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Best Practice & Research Clinical Obstetrics & Gynaecology Vol. 15, No. 1, pp.

1747, 2001

doi:10.1053/beog.2000.0147, available online at http://www.idealibrary.com on

2 Techniques for performing caesarean section


Karumpuzha R. Hema*
Sta Grade in Obstetrics

MBBS, MRCOG

Richard Johanson*

BSc, MA, MD, MRCOG

Senior Lecturer in Obstetrics North Staordshire Hospital NHS Trust, Stoke on Trent ST4 6QG, UK

In many countries caesarean section has become the mode of delivery in over a quarter of all births. Safety of the mother and cost are the two main areas of concern. Various studies on the techniques of performing a caesarean section have focused on reducing the operating time, blood loss, wound infection and cost. Given the fact that caesarean section is the most commonly performed operation in obstetrics, it is important that trainers and trainees are familiar with the basic surgical techniques and that best practice is followed. At the same time surgeons should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV. The skin incision and entry into abdominal cavity is best achieved by the modied Cohen's incision. The lower segment transverse uterine incision has stood the test of time over a period of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer appears to be acceptable, whenever technically possible. Placental delivery should be by controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers of the peritoneum no longer seems to be necessary. Obliteration of space in the subcutaneous layer, either by suture or by suction, seems to reduce wound disruption. These issues are being considered in the CAESAR randomized controlled trial of surgical techniques currently underway in England. Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the above mentioned steps have been tested in randomized trials. Further studies are needed to examine a wide range of questions arising from this review, e.g. best position of the patient, the value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax the uterus in dicult deliveries. Key words: caesarean section; methods; materials; complications; research.

Ever since the wider introduction of caesarean section in the latter part of the 19th century, the safety of the procedure has improved. Indeed, condence in safety1 has increased to the point that, in some countries, nearly a quarter of all deliveries are now being conducted by the abdominal route.2 There is currently widespread debate about the relative merits of abdominal and vaginal delivery3 and this discussion is dealt with in depth in Chapter 9.
*Address for correspondence: Clinical Governance Support Oce, North Staordshire Hospital NHS Trust, Ward 58, Maternity Unit, Newcastle Road, Stoke on Trent ST4 6QG, UK. 15216934/01/01001731 $35.00/00 c * 2001 Harcourt Publishers Ltd.

18 K. R. Hema and R. Johanson

Improved safety is related to the availability of antibiotics and blood transfusion1 and also to advances in anaesthesia, as well as to improvements in technique. The principal complications are haemorrhage and infection and these, in turn, are related to the complexity of each case. Prolonged labour, prolonged rupture of membranes and increased frequency of vaginal examinations all predispose to infection. Previous caesarean section, placenta praevia and placenta accreta increase the risk of haemorrhage. In general, the risks and complications are greater for emergency than for elective procedures. Generic risks relate to excessive speed and lack of surgical experience in performing the operation. While surgical techniques do vary from surgeon to surgeon, good adherence to basic surgical principles and an awareness of recognized methods of performing caesarean sections will minimize morbidity. Caesarean section is widely accepted to be more expensive than vaginal delivery4,5, and limiting morbidity will reduce costs. This chapter deals with techniques for caesarean section, including the relevant aspects of the basic surgical principles and suturing techniques. In addition, we address complications of caesarean section. Issues related to anaesthesia and preparation for the anaesthetic are dealt with separately in Chapter 8. IDENTIFICATION OF EVIDENCE For the purposes of this chapter we have carried out the following review of the literature. The Cochrane Library and the Cochrane Register of Controlled Trials (RCTs) were searched for relevant RCTs, systematic reviews and meta-analyses. A search of MEDLINE from 1970 to 1999 was also carried out. The databases were searched using the relevant MeSH terms: caesarean, repeat caesarean section and methods. GENERAL PRINCIPLES Good practice dictates that the operator should have full knowledge of the patient's history, especially in relation to any previous surgery. Highlighting the relevant points of history, and risk factors, on the delivery page in the maternity record will draw attention to potential diculties. In dierent situations, the exact operative technique chosen will vary. Factors determining the need to individualize practice include gestational age, fetal presentation and position, size and number of fetuses, maternal health and the perceived degree of urgency. Anticipation and proper planning are important keys to the avoidance of complications. Careful explanation to the mother of the planned operation prior to surgery and a resume after the procedure constitute good clinical practice and are essential risk management. It is clearly very important to have appropriate assistance and a readiness to call for help when presented with diculties. On the basis of surgical studies, it is evident that the choice of correct suture material may enhance healing. However, there are no published randomized controlled trials on suture material for caesarean section. Nevertheless, the general principle of choosing a material with sucient tensile strength is accepted. Natural threads, such as catgut, have largely been replaced by synthetic materials. This is because they have been shown to cause an inammatory reaction and because they may harbour infection and also lose their strength capriciously. The non-absorbable

Techniques for performing caesarean section 19

Figure 1. Knots commonly used in surgical practice.

synthetic polyamide sutures cause very little reaction and retain their strength reliably. These sutures decompose in tissue by hydrolysis rather than phagocytosis.6 The commonly used monolament sutures are polypropylene (Prolene), polydioxanone (PDS) and polyglyconate (Maxon). The commonly used multilament sutures are polyglactin 910 (Vicryl) and polyglycolic acid (Dexon). Regardless of the actual material chosen, the knot is the weakest link in the suture. This is the site of maximum foreign body reaction aecting the adjacent layers of tissue. Although knot security is important, especially when monolament materials are used, multiple throws beyond the breaking point should be avoided. It has been shown that knot-holding capacity is maximal with all materials after the addition of a maximum of two throws to any of the starting knots.7 Any additional throw will leave extra amounts of suture material, leading to increased foreign body reaction. However, when van Rijssel et al8 examined suture size and knot volume, they found that the use of thick gauge suture material added more than the addition of extra throws to the total amount of foreign body and tissue reaction.9 They also examined dierent types of knot and found that, throw-for-throw, square knots were superior to slip knots (see Figure 1) but that an additional throw to a sliding knot improved its security. Use of the `surgeon's' knot (Figure 1) is thought to increase the holding power of the rst throw and prevent slippage and is also considered helpful when there is a high risk of the suture tearing through a delicate structure. On the other hand, in laboratory studies, the security of the surgeon's knot was not found to be superior to square knots.8 Asepsis, minimal and meticulous handling of the tissue, `perfect' haemostasis and reapproximation of the layers without `strangulation' are essential steps that should be followed.10 Dehiscent wounds are almost always found with unbroken sutures and intact knots, which have cut through the tissue, having been tied too tightly or having been placed too close to the edge.7 The best scar results when wound edges, which retain good blood supply, are opposed without tension or trauma and with a minimum of foreign material. Lyon and co-workers, in a review that spanned three decades, showed that morbidity could be reduced by improving surgical technique. They decreased the needle size used, switched to polyglycolic sutures, avoided using laparotomy packs (the packs may cause abrasions, leading to formation of adhesions), used sharp dissection and paid attention to the basic rules of surgical practice in minimizing damage to tissues.11 The problem of latex sensitization should be considered in all obstetric patients. Chen and co-workers, in their interesting study, found that nine of 333 obstetric patients showed latex-specic immunoglobulin E. When details about atopy, exposure to condoms, previous deliveries and operations were obtained, it was evident that a

