Caesarean Section - PENDING REVIEW
last authored: March 2012, Smriti Khosla
last reviewed:
Introduction
Caesarean section (C/S) is a critical skill required for extraction of the fetus in situations where the safety of the mother, the infant, or both are threatened.
Worldwide, the caesarean delivery rate is 15 percent of births (Betran, 2007). This rate continues to rise in most developed countries. Though the reason for this increase is uncertain, some evidence suggests that the number of women having elective Caesarean sections in the absence of clinical indications may be climbing (McCourt, 2007).
Indications for Caesarean Section
There are several situations in which C/S are required. But in situations where an elective C/S is being considered, both the patient and the obstetrician must weigh the risks and benefits of C/S versus vaginal birth.
Presently, most indications for caesarean section are relative, with few exceptions marked * (Penn, 2001).
most common
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less common
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Equipment Required
The following equipment is required for safe C/S:
medications
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Retractors
Clamps
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Forceps
Other
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Procedure
The following videos have been provided by an open-access collaboration between the University of Michigan, and the University of Ghana Medical School, viewable here.
Like many surgical procedures, there is no standard technique for cesarean section. This procedure is constantly evolving and much research has been done to provide evidence-based guidance for surgical decisions during cesarean delivery (Berghella, 2005).
- anaesthesia
- cleansing &
draping - abdominal
incision - uterine
incision - delivery of
the infant - closing the
uterus - closing the
incision
Anaesthesia
After regional or general anesthesia is administered, the patient is tilted 10 to 15 degrees to her left using a wedge or blanket. This is done to avoid vena caval compression by her uterus (supine hypotensive syndrome) (Cluver, 2010).
Cleansing and Draping
The skin should be cleansed preferably with chlorohexidine-alcohol in order to prevent surgicial site infection (Darouiche, 2010).
Surgical site should be draped with nonadhesive drapes if possible. These have been shown to be associated with a lower rate of wound infection than adhesive drapes (Berghella, 2005).
Abdominal Incision
A transverse skin incision is recommended. It is associated with reduced postoperative pain and is more esthetically acceptable to patients compared with a vertical incision (Berghella, 2005). The Pfannenstiel incision is slightly curved and made 2 to 3 cm above the symphysis pubis.
Alternatively, the Joel-Cohen incision is straight and is made 3 cm below the line joining the anterior superior iliac spines. Either of these incisions can be made. However, vertical incisions have the benefit of allowing faster abdominal entry, causing less bleeding and nerve injury and they can be easily extended (Wylie, 2010).The incision should allow for at least 15 cm of exposure (Berghella, 2005).
Perform a blunt dissection of the subcutaneous tissue to avoid vessel injury. Then make a small transverse fascial incision medially with a scalpel before extending it laterally bluntly with fingers or with scissors. The rectus muscles can then be separated bluntly. Following this, the peritoneum is opened with blunt dissection and expansion high above the bladder (avoids injury to the lower organs).
Uterine Incision
A transverse incision in the lower uterine segment is recommended and this incision is extended bluntly using fingers (Berghella, 2005). In order to avoid fetal injury, the inner myometrial and decidual layers should be elevated and carefully thinned. This minimizes bleeding, maximizes exposure, and stimulates separation of the uterine tissue from the fetal membranes (Morrison, 1995).
Delivery of the Infant
Manual delivery of the fetal head should be performed where possible in order to avoid injury due to forceps or vacuum use.
Once the umbilical cord is clamped and cut, it is time to deliver the placenta via spontaneous extraction. Gentle traction is placed on the cord and oxytocin is used to enhance uterine contractions (Anorlu, 2008).
The placenta is checked to make sure it is complete and the uterus is explored with one hand to remove any remaining membranes or placental tissue.The uterus is than massaged to promote contraction. Oxytocin is given to promote uterine contraction and involution (Berghella, 2005).
Closing the Uterus
The uterus is exteriorized to assist with closure of the uterine incision. Neither the visceral or parietal peritoneum is closed (Bamigboye, 2003). Similarly, the rectus muscles are not surgically reapproximated.
Closing the Incision
The fascial tissue is carefully closed to provide good wound strength.
The skin is closed with a subcuticular suture (Berghella, 2005).
Post-Operative Care
Further information on different pages includes:
Consequences of Caesarean Section
Excluding prior co-morbidities, outcomes are normally excellent for both mother and infant. However, the following may be negative consequences of C/S:
maternalshort-term
long term
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neonatal
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Delivery by C/S also increases health care costs, in terms of supplies, personnel, and length of stay.
Vaginal Birth After Caesarean
Many women prefer to attempt Vaginal birth after Caesarean (VBAC) in subsequent surgeries, though the safety of this is controversial, focusing largely on risk of increased uterine rupture during labour.
A low transverse scar is safer, as the lower uterus is thinner and contracts less.
Contraindications to VBAC include (SOGC, 2005):
- previous classical or inverted “T” uterine scar, or unknown incision
- previous hysterotomy or myomectomy entering the uterine cavity
- previous uterine rupture
- presence of a contraindication to labour (ex. Placenta previa, malpresentation, etc.)
- current high risk pregnancy:
- multiple gestation
- diabetes/macrosomia
- facility unable to do emergency C/S
- the woman declines VBAC and requests a repeat cesarean
Resources and References
Universities of Michigan and Ghana video collaboration
further references pending
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