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This chapter should be cited as follows:

Naji, O, Abdallah, Y, et al, Glob. libr. women's med.,

(ISSN: 1756-2228)2010 DOI 10.3843/GLOWM.10133

This chapter was last updated:

November 2010

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Cesarean Birth: Surgical Techniques

Osama Naji, MBChB, DFSRH

Institute of Reproductive and Developmental Biology, Imperial College, London, UK

Yazan Abdallah, MD

Institute of Reproductive and Developmental Biology, Imperial College, London, UK

Sara Paterson-Brown, FRCS, FRCOG

Queen Charlotte's and Chelsea Hospital, Imperial Healthcare Trust, London, UK

INTRODUCTION

HISTORY

EPIDEMIOLOGY

CLASSIFICATION AND INDICATIONS

TECHNIQUE

SPECIAL SITUATIONS

COMPLICATIONS

CONCLUSION

REFERENCES

INTRODUCTION

A cesarean section is the delivery of a fetus through an abdominal and uterine incision technically, it is a

laparotomy followed by a hysterotomy. This definition considers only the location of the fetus and not

whether the fetus is delivered alive or dead. Over recent decades, cesarean delivery has become more

commonly used, and this increase has generated a number of controversial issues, including the optimum

rate, what constitutes a suitable indication and what is the best technique.

Legends and myths about the abdominal delivery of an infant appear in many cultures. One of the earliest

Greek myths includes the birth of Aesculapius, who according to legend, was cut from his mother's

abdomen by Apollo, Bacchus, and Jupiter. Legend holds that Julius Caesar was also delivered

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abdominally, but his mother's survival well into adult life makes the story highly unlikely. It is the birth of

Caesar that some authors have attributed to the origin of the term cesarean delivery. Another

possible source for the term is the Latin verb caedare, meaning to cut, or the term for the children who

were born by postmortem cesarean sections, who were called caesones. The Roman lawLex Regis, which

dates from 600BC, required that infants be delivered abdominally after maternal death to facilitate

separate burial this has also been proposed as the origin of the term. The specific law in question was

called theLex Cesare.

HISTORY

Historic records that elude to the performance of cesarean section date back as far as the fifth century BC

and seem to imply that the outcomes for both mother and child were favorable. The earliest

authenticated report of a child who survived cesarean birth is a document describing the birth of Gorgias

in Sicily in approximately 508BC. There are no other accurate descriptions of the performance of a

cesarean section or the immediate outcome of the mother or the neonate until 1610.

Gabert and Bey assessed the evolution of cesarean section by dividing its development into three eras:

before 1500, between 1500 and 1877, and from 1878 until the present. Before 1500, references to

cesarean section are often clouded in mystery and misinformation, although some religious texts lead us

to believe that cesarean sections were performed with the survival of both the mother and the infant.

After 1500, the available literature describing delivery by cesarean section and the success of the

operation is more plentiful. In 1500, Nufer is reported to have performed the first successful modern

cesarean section, with both the mother and infant surviving. The authenticity of this report is doubtful,

because it was not documented until 82 years after the operation was performed. In his book Treatise on

Caesarean Sectionpublished in 1581, Roussett advised that the cesarean operation be performed on a

living woman as such, he was the first physician to do so. In 1610, Trautmann performed a well-

documented cesarean section in Wittenberg. Unfortunately, the patient died from infectious

complications on postoperative day 25. In 1692, a patient who had died 14 years after delivering a child by

cesarean section underwent autopsy. The accuracy of the claimed cesarean section was validated by

finding a well-healed scar on her uterus.

During this time period, the cesarean operation remained crude at best. The abdominal incision was made

lateral to the rectus muscles, and the uterus was incised at whichever portion was accessible through the

laparotomy incision. The uterine musculature was not reapproximated, and the patient had to be

physically restrained during the procedure because anesthesia was not available.

Closure of the abdominal incision slowly evolved from choosing to leave the wound open and apply only

bandages to allow healing by secondary intention through closing only the skin to full closure of the

abdominal wall. Early surgeons often sutured the uterine incision to the anterior abdominal wall to

encourage adhesion formation to reinforce the uterus and allow it to tolerate future gestations. The first

report of uterine closure was not until 1769. Uterine closure was associated with decreased perioperative

blood loss. Drainage of the surgical site was also introduced.

By the modern era of cesarean section (1878 to present), several modifications were being made in thecesarean operation. The Porro operation was instituted and became popular in the US and England as it

became evident that this procedure was associated with decreased maternal mortality. The operation

consisted of a laparotomy and hysterotomy followed by supracervical hysterectomy and bilateral

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salpingo-oophorectomy. The rationale behind this radical cesarean section was that with removal of the

uterus and adnexa, the rates of uterine infection, sepsis, and hemorrhage would decrease. Sterility and

premature menopause were unfortunate side effects of the Porro procedure.

The first step toward the cesarean operation as it is currently performed was described by Sanger. He

proposed a procedure that was much less radical and designed to conserve fertility. His operation did not

involve hysterectomy and salpingo-oophorectomy, but instead consisted of removing the peritoneum

from a portion of the anterior uterine wall and performing a 2 cm-wide wedge resection of the anterioruterine wall. The wedge was cut so that a thick edge of myometrium was adjacent to the peritoneum and a

thin edge was adjacent to the endometrial cavity. These modifications allowed the serosal edges to be

incorporated into the closure with interrupted silk sutures. The technique was further improved by

Garrigues, who did not resect the myometrium but instead simply closed the uterine incision. Other

modifications included not dissecting the uterine serosa from the uterus and the introduction of silver

wire to approximate the myometrium in addition to the interrupted silk sutures on the serosal surface.