20 K. R. Hema and R. Johanson

previous caesarean delivery was more frequent in latex-sensitized patients with positive latex-specic immunoglobulin E (33 versus 8.4%; P 5 0.05). Patients with atopy and additive risk factors should be treated in a latex-free environment to avoid latex sensitization.12

PROTECTING HEALTH PERSONNEL Precautions are important to avoid risks associated with exposure to, or inoculation of, body uids e.g. human immunodecient virus. Any contact with sharp objects by the surgeon and assistants should be kept to a minimum. The use of scissors rather than a scalpel for extending incisions in the fascia, peritoneum and myometrium may be safer. After use, sharp instruments need to be transferred in a basin or a tray, to avoid injury. Retraction of tissues using instruments may be safer than using a hand. Needlestick injuries can be prevented by mounting the needle onto the holder for transfer after use, by using forceps to re-position the needle and by mounting the tip and the eye of the needle together while not in use (Figure 2). If counter-pressure is needed while positioning a needle, either a tissue forceps or a metal thimble on a nger can be used. The needle should be cut o and handed over to the scrub nurse before tying the nal knot.10 Although double gloving or the use of thicker gloves does not eliminate the risk of needlestick injuries, it helps to reduce the incidence of such injuries.13,14 A randomized prospective study evaluated the use of surgical pass trays to reduce the incidence of glove perforations during caesarean section. Surgical team members were assigned to pass the instruments in a normal way or to use a surgical pass tray. Although in this study the frequency of glove perforations was not reduced by the use of trays, the authors found that there were no complete perforations where double glove sets had been used.15 Smith and Grant reported glove puncture in 54% of caesarean sections, with 60% of these occurring at closure.16 Double gloving reduced the incidence of puncture of the inner glove by a factor of 6. The use of blunt needles and tissue handling by forceps will also help to reduce needlestick injuries.17 Contact with body uids can be minimized by using a drape with a bag on either side to collect the amniotic uid and the blood. The use of a clear plastic shield will protect the surgeon and assistants' faces. Double gloving, use of waterproof gloves and the wearing of spectacles all reduce the risk of exposure and need to be implemented universally.

POSITION OF THE PATIENT When pregnant women near term lie in the supine position, the uterus may compress the inferior vena cava, interfering with the venous return to the heart. This, in turn, is thought to result in hypotension, hypoperfusion of the placenta and decreased fetal oxygenation. Hence, it is standard practice that a lateral tilt of 10 to 158 is used while the caesarean section is performed. Wilkinson and Enkin, in their Cochrane review18, analysed the limited evidence to support this practice from three (poor quality) trials involving 293 women. When tilt had been used there were fewer low Apgar scores and better cord pH measurements. However, the authors did not consider the evidence to be sucient for making denitive recommendations about practice.18 Interestingly, a recent study by Mattorras and co-workers found no benets in performing emergency sections with left lateral tilt.19

Techniques for performing caesarean section 21

Using thimble

Holding needle

Using forceps to manipulate needle

Figure 2. Technique to avoid needlestick injuries.

CATHETERIZATION Single catheterization before starting the procedure to avoid injury to bladder is recommended. The use of an indwelling catheter after caesarean section under epidural is thought to lessen the risk of urinary retention and the need for repeat catheterization. PREPARATION OF THE SKIN Infection rates are lowest in cases where shaving is done just prior to the surgery. Depilatory agents have been shown to be better than razor preparation.20 The agent

22 K. R. Hema and R. Johanson

used for the skin preparation should be non-toxic, fast acting and easy to apply and should have broad-spectrum antibacterial activity. Iodophores, such as iodine plus polyvinyl pyrolidine (povidoneiodine) and tincture of chlorhexidine gluconate (0.5% in 70% isopropyl alcohol), are usually recommended. However, the use of povidone iodine should be restricted to intact skin as it contains large molecular fractions which cannot be excreted completely.21 Alcohol and hexachlorophane should be used only if there is hypersensitivity to other usually recommended agents. If 10% alcohol is used on its own as an antiseptic, diathermy should be used only after full evaporation has occurred. The use of iodophor-impregnated adhesive lm is protective and allows rapid skin preparation, provided it is not dislodged at surgery.22 Pre-operative skin preparation along with pelvic irrigation with antibiotics was tested in a randomized study of 100 women.23 No signicant dierences in the incidences of wound infection and endometritis were found in a comparison of two agents (povidoneiodine versus parachlorometaxylenol). However, endometritis occurred signicantly more frequently in the group that did not receive antibiotic irrigation. SKIN INCISION Type of incision Vertical incision Traditionally, both transverse and vertical incisions have been used for caesarean section (Figure 3). Each type has its own advantages. A vertical incision allows a less

Midline incision

Maylard incision Cohen's incision Pfannenstiel incision

Figure 3. Position of various skin incisions.

Techniques for performing caesarean section 23

vascular rapid entry and good exposure of both the abdomen and pelvis. This incision may be indicated in cases of urgency, such as massive haemorrhage, when upper abdominal exploration is required, and at perimortem caesarean section. It may also be appropriate in patients on systemic anticoagulants or with a coagulopathy and when those who refuse blood transfusion are operated on. Pfannenstiel incision Pfannenstiel introduced the Pfannenstiel incision in 1900 (see references in Stark et al.24). This incision is extensively used because of its excellent cosmetic results, along with the benets of early ambulation and a low incidence of wound disruption, dehiscence and hernia. However, the Pfannenstiel incision involves dissection of the subcutaneous layer and the anterior rectus sheath and, when extended into the external and oblique muscles, may result in injury to the ilioinguinal and iliohypogastric nerves.25 In addition, use of this incision limits views of the upper abdomen and may increase the blood loss and haematoma rate because of the increased dissection. Mowat and Bonnar reported a wound dehiscence rate of 2.94% (48 of 1635) after a midline incision, compared to only 0.37% (two of 540) after a Pfannenstiel incision.26 Similar ndings when comparing transverse and vertical incisions have been reported by other authors. One group found an eightfold increase in post-operative wound dehiscence and infection with the vertical incision.27 On the other hand, when the emergency use of these incisions was tested in a randomized controlled trial, no advantages of one over the other were seen in terms of wound disruption and hernia formation.21 Ellis in his commentary21a stated that the perceived dierence in morbidity between transverse and vertical incisions may be attributed to the bias in choosing the incision type, where midline incisions are chosen for emergency situations such as haemorrhage, sepsis and trauma. The Pfannenstiel incision continues to be commonly used to perform caesarean sections, primarily for its cosmetic appeal and also for the perceived dierences in outcome.28 Joel Cohen's incision Professor Joel Cohen introduced an incision for abdominal hysterectomy in 1954, and this incision has since been used widely by obstetricians to perform caesarean sections.29 The incision is a straight transverse incision, positioned slightly higher than the Pfannenstiel (Figure 3). The subcutaneous tissue is not sharply divided. The anterior rectus sheath is incised in the midline for 3 cm, but the muscles are not separated from the sheath. The peritoneum is bluntly opened in a transverse direction and, with the assistant's help, the opening is widened by traction in a transverse direction. Cohen and Pfannenstiel incisions were compared in a retrospective study in 245 women who underwent caesarean section.29 The length of the operation was less by 1.6 minutes, and post-operative morbidity was also less in the Cohen's incision group (7.4 versus 18.6%; P 5 0.05). `Modied' Joel Cohen's incision Wallin and Fall30 carried out an RCT of standard and `modied' Cohen's methods of caesarean section with 36 women in each group. In the modied Cohen's method, they placed the incision 3 cm above the pubic symphysis and bluntly opened the peritoneum (Figure 3). In addition, they did not close the parietal and visceral layers of

