CESAREAN DELIVERYJOHN PAUL AMATA TADAY, MD-MPA Level III

Bicol University – College of Medicine

• Birth via LAPAROTOMY & then HYSTEROTOMYTWO GENERAL TYPES:1. PRIMARY CESAREAN refers to a first-time hysterotomy

2. SECONDARY CESAREAN one or more prior hysterotomy incisions

• CESAREAN HYSTERECTOMY performed at time of CS delivery

• POSTPARTUM HYSTERECTOMY done within a short time after delivery

• PERIPARTUM HYSTERECTOMY broader term that combines above two terms

WHAT IS CESAREAN SECTION?

FOUR MAJOR REASONS:1. Prior cesarean delivery

2. Shoulder dystocia

3. Fetal jeopardy

4. Abnormal fetal presentation

85% of CASES

WHEN TO PERFORM CESAREAN SECTION?

• Some request elective cesarean delivery

MAJOR REASONS:

1. Reduced risk of fetal injury

2. Avoidance of uncertainty & labor pain

3. Protection of pelvic floor support

4. Convenience

CS DELIVERY ON MATERNAL REQUEST (CDMR)

CDMR contraindicated to <39 weeks’ gestation

unless there is evidence of fetal lung maturity

MATERNAL MORTALITY RATES:• CS has higher maternal surgical risks

for current & subsequent pregnancies

• Clark and colleagues (2008) study:

N = 1.5M pregnancies

CS Maternal Mortality Rate 2.2/100,000

NSD Maternal Morality Rate 0.2/100,000

WHAT ARE THE DANGERS OF CS?

MATERNAL MORBIDITY RATES:• Similar to mortality rates, frequency of

some maternal complications with all

CS compared with vaginal deliveries

• Villar and colleagues (2007) study:

CS Maternal Morbidity Rate 2X than

NSD Maternal Morbidity Rate

NEONATAL MORBIDITY RATES:• Associated with less risk of fetal trauma

• Influences the CHOICE of CS despite the

associated maternal risks

• Alexander and colleagues (2006) study:

Injury rate 0.5% occurred in the ELECTIVE

cesarean delivery group than CS following a

failed operative vaginal delivery attempt

• DELIVERY AVAILABILITY facilities giving OB care should have the ability to initiate

CS in a time frame that incorporates maternal & fetal risks & benefits

• INFORMED CONSENT process and not merely a medical record document

• TIMING OF CS assurance of fetal maturity before scheduled elective CS

• PERIOPERATIVE CARE NPO 8 hours before surgery, regional analgesia (preferred),

FHR documented, IC placed, pneumatic compression hose

• INFECTION PREVENTION febrile morbidity (frequent), 1-g CEFAZOLIN (efficacious

& cost-effective), prophylaxis recommended within the 60 min prior CS (ACOG)

WHAT TO DO BEFORE THE CS DELIVERY?

WHAT YOU NEED IN CS DELIVERY?

• As with all surgery, a clear understanding of

RELEVANT ANATOMY is essential

HOW TO DO CS DELIVERY? JUST THE BASICS!

• In OB, usually the

midline vertical or

suprapubic transverse

incision is chosen for

LAPAROTOMY

PARAMETERSINCISION

TRANSVERSE VERTICAL

COSMETIC RESULTS Superior Poorer

POST-OP PAIN

WOUND DEHISCENCE

INCISIONAL HERNIA

NEUROVASCULAR

STRUCTURES

Ilioinguinal & iliohypogastric nerves,

superficial and inferior epigastric vessels

often encountered

No important neurovascular structures

traverse this incision

BLOOD LOSS,

WOUND & HEMATOMAMore frequently complicated Minimal only

OTHER INFORMATION

Because of the layers created during incision

of the internal and external oblique

aponeuroses with transverse incisions, purulent

fluid can collect between these

Cases with high infection risks may favor a

midline incision

LAPAROTOMY1. VERTICAL INCISION• Begins 2-3cm above the symphysis

• Length corresponds with the estimated

fetal size (12-15cm TYPICAL)