As operative techniques improved cesarean section became safer and could be used at an earlier stage in

difficult labors. Further modifications emerged including emptying the bladder and rectum

preoperatively, with catheters and enemas, respectively, to decrease the volume of these organs in theoperative field, thereby reducing the risk of injury during the surgical procedure. Preoperative

antimicrobial preparation was introduced by Lister in 1876 and included shaving the operative area and

applying antiseptic solutions to the operative field. Vaginal douching was also introduced and routinely

performed before performing cesarean deliveries.

The technique of laparotomy and site of hysterotomy incision were vigorously debated and modified.

Abdominal incisions were made to the right or left of the rectus muscles or in the midline along the linea

nigra. The uterine incision was made vertically in the midline, obliquely, transversely through the

contractile myometrium, laterally 7.210 cm from the fundus, or on the posterior aspect of the uterus.

Johnson first described a lower segment uterine incision in 1786. In 1908, Selheim suggested that a

uterine incision made in the lower uterine segment rather than the contractile segment of the

myometrium would decrease blood loss at surgery and decrease blood loss in the event of uterine

dehiscence.

The development of the modern cesarean operation has not been a recent accomplishment but instead

represents a series of innovations over many centuries. Many aspects of the operation as it is commonly

performed today are not based on randomized trial or techniques that have been proven to be superior by

rigorous study, but instead are the culmination of many years of trial and error.

EPIDEMIOLOGY

Cesarean section rate is defined as the number of cesarean deliveries over the total number of livebirths,

and is usually expressed as a percentage. Increasing cesarean section rates are a cause of concern in both

developed and developing countries. In 1985 WHO stated: there is no justification for any region to have

cesarean section rates higher than 1015%. However, over two decades later, the optimal rate of

deliveries by cesarean section remains controversial, and the debate regarding desirable levels ofcesarean section continues. Betran et al. (2007) set out to estimate the proportion of births by cesarean

section at national, regional and global levels. Data were available for 126 countries, representing nearly

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South America 29.3 12.936.7 90

Northern America 24.3 22.524.4 100

Australia/ New Zealand 21.6 20.421.9 100

World total 15.0 0.440.5 89

More developed countries 21.1 6.236.0 90

Less developed countries 14.3 0.440.5 89

Least developed countries 2.0 0.46.0 74

*Countries categorized according to the UN classification. Countries with a population of less than

140,000 in 2000 are not included.Refers to population of live births for which nationally representative data were available.

The proportion of births by cesarean section has been proposed as an alternative indicator for measuring

access, availability or appropriateness of medical care, as well as for monitoring changes in maternal

mortality. In addition rising cesarean section rates will also reflect changes in the demographic risk profile

of pregnant women (age, body mass index (BMI) and other medical disorders).

Organisation for Economic Co-operation and Development (OECD) released a comprehensive source of

comparable statistics on health and health systems across OECD countries on 29 June 2010. According

to its website, it is an essential tool for health researchers and policy advisors in governments, the private

sector and the academic community, to carry out comparative analyses and draw lessons from

international comparisons of diverse health care systems.

The following figure from the official OECD website shows the cesarean rates of OECD countries from

2006 to 2008 (Fig. 1).

Fig. 1Cesarean delivery rate among OECD countries

Repeat cesarean deliveries account for a large percentage (37%) of the cesarean sections in the US.

While patient and health care provider education may reduce the number of repeat cesarean sections

there are other factors influencing cesarean section rates: for example the rate of cesarean delivery was

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also increased in women older than 35 years, in hospitals with more than 500 beds, in for-profit hospitals,

and in patients with private insurance. The cesarean section rate in the US, when compared with that in

other developed countries, is the among the highest in the world.

An analysis of cesarean deliveries at the University of Vermont by Pollard and Capeless in 1995 revealed

that the primary cesarean section rate was 11.4%. Dystocia (arrest of dilatation or descent) accounted

for over 35% of cesarean sections and together with abnormal presentation were the major indications for

abdominal delivery. A significant problem in analyses of indications for cesarean section is that diagnosessuch as dystocia, cephalopelvic disproportion, and failure to progress are inherently vague and do not

reflect the true reason why the labor is not progressing as anticipated. An accurate understanding and

recording of the reason that labor has not progressed, including the fetal size and position, the strength

and frequency of the uterine contractions, and the adequacy of the maternal pelvis would help. It is

noteworthy that primary cesarean sections for dystocia predominate in first labors and are a relatively

uncommon event in subsequent labors and also that the majority of repeat cesarean operations result

from women who have had a primary cesarean delivery for dystocia. Therefore critical evaluation of

patients with evidence of dystocia in their first labor, with identification and alleviation of correctable

problems, could significantly impact on overall cesarean section rates.

Fetal malpresentation currently accounts for approximately 34% of cesarean sections in the US.

Because of the International Term Breech Trial, cesarean section is routinely offered to nonvertex infants

if external cephalic version is contraindicated or unsuccessful.

