MODERN APPROACH to the CESAREAN SECTION

TECHNIQUE(Evidence Based)

Agus Sulistyono

GENERAL PROCEDUREPreparation, IndicationAssessment of presenting part, FHRAnasthesia regional vs generalIdentification of incision site

TransverseVertical

Opening cavum abdomensharp blunt

GENERAL PROCEDURE

Uterine incisionTransverse - Low segmenLongitudinal – low, high

Rupturing amnionic sacDelivery the babyCutting umbilical cordRemoving placenta

manual vs gentle traction

Suturing uterine incisionexterioritazion vs intra abdomen1 vs 2 layer suture

Closing cavum abdomenperitoneum suturing vs non suturingrectus sheath Subcutan tissue suturing vs not

Skin closingsub cuticuler vs interupted

GENERAL PROCEDURE

- Access to anticipated pathology

- provide adequate exposure

- allow for extension

CHOICE OF INCISION

- interfere minimally with abdominal wall function - preserving important abdominal structures

- heal with adequate strength - reduce the risk of wound disruption - subsequent incisional hernia.

Considerations in selecting the

incision :Need for rapid entry

Certainty of the diagnosis

Body habitus

Location of previous scars

Potential for significant bleeding

Cosmetic outcome

TRANSVERSE VERTICAL

Rapid Better

Exposure Better

Wound strength Better

Adhesion formation Lower

Postop bowel obstruction Lower

Pain Less

Bleeding Less

Nerve injury Less

Impact on pulmonary function Less

Cosmetic Better

Wylie,BJ et al, Obstet Gynecol,2010; Brown SR, et al. Cochrane Database Syst Rev,2005

INCISION TYPE

SKIN INCISION

SIZE OF INCISION

Adequate for delivery of the fetus less traumatic allow delivery term fetus ± 15 cm

Adequate exposure stretch manually apart opening the

incisions angles

Scalpel vs electro-cauter no RCT prefer scalpel (either approach is acceptable)

DISSECTION of SUB-CUTAN TISSUES

Prefer blunt than sharp dissection (no RCT datas) quicker less injury to vessels (bleeding)

FASCIAL LAYER

Transverse incision & extended laterally - with scissors (Pfannenstiel)- with fingers bluntly (Joel-Cohen / Misgav-Ladach)

SUBCUTANEUS TISSUES

OPENING PERITONEUMBLUNT (FINGER) VS SHARP (PINCET & SCISSORS)

- data RCT not significant different in morbidity & mortalityBlunt (theoretical)minimize risk of injury to bowel, bladder or other

organ that addherent to peritoneumDense intra-peritoneal adhesions bluntly opening to upper abdomen (avoid dense area/scar

tissue) sharply opening cautiously using shallow incisions direct vision

TRANSVERSE vs VERTICAL no RCT principle : the incision ~ all atraumatic fetus

delivery FACTORS : fetus (EFW, position) placental location presence of myoma development of LUS

OPENING PERITONEUM

INTRA ABDOMINAL PROCEDURES

BLADDER FLAP Undergo bladder flap vs no bladder flap no RCTmorbidity (bladder injury ) ~

NO BLADDER FLAP quicker less bleeding

BLADDER FLAP

fetal head deep in the pelvis bladder attached above LUS (post SC) LUS not formed (not in labor)

HYSTEROTOMY

Be aware : placental location (avoid

laceration) fetal lie (delivery the fetus)head deep in the pelvis prolonged labor & head deep

in the pelvis avoid incision too low LUSmay transect Cx / vagina

Uterine Incisions

Kerr Incision vs Sellheim Incision vs Classical

TRANSVERSE INCISION : recommend for most SC LUS less blood loss less bladder dissection easier reapproximation lower risk rupture in VBAC RISK of laceration of major blood

vessel (extended) problematic if required larger

incision

INDICATIONS OF CLASSICAL CAESAREAN SECTION

1. when the LUS is abnormally vascular.

2. when the LUS can not identified due to adhesion.

3. Cases needs rapid delivery.

4. When the fetus lie is transverse and can not be corrected.

5. When hysterectomy will follow caesarean section

6. Poorly developed LUS when more than normal intra-ut manipulation is anticipated

7. LUS pathology (myoma, PPT anterior or accreta)

8. Post-mortem delivery

Advantages of the lower segment:

• The wound is extra peritoneal so less risk of infection.

• Healing scar is better.

• The risk of rupture of the scar is less.

• Hemorrhage is less.

• Placenta is away from the incision.

• Easier reapproximation

• Less need bladder dissection

DISADVANTAGES OF THE LOWER SEGMENT:

The operation requires more skill and experience.

The incision may extend down to the bladder.

Lateral extension risk laceration major blood

vessels

J or T incision: if need large incision weaker scar

DISADVANTAGES OF CLASSICAL OPERATION:

More liable to chest infection.

More liable to intestinal distension.

The scar is more liable to rupture (next pregnancy).

