1. Cesarean Delivery Overview
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, Lex Ceasarea, 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 Cherney Maylard
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
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 Placenta Prevention of atony
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 Placenta accreta, increta, percreta
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:
Chelmow, D et al. Suture Closure of Subcutaneous Fat and Wound Disruption After Cesarean Delivery: A Meta-Analysis. Obstetrics & Gynecology. 103(5, Part 1): , May 2004.
Coutinho, IC et al. Uterine Exteriorization Compared With In Situ Repair at Cesarean Delivery: A Randomized Controlled Trial. Obstetrics & Gynecology. 111(3): , March 2008.
Minkoff, H et al. Ethical Dimensions of Elective Primary Cesarean Delivery. Obstetrics & Gynecology. 103(2): , February 2004.
Lyell, D et al. Peritoneal Closure at Primary Cesarean Delivery and Adhesions. Obstetrics & Gynecology. 106(2): , 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): , September 2007.