Similar findings were published in the UK National Sentinel Cesarean Section Audit commissioned by the

UK Department of Health. Data on 99% of births that took place in England, Wales and Northern

Ireland over a 3-month period in 2000 were analyzed and the main reasons for cesarean section

identified by this audit are illustrated in Table 2.

Table 2Reasons for cesarean section (CS) in 2000 in the UK

Of all CS in the UK %

Repeat cesarean 29

Presumed fetal distress 22

Failure to progress 20

Breech birth 16

Maternal request 1.5

Influence of maternal age on CS

Maternal age 40 years 33

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The studies above conclude that repeat cesarean delivery and failure of labor progression are the most

common causes behind the high rates of this operation in both the UK and North America. Fetal distress

was also a significant contributor in the UK (22%), possibly because of the methods adopted to diagnose

fetal compromise during labor. On the other hand, in the US, fetal intolerance of labor contributes

minimally to the overall cesarean rate. However, and generally speaking, the cesarean section rate has

increased with the widespread use of electronic fetal monitoring. The use of centralized

fetal monitoring increases the cesarean rate even more. Because of the well-documented low specificity

of a nonreassuring fetal heart rate pattern, further assessment by other diagnostic means should beundertaken in all but the most pressing cases. Recently fetal electrocardiogram (ECG) recording using a

scalp electrode (with analysis of the ST segment, called STAN) has been used in combination with

cardiotocograph (CTG) recording for intrapartum fetal monitoring in Europe, because initial trials

suggested that it might reduce the need for fetal blood sampling and reduce the number of babies

delivered with a metabolic acidosis, but it is not without problems and its value is still being

assessed. A number of other programs have been implemented at various institutions in an attempt to

reduce the cesarean section rate.

In the US a labor-adjusted cesarean rate has been proposed as a more accurate indicator of the

appropriateness of the rate of cesarean section than raw numbers and rates. This labor-adjusted rate

excludes patients who are determined not to be candidates for vaginal delivery by a reasonable physician

standard. For example, excluded patients would include women with a history of classical cesarean

section, proven pelvic inadequacy, invasive cervical malignancy, suspected ruptured uterus before labor,

maternal disease that may be life-threatening because of the physiologic changes involved in labor,

macrosomia, macrocephaly, monoamniotic twins, and nonreassuring fetal heart rate on antenatal

surveillance. In one population in which the labor-adjusted rate was studied, the adjusted cesarean rate

was almost one-third of the raw cesarean rate.

CLASSIFICATION AND INDICATIONS

Traditionally, cesarean section has been classified as emergency or elective. However, with advanced

practice in obstetrics, and more complicated deliveries encountered, this definition has become too

simplistic and more detailed categories are needed. Therefore, distinguishing between prelabor cesarean

section (which may be elective or emergency) and intrapartum cesarean delivery (which is, by default,

emergency) is preferable (Table 3). Classification of the urgency of cesarean delivery has also been

investigated by Lucasand colleagues and this has developed into the most consistent method

recommended by NCEPOD and approved by the Royal College of Obstetricians and Gynaecologists

(RCOG) and the Royal College of Anaesthetists (RCA) in the UK.

Table 3Classification of urgency of cesarean section

Classification Indication

Grade 1: Emergency

cesarean section

Immediate threat to the life of the woman or the fetus, i.e. placental

abruption: antepartum or uterine rupture: intrapartum

Grade 2: Urgent

cesarean section

No immediate risk to the life of the woman or baby but delivery should be

achieved as soon as possible, i.e. three previous cesarean sections,

membranes are ruptured with meconium-stained liquor: antepartum or

nonreassuring CTG and FBS is not possible or contraindicated: intrapartum

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Some congenital anomalies

Fetal compromise

Maternal infection: primary genital herpes, HIV

Maternalfetal Placenta previa

Obstructed labor

Indications for cesarean delivery for maternal benefit include any situation in which it is inadvisable to

continue to strive for a vaginal delivery out of concern for maternal outcome. In these situations, the

woman undergoes a major abdominal operation for indications that are likely to decrease her risk for

morbidity and/or mortality. In contrast, when a cesarean section is performed for fetal indications, the

mother is undergoing major abdominal surgery when there is no immediate benefit to her but there is

potential benefit to the neonate. In these situations, fetal health would be compromised if further efforts

toward vaginal delivery were pursued. When counseling the patient before cesarean section regarding therisks and benefits of abdominal delivery, the possibility of morbidity and mortality must be discussed.

Before performing an elective repeat cesarean delivery, several considerations must be addressed. In

1995, the ACOG Committee on Quality Assessment published a criteria set outlining these considerations.

The committee suggested that the type of previous uterine incision should be documented from the

previous operative notes, the risks and benefits of attempting a vaginal birth after a cesarean section

(VBAC) should be thoroughly discussed with the patient and documented in the chart, the risks and

benefits of repeat cesarean delivery should be thoroughly discussed with the patient and documented in

the chart, and fetal maturity should be considered.

Fetal lung maturity is an important factor to be considered before attempting any prelabor elective CS.

Morrison et al.(1995) conducted a study on 33,289 deliveries occurring at or after 37 weeks of gestation

and over 9 years. The aim was to establish whether the timing of delivery between 37 and 42 weeks

gestation influences neonatal respiratory outcome and thus provide information which can be used to aid

planning of elective delivery at term. They found a significant reduction in neonatal respiratory morbidity

would be obtained if elective cesarean section was performed in the week 39+0 to 39+6 of pregnancy. A

more recent study from the USA has mirrored these findings and prelabor elective procedures should

be deferred until after 39 completed weeks.