24 K. R. Hema and R. Johanson

the peritoneum. They found a reduced intraoperative blood loss (250 versus 400 ml: P 0.026) and a reduced operating time (20 versus 26 minutes; P 5 0.001) in the modied Cohen's group. The Cohen's incision has been examined in a number of RCTs where modications, such as single-layer closure of the uterus and non-closure of parietal and visceral layers of peritoneum, have also been evaluated31,32 (Table 1). Darj and Nordstrom compared Joel Cohen's incision (n 25) with Pfannenstiel's incision (n 25) and reported less operating time (12.5 versus 26 minutes; P 5 0.001), less blood loss (448 versus 608 ml; P 0.017) and less analgesic requirement (P 0.004) with the Cohen's incision.31 The study did not reveal any negative aspects of using the new technique. This technique is well described, with gures, in the paper published by Holmgren, Sjoholm and Michael Stark.32 This package of renements in techniques was introduced by Michael Stark and is known, after a hospital in Jerusalem, as the `Misgav Ladach method'. Maylard incision Another transverse approach has been described: the Maylard incision (Figure 4), which involves cutting the rectus muscles transversely and ligating the inferior epigastric artery to provide good access to the pelvis. This incision was originally described for use in radical pelvic surgery. It is comparable to vertical incisions in terms of complications and outcome.33,34 Ayers and Morley, in their randomized trial comparing Pfannenstiel and Maylard incisions for caesarean sections, did not nd any dierence in morbidity.35 They suggested that the Maylard incision is a safe option which should be strongly considered when risk factors are present, such as macrosomia or twins needing maximal exposure for a non-traumatic delivery. Although there was no increase in blood loss and post-operative morbidity with the Maylard incision, it is clear that, because more dissection is required, post-operative discomfort is likely to be greater.10

Inferior epigastric artery and vein


Figure 4. Maynard incision explained. Inferior epigastric vessels ligated and recti muscles cut.

Techniques for performing caesarean section 25

Length of incision Whatever type is chosen, the length of the incision should be adequate. A dicult caesarean section should not be a substitute for a dicult vaginal delivery. The incision should be approximately the same length as an `Allis' clamp, laid on the skin (15 cm). Finan and co-workers showed in their prospective study that the time (uterine incisiondelivery) was shorter in the group that passed the `Allis test', compared to the group that failed the test (mean 58.4 versus 95.7 seconds, P 0.002).36 Previous scars As already indicated, wound healing is aected if the edges are not approximated properly. This becomes an important point to remember whenever previous scars are encountered. Excision of the previous scar will improve wound healing and gives better cosmetic results. Bowen and Charnock found, in a series of 25 women undergoing repeat caesarean section, that the use of a double-bladed scalpel yielded better healing and aesthetically more pleasing scars than the conventional scalpel. This is because it uniformly excised the scar tissue and avoided the need for two incisions. An adjusting screw allows the necessary width to be excised37 (Figure 5).

Figure 5. Double-bladed scalpel.

Method of incision The time-honoured practice of using two scalpels at caesarean section (one for the skin and sheath and a dierent one for internal divisions) has been studied. No dierence in wound infection was found with the use of either one or two scalpels.38 Another study revealed that the rst scalpel usually remained sterile.39 Whichever scalpel is used, the incision should be made using one stroke rather than with multiple strokes, which may lead to infection and poor healing.40 Nygaard and Squatrito21, in their review of methods of abdominal incisions, have discussed the merits identied in various studies of a scalpel compared to ultrasound knife, laser or diathermy. Although animal studies have shown that the scalpel is

26 K. R. Hema and R. Johanson

associated with less tissue damage, ndings from controlled studies in humans are mixed. The authors comment that, with some exceptions, the bulk of the literature on humans suggests little advantage or disadvantage to incisions made with scalpel, cautery, or laser.21 Uterine incision Lower segment transverse incision (Kerr) (Figure 6) Ever since its introduction in 1926 by Munro Kerr41, the lower segment incision has been the most commonly performed uterine incision. A Doyen's retractor is used for good exposure of the lower segment. The loose fold of peritoneum, where the bladder is attached, should be identied. Before an incision is made, rotation of the uterus should be noted (it is usually dextro-rotated) and, if possible, corrected, so that the incision will not be asymmetrical, risking extension on the opposite side. The loose fold of peritoneum should be incised and the bladder pushed down gently with care, mainly in the centre in order to avoid disturbing the vascular plexus.22 In cases of obstructed labour, with formation of Bandl's ring, this fold of peritoneum is located higher and the peritoneum should be opened higher up, with particular care to avoid bladder injury. The uterine incision should be made in the centre, for a length of 23 cm, until the membranes are exposed. In order to avoid injury to the fetus, the deeper bres of the myometrium should be opened with the blunt end of the scalpel or with ngers. Extension of the incision should be achieved by ngers along the path of least resistance. It must be remembered that the force used on the left side should be less than that on the right side to avoid haemorrhage from the left angle. This risk can usually be minimized by correcting the dextro-rotation. If sharp dissection is required, the use of thick bandage scissors is recommended for cutting the thick lower segment

'Classical' incision

De Lee's incision

Lower segment incision


Figure 6. Position of various uterine incisions.

Techniques for performing caesarean section 27

in a concave manner to avoid injuring the fetus and the major uterine blood vessels.22 However, Rodriguez and co-workers, in their RCT of blunt versus sharp extension of the incision, did not nd any dierence in ease of delivery, blood loss, unintended extension or post-operative endometritis.42 When dicult circumstances are encountered, requiring an extension of the transverse incision, a `J'-shaped extension into the upper segment, on the most accessible side, is better than an inverted `T' incision (which will form a weaker scar due to poor healing). However, both of these incisions have been shown to be frequently associated with intraoperative complications and prolonged hospital stays.43 Extension of the uterine decision using an absorbable stapling device, called Auto Suture Poly CS, has been described. After a small incision, the stapling device is introduced between the membranes and the uterine wall. The stapler is then red to produce two columns of absorbable staples. Thereafter, a hysterotomy is performed between the rows of the staples. However, in an RCT between the conventional type and the stapling type of caesarean section, the operating time was prolonged and the other measures of outcome were the same. Hence, its routine use is not recommended.44 A Cochrane review analysed four trials involving 526 women where the stapling device was used to extend the incision. There was no dierence in the total operating time compared with the other techniques used to extend the incision, but the stapler increased the time needed to deliver the baby (weighted mean dierence 0.85 minutes, 95% Cl 0.48 to 1.23). Blood loss was lower with the stapling device. The reviewers conclude that there is not enough evidence to justify the routine use of the stapling device to extend the uterine incision. Indeed, there is a possibility that this device could cause harm by prolonging the time to deliver the baby.45 Lower segment vertical incision (De Lee and Cornell) (Figure 6) The lower uterine vertical incision, introduced by De Lee and Cornell46, has the advantage of sparing the uterine vessels but it needs careful dissection to reect the bladder, which may nevertheless become involved in an extension. The incidence of scar dehiscence is equivalent to that expected with the transverse incision and it may be regarded as an alternative to the upper uterine vertical incision.46a Shipp and coworkers have also shown that women with a prior lower vertical incision are not at an increased risk of uterine rupture compared to those who have had a lower transverse incision.47 No statistical dierences in terms of perinatal and maternal morbidity were noted when singleton breech fetuses were delivered via lower transverse (n 221) or lower vertical incisions (n 195).48 The lower segment transverse incision has also been compared with the vertical incision in triplet pregnancies. In a case-controlled study, no signicant dierences were observed in perinatal mortality or operative complications.49 Because of the risks of bladder extension, it remains advisable to do a lower segment transverse incision whenever the lower segment is well formed. Where this is not the case, then a low vertical incision is acceptable. Classical incision (Figure 6) In recent years, the rate of `classical' incision has gone up, due particularly to increased preterm deliveries, especially those performed before 26 weeks of gestation or after rupture of membranes. Bethune and Permezel, in their retrospective study undertaken over a 9 year period in Melbourne, noted that 1% of all their caesarean

