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Christopher R Graber, MD Salina Women’s Clinic Jan 22, 2010.

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Presentation on theme: "Christopher R Graber, MD Salina Women’s Clinic Jan 22, 2010."— Presentation transcript:

1 Christopher R Graber, MD Salina Women’s Clinic Jan 22, 2010

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 ○ 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? 2 nd 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  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  Coutinho, IC et al. Uterine Exteriorization Compared With In Situ Repair at Cesarean Delivery: A Randomized Controlled Trial. Obstetrics & Gynecology. 111(3): , March  Minkoff, H et al. Ethical Dimensions of Elective Primary Cesarean Delivery. Obstetrics & Gynecology. 103(2): , February  Lyell, D et al. Peritoneal Closure at Primary Cesarean Delivery and Adhesions. Obstetrics & Gynecology. 106(2): , August  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.

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