TECHNIQUE

As noted in the historical review at the beginning of this chapter, the cesarean operation has undergone a

number of technical changes as the procedure has evolved. Many different practitioners extol the benefits

of various techniques of skin incision, uterine incision, uterine closure, and many other technical aspects

of the operation. However, there are relatively few randomized trials to support many of the commonly

used practices at cesarean section.

Preoperative evaluation

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In the case of a planned procedure, the preoperative assessment should include a full history and physical

examination, past medical and surgical history, current medications, drug allergies, consent, and

indication for cesarean section. In the uncomplicated patient checking a full blood count and having serum

in the laboratory usually suffice should blood transfusion become necessary. In more complex instances

preoperative consultation with an anesthetist, or other relevant specialist should be considered on an

individual basis. The obstetrician should usually highlight women who are at high risk of anesthetic

complications during the antenatal period. The risks should be documented in the medical notes and

communicated with the anesthetist nearer the time. The form of anesthetic to be used will be discussedand decided on by the anesthetist who is also responsible for discussing all anesthetic risks and

complications.

Conversely in cases of an emergency cesarean section, once the decision to operate has been made by the

obstetrician, discussion with the patient, consent and preoperative preparation should be carried out as

best as circumstances allow.

In very high-risk cases, such as placenta previa or suspected accreta, other preoperative measures should

also be considered: these include the presence of a senior obstetrician and anesthetist at the time of the

operation it may be necessary to involve interventional radiologists and a cell saver may be madeavailable. Most importantly, the woman should have been fully counseled and consented for the different

treatment options including the possibility of hysterectomy in extreme circumstances. Protocols should

be present on every delivery suite for the event of massive obstetric hemorrhage

Consent

The person performing the procedure is responsible for checking that written informed consent has been

given. He/she should explain the reasons why this operation is needed. Associated risks and

complications should be clearly communicated with the patient and care must be taken when explaining

the frequently occurring complications and those that are less likely but serious. The importance of good

communication is essential and has been highlighted in the reportSafer Childbirth.

Abdominal preparation

There is evidence that any abdominal shave performed should be performed in the operating room just

before applying the antibacterial preparations and not the night before. Shaving the patient the night

before surgery actually increases the bacterial count on the maternal abdomen. Shaving should be

performed only to remove the hair that will physically interfere with the operation itself.

Patient preparation

Placing the patient in the left lateral tilt position using either a hip wedge or an operative table with lateral

tilt capability will help minimise uterine compression of the inferior vena cava. Before the abdominal

preparation and draping of the patient, a Foley catheter should be placed to allow the bladder to drain

during the operation keeping the operative field clear and allowing urinary output to be evaluated

intraoperatively.

Surgical principles

Any kind of surgery should be carried out with adequate but not excessive access. Gentle handling andrespect of tissues, together with meticulous attention to hemostasis are essential and important factors in

all aspects of surgery. Anatomical knowledge should be thorough in order to avoid unplanned damage,

especially when pathology is encountered.

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low-transverse incision can be extended laterally and cephalad to increase the length of the incision

without endangering the uterine arteries. C.Another option in this situation is to use a T-extension in

the midline. D.The classical uterine incision is made through the contractile portion of the

myometrium above the bladder reflection.

Historically, the creation of a bladder flap was advocated before making any uterine incisions. More

recently, randomized controlled trials have noted that the omission of the bladder flap provides short-term advantages such as reduction of operating time and incisiondelivery interval, reduced blood loss

and need for analgesics. Practically speaking adequate access to the lower segment may require some

dissection but this should be kept to what is needed and not be excessive. The peritoneum is grasped with

a pair of forceps, elevated, and then incised transversely with scissors. Next, the inferior portion of the

peritoneum is elevated from the lower uterine segment. A Doynes retractor should then be inserted to

keep the bladder clear of the surgical field. Before making the uterine incision, the surgeon should also

identify the round ligaments to assess the degree of dextra-rotation of the uterus and to evaluate for the

presence of any myomas or other malformations that might affect the choice and/or placement of the

incision.

Lower uterine segment incision

The standard low-segment transverse incision accounts for 90% of all uterine incisions. This incision

should be made 23 cm below the upper edge of the uterovesical fold of peritoneum. This is especially

important when the cesarean is performed at or near full dilatation, as the tendency is to go in too low,

due to the stretched and ballooned out lower segment. A low entry in this situation risks extension of the

uterine angles into the broad ligament, or even more dangerously it can risk entry into the vagina

(inadvertent laparoelytrotomy) both complications carry attendant risks to the ureters. The incision is

then made sharply with the scalpel in the midline and performed down to the level of the fetalmembranes, with care being made not to incise the membranes, and extended laterally using either blunt

dissection with the fingers or scissors (Fig. 4). It is best to try to leave the membranes intact at this stage in

order to avoid the risk of cutting the baby and to maintain the liquor until the uterine incision is

completed (particular attention to avoid cutting the baby is necessary where the membranes have already

ruptured, in cases of oligohydramnios, breech presentations, advanced labor or after repeat cesarean,

where the lower segment can be very thin). There was thought to be no difference between the two

methods of extending the uterine incision in amount of blood lost or in the rate of extension of the

incision into the lateral uterine vessels when they were compared and correlated by the stage of labor.