28 K. R. Hema and R. Johanson

sections were `classical'. The frequency correlated inversely with the gestational age: 20% at 24 weeks, 5% at 30 weeks, and less than 1% from 34 weeks onwards.50 The `classical' upper segment vertical incision is thought to be associated with excessive blood loss, infection, poor healing and an increased risk of rupture in subsequent pregnancies. However, Blanco and Gibbs found comparable early morbidity and wound infection rates between two groups of women who had lower segment transverse and classical incisions.51 They attributed this to improved surgical techniques. `Classical' sections are indicated when the lower segment is inaccessible due to dense adhesions or large broids. This route may also be necessary with preterm breech presentations or with a transverse lie and prolonged rupture of membranes (particularly those that are `dorsoinferior'). Placenta praevia in general is no longer regarded as an indication for a classical section22, but this incision should be undertaken at perimortem caesarean (Table 1).
Table 1. Classical caesarean section: possible indications. Preterm delivery with poorly formed lower segment Premature rupture of membranes, poor lower segment and transverse lie Transverse lie with back inferior Large cervical broid Severe adhesions in lower segment reducing accessibility Postmortem caesarean section Placenta praevia with large vessels in lower segment

Delivery of the fetus In an observational study of 105 deliveries, inductiondelivery intervals of more than 8 minutes under general anaesthetic and incisiondelivery intervals of more than 3 minutes under both general or spinal anaesthetic were associated with increased numbers of low Apgar scores and neonatal acidosis.52 The same group found that with longer uterine incisiondelivery intervals, umbilical arterial (UA) noradrenaline concentrations increased signicantly, resulting in lower UA pH values.53 However, Vatashsky and co-workers (n 568) and Anderson and co-workers (n 204) concluded after their studies on the inuence of incisiondelivery interval that it did not signicantly aect the outcome. Both a high head and a deeply engaged head could pose problems with delivery. Ideally, the fetal head should always be delivered in an occipito-anterior position. Management of the dicult situations that may arise in this area are discussed later in this chapter. When faced with diculties, a general principle is that uterine relaxation may help. Glyceryl trinitrite has been used intravenously in a randomized double-blind trial at elective caesarean section.54 Although routine administration of glyceryl trinitrite in elective cases did not have signicant benets, there were no signicant maternal or fetal side-eects to the drug. In the light of this nding, it may be worth trying this in dicult deliveries. Injury to the fetus during caesarean section is not uncommon and is often underreported. These injuries are likely to occur at the time of uterine incision or at extraction of the fetus. The legal literature contains several cases involving scalp wounds resulting from incisions during caesarean section. Such injuries cannot be considered as `expected' complication.55 Durham and co-workers even reported an iatrogenic brain injury during emergency caesarean section. There have also been reports of long bone

Techniques for performing caesarean section 29

Figure 7. Blunt-edged notched scalpel.

fractures and of extensor tendon laceration in preterm neonates.55,56 The use of a newly devised, blunt-edged, notched scalpel has been shown to be easy and safe for making uterine incisions (Figure 7).57 There were no major complications or fetal injuries when the authors used this tool in 41 women at caesarean delivery. Delivery of the placenta Traditionally the placenta is removed manually at the time of caesarean section. The method used should not be any dierent from the controlled cord traction used at vaginal delivery. Manual shearing of the placenta does not allow time for retraction of the myometrial bres, and hence leads to unaltered perfusion and increased blood loss. Four randomized trials comparing manual extraction and controlled cord traction for expulsion of the placenta have been undertaken5861 (Table 2). Wilkinson and Enkin, in their systematic Cochrane review, conclude that manual removal of placenta at section may do more harm than good by increasing maternal blood loss and increasing the risk of infection.62 In a recent study, Lasley and co-workers found that post-operative infections occurred in 25 of 168 (15%) women in the spontaneous group compared with 44 of 165 (27%) in the manually delivered group (relative risk 0.6%, 95% condence interval 0.4 to 0.9, P 0.01). The incidence of infection in the sub-group of women with ruptured membranes signicantly increased in the manual extraction group (20 versus 38%, relative risk 0.5. 95% Cl 0.3 to 0.9, P 0.02).61 Yancey and co-workers isolated non-staphylococcal bacteria from surgeons' gloves soon after fetal extraction in 11 out of 14 labouring women, as compared to one of 11 non-labouring women.63 Based on this nding, Atkinson and co-workers conducted a randomized study in a large number of patients (n 643) who were divided into four groups. In this study the eects of a glove change for surgeon and assistant, just after

30 K. R. Hema and R. Johanson Table 2. Placental delivery. Subject Spontaneous expulsion/ manual extraction Number of patients Country 31/31 USA Author McCurdy & co-workers59 Magann & co-workers60 Year 1992 Result Less blood loss; lower incidence of postoperative endometritis Less blood loss and postoperative morbidity with spontaneous expulsion and in-situ repair No signicant change in morbidity with or without glove change; lower incidence of endometritis with spontaneous placental delivery Lower incidence of postoperative infections with spontaneous expulsion

Spontaneous versus manual 100 placental removal combined with exteriorization/in-situ repair (four groups) Spontaneous versus manual 760 extraction combined with glove change/no glove change after delivery of the fetus (four groups)

USA

1993

USA

Atkinson & co-workers64

1996

Spontaneous expulsion versus manual extraction

168/165

USA

Lasley & co-workers61

1997

delivery of the fetus, along with a spontaneous delivery of the placenta, were compared to a policy of manual removal and no glove change. Although they found that changing gloves was not associated with a reduced incidence of post-operative endometritis, they conrmed that manual removal was associated with a greater risk of post-caesarean endometritis64 (Table 2). In a smaller study which looked at intraoperative `glove change' no signicant dierences were noted in measures of post-operative morbidity.65 The practice of exploring the uterus with a gauze sponge after delivering the placenta (to check for retained placental cotyledons or membranes) has not been tested properly. This practice could theoretically increase the chances of bacterial contamination and hence post-operative endometritis. However, as the uterus is well contracted at this stage, the chances of bacterial inoculation deep into the decidua and the myometrium are small.61 At elective caesarean section, some operators choose to dilate the cervix with ngers or dilators after delivery of the placenta. This practice has not been tested in randomized trials and could, theoretically, introduce infection and cause damage to the cervix. Exteriorization of the uterus Exteriorization and traction on the uterus has been shown to reduce blood loss and facilitate suturing.66 However, exteriorization may cause nausea and vomiting and some women do complain of pain. Using Doppler monitoring, a signicantly higher incidence of venous air embolism was reported by Handler and Bromage.67 The theory of this can be explained: traction enlarges the uterine sinuses and raises the incision to a level higher than that of the heart, and this increases the hydrostatic gradient, thereby promoting venous air embolism.68 Prospective trials of exteriorization of the uterus to repair the uterine wound have been evaluated by Enkin and Wilkinson, who found that, because of unsatisfactory randomizations and unspecied exclusions, there