• Small opening made in superior part of

LINEA ALBA in order to avoid

potential CYSTOTOMY

STEP 1 – Pfanensteil Incision & dissection

up to the level of the FasciaLAPAROTOMY2. TRANSVERSE INCISION• Skin & SQ tissue incised using a low,

transverse, slightly curvilinear incision

• Made at the level of the pubic

hairline, which is typically 3cm

above the superior border of the

symphysis pubis

Should be of adequate width to accommodate

delivery (12 to 15 cm is TYPICAL) LOW TRANSVERSE

ABDOMINAL INCISION

• Anterior abdominal fascia then

incised sharply at midline

• Composed of TWO VISIBLE LAYERS:a. External oblique muscle aponeurosis

b. Conjoined aponeuroses of the internal

oblique & transverse abdominis muscles

• These two individually incised in

order to spare from incising the

INFERIOR EPIGASTRIC VESSELS

STEP 2 – Dissection of the Fascia

• Fascial separation is carried near

enough to the umbilicus to permit

adequate midline LONGITUDINAL

PERITONEAL INCISION

• Rectus abdominis & pyramidalis,

then separated in the midline by

sharp & blunt dissection to EXPOSE

the TRANSVERSALIS FASCIA and

the PERITONEUM

STEP 2 – Separation of fascia from

rectus muscle, then dissection

RECTUS SHEATH IS INCISED RECTUS SHEATH

DISSECTED & CUT FREE OF

THE RECTUS MUSCLE

• TRANSVERSALIS FASCIA & PREPERITONEAL FAT are

dissected carefully to reach the underlying

PERITONEUM

• Peritoneum near the upper end of the incision is

opened carefully, then INCISED, (extended superiorly

to upper pole and downward to just above the

peritoneal reflection over the bladder)

STEP 3 – Separation of rectus muscle

and peritoneal entry, then dissection

PERITONEUM INCISED

LOWER SEGMENT EXPOSED PERITONEUM OVER THE LOWER

SEGMENT IS INCISED

PERITONEUM IS REFLECTED FROM

THE LOWER SEGMENT

HYSTEROTOMYLOW TRANSVERSE CESAREAN INCISION• Preferred method, easier to repair, least

likely to rupture during a subsequent

pregnancy, less incision-site bleeding

• “BLADDER FLAP” overlies the anterior

lower uterine segment grasped in the

midline with forceps and incised

transversely with scissors

STEP 4 – Uterine Incision

• Transversely incise the exposed lower

uterine segment for 1 TO 2 CM MIDLINE

• NOTE: Should be made large enough to

allow delivery of the head and trunk of the

fetus without either tearing into or having to

cut into the uterine vessels that course

through the lateral margins of the uterus

After entering the uterine cavity, the incision is extended laterally

with FINGERS or with BANDAGE SCISSORS.

STEP 5 – Extraction of the Fetus

• HAND SLIPPED into the uterine cavity b/w

the symphysis and fetal head

• UPWARD PRESSURE exerted by a hand in

the vagina by an assistant will help to

dislodge the head and allow its delivery

above the symphysis

Either forceps or a vacuum device may be used to deliver the

fetal head in WOMEN WITHOUT LABOR

IV infusion containing

2 Amp or 20“U” of

OXYTOCIN per L of

crystalloid infused at

10 mL/min

SHOULDERS then are

delivered using gentle

traction plus fundal

pressure

REST OF THE BODY

readily follows

Prevent UTERINE ATONY

• Umbilical cord is clamped

• NEWBORN given to other health-

care team member

• Uterine incision is observed for any

vigorously bleeding

• PLACENTA is then delivered

• FUNDAL MASSAGE performed

STEP 6 – Extraction of the Placenta

Many surgeons prefer manual removal, but

SPONTANEOUS DELIVERY along with SOME

CORD TRACTION has been shown to reduce

the risk of operative blood loss and infection

STEP 7 – Uterine Closure

• Inspect the ADNEXA, its exposure can

render into the performance of TUBAL

STERILIZATION

• Immediately after delivery, the UTERUS is

inspected and either suctioned or wiped

out with a gauze pack to remove avulsed

membranes, vernix, clots, and other debris

Closed with one or two layers of (CHROMIC)

CONTINUOUS 0- OR #1 ABSORBABLE SUTURE

STEP 8 – Abdominal Closure

• All packs are removed

• After the sponge and instrument counts are found to be correct,

the abdominal incision is CLOSED IN LAYERS

• Many surgeons OMIT PARIETAL PERITONEAL CLOSURE, because it

serves little purpose

• BLEEDING SITES located, clamped, and ligated or coagulated

with an electrosurgical blade

RECTUS MUSCLES closed

with one or two figure-of-

eight sutures of 0 or #1

chromic

RECTUS FASCIA closed

either with interrupted 0-

gauge delayed-

absorbable sutures

SQ TISSUE

usually need

not be closed

if <2cm thick

SKIN closed

with vertical

mattress sutures

of 3-0 or 4-0 silk

• William's Obstetrics – 24th Edition 2014

• Luz Gibbons, et al (WHO). The Global Numbers and

Costs of Additionally Needed and Unnecessary

Caesarean Sections Performed per Year: Overuse as

a Barrier to Universal Coverage – 2008

WHAT ARE THE LEARNING RESOURCES?

END