However, a recent investigation revealed a greater risk of subsequent blood transfusion in women whose

incision was extended sharply compared to those extended bluntly. When blunt dissection is used, an

upward curve of the incision may be created by the surgeons placing their thumbs on the patient's

anterior superior iliac spines and index fingers in the uterine incision. By keeping the hand in this

position, the incision is pulled open in an arc.

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Fig. 5.Extraction of the fetal head. The surgeon's dominant hand is placed into the uterine incision so

that the back of the hand is against the inside of the lower uterine segment and the fingers cup the fetal

head. Firm, gentle traction is used to elevate the fetal head toward the incision. The fetal head may

then be rotated to an occiput anterior position and delivered through the uterine incision with the

assistance of fundal pressure. Courtesy of R Preston McGehee MD.

(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/007f.jpg)Fig. 6.Disimpaction of

the fetal head. When the fetal head has descended so far into the vagina that extraction of the fetal

head is difficult, having an assistant place a gloved hand into the vagina and elevate the fetal head frombelow can increase the ease of delivery and decrease the trauma to the lower uterine segment and

vagina.

After the infant is delivered, it should be quickly dried and then after a short time the cord should be

doubly clamped and cut. Depending on the condition of the infant it can either be handed straight to its

mother for skinskin contact, or, if needed it can be handed to the relevant personnel who have been

assigned to care for the newborn. The baby should not be lifted up before the cord is clamped, and a time

delay to clamping the cord of about a minute, to allow fetal transfusion, should be facilitated where

possible.

Delivery of the fetus breech presentation and transverse lies
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In breech cesarean, if the legs are extended the operators right hand should be cupped around the

bottom and the breech delivered by lateral flexion while the assistant exerts fundal pressure.

Alternatively, a f oot (recognized by the heel) can be held and the legs delivered first. In either situation

the fetal back should be kept anterior, and completion of the delivery is again achieved by fundal pressure

with minimal traction: as in the vaginal breech delivery, the shoulders should be delivered with gentle

rotation, and a modified Maurcieu Smellie Veit technique can then be used to facilitate delivery of the

head. If the baby is transverse, a foot should be identified and the baby delivered as breech. In this

circumstance, leaving the membranes intact for as long as possible will facilitate the internal rotation ofthe baby.

Delivery of the placenta

Attention is now turned to the delivery of the placenta. Spontaneous delivery of the placenta, when

assisted with uterine massage, 5 IU of intravenous oxytocin and gentle traction on the umbilical cord, is

associated with a lower rate of postpartum endomyometritis and maternal blood loss compared with

manual extraction. Infrequently, the placenta does not separate despite the uterus being well

contracted and manual removal is required. Manual removal carries higher risks of hemorrhage and

infection, and therefore the operator should guard against impatience and certainly not perform manual

removal while the uterus is not contracting, as this will increase blood loss considerably. Any bleeding

sinuses on the uterus can be compressed using GreenArmitage clamps while awaiting placental

separation. In cases of morbidly adherent placenta (placenta accreta), there are several management

options: first, if the placenta has not been breached during uterine entry and delivery of the baby and no

placental separation has occurred, the placenta may either be left in situand the patient managed

conservatively, or, second, a hysterectomy may be preferred (depending on the preoperative discussion

with and consent by the patient).

Once the placenta has been delivered, the uterine cavity should be checked to ensure it is empty and the

uterus may be either exteriorized or left in situto be repaired. Blood loss is not significantly different with

either method. Exteriorization of the uterus does allow for better visualization of the adnexal

structures and increases the ease with which tubal ligation can be performed but produces more

discomfort in women having regional blockade.

A broad spectrum antibiotic such as co-amoxiclav 1.2 g or, if penicillin allergic, clindamycin 600 mg

intravenously should be given to all women at the time of cesarean section after delivery of the baby and

placenta. If there is extensive hemorrhage from the placental bed after the placenta has been removed, a

number of techniques can be used to help control the bleeding, these include local infiltration with

uterotonics, under running the bleeding areas with sutures, local pressure with a Rusch balloon, orembolization by intervention radiology. If the bleeding is due to atony then a B-Lynch compression suture

may help. Hysterectomy remains an option in case of failure of these latter measures or with catastrophic

bleeding.

Uterine closure

Closing the uterus after cesarean section is best performed with a double layer technique. NICE supports

this practice as studies have found a four to six-fold increase in the risk of uterine rupture in women

who had a single layer closure (Fig. 7) in their previous pregnancy. The recent CAESAR study

in the UK which compared single and double closure did not look at long-term outcomes.

Whether single or double layer closure is used, suture material should be of a short-term absorbable

type (such as polyglycolic acid or polyglactin) as the uterus involutes postnatally and sutures loosen, to

avoid loops of thread being present in the pelvis for any longer than necessary. Both uterine angles should

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In the first hour after an uncomplicated cesarean section, the patient should be monitored closely in a

recovery area where urine output, pulse, blood pressure, respirations, and any evidence of bleeding can

be closely observed if the patient remains stable and without complication, she may then be transferred

to the postpartum ward. Once any nausea has abated, the patient should be encouraged to take fluids

orally and she can eat when she feels hungry. Early institution of feeding in the postsurgical patient with

minimal intraoperative bowel manipulation does not increase the incidence of postoperative ileus.