Techniques for performing caesarean section 31

were insucient data to permit denitive conclusions about exteriorization.69 However, a recent RCT (n 194), which avoided the major drawbacks of previous studies, indicated that maternal morbidity was not increased with exteriorization70 and in another recent RCT (involving 316 women) the authors found no signicant dierences in post-operative wound sepsis, pyrexia, blood transfusion or length of hospital stay. They concluded that, with eective anaesthesia, exteriorization is not associated with signicant problems and is associated with less blood loss ( p 5 0.05).71 Closure Suturing of the uterus Traditionally the uterine wound is closed, as was recommended by Kerr in 192641, in two layers. The traditional two-layer suturing technique was borrowed directly from the initial vertical incision closure.22 Until fairly recently, recommendations varied only in terms of the method of actual suturing: locking, continuous or interrupted. In 1976 Pritchard and MacDonald72 rst noted that a satisfactory approximation of the edges can be obtained by a single-layer closure. Theoretically, single-layer closure should cause less tissue damage, include less foreign material and take less operative time. Hauth and co-workers72a randomized 906 women and compared the two methods. Their conclusion was that a one-layered locking suture closure required less operative time, (43.8 versus 47.5 minutes (P 0.0003)). In no outcome assessment, such as haemostasis or endometritis, was the two-layer closure superior to the singlelayer closure.72 Insertion of interrupted haemostatic sutures was required for 16 women in each group. The authors recommended a single-layer closure, when anatomically feasible. A single-layer closure can be achieved using a Polyglactin No. 1 suture with a locking or non-locking method. Animal studies, histological and hysterographic studies, have demonstrated that a single-layer closure provides the best anatomical result and the strongest scar.73 Concerns about the integrity of the scar during a subsequent trial of labour after single-layer closure have been examined in a retrospective cohort study of 292 women (149 after a one-layer closure and 143 after a two-layer closure).74 Tucker and coworkers found that asymptomatic ruptures were not higher in the single-layer group. Eight women had scar dehiscence in the single-layer closure group, as compared to ve in the two-layered closure group.75 Chapman and co-workers studied the outcome of subsequent delivery in a group of 164 women who had previously been randomized to single-layer closure (n 83) or double-layer closure (n 81). Of these 164 women, 145 experienced a trial of labour. There were no dierences between the two groups during a subsequent trial of labour, in terms of maternal or fetal outcome measures.76 The classical incision needs to be closed in three layers because of its thickness and vascularity. Traditionally about six `all layer' interrupted sutures are placed but not tied. Thereafter a `herring-bone' suture is used for the deep and middle layers. The supercial myometrium and serosa are then juxtaposed by a non-locking continuous suture, followed by ligation of the `all layer' interrupted sutures (see Figure 8). Peritoneal closure The traditional arguments for peritoneal closure have included, rst, restoring the anatomy and approximation of tissues for healing, and second, the re-establishment of

32 K. R. Hema and R. Johanson

a b

Figure 8. Closure of classical section. (a) `All layer' suture; (b) `Herring-bone' suture.

a peritoneal barrier to reduce the risk of wound herniation or dehiscence. In addition, peritoneal closure was thought to minimize the formation of adhesions.77 Buckman and co-workers have shown that deperitonealized surfaces heal without permanent adhesions. The closure of peritoneum at the time of caesarean section has been examined in four RCTs. The Cochrane review by Wilkinson and Enkin concluded that there seems to be no signicant dierence in short-term morbidity with nonclosure of the peritoneum at caesarean section and that non-closure of the peritoneum saved operating time (weighted mean dierence of 612 minutes, 95% Cl 8.00 to 4.27). There was a consistent, although non-signicant, trend for improved immediate post-operative outcome.78,79 The results of the trials that have now been published are given in Table 3. It is evident that non-closure of the parietal and visceral layers of peritoneum is likely to be cost eective, time saving and, above all, associated with less post-operative morbidity, as well as requiring less analgesia.7883 Closure of fascia The rectus sheath is commonly closed using a synthetic suture. Wound healing is best if the stitches are inserted 10 mm from the edge and 10 mm apart. This is because collagenolysis occurs over an area of 10 mm from the wound edge. Any wound closures constructed within this zone will therefore be weaker.10 Closure of Camper's fascia Wound infection can cause disruption of the wound, requiring opening and drainage and a protracted healing time. The formation of seromas and haematomas due to the dead space in the subcutaneous layer can lead to infection. Del Valle and co-workers, in their RCT conducted on 438 women, used 3-0 pain catgut continuous suture to approximate the Camper's fascia. They found that wound disruption was less in this group, compared to the non-closure group, (2.7 versus 7.4%; P 0.03).84 However, no analysis was made in terms of the depth of the subcutaneous tissue.84 In another

Techniques for performing caesarean section 33 Table 3. Peritoneal closure. Subject Number of patients Country USA Author Pietrantoni & co-workers122 Hull and Varner123 Year 1991 Result Shorter operating time; no dierence in morbidity Reduced need for postoperative analgesia; quicker return of bowel function Shorter operating time (P 5 0.005); shorter hospitalization Less post-operative febrile morbidity; less wound infection (P 5 0.001); shorter operating time (P 5 0.01) No dierence in postoperative morbidity; shorter operating time Overall, no dierence in post-operative pain; use of analgesic requirements reduced in non-closure group from 3rd day Lower febrile and infectious morbidity; shorter operating time; use of analgesic requirements reduced in non-closure group Lower post-operative morbidity and pain; shorter operating time

RCT between non127/121 closure versus closure of parietal layer RCT of non-closure versus closure of visceral and parietal layers RCT of non-closure versus closure of visceral and parietal layer 117

USA

1991

300

Switzerland

Luzuy et al124

1994

RCT of both layer 192/179 closure versus nonclosure 1 year post-op follow-up

UAE

Grundsell & co-workers81

1991 1994

RCT non-closure/ both layers closure RCT double-blind study (post-operative pain assessment)

96/94

Malaysia

Ho & coworkers125 Hjberg & co-workers82,83

1997

21/19

Denmark

1996/ 1998

RCT non-closure/ closure of visceral peritoneum

262/287

Austria

Nagele & co-workers126

1996

RCT closure/non 137/143 closure of the visceral and parietal layers

Canada

Irion & co-workers127

1996

prospective trial, 245 women with a subcutaneous space of 2 cm or more were randomized to closure of subcutaneous space with a 3-0 polyglycolic acid suture or to non-closure. The incidence of infections in the two study groups, from all causes, was 14.5% in the closure group compared to 26.6% in the non-closure group (RR 0.5, 95% Cl 0.30.9).71,85 An alternative to suturing Camper's fascia is to leave a drain above the sheath with continuous suction. An RCT was conducted by Saunders and Barclay in 200 women undergoing lower segment caesarean section.86 They placed a Redivac drain behind the sheath and closed the sheath with Polyglactin sutures. They did not nd any signicant advantage to the routine use of the drain in non-obese patients.86 The use of closed suction drainage in `obese' women (42 cm subcutaneous tissue) has been shown to reduce wound complications.87