• HYSTEROTOMY EXPANSION

Blunt (finger) vs sharp (scissors) Extended the incisionBlunt :

- Fast- less risk trauma to fetus- less blood loss, lower drop in Hb and HCT

postpartum - less risk of unintended extension (RR 0,47;

95%CI 0,28-0,79)

BLUNT HYSTEROTOMY EXPANSION

FETAL EXTRACTI-

ON

CORD CLAMP

Early Cord Clamping

Delayed Cord Clamping

Milking Cord

PLACENTAL EXTRACTION

DRAIN vs NOT DRAIN umbilical cord before placental extracrion :

Drain less fetomaternal transfusiononly small trial

GENTLE TRACTION vs MANUAL EXTRACTION :MANUAL EXTRACTION :

Endometritis post-partum > (RR 1,64 95%CI 1,42-1,90)

blood loss > (mean difference 94 mL, 95%CI 17-172mL)

blood loss > 1000mL > (RR 1,81 95%CI 1,11-2,28)lower postpartum Hematocrit

Cavum uteri : wiped with gausge sponge - remove remaining membrane- stimulate uterine contraction

EXTERIORIZING vs INSITU UTERINE REPAIR

EXTERIORIZING

improve uterus exposure

facilitate closure uf hysterotomy

shorter time

Post-op nausea & vomiting

other complication ~

UTERINE EXTERIORIZING

CERVICAL CANAL

Routine manual/instrumental Cxdilatation

- unnecessary both labor or not laboring- Hb post-op ~- fever ~- wound infection ~

SUTURING

Choice of suturing ~ personal preferenceChromic catgut vs delayed absorbable not difference in maternal outcome

Chromic, monofilament (monocryl), braided (vicryl),

LOCKED vs UNLOCKED CLOSURELOCKED SUTURE:

scar weakness >thinner myometrialbell shaped wall defect dehiscence / rupture >

but data are limited

PARAMETER LUS CLOSURE

SINGLE DOUBLE

Operative time Less 6’ shorter

Endometritis ~ ~

Wound infection ~ ~

Blood transfusion ~ `

Thick LUS better

Uterine rupture (next pregnancy)

4,8% 2,9% Not significant

Risk bladder adhesion

> Need furtherstudy

SINGLE vs DOUBLE LUS CLOSURE(20 STUDY INCLUDING 15.000 PATIENTS)

ABDOMINAL IRRIGATION

maternal infection : not reduced

Increased intra-op nausea

estimated blood loss ~

operating time >

hospital stay ~

return GIT function ~

PERITONEUMCLOSURE vs NON CLOSURE (533 women)NON CLOSURE :

decreased operating time (± 6’)on repeat CS

adhesion ~time incision – delivery ~

NON CLOSURE PERITONEUM

Less time

Less post operative fever

Less post operative analgetics

Less wound infection

Less of length of hospital stay

RECTUS MUSCLES

Reapproximate naturally

Not need suturing

SUTURING :

increased pain (first start moving)

decreased dense adhesion formation

FASCIA :the most wound strengthavoid to much tension since approximationnot strangulation

MIDLINE FASCIAL INCISION :- simple running technique- no 1 or 2 delayed absorbable monofilamen- mass closure, all laye of the abdominal wall- wide tissue bites (≥ 1 cm)- short stitch interval (≤ 1 cm)- non strangulation tension suture

TRANSVERSE INCISION :- continuous closure - slow absorbable no 0 or 1 braided suture

SUBCUTANEUS TISSUE

Not need irrigationClosing with interrupted delayed absorbable

if subcutaneous layer ≥ 2 cminhibit blood and serum accumulation

WOUND DRAINAGE routine use not beneficialnot reduce :

seromahematomainfectionwound disruption

SKIN

STAPLE vs SUBCUTICULER SUTURE

STAPLE :

increase infection and separation

shortening operating time (only few

minutes)

post-op discomfort >

cosmetic appearance ~

PFANNENSTIEL PELOSI-TYPE JOEL-COHEN MISGAV-LADACH

Incision Pfannenstiel Pfannenstiel Joel-Cohen Joel-Cohen

Sub-cutan tissue Electro cauter Open 3 cm Open 3 cm

Fascia dissection Transverse, sharp Electro-cauter Transverse, blunt lateral extended

Transverse, sharp (semi open scissors)

Rectus musledissection

sharp Blunt Blunt Blunt

Peritoneal opening

Longitudinal, sharp

Blunt (finger & all layer stretched manually

Blunt (finger & all layer stretched manually

Blunt (finger & all layer stretched manually

Reflected bladder inferiorly

(+) (-) (+) (-)

SUMMARY

PFANNENSTIEL PELOSI-TYPE JOEL-COHEN MISGAV-LADACH

Uterine opening Transverse LUS Transverse LUS, blunt lateral extended

Transverse LUS, blunt lateral extended

Transverse LUS, blunt lateral extended

Uterine closing 2 layers, continuous

Single layer continuous locking

Interrupted sutures

Single layer locking sutures (exteriorization)

Peritoneal suturing (+) (-) (-) (-)

Fascia suturing Continuous /interupted

Continuous non locking

Continuous non locking

Continuous non locking

Sub-cutan layer suturing

(+) (+) in thick (>2 cm)

(-)

Skin Continuous /interupted

Staples 2-3 mattressutures

Others Placenta removed manuallyAllis clamp (5’)

RECOMMENDATION

Procedure Type of Preocedure GradeIncision abdominal wall Transverse 2 C

Skin incision Scalpel ~ cauter Personal preference

Open peritoneum Blunt -

Bladder flap No -

Hysterotomy Transverse 2 C

Expansion hysterotomy Blunt 2 B

Placental extraction Spontaneous 1 A

Uterus exteriorization Both acceptable Personal preference

Uterine closure 2 layer (if VBAC in next pregnancy)

2 C

Closing peritoneum Not closing 2 B

Subcutan tissue closure Closure (if s.c. tissue ≥ 2 cm) 1 A

Skin closure Subcuticular suture 2 C