1. Improving skills - II : Tips to Manage difficulties & avoid complications at CS Improving skills - II : Tips to Manage difficulties & avoid complications at CS Dr. Haresh U. Doshi MD (Gynec), PhD (Med), FICOG, Diploma(USG), PGDMLS, PGCML PGDCR, PGDHHM Professor & Head of ObGyn GCS Medical college & Hospital Ahmedabad Dr. Haresh U. Doshi MD (Gynec), PhD (Med), FICOG, Diploma(USG), PGDMLS, PGCML PGDCR, PGDHHM Professor & Head of ObGyn GCS Medical college & Hospital Ahmedabad

2. Key Points in Reducing Complications Anticipation is the key to safe Cesarean section. Avoid undue haste at every step, particularly in delivery of fetus Good assistance (trained assistant), preferably a professional colleague Check suction machine, O2 supply & emergency drugs availability before starting CS Pediatrician (Neonatologist) must have reached Anticipation is the key to safe Cesarean section. Avoid undue haste at every step, particularly in delivery of fetus Good assistance (trained assistant), preferably a professional colleague Check suction machine, O2 supply & emergency drugs availability before starting CS Pediatrician (Neonatologist) must have reached

3. Key Points in Reducing Complications Blood (PCV), 1 unit kept ‘X’ matched & ready. I/V Ringer lactate at least 750 ml before anesthesia is given ( Although hypotension is quite less with sensorcaine, adequate I/V fluid preop cause hemo- dilution & decreases RBC loss after delivery - PPH) Proper antibiotics in adequate dosage. Preoperative counting – instruments, mops, swabs

4. Cesarean section – Opening the abdomen - Pffannensteil incision / Modified pffannensteil - Even if the previous scar is vertical, keep transverse 2 nd time, 2 vertical makes wall weak - Adequate Skin incision: Minimum  Allis size : Length of routine Allis’ forceps  15 cm 15 cm   10 cm diam. BPD is 9.4 cm, so head can easily be delivered. - Pffannensteil incision / Modified pffannensteil - Even if the previous scar is vertical, keep transverse 2 nd time, 2 vertical makes wall weak - Adequate Skin incision: Minimum  Allis size : Length of routine Allis’ forceps  15 cm 15 cm   10 cm diam. BPD is 9.4 cm, so head can easily be delivered.

5. Cesarean section – Opening the abdomen - Excise the abdominal scar of previous CS while opening the abdomen (except emergency), NOT at the end, this gives a clean scar - Muscles separated from the sheath adequately, particularly from upper part - Sharp dissection for muscles in previous CS g. - Excise the abdominal scar of previous CS while opening the abdomen (except emergency), NOT at the end, this gives a clean scar - Muscles separated from the sheath adequately, particularly from upper part - Sharp dissection for muscles in previous CS g.

6. Cesarean section – Opening the abdomen Clues for anticipating bad adhesions  1. P/V in first trimester – Do it always in previous CS case & check for uterine mobility & record it in case paper 2. Patient complains of constant pain in abdomen throughout pregnancy (more than usual). 3. After anesthesia is given, if you notice, abdomen at the site of scar is indrawn (if bad adhesions) OR catch the anterior abdominal wall & try to lift it(easy or not !) Unexpected adhesions annoys you & cause problems

7. Opening the Abdomen Parietal peritoneum opened as high as possible (in advanced labour bladder may be high) In previous scar there may be - Shallow Uterovesical pouch - 2 layers of visceral peritoneum  If there is difficulty in entering the abdomen, go higher up & laterally, dense adhesions of uterus with abdominal wall should be cut between two clamps/artery forceps

8. Tips for cesarean – Uterine incision Uterine incision must be adequate Adequacy of the uterine incision should be checked before delivering the head I repeat  Adequacy of the uterine incision should be checked Undue haste is to be avoided. Under any anesthesia incision delivery interval upto 180 seconds quite safe. - JPOG 2010

9. Uterine Incision Cutting -  After incising with knife, extending with scissors gives adequate space & cut in desired direction i.e. curved upwards  Good margins for suturing  More bleeding but it can be controlled by applying Allis forceps or sponge holding forceps  Cut & sutured fibers gives Strong scar Cutting -  After incising with knife, extending with scissors gives adequate space & cut in desired direction i.e. curved upwards  Good margins for suturing  More bleeding but it can be controlled by applying Allis forceps or sponge holding forceps  Cut & sutured fibers gives Strong scar

