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

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 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

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 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

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

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

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

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

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

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

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

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 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

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 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

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

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].”

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.