clinda Patient tilt Skin cleansing Adhesive drapes Changing knives Instrumental delivery

Evidence-based Techniques “There are only three kinds of lies …

lies, damned lies, and statistics.”Popularized by Mark Twain

“There are only three kinds of lies … lies, damned lies, and evidence-based medicine.”Kevin Miller, MD, Urogynecologist in

Wichita, KS

Evidence-based Techniques Prophylactic antibiotic – 81 studies, rec

Multiple doses do not improve outcomes Left tilt – 3 studies, no change Adhesive drapes – 2 large studies, not

rec Changing blades – 1 gen surg, no

change Transect rectus – 3 studies, no change Bladder flap – 1 study, longer time

Evidence-based Techniques Uterine incision – transverse

Consider vertical if <28w Incision extension – 2 studies

Increased blood loss with scissors Placenta removal – 6 studies

Passive: decrease in endometritis, blood loss

Evidence-based Techniques Uterine exteriorization – 8+ studies

Pain and nausea vs. fewer stitches and less time

Uterine closure – many studies2-layer takes longer, decreases VBAC

rupture Peritoneal closure – 10+ studies, rec Sub-Q closure – 15+ studies, rec if >2cm Skin closure – few studies

Avoiding Trouble Try to stay midline – always better than

lateral Handle tissue carefully Pick-ups – use based on indications

Visceral organs vs. diffusion-based tissues Suture hints – protection, crossing Cautery – cut vs. coag

Avoiding Trouble Placenta previa

Consider low vertical or classical uterine incision

Plan at 36 weeks Placenta accreta, increta, percreta

Beware if previa and prior sectionS/S – incr. AFP, bleeding, hematuriaConsider a planned C-hyst

Bladder injury

Consent for Surgery For any procedure: have a very set

consent talk that you use every time Common risks for Cesarean Delivery

Bleeding (transfusion), infection, injury to baby or nearby organs

Less common risksFuture surgery, hysterectomy, uterine

rupture, complications in future pregnancy

Consent for Surgery Be sure to document risks of

FailureDeath

“I discussed with the patient the risks, benefits, and alternatives for [the procdure] including the risks of failure and death. Ms. [name] acknowledges and accepts these risks and gives consent for [the procedure].”

References Baskett, Thomas F. Uterine Compression Sutures for Postpartum Hemorrhage:

Efficacy, Morbidity, and Subsequent Pregnancy. Obstetrics & Gynecology. 110(1):68-71, July 2007.

Berghella, V et al. Evidence-based surgery for cesarean delivery. American Journal of Obstetrics and Gynecology. 193: 1607-17. 2005.

Chelmow, D et al. Suture Closure of Subcutaneous Fat and Wound Disruption After Cesarean Delivery: A Meta-Analysis. Obstetrics & Gynecology. 103(5, Part 1):974-980, May 2004.

Coutinho, IC et al. Uterine Exteriorization Compared With In Situ Repair at Cesarean Delivery: A Randomized Controlled Trial. Obstetrics & Gynecology. 111(3):639-647, March 2008.

Minkoff, H et al. Ethical Dimensions of Elective Primary Cesarean Delivery. Obstetrics & Gynecology. 103(2):387-392, February 2004.

Lyell, D et al. Peritoneal Closure at Primary Cesarean Delivery and Adhesions. Obstetrics & Gynecology. 106(2):275-280, August 2005.

Siddiqui, M et al. Complications of Exteriorized Compared With In Situ Uterine Repair at Cesarean Delivery Under Spinal Anesthesia: A Randomized Controlled Trial. Obstetrics & Gynecology. 110(3):570-575, September 2007.