10. Uterine Incision Finger Splitting  Rapid & easy  Less bleeding !  More extension Finger splitting though fast, leads to direction downwards due to anatomical reasons & as less space is available due to muscle elasticity, there are more chances of extension & bleeding – angle tear Finger Splitting  Rapid & easy  Less bleeding !  More extension Finger splitting though fast, leads to direction downwards due to anatomical reasons & as less space is available due to muscle elasticity, there are more chances of extension & bleeding – angle tear

11. Tips for all cesarean Insert the full hand well below the head ( Don’t keep thumb outside) Have the proper grip (Biparietal) Flex the head, elevate it towards the incision and deliver it - shoe horn technique Anterior rotation not must Lateral flexion is sufficient Fundal pressure if required

12. Head at incision site- not delivering ! Never hurry - Panic & aimless attempts are futile and dangerous Identify the problem & deal with it. 1.Is skin incision less ?  Extend it 2.Are the muscles tight ?  Cut Recti muscles - Maylard incision, one side/both sides ; half/full Cut lower edge of rectus sheath vertically

13. Head at incision site- not delivering ! 3. Is uterine incision small ? Extend it  J, U shape (or inverted T shape) J shape or U shape should be kept from the beginning i.e. Prematurity, Elective LSCS – as lower segment is poorly formed  Intravenous bolus of dilute solution of Nitroglycerine (150-300 ug). This is available in ICU ( Institute set up).

14. Head at incision site- not delivering ! 4.Is fundal pressure inadequate ? Importance of good fundal pressure cannot be overemphasized. 5.Is head deflexed ? Flex it & then try to deliver. Deflexed head presents larger diameter.

15. Deeply engaged head 1.Push from below 2. Modified Patwardhan method - EASY ! 3.Lift the fetal shoulders up, passing hand inside the uterus. This moves the whole uterus up & might lift the head out of pelvis. (There are Devices for lifting the head, but if you have not used it, don’t try now)

16. Deeply engaged head 1.Push from below  - Anticipate this - Full vaginal preparation to prevent infection - Assistant ready from the beginning - Push after anesthesia but before incision is kept

17. Deeply engaged head 2.Modified Patwardhan method – delivering as breech Pull method Original Patwardhan for anterior back Deliver one shoulder, then second one Deliver lower part of the baby by doubling up Modified Patwardhan for posterior back Pass the hand up in the uterus, Catch the anterior foot & deliver as breech Pull the head up from pelvis last, it comes out easily

18. High Floating Head Let the liquor drain out Wait till head descends to the incision site Head slips from the hand Have the proper grip Good Fundal pressure is must

19. High Floating Head  Internal version & breech delivery  Use of vacuum extractor  Use of forceps If you are not doing instrumental vaginal delivery don’t try to use it at cesarean section !

20. LSCS - Breech Presentation Cesarean section in Breech presentation is for baby so its safety is of utmost mportance Adequate uterine incision – cutting the muscles (not splitting), gives adequate space Breech extraction method(vaginal delivery) is used but one has to be gentle Head can be delivered by modified MSV technique

21. LSCS - Shoulder presentation Lower segment transverse incision is sufficient (Previously classical incision was recommended) Deliver as breech by passing hand in the uterus & catching the leg (avoid shaking hands with baby & accidental delivery of the arm should be replaced forthwith). Prior USG helps in guiding the hand

22. LSCS - Multiple pregnancy More Twins are delivered by cesarean section at present. Adequate incision is must - Prematurity, lower segment not wellformed Deliver as per presentation and station Anterior fetus is delivered first

23. Placental delivery - Avoid routine MRP It can cause more bleeding & more infection - Timely given ecbolics (oxytocin, methergin) separates placenta early - While waiting for placenta to separate on its own you can catch the angles & lower edge. ( Close your eyes & then pass hand in the uterus to have the experience (learn) of MRP ! ) - Avoid routine MRP It can cause more bleeding & more infection - Timely given ecbolics (oxytocin, methergin) separates placenta early - While waiting for placenta to separate on its own you can catch the angles & lower edge. ( Close your eyes & then pass hand in the uterus to have the experience (learn) of MRP ! )

24. Uterine suturing Always exteriorize for suturing  If you are not doing it routinely at least do it when there is excessive bleeding Always exteriorize for suturing  If you are not doing it routinely at least do it when there is excessive bleeding Advantages Ease of suturing Better control of hemorrhage No injury to bowel (particularly at the angle) Advantages Ease of suturing Better control of hemorrhage No injury to bowel (particularly at the angle) Disadvantages of exteriorizing are only theoretical

25. Since > 20 years I believe, practice & teach single layer. EBM : There are no enough studies at present to recommend either single layer or double layer closure as better method. The above discussion is irrelevant when you are not practicing VBAC & doing repeat elective CS in all cases of previous cesaraen sections ! Since > 20 years I believe, practice & teach single layer. EBM : There are no enough studies at present to recommend either single layer or double layer closure as better method. The above discussion is irrelevant when you are not practicing VBAC & doing repeat elective CS in all cases of previous cesaraen sections ! Single layer closure V/S double layer closure ?