All women should be given compression stockings and kept well hydrated after cesarean section tominimize the risk of thromboembolism. Heparin thromboprophylaxis should be given if there are risk

factors and in accordance with local guidelines. Early ambulation should also be encouraged. Getting the

patient out of bed as soon as regional anesthesia has worn off or as soon as she has recovered from

general anesthesia will decrease the incidence of pulmonary complications such as atelectasis and

pneumonia, and the incidence of thrombotic complications. Encouragement of deep breathing and

coughing will also help prevent collapse of alveoli in the lung and subsequent infection.

In the uncomplicated patient with adequate urine output, the catheter should be removed 12 hours

postoperatively unless this would be in the evening in which case it should wait to be removed until the

following morning. Encouraging mobilization will also facilitate the removal of bladder catheters,

therefore decreasing the incidence of catheter-associated urinary tract infections.

Routine laboratory studies are probably unnecessary in most postcesarean patients who have no

unexpected symptoms. However, a single hemoglobin determination on postoperative day 2 is probably

reasonable to screen for significant anemia. Most postpartum patients with asymptomatic anemia

respond well to oral iron therapy.

The wound should be cared for in the standard manner, with occlusive dressings removed on the first

postoperative day and the wound examined daily during the hospitalization for evidence of infection,

seroma, or hematoma. The patient may be discharged when she is able to care for herself and her

newborn. Many patients are ready to leave the hospital by postoperative day 2 or 3. Discharge

instructions should include patient education concerning expectations on activity level, lochia,

breastfeeding or milk suppression, contraception, and newborn care, and the plans for suture removal.

SPECIAL SITUATIONS

Vaginal birth after cesarean section

The vaginal birth after cesarean section (VBAC) rate is defined as the number of vaginal births to women

with a previous cesarean section per 100 deliveries to women who had a previous cesarean delivery. New

evidence is emerging to state that VBAC may not be as safe as its originally thought. In addition, fear of

medico-legal litigations have led to a decline in the number of clinicians offering and women accepting

planned VBAC in the UK and North America. There are no randomized controlled trials comparing

planned VBAC with planned elective repeat cesarean delivery (ERCD) and this may be an unrealistic

aspiration. The agency for health quality and research in the US ranks the current available evidence

related to VBAC as level two or three, and acknowledges considerable heterogeneity in the reported

outcomes and poor comparability between the treatment groups.

In the USA in the late eighties and nineties there was a drive to increase VBAC and the rate rose from 6.6%

in 1985 to 28.3% in 1996, but enthusiasm waned as complications arose and by 2006 it had fallen to just

under 9% (Fig. 9)

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(http://resources.ama. uk.com/glowm_www/uploads/1294479767_ch_2.74_10Capture.JPG)Fig. 10.

Originally described using a 7080-mm round-bodied hand needle with mounted number-2 plain or

chromic catgut: now a rapidly absorbable synthetic suture is recommended. With the bladder displaced

inferiorly, the first stitch is placed 3 cm below the lower cesarean incision on the patient's left side and

threaded through the uterine cavity to emerge 3 cm above the upper incision margins, approximately 4

cm from the lateral border of the uterus. Now, carry the suture on the outside of the uterus over the

top and to the posterior side. The suture should be more or less vertical and lying approximately 4 cm

from the cornua. It does not tend to slip laterally toward the broad ligament because the uterus has

been compressed and the suture milked through, ensuring that proper placement is achieved and
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maintained. The suture is placed exactly the same way as it was on the left side that is, 3 cm above the

incision, 4 cm from the lateral side of the uterus through the top of the incision, into the uterine cavity,

and then again back through 3 cm below the incision.

(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/009f.jpg)Fig. 11.O'Leary stitch

(uterine artery ligation). While placing the broad ligament on traction to displace the uterine veins

laterally, the uterine artery is palpated and isolated. A suture is then placed below the laceration to theuterine artery to incorporate the artery with the myometrium. If necessary, a second stitch may be

placed above the incision in the same manner.
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In cases of hemorrhage not caused by uterine atony, careful exploration of the uterus for possible

retained placental fragments and exploration of the operative field for unrecognized lacerations should

be performed. Placental fragments may be removed manually or with a swab. Areas of placental

adherence should be examined for evidence of placenta accreta. Genital tract lacerations should be

identified, isolated, and closed in a hemostatic manner.

Urinary tract injuries

Injury to the urinary tract is a relatively rare complication of cesarean delivery. The incidences of bladder

and ureteral injury are 0.3% and 0.1%, respectively. Bladder injuries are more common with a

history of previous cesarean section. The most common site for bladder injury during cesarean delivery is

at the dome of the bladder. Laceration of the bladder should be evaluated by first ensuring that the

trigone and ureters are not involved. This may be accomplished by direct visualization of the ureters

through the cystotomy. If the trigone is not involved and the ureters are functioning, the cystotomy can be

closed in two layers using an absorbable suture. Whenever there is a possibility of inadvertent cystotomy

at the time of cesarean section, this can be evaluated by distending the bladder with sterile saline through

the Foley catheter and observing the operative field for the appearance of the fluid.

Ureteral injury is less common than injury to the bladder. If there is concern during the operative

procedure that the ureter has been compromised, the situation should be thoroughly evaluated and

consultation with a specialist urologist is needed.

