Cesarean Delivery Overview

1. Christopher R Graber, MD Salina Women’s Clinic Jan 22, 2010 Cesarean Delivery Overview

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

3. 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

4. History of Cesareans • First deliveries • Roman Law, LexCeasarea, for maternal death • 1500, 1580 – first documented • 1820 – first documented in British Empire • By James Miranda Stuart Barry • Common not to close uterus • 1876 – Italian Porro – hyst to control bleeding • 1882 – German Sanger – wire sutures • Other: anesthesia, abx, blood products

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

6. 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

7. Procedure Details • Fascial incision • Nick fascia in midline with knife or cautery • Extension with scissors laterally • Usually a slight curve upward • Undermining is an option • Avoid muscles and superficial epigastric vessels • Free fascia from rectus • Blunt vs. knife vs. scissors

8. Procedure Details • Rectus muscle separation • More important for repeats • Knife vs. scissors

9. 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

10. Procedure Details • Bladder flap • Optional step • Easy to create on primary • Pick-up bladder at peritoneal reflection • Blunt vs. sharp development • Bladder blade

11. Procedure Details • Uterine incision • Classical • Low vertical • Low transverse • Knife entry, 1-layer at a time • Blunt vs. sharp extension • AROM if necessary • Inverse-T extension • If more room needed

12. Procedure Details • Delivery • Hand under head, flex fingers to elevate • Find occiput • If complete – “Break the seal”, consider vaginal assist • Fundal pressure, consider vacuum or forceps • Placenta • Active vs. passive • Prevention of atony • Quick closure, massage, pitocin, methergine • Uterine compression stitches, hysterectomy

13. Procedure Details • Closures • Uterine – locking (0-chromic on a big needle) • Exteriorized? 2nd layer? • Bladder flap – optional • Peritoneum – optional (2-0 vicryl or plain) • Rectus muscles – optional • Fascia – required (0 or 2-0 vicryl) • Sub-cutaneous – optional (small vicryl or plain) • Skin

14. Other Procedure Details • Prophylactic antibiotics • If chorio – amp/gent then add clinda • Patient tilt • Skin cleansing • Adhesive drapes • Changing knives • Instrumental delivery

15. 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

16. 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

17. 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

18. Evidence-based Techniques • Uterine exteriorization – 8+ studies • Pain and nausea vs. fewer stitches and less time • Uterine closure – many studies • 2-layer takes longer, decreases VBAC rupture • Peritoneal closure – 10+ studies, rec • Sub-Q closure – 15+ studies, rec if >2cm • Skin closure – few studies

19. 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

20. Avoiding Trouble • Placenta previa • Consider low vertical or classical uterine incision • Plan at 36 weeks • Placenta accreta, increta, percreta • Beware if previa and prior section • S/S – incr. AFP, bleeding, hematuria • Consider a planned C-hyst • Bladder injury

21. 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 risks • Future surgery, hysterectomy, uterine rupture, complications in future pregnancy

22. Consent for Surgery • Be sure to document risks of • Failure • Death • “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].”

23. 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.