34 K. R. Hema and R. Johanson

Closure of skin Skin edges of the incision can be approximated either by intracutaneous sutures, staples or clips, or by subcuticular sutures. The choice is usually based on the surgeon's preference, speed and cosmetic advantage. The subcuticular suture has particular advantages based on its cosmetic appeal. In studies which compared sutures and staples at the time of laparotomy (with a vertical incision), subcutaneous polydioxanone (PDS) was found to give the best results.88 A non-randomized Danish study compared three methods of skin closure. The best cosmetic outcome, from both the mother's and surgeon's perspective, was obtained with subcuticular sutures.89 The rst randomized trial, looking at Pfannenstiel incision closure at caesarean section was conducted by Frishman and co-workers on 50 women; it compared staples with subcuticular polyglycolic acid sutures. The patients who had subcuticular suturing felt less pain at discharge and at the post-operative visit (P 5 0.01 and P 0.002). The subcuticular repair was cosmetically more attractive to both the patients and the surgeons at the post-operative visit (P 0.04, P 0.01).90 A prolene subcuticular suture has the advantage over Dexon that it can be removed in the early postoperative period22, but this suture has not been tested in randomized trials. The use of cyanoacrylate (a skin `glue') to close the skin at caesarean section has been evaluated in a series of 44 patients. In this case-controlled study, using nylon and silk, the authors found cyanoacrylate to be safe and ecient, reducing both the time and cost of skin closure.91 Further evaluation is required. Delayed closure has been proposed where there are signicant concerns about ooze into the wound. Brigg and colleagues studied the eects of primary versus delayed closure in cases of HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome, and at the same time they compared Pfannenstiel and midline incisions. In this study, they found that the wound complication rate was not inuenced by skin incision or timing of skin closure.92

THE MISGAVLADACH METHOD OF CAESAREAN SECTION As indicated above, a number of dierent features discussed in this section contribute to the MisgavLadach method of caesarean section. The whole procedure can be summarized as follows. The principal features followed include the Joel Cohen method of opening the abdomen, suturing the uterus in one layer and non-closure of visceral and parietal layers of peritoneum. Holmgren and co-workers carried out a retrospective comparative study between this method and the conventional method (Pfannensteil incision, with two-layered uterine closure of both the peritoneal layers).32 They concluded that the incidence of febrile morbidity, adhesions and analgesic requirements was lower in the MisgavLadach method. The method is well described and the steps are illustrated in gures by the authors in their article.32 Table 4 summarizes the methodology and results of various trials related to this technique of caesarean section. The details of these have already been separately discussed in the text. The advantages of this approach include a quicker post-operative recovery, lower febrile morbidity and antibiotic requirement, early return of bowel movements and fewer adhesions.

Techniques for performing caesarean section 35 Table 4. Study of combinations of methods. Subject Number of patients Country Israel Author Ohel & co-workers80 Year 1996 Result Less operative time (32 + 11 versus 44 + 16); less postoperative sedation Less operating time; less wound infection

RCT of single-layer uterine 100/100 closure and non-closure of peritoneum versus double-layer uterine closure and visceral and parietal layer closure RCT of two surgical techniques. 149/153 Joel Cohen's entry, single, nonlocking uterine closure, nonclosure of both peritoneal layers versus Pfannenstiel's opening, single uterine layer and closure of both peritoneal layers RCT of MisgavLadach method. 25/25 Joel Cohen's entry, single uterine layer, locking suture, non-closure of peritoneum versus Pfannenstiel's incision, double-layer uterine closure and closure of both parietal and visceral layers RCT MisgavLadach method. 339 Cohen's entry, single locking uterine closure versus nonclosure of peritoneum interrupted skin closure; lower midline incision double uterine layer closure with closure of both parietal and visceral layers

Italy

Franchi & co-workers74

1998

Sweden

Darj & Nordstrom31

1998

Less operating time; reduced blood loss (P 0.017); less analgesic requirement

Tanzania

Bjjorklund & co-workers128

2000

Less operating time; less blood loss

FUTURE RESEARCH INTO TECHNIQUE A randomized factorial trial is under way in the United Kingdom, organized by the National Perinatal Epidemiology Unit, in Oxford, called the CAESARean trial. This is based on an initial survey undertaken among obstetricians which determined (a) current practice with respect to the techniques used at caesarean section, and (b) what aspects of the operation clinicians would like to see evaluated in a randomized controlled trial. The trial will assess the following three pairs of alternative surgical techniques (1) single versus double-layer closure of the uterus, (2) closure versus nonclosure of the pelvic peritoneum, and (3) restricted versus liberal use of sub-sheath drain (The CAESAR study Protocol, National Perinatal Epidemiology Unit, Oxford). ANTIBIOTICS IN CAESAREAN SECTION Prophylactic antibiotics for caesarean section have been shown to reduce the incidence of maternal post-operative infectious morbidity. In a systematic Cochrane review on this subject, 51 trials were analysed.93 The odds ratio (95% Cl) for their eect on

36 K. R. Hema and R. Johanson

serious infectious morbidity/death is 0.25 (0.110.56). The particular antibiotic that is used does not appear to be very important. Both ampicillin and rst-generation cephalosporins have a similar ecacy, with an odds ratio (OR) of 1.27 (95% Cl: 0.84 1.93). In comparing ampicillin with a second- or third-generation cephalosporin, the odds ratio was 0.83 (95% Cl: 0.541.26) and in comparing a rst-generation cephalosporin with a second- or third-generation agent the odds ratio was 1.21 (95% Cl 0.971.51). A multiple-dose regimen for prophylaxis appears to oer no added benet over a single-dose regimen; OR 0.92 (95% Cl 0.701.23). Systemic and lavage routes of administration appear to have no dierence in eect; OR 1.19 (95% Cl 0.81 1.73). In addition, the reviewers conclude that there is a need for an appropriately designed randomized trial to test the timing of administration of antibiotics immediately after the cord is clamped versus pre-operatively.93 Similar studies will not necessarily have the power to assess these questions. For example, a study by Rizk and co-workers concluded that administration of prophylactic antibiotics at elective sections (61 placebo versus 59 sections) was not associated with any reduction in post-operative morbidity.94 Similarly, Rouzi and colleagues, in their placebo-controlled RCT (211 elective sections and 230 emergency deliveries), found that routine use of a single dose of cefazolin is eective in emergency sections but not in elective deliveries.95 Studies such as these contribute to the debate about the need for universal prophylaxis. It may not be necessary in units that can prove that they have low infection rates. Interestingly, if follow-up extends to the community, even units with high rates of prophylaxis continue to have late infections.96 Further research should have longer term outcomes and not just hospitalbased infection rates.

