techniques of lscs a review
TRANSCRIPT
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Review of techniques of LSCS
Veerendrakumar C.M MD.,DNB
VIMS, Bellary
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James Young Simpson1811-1870
Obstetrics is not one of the exact sciences and in our penury of truth
- we ought to be accurate in our statements,
- generous in our doubts, - tolerant in our convictions.
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evolutionBeing Bipedal
Being intelligent
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Caesarean has evolved over centuries. It has meant different things to different people at different times.
Dead mother dead babyDead mother live babyLive mother live babyHealthy mother healthy babyHealthy mother, healthy baby & healthy
pelvic floor.
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IS C.S. SAFE ?
NO !
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….if a C.S is not done, the woman and her baby take the risks
….while if the C.S is done, The doctor takes the risk
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‘REDUCE THE QUANTITY IMPROVE THE
QUALITY’
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‘8’ hours Vs ‘8’ minutes
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easy normal delivery or s. c. s.
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O. T.A. Good Boyle’s apparatusB. Multipara monitorC. Suction apparatusD. Defibrillator ‘?’
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Decorum of the O.T.
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Timing of antibiotic administration
NICE RECOMMENDATION [new 2011]
• Offer women prophylactic antibiotics at CS before skin incision.
• Offer women prophylactic antibiotics at CS to reduce the risk of postoperative infections.
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Choose antibiotics effective against endometritis, urinary tract and wound infections, which occur in about 8% of women who have had a CS.
Do not use co-amoxiclav when giving antibiotics before skin incision.
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Skin preparationShaving results in microscopic
nicks and tears of the epidermis
Actually increases the risk of skin infection unless done immediately preoperatively.
Surgical obstetrics 1992
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Betadine sprayBefore shifting to OT abdomen
cleansed and betadine spray applied
operating area covered with sterile drape
Prepackaged adhesive draping
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IncisionPfannensteilJoel cohenMidline verticalSupraumbilical in morbidly obese
Am J obst gynecol
2000
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Abdominal entry
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Abdominal incision
NICE RECOMMENDATIONSThe transverse incision of choice should be the
Joel Cohen incision (straight skin incision, 3 cm above the symphysis pubis; subsequent tissue layers are opened bluntly and if necessary extended with scissors and not a knife).
It is associated with shorter operating times and reduced postoperative febrile morbidity. A
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Meticulous attention to placement of skin incision
Allis clamp test
Am J Obst Gynecol 1991
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Abdominal exposureTubular plastic
retractor with a rolled edge
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UV fold entryBlunt or sharpPrevious surgery- sharp better
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Uterine incision
-CLASSICALLY - several centimetres below the UV fold
- just below the UV fold
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Uterine incision
NICE RECOMMENDATIONSWhen there is a well formed lower uterine
segment, blunt rather than sharp extension of the uterine incision should be used as it reduces blood loss, incidence of postpartum haemorrhage and the need for transfusion at CS. A
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T incision is the weakest and poorest of uterine wound healing
Use J or double J (trap door) incision
Use of intravenous dilute 150 mcg-300 mcg NTG O’grady, operative obstetrics
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E R R- for extraction of the head
Elevation Rotation Reduction
Cho, OBG management 2003
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Difficult cranial deliveryThinking ahead is a great
boon
keep relaxants ready
Vaccum/short forceps/vectis
Keep asst ready for ‘Passing it up” technique
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Delivery of the baby
NICE RECOMMENDATIONS
Forceps should only be used at CS if there is difficulty delivering the babies head. The effect on neonatal morbidity of the routine use of forceps at CS remains uncertain. C
[Either forceps or a vacuum device may be used to deliver the fetal head-Williams]
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Delayed cord clampingSuggested benefits of delayed cord clamping
include decreased neonatal anaemia; Better systemic and pulmonary perfusion; and
better breastfeeding outcomes. Possible harms are polycythaemia,
hyperviscosity, hyperbilirubinaemia, transient tachypnoea of the newborn and risk of maternal fetal transfusion in rhesus negative women.
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Delivery of placenta
NICE RECOMMENDATIONOxytocin 5 iu by slow intravenous injection
should be used at CS to encourage contraction of the uterus and to decrease blood loss. C
At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of endometritis.
A .
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Mechanical dilatation of the cervixThree trials with a total of 735
women(CDSR)
There was insufficient evidence of mechanical dilatation of the cervix at non-labour caesarean section for reducing postoperative morbidity.
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EXTERIORISATION OF UTERUS
"Misgav Ladach" Cesarean Section
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Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean
Six studies were included, with 1294 women (CDSR)
There is no evidence from this review to
make definitive conclusions about which method of uterine closure offers greater advantages
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Uterine closureNICE RECOMMENDATION Intraperitoneal repair of the uterus at CS should be
undertaken. Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection. A
The effectiveness and safety of single layer closure of the uterine incision is uncertain.
Except within a research context the uterine incision should be sutured with two layers.
B
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Correct method of uterine closure
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Uterine closure auto stapler preloaded with
dissolving copolymer staples made of polylactic and polyglycolic acid
Incises and staples the myometrium in single actionNo advantage -cochrane review 2006
May be of use in fetal surgery
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Suction… mop…
GUTTER CLEANING
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Routine gutter cleaning with mopTo be avoidedMay result in microscopic
abrasions Adhesions may develop
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Forgotten mop with sigmoid injury !!!
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Closure versus non-closure of the peritoneum at caesarean section
Fourteen trials, involving 2908 women.(CDSR)
There was improved short-term postoperative outcome if the peritoneum was not closed.
Long-term studies --limited
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Examination of adnexa mandatory
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NICE RECOMMENDATIONRoutine closure of the subcutanoues tissue space
should not be used, unless the woman has more than 2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.
A
Superficial wound drain should not be used at CS because they do not decrease the incidence of wound infection or wound haematoma.
A
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NICE RECOMMENDATIONWomen having a CS should be offered
thromboprophylaxis as they are at increased risk of venous thromboembolism.
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CAESAR trial european study3000 women recruited2x2x2 factorial multicentric RCT
Single- versus double-layer uterine closure.
Closure of the peritoneumLiberal versus restricted use of a
subsheath drain.
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there is a difference in the duration of surgery(mean difference, 2.4 minutes; 95% CI, 1.3–3.6 minutes),favouring nonclosure. However, the duration of surgery is a poor surrogate for morbidity.
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However, there have been suggestions that non closure of the peritoneum may be harmful in the longer term.
Lyell D, Peritoneal closure at primary caesarean delivery and adhesions. Obstet Gynecol 2005;106:275–80.
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CORONIS 2x2x2x2x2fractional factorial randomised TRIAL in developing countries 15936 women
Blunt versus sharp abdominal entryExteriorisation of the uterus for repair versus
intra-abdominal repairSingle versus double layer closure of the
uterusClosure versus non-closure of the
peritoneum (pelvic and parietal)Chromic catgut versus Polyglactin-910 for
uterine repair
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ReferencesTHE COCHRANE
LIBRARYCochrane Database
of Systematic Reviews
NICE GUIDELINES Issued: November
2011 NICE clinical guideline
132