Breastfeeding After a Cesarean Delivery - InTech - Open Science
Cesarean Delivery Overview
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Transcript of Cesarean Delivery Overview
Christopher R Graber, MDSalina Women’s Clinic
Jan 22, 2010
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 documented1820 – first documented in British Empire
○ By James Miranda Stuart BarryCommon 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○ 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 cauteryExtension with scissors laterally
○ Usually a slight curve upward○ Undermining is an option○ Avoid muscles and superficial epigastric
vesselsFree fascia from rectus
○ Blunt vs. knife vs. scissors
Procedure Details Rectus muscle separation
More important for repeatsKnife vs. scissors
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
Procedure Details Bladder flap
Optional stepEasy to create on primaryPick-up bladder at peritoneal reflection
○ Blunt vs. sharp developmentBladder blade
Procedure Details Uterine incision
ClassicalLow verticalLow 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
Hand under head, flex fingers to elevate○ Find occiput○ If complete – “Break the seal”, consider vaginal
assistFundal pressure, consider vacuum or forceps
PlacentaActive vs. passive
Prevention of atonyQuick closure, massage, pitocin, methergineUterine compression stitches, hysterectomy
Procedure Details Closures
Uterine – locking (0-chromic on a big needle)○ Exteriorized? 2nd layer?
Bladder flap – optionalPeritoneum – optional (2-0 vicryl or plain)Rectus muscles – optionalFascia – 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 studies2-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
Consider low vertical or classical uterine incision
Plan at 36 weeks Placenta accreta, increta, percreta
Beware if previa and prior sectionS/S – incr. AFP, bleeding, hematuriaConsider 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 risksFuture surgery, hysterectomy, uterine
rupture, complications in future pregnancy
Consent for Surgery Be sure to document risks of
FailureDeath
“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.