COMPLICATIONS DURING CAESAREAN SECTION The rising caesarean section rate in the past two decades indirectly vouches for its safety. Nevertheless, it is associated with increased morbidity for the mother, and the procedure can result in serious complications. The need for blood transfusion is greater when trainees perform caesarean sections without supervision.97 Yet this is an operation commonly performed by trainees and residents. A regular review of the methods used, along with good supervision and, where available, periodic training in a `skills laboratory', will all help to reduce complications. The following were identied as risk factors for complications at caesarean section: excessive speed, lack of experience, gestational age 532 weeks, ruptured membranes and low station of the presenting part. The Condential Enquiries into Maternal Mortality have consistently referred to the need for senior obstetricians to be involved early in the event of complications.98 Ideally, all high-risk cases should be performed during the daytime, when the availability of expertise is maximum. Anticipation is the key to avoidance of complications.99 Complications are increased in emergency procedures. A comparative series from Cape Town suggested that the relative risk for mortality, after excluding medical disorders and major antenatal complications, of intrapartum emergency versus elective sections, was 1.7:1.0.100 There can be diculties encountered at various stages while performing an abdominal delivery. These include: dicult entry into the peritoneal cavity due to dense adhesions, diculties associated with obstructed labour, and diculties due to limited exposure and space in the lower segment. The last problem occurs especially in

Techniques for performing caesarean section 37

preterm sections with ruptured membranes and with abnormal presentations of the fetus. Each case needs to be managed on an individual basis. Dicult deliveries at caesarean section A high head at elective section may give rise to diculty in delivering the fetus. The rule of thumb is to deliver the fetus in a exed position, very similar to the fetal attitude in utero. In such situations the head can be delivered by applying a pair of Wrigley's forceps, or one forceps blade can be used as a vectis to gently lever out the head (this blade occupies less space than the hand). The ventouse can also be used to extract the fetus at caesarean section.101 However, in one series this was shown to increase the incisiondelivery interval and hence caution is necessary.102 In cases of direct occipito posterior position, the head should be exed before delivery and a pair of forceps may need to be used. With face or brow presentations the same principle needs to be applied: `ex and deliver'. Breech delivery should be conducted in the same way as vaginal breech deliveries, using slow and steady traction, avoiding unnecessary speed. Either both feet or one foot (if only one is accessible) need to be grasped and gentle traction will enable a smooth assisted delivery. Delivery of the shoulders needs to be conducted in the same way as in a vaginal delivery, by gentle rotation. Delivery of the after-coming head can be dicult, especially in emergency caesareans or after rupture of membranes. The assistant needs to maintain pressure on the fundus of the uterus and MauriceauSmellie-Veit's technique or forceps delivery may be helpful. With a transverse lie, an external cephalic or podalic version should be tried before the uterus is incised! If unsuccessful, an internal podalic version will need to be undertaken. It is not very uncommon to nd a hand within easier reach than the foot. It is therefore important to identify the limb carefully before beginning an extraction. If a hand is grasped, it needs to be pushed back gently and the delivery should be completed as a breech extraction. In placenta praevia, when the placenta is encountered anteriorly at the level of incision, it should simply be pushed aside to expose the membranes. The placenta itself needs to be incised only when the former steps are not possible. Where a caesarean section is performed in the second stage of labour or after failed trial of instrumental delivery, it may be helpful if an assistant pushes the head from below or, alternatively, the fetus can be delivered by breech extraction.103 Preterm caesarean section Physiological studies suggest that cord clamping delayed by 30 seconds in preterm infants, born between 26 and 33 weeks, increases the placental transfer of fetal blood by 1520 ml/kg. However, when the eects of immediate versus delayed clamping (by 30 seconds) were studied, no signicant change in the haematocrit was noted. The authors recommend that future studies be done to examine the benets of delaying clamping for more than 30 seconds.104 Preterm infants (2432 weeks of gestation) in theory benet from delivery `en caul' (with an intact sac at the time of delivery) but authors from Leeds observed a relatively high rate of fetal blood loss.105 Maternal blood loss is reported to be more with preterm caesarean sections.106 In a case-controlled study, caesarean section before 28 weeks of gestation was shown to be associated with increased maternal morbidity.107

38 K. R. Hema and R. Johanson

Haemorrhage in caesarean section The average blood loss at caesarean section is about 0.71.01 litres.59 However, blood loss is usually underestimated, particularly when this has been large. This has been shown in a prospective observational study, using the alkaline haematin method, carried out on 40 women at elective caesarean section.108 When the measured blood loss was less than 500 ml it was estimated with reasonable accuracy, but amounts were signicantly underestimated when the measured loss exceeded 600 ml.108 Among the risk factors known to be associated with increased blood loss are prolonged labour, second stage caesarean section, placenta praevia, chorioamnionitis, antepartum haemorrhage, previous postpartum haemorrhage, preterm caesarean section, classical incision, general anaesthesia and obesity. Precautions and prevention A caesarean scar increases the incidence of placenta praevia in subsequent pregnancies.99 At caesarean section for placenta praevia, it is recommended98 that a senior obstetrician and anaesthetist be present in theatre. Patients with placenta praevia need to be informed of the possible complications and the possible need for further surgical procedures, including hysterectomy. There should be cross-matched blood available in theatre before the operation is started. Second-stage caesarean sections need to be performed with caution. Delivering the fetus in a exed position using steady traction is important in terms of reducing the blood loss. When the uterine vessels become involved, due to an unintended lateral extension of the incision, the artery needs to be ligated separately. Caution needs to be exercised when suturing the angle, especially in the presence of excessive bleeding. The bleeding edge may be inverted while inserting a haemostatic suture, hiding the bleeding point from view. Aetiology and steps of treatment The commonest cause of haemorrhage is uterine atony and this should be controlled in a systematic way according to standard protocols, with oxytocics, uterine massage and intramuscular injection of prostaglandin F2a (Carboprost) as necessary. Carboprost should be kept as third-line therapy. A prospective, double-blind, randomized comparison of prophylactic intramyometrial 15-methyl prostaglandin F2a and intravenous oxytocin in cases of elective sections, showed that routine prostaglandins did not oer any advantage over oxytocin for the control of haemorrhage.109 When haemorrhage continues, the next step is to check for lateral and vertical extensions of the incision and trauma to the uterine vessels. Haemostatic sutures to the placental bed have been recommended and used successfully.109 Thereafter unilateral or bilateral ligation of the uterine arteries is recommended.110 This suture should also include veins, along with a full thickness of myometrium. O'Leary and coworkers reported failure with this procedure and a need to resort to hysterectomy in only 10 cases in a series of 265 patients with uncontrolled haemorrhage.110a A wider knowledge of the procedure of ligation of internal iliac arteries is necessary among obstetricians, as a lower rate of caesarean hysterectomy has been reported with its use.111113 The `B-Lynch Brace' suturing technique involves a single suture enveloping the body of the uterus, occluding the blood supply temporarily and allowing stabilization and further assessment of the patient (Figure 9).114

Techniques for performing caesarean section 39

(a)

Fallopian tube Round ligament Broad ligament 2 3 4 5 1 6 4 cm

3 cm 3 cm

3 cm

(b) Fallopian tube Ligament of ovary

(c)

Figure 9. The `B-Lynch Brace' suture. (a) Method of B-Lynch suture. (b) Posterior surface of the uterus. (c) The B-Lynch suture after completion.