26. Continuous locking suture is traditionally practiced (for first or single layer), although it can cause somewhat ischemic necrosis, they are best for hemostasis. For Angles - Lateral to medial & not below upward, If there is active bleeder at the angle - suture it separately Edges – If you require to take extra stitches for bleeding from the suture line take ‘ figure of 8 ‘ transverse stitches parallel to the edge Continuous locking suture is traditionally practiced (for first or single layer), although it can cause somewhat ischemic necrosis, they are best for hemostasis. For Angles - Lateral to medial & not below upward, If there is active bleeder at the angle - suture it separately Edges – If you require to take extra stitches for bleeding from the suture line take ‘ figure of 8 ‘ transverse stitches parallel to the edge Method of suturing

27. Reducing Hemorrhage Proper and timely ecbolic – Oxytocin, M. ergometrine Prompt and adequate suturing Exteriorize and massage Bimanual compression, hot mops Prostaglandins - I/M, Intramyometrial ( Intramyometrial PG is superior to I/M route, only in cases of shock & when Internal iliac artery ligation is aready done ) Proper and timely ecbolic – Oxytocin, M. ergometrine Prompt and adequate suturing Exteriorize and massage Bimanual compression, hot mops Prostaglandins - I/M, Intramyometrial ( Intramyometrial PG is superior to I/M route, only in cases of shock & when Internal iliac artery ligation is aready done )

28. Controlling Hemorrhage Tips of managing excessive hemorrhage at cesarean section is discussed under the heading of obstetric emergencies along with the topic of PPH. (Presentation 6)

29. Prevention of Injuries Bladder : Be careful while entering the peritoneal cavity. Empty the bladder before CS - if catheter can’t be negotiated empty it by needle puncture and syringe. In case of previous CS always do sharp dissection. Beware of enthusiastic assistant holding Doyens retractor ! Slightly higher incision in advanced labour If doubt, check and repair on table Bladder : Be careful while entering the peritoneal cavity. Empty the bladder before CS - if catheter can’t be negotiated empty it by needle puncture and syringe. In case of previous CS always do sharp dissection. Beware of enthusiastic assistant holding Doyens retractor ! Slightly higher incision in advanced labour If doubt, check and repair on table “BLADDER IS A VERY FORGIVING ORGAN”

30. Prevention of Injuries Ureter : Vary rare 0.09% In an attempt to control angle bleeding or from down ward extended tear or dealing with broad ligament hematoma. “Patients do not die from ureteric injury immediately but can die from hemorrhage.” So even if you have injured the ureter in crisis, while dealing with severe hemorrhage, it is pardonable. Ureter : Vary rare 0.09% In an attempt to control angle bleeding or from down ward extended tear or dealing with broad ligament hematoma. “Patients do not die from ureteric injury immediately but can die from hemorrhage.” So even if you have injured the ureter in crisis, while dealing with severe hemorrhage, it is pardonable.

31. Prevention of Fetal Injuries Knife injury to soft parts Be gentle & incise the uterus slowly. In advanced/obstructed labour lower segment can be papery thin. Palpate before you cut to know the thickness Injuries during delivery Adequate incision and slow delivery avoids injury. Knife injury to soft parts Be gentle & incise the uterus slowly. In advanced/obstructed labour lower segment can be papery thin. Palpate before you cut to know the thickness Injuries during delivery Adequate incision and slow delivery avoids injury. “ Fetal injuries amounts to negligence & liable to litigation ”

32. ANGLE TEAR A – Assistant N – Needle holder G – Good Suction L – Light E - Exposure Angle in ObGy should be respected like Angles

33. “Ideally each obstetrician should be able to review his or her rate and type of complications so that continuous improvement in technique is fostered” “Ideally each obstetrician should be able to review his or her rate and type of complications so that continuous improvement in technique is fostered” - Charles Stedman

34. “ To improve is to change; To be perfect is to change often ” “ To improve is to change; To be perfect is to change often ” - Winston Churchill

35. NEBULA GRAPHIC Thank You www.plexusmd.com/drhareshdoshi doshiharesh@hotmail.com