Gastrointestinal tract injury

Injury to the bowel at the time of cesarean section is exceedingly rare. An incidence of less than 0.1% has

been reported. This low incidence is caused by the displacement of the bowel out of the operative fieldby the enlarged, gravid uterus. The risk of bowel injury is increased in patients with previous abdominal

surgery or intra-abdominal adhesions. Injury is usually obvious because of the appearance of bowel

contents in the surgical field. These injuries should be quickly identified and isolated to minimize

contamination of the peritoneal cavity. Injury to the small bowel can be primarily repaired with a two-

layer closure using a delayed absorbable suture. The closure should be performed at 90 degrees to the

bowel lumen to decrease its constriction. Larger lacerations of the small bowel or multiple lacerations

may require resection of a length of bowel, and a specialist surgeon should be called for this and for any

injuries to the large bowel which may require a defunctioning colostomy as well as primary closure.

Wound infections

Wound infections occur at a rate of approximately 7% after cesarean section when prophylactic antibiotics

are not given this incidence is reduced to 2% with the use of prophylactic antibiotics. Wound

infections that occur after cesarean section include endomyometritis, pelvic abscess, incisional abscess,

and wound cellulitis. The antibiotic of choice for each infection depends on the location of the infection

and the suspected pathogen. Antibiotic therapy should be instituted empirically and adjusted as needed

based on culture results. For pelvic abscesses treatment includes drainage of pus and broad-spectrum

antibiotics including anaerobic coverage are required for superficial wound infections, simply opening

the incision and draining the infectious source usually alleviates the problem in patients who do not havesigns of systemic infection. Superficial wound cellulitis can usually be treated using penicillinase-resistant

penicillin.

Endomyometritis

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Endomyometritis complicates up to 80% of cesarean sections performed after the membranes have been

ruptured for more than 6 hours in patients who are not administered antibiotic prophylaxis and 30% in

patients with intact membranes. The incidence has been shown to be high in patient populations of lower

socioeconomic status, in patients who have had six or more vaginal examinations during labor and in

patients with longer duration of rupture of membranes. The rate of uterine infection can be reduced to

5% or less with the use of prophylactic antibiotics given at the time of cord clamp. A single dose of a

broad-spectrum antibiotic is relatively inexpensive and effectively decreases the infection rate.

Incomplete scar healing

A deficient cesarean section scar has become one of the recognized complications associated with this type

of operation. The exact cause and mechanism of incomplete healing of the scar and whether this leads to

functional uterine deficiency is not well understood. As more women undergo transvaginal

ultrasonography, the morphology of section scars has come under increasing scrutiny. Currently it is not

known if the appearances of a cesarean section scar using ultrasound translate into any relationship to the

functional integrity of the uterus, risk of ectopic pregnancy, pathological placentation, uterine rupture or

performance in labor. There is an urgent need to explore this relationship so that we can understand how

to interpret images of the uterus following cesarean section and the implications of various types of scar

on patient management. Studying the natural history of cesarean section scar in the pregnant state and

following it to delivery could achieve this, and analyzing whether certain scar features on ultrasound scan

can lead to a successful vaginal delivery or a repeat cesarean section.

There is growing evidence to suggest that complete healing of the previous cesarean scar and myometrial

thickness at the lower uterine segment are important factors in achieving uneventful pregnancy outcome,

whether by ERCD or VBAC. Over the past 10 years there have been multiple attempts to study these

factors by ultrasonography and different reports have been published in the literature regarding the

prevalence and the clinical significance of incompletely healed cesarean scars. VBAC is considered to be

a safe alternative to ERCD when the risk of uterine rupture in minimal, and as mentioned above several

factors must be examined before considering this option. However, to better assess the risk of uterine

rupture, some authors have proposed sonographic measurement of the cesarean scar and the thickness of

the lower uterine segment, assuming that certain scar features and cut-off values are correlated with the

uterine scar defect. These ultrasound measurements may increase the safety of labor after cesarean

section because they provide additional information on the risk of uterine rupture. Recent evidence also

states that transvaginal ultrasound scan is a reliable and reproducible method for measuring the

myometrial thickness near term, and concludes that this value may serve as a predictor of uterine scar

defect in women contemplating VBAC. However, an ideal cut-off value cannot be recommended yet,

underlining the need for further well-designed prospective and longitudinal studies during pregnancy.

Uterine scar rupture

In spite of the recent advances in modern obstetric practice, rupture of the pregnant uterus is still one of

the most life-threatening complications of pregnancy, and it is associated with high rates of maternal

morbidity and fetal morbidity and mortality. Previous cesarean section has been shown to be the most

important risk factor, but no difference in the outcome of labor with regard to uterine rupture,

between women with and those without previous cesarean section has also been reported. The most

commonly quoted scar rupture for lower segment cesarean section (LSCS) is 0.5%, or one in 200.

The incidence of uterine rupture may be increased in patients with a previous single-layer closure.