Blood transfusion Blood transfusions should not be prescribed without a strong indication, especially as the majority of the obstetric population in a developed country will compensate for blood loss without compromise to other systems. However, uid replacement should be adequate and timely. In patients at risk of losing a large volume within minutes, blood should be replaced quickly.115 In a retrospective study over 12 years, which included 1618 women who had a caesarean section, the transfusion rate was 2.4%.116 However, Naef and co-workers, in their retrospective study of 1610 women delivered by caesarean section, found 103 (6%) to have been transfused. The authors went on to compare the outcome of those who had been transfused with a matched group of women who had experienced a haemorrhage but who did not have transfusion. Patients in the transfused group received an average of nearly 4 units of packed red cells (with a range of 1 to 40 units). The mean equilibrated post-operative haematocrit was signicantly higher in these women than in the non-transfused group (28.4+5.4% versus 22.7+4.6%: P 5 0.0001). Despite this, the hospital stay, post-operative infection and wound complication rates were similar in the two groups.117

40 K. R. Hema and R. Johanson

Injuries to urinary and gastrointestinal tract Surgical injuries to the urinary and the gastrointestinal tract during caesarean section are infrequent. However, their recognition and their proper management are important in preventing further morbidity. Bladder injuries The bladder is at risk of injury in cases of emergency sections, repeat sections, previous abdominal surgery and obstructed labour. Precautions should be taken to drain the bladder before surgery. The surgeon should avoid haste and should open the abdomen in a controlled manner.118 If necessary, the dissection should be carried out with sharp instruments and the peritoneum should be opened higher up in cases of dense adhesions and in obstructed labour. An adequate bladder ap should be mobilized by sharp dissection in cases of scarring with the lower uterine segment. The reported incidence of bladder injuries varies from 0.0016 to 0.94%. The incidence was 0.31% in a 5-year study conducted by Eisenkop and co-workers.100 In a series of 11 284 caesarean sections an incidence of 0.14% was reported and 75% of these injuries occurred at the time of emergency caesarean section.23 Inadvertent opening of the bladder at the time of caesarean section should be recognized immediately by the presence of a Foley's catheter in the operating eld or by drainage of urine. The extent of the damage should be assessed by noting the location and size of the defect and its proximity to the trigone and the ureteric orices. The expertise of a urologist needs to be sought in cases of extensive damage. A simple cystotomy can be closed in two layers, using absorbable sutures of 2-0 or 3-0 calibre. The mucosa is sutured rst and the submucosa and the muscularis are included in the second layer. The integrity of the suturing can be tested with sterile milk or methylene blue dye injected into the bladder. The serosa should be apposed if feasible. Bladder injuries usually heal very well, but for this the bladder needs to be drained for a minimum period of 710 days. A suprapubic catheter, prophylactic antibiotics and cystourethrogram are not thought to be necessary.118 Injury to the bladder at the time of caesarean section does not usually involve the trigone. If any doubt arises, ureteral integrity needs to be checked. Ureteric catheters may need to be used before suturing the bladder. Ureteric injuries These injuries are rare, with the reported incidence ranging from 0.02 to 0.05%.92,100a The majority of ureteric injuries that occur are due to attempts to control bleeding from extension of the angle of the uterine incision into the broad ligament. Although it is generally believed that the left ureter is more prone to damage because of its anterior placement (due to the dextro-rotation of the uterus), the studies by Eisenkop and Rajasekar do not support this. These injuries are associated with less morbidity when repaired immediately, avoiding the need for a second operation. Recognition again is dependent upon the type and site of the injury. Injuries due to clamping, crushing or kinking of the ureter by a clamp or a suture, not leading to devitalization of the suture, can be reversed by undoing the procedure. Subsequently, urinary function should be checked and a peritoneal drain needs to be left. A urologist's opinion should be sought and he/she may recommend placement of a ureteric catheter via an incision in the bladder. Severe injuries of transection to the distal ureter can lead to devitalization, due to

Techniques for performing caesarean section 41

devascularization, requiring uretero-neocystotomy. A urologist should be involved immediately. Some ureteric injuries are diagnosed only post-natally. Following a dicult caesarean section, with a lateral `pelvic wall' placement of suture to control haemorrhage, a high index of suspicion should exist. In such cases, a renal ultrasound should be undertaken prior to discharge or if any symptoms of obstruction develop. Gastrointestinal injuries Nielson and Hokegard reported an incidence of 0.08% of bowel injury in a series of 1319 caesarean sections.119 Bowel is at particular risk of injury in women with previous abdominal surgery for inammatory bowel disease. Bowel can also be adherent to the previous scar, or higher on the uterus in cases where myomectomy, closure of perforation of uterus or previous classical sections have been performed. The bowel is usually injured at the time of entering the peritoneal cavity, or when dissecting the bowel from the uterus for gaining access to make an incision, or when an incision extends on to the adherent bowel. Bowel injury can be avoided by careful sharp dissection of adherent bowel, avoiding haste in opening the peritoneal cavity, especially in women who have had previous abdominal surgery, and by employing a vertical incision. Whenever the uterine incision is involved in an extension into the broad ligament, loops of bowel should be kept away while suturing and checking for injury. Small bowel injury When an injury to the bowel is suspected or recognized before delivery of the fetus, the area should be marked with a stitch and covered with a moist abdominal pack. The site should be inspected for repair after the uterine incision is closed.118 Management depends on the size, depth and number of injuries and the vascularity of the involved segment of the bowel. Small serosal injuries can be left alone. Larger serosal defects should be sutured using 2-0 or 3-0 absorbable or non-absorbable suture, keeping the suturing line perpendicular to the axis of the bowel. When fullthickness injuries are encountered, either a single-layer or double-layer closure is advised. A single-layer closure, using a delayed absorbable monolament, with the knots within the lumen of the bowel, has been shown to allow greater blood ow, decreased inammation and greater lumen size compared to a double-layer closure.120,121 An end-to-end anastomosis after resection is required when greater than one-half of the circumference of the bowel is involved, or when blood supply is compromised or when the injuries are over multiple sites. A general or colorectal surgeon's help is essential in managing these injuries. Systemic antibiotics are not usually required. Early feeds with clear uids are recommended.118 Large bowel injuries These injuries are managed in the same way as small bowel injuries. Randomized studies have shown that penetrating injuries of the large bowel can be managed by primary closure, regardless of the amount of faecal contamination. A colostomy is no longer considered necessary for patients with large bowel injury. Drains are not usually necessary, and systemic antibiotics should be started intraoperatively.118

42 K. R. Hema and R. Johanson

CONCLUSION The safety of caesarean section can be improved by adopting proper basic techniques, combined with evidence based developments covering a number of aspects of care. Joel Cohen's incision, single-layer closure when feasible, and non-peritonealization are currently recommended. This is a eld which warrants further research. The CAESAR study will hopefully answer some questions. Clinicians and patients should be encouraged to participate in current and future research developments. Caution is necessary whenever repeat caesarean sections are performed, and there should be early senior involvement in complex cases. Anticipation, proper planning and preparation are key steps in achieving good results.

Acknowledgements
The assistance of the North Staordshire Medical Institute librarians, led by Irene Fenton, is appreciated. We are also grateful to Claire Rigby, Clinical Governance Support Ocer, for preparing this manuscript, and to Nicola Leighton and Linda Lucking (supported by West Midlands Clinical Trials Grant) for assistance with reference management.

Practice points Caesarean section key points . prophylactic antibiotics . Joel Cohen's incision . deliver the placenta by continuous cord traction . leave the uterus in for repair . single-layer closure of the uterus, if feasible . no reperitonealizing

Research agenda . the position of the patient whilst performing the caesarean section to check whether lateral tilt is absolutely essential . whether preoperative antibiotic irrigation of the vagina is helpful in reducing the incidence of post-operative endometritis and wound infection . whether prophylactic antibiotics are necessary for elective caesarean sections where the baseline infection rates are very low . whether exteriorization of the uterus after delivery should be practised . whether routine swabbing of the uterine cavity after placental delivery is essential . the best suture material to perform a satisfactory sub-cuticular suture of the wound

Techniques for performing caesarean section 43

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