However, in patients with a previous classic uterine incision, the risk of uterine rupture may be

as high as 9%, with one-third of these occurring before the onset of clinical labor. In one study on

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21Leveno KJ, Cunninhgam FG, Nelson S et al: A prospective comparison of selective and universal

electronic fetal monitoring in 34,995 pregnancies. N Engl J Med 315:615, 1986

22Weiss PM, Balducci J, Reed J et al: Does centralized monitoring affect perinatal outcome. J Matern

Fetal Med 6:317, 1997

23 Ragupathy K, Ismail F, Nicoll AE. The use of STAN monitoring in the labour ward. J Obstet Gynaecol

2010 30:5, 465-469

24 Ojala K, Makikallio K, Haapsamo M, Ijas H, Tekay A. Interobserver agreement in the assessment of

intrapartum automated fetal electrocardiography in singleton pregnancies. Acta Obstetr Gynecol

Scand 2008. 87:536540

25 Neilson JP. Fetal electrocardiogram (ECG) for fetal monitoring during labour. Cochrane Database Syst

Rev 2006, Issue 3. Art. No.: CD000116. DOI: 10.1002/14651858.CD000116.pub2

26American College of Obstetrics and Gynecology. Criteria Set Number 13. December 1995

27 Story L, Paterson-Brown S: Cesarean deliveries: indications, techniques and complications. Chapter

10: Best Practice in Labour and Delivery, ed. R. Warren and S. Arulkumaran. Published by Cambridge

University Press 2009.

28Lucas DN, Yentis SM, Kinsella SM, et al. Urgency of cesarean section: a new classification. J R Soc Med

2000 93: 34650

29 Report of the National Confidential Enquiry into Perioperative Deaths 1992/1993. London: NCEPOD,

1995

30Joy S, Contag SA. eMedicine Specialties > Obstetrics and Gynaecology > Labor and Delivery: Cesarean

delivery 2010

31American College of Obstetrics and Gynecology. Committee Opinion No. 98. September 1991

32 Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term:

influence of timing of elective cesarean section. Br J Obstet Gynaecol. 1995 Feb 102(2): 101-6

33 Tita AT, Landon MB, Spong CY et al. Timing of elective repeat cesarean delivery at term and neonatal

outcomes. N Engl J Med 2009 Jan 8360(2):111-20.

34 RCOG, RCM, RCA, RCPCH. Safer Childbirth. Minimum Standards for the Organisation and Delivery

of Care in Labour. London: RCOG Press, 2007. Available online at:

http://www.rcog.org.uk/resources/ public/pdf/safer_childbirth_report_web.pdf (accessed 30

January 2008).

35Alexander JW, Fisher JE, Boyajiam M et al: The influence of hair removal methods on wound

infections. Arch Surg 118:347, 1983

36 Greenmall MJ, Evans M, Pollack AV: Mid-line or transverse laparotomy? A random controlled clinical

trial period Br J Surg 67:188, 1980


32/36



37 Franchi M, Ghezzi F, Raio L et al: Joel-Cohen or Pfannenstiel incision at cesarean delivery: does it

make a difference? Acta Obstet Gynecol Scand 81:1040-1046, 2002

38Hohlagschwandtner M, Ruecklinger E, Husslein P et al: Is the formation of a bladder flap at cesarean

necessary? A randomized trial Obstet Gynecol 98:1089-1092, 2001

39 Rodriquez AI, Porter KB, O'Brien WF: Blunt versus sharp expansion of the uterine incision in low-

segment transverse cesarean section. Am J Obstet Gynecol 152:971, 1985

40Boyle JG, Gabbe SG: T and J Vertical extensions in low transverse cesarean births. Obstet Gynecol

87:238, 1996

41Martin JN Jr, Perry KG Jr, Roberts WE et al: The case for trial of labour in the patient with a prior

low-segment vertical cesarean incision. Am J Obstet Gynecol 177:144, 1997

42Atkinson M, Owen J, Wren A et al: The effect of manual removal of the placenta on post-cesarean

endometritis. Obstet Gynecol 87:99, 1996

43 McCurdy CM Jr, Magann EF, McCurdy CJ et al: The effect of placental management at cesarean

delivery on operative blood loss. Am J Obstet Gynecol 167:1363, 1992

44Khan GQ, John IS, Wani S et al: Controlled cord traction versus minimal intervention techniques in

delivery of the placenta: A randomized controlled trial. Am J Obstet Gynecol 177:770, 1997

45Wilkinson C, Enkin MW Uterine exteriorization versus intraperitneal repair at cesarean section

Cochrane Database Syst Rev. 2000(2):CD000085.

46National Institute of Clinical Excellence. Clinical Guideline 13 Cesarean Section. London: RCOG Press,

2004. Available online at: http://www.nice.org.uk/ nicemedia/pdf/CG013fullguideline.pdf (accessed

30 September 2010).

47 Hauth JC, Owen J, Davis RO: Transverse uterine incision closure: One versus two layers. Am J Obstet

Gynecol 167:1108, 1992

48Tucker JM, Hauth JC, Hodgkins P et al: Trial of labour after a one or two-layer closure of a low

transverse uterine incision. Am J Obstet Gynecol 168:545, 1993

49Chapman SJ, Owen J, Hauth JC: One-versus two layer closure of a low transverse cesarean: The next

pregnancy. Obstet Gynecol 89:16, 1997

50Bujold E, Bujold C et al: The impact of a single-layer or double-layer closure on uterine rupture. Am J

Obstet Gynecol 186:1326-1330, 2002

51The CAESAR study collaborative group. Cesarean section surgical techniques: a randomised factorial

trial (CAESAR). BJOG 2010 117:13661376

52Wound healing: Techniques and materials. In Visscher HC, (ed): Precis V: An Update in Obstetrics and

Gynecology. Washington, American College of Obstetrics and Gynecology, 1994


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