Seminar Evidence Based Obstetric & Gynecology POGI Cabang Surabaya 17 Juli 2016 - Pullman Hotel Surabaya

1. MODERN APPROACH to the
CESAREAN SECTION
TECHNIQUE
(Evidence Based)
Agus Sulistyono

2. GENERAL PROCEDURE
Preparation, Indication
Assessment of presenting part, FHR
Anasthesia regional vs general
Identification of incision site
Transverse
Vertical
Opening cavum abdomen
sharp
blunt

3. GENERAL PROCEDURE
Uterine incision
Transverse - Low segmen
Longitudinal – low, high
Rupturing amnionic sac
Delivery the baby
Cutting umbilical cord
Removing placenta
manual vs gentle traction

4. Suturing uterine incision
exterioritazion vs intra abdomen
1 vs 2 layer suture
Closing cavum abdomen
peritoneum  suturing vs non suturing
rectus sheath
Subcutan tissue  suturing vs not
Skin closing
sub cuticuler vs interupted
GENERAL PROCEDURE

5. - Access to anticipated
pathology
- provide adequate
exposure
- allow for extension
CHOICE OF INCISION
- interfere minimally with abdominal wall function
- preserving important abdominal structures
- heal with adequate strength
- reduce the risk of wound disruption
- subsequent incisional hernia.

6. Considerations in selecting the
incision :
Need for rapid entry
Certainty of the diagnosis
Body habitus
Location of previous scars
Potential for significant bleeding
Cosmetic outcome

10. TRANSVERSE VERTICAL
Rapid Better
Exposure Better
Wound strength Better
Adhesion formation Lower
Postop bowel obstruction Lower
Pain Less
Bleeding Less
Nerve injury Less
Impact on pulmonary function Less
Cosmetic Better
Wylie,BJ et al, Obstet Gynecol,2010; Brown SR, et al. Cochrane Database Syst Rev,2005
INCISION TYPE

11. SKIN INCISION
SIZE OF INCISION
Adequate for delivery of the fetus
 less traumatic
 allow delivery term fetus
 ± 15 cm
Adequate exposure
 stretch manually apart  opening the
incisions angles
Scalpel vs electro-cauter
 no RCT
 prefer scalpel (either approach is acceptable)

13. DISSECTION of SUB-CUTAN TISSUES
Prefer blunt than sharp dissection (no RCT datas)
 quicker
 less injury to vessels (bleeding)
FASCIAL LAYER
Transverse incision & extended laterally
- with scissors (Pfannenstiel)
- with fingers  bluntly (Joel-Cohen / Misgav-
Ladach)

14. SUBCUTANEUS
TISSUES

15. OPENING PERITONEUM
BLUNT (FINGER) VS SHARP (PINCET & SCISSORS)
- data RCT  not significant different in morbidity &
mortality
Blunt (theoretical)
 minimize risk of injury to bowel, bladder or other
organ that addherent to peritoneum
Dense intra-peritoneal adhesions
 bluntly opening
 to upper abdomen (avoid dense area/scar
tissue)
 sharply opening
 cautiously
 using shallow incisions

16. TRANSVERSE vs VERTICAL
 no RCT
 principle :
 the incision ~ all atraumatic fetus
delivery
 FACTORS :
 fetus (EFW, position)
 placental location
 presence of myoma
 development of LUS
OPENING PERITONEUM

18. INTRA ABDOMINAL PROCEDURES
BLADDER FLAP
Undergo bladder flap vs no bladder flap
 no RCT
 morbidity (bladder injury ) ~
 NO BLADDER FLAP
 quicker
 less bleeding
 BLADDER FLAP
 fetal head deep in the pelvis
 bladder attached above LUS (post SC)
 LUS not formed (not in labor)

19. HYSTEROTOMY
Be aware :
 placental location (avoid
laceration)
 fetal lie (delivery the fetus)
head deep in the pelvis
 prolonged labor & head deep
in the pelvis
 avoid incision too low LUS
 may transect Cx / vagina

20. Uterine Incisions
Kerr Incision vs Sellheim Incision vs Classical

21. TRANSVERSE INCISION :
 recommend for most SC
 LUS
 less blood loss
 less bladder dissection
 easier reapproximation
 lower risk rupture in VBAC
 RISK of laceration of major blood
vessel (extended)
 problematic if required larger
incision

23. INDICATIONS OF CLASSICAL
CAESAREAN SECTION
1. when the LUS is abnormally vascular.
2. when the LUS can not identified due to adhesion.
3. Cases needs rapid delivery.
4. When the fetus lie is transverse and can not be
corrected.
5. When hysterectomy will follow caesarean section
6. Poorly developed LUS when more than normal
intra-ut manipulation is anticipated
7. LUS pathology (myoma, PPT anterior or accreta)
8. Post-mortem delivery

24. Advantages of the lower segment:
• The wound is extra peritoneal so less
risk of infection.
• Healing scar is better.
• The risk of rupture of the scar is less.
• Hemorrhage is less.
• Placenta is away from the incision.
• Easier reapproximation
• Less need bladder dissection

25. DISADVANTAGES OF THE LOWER SEGMENT:
The operation requires more skill and experience.
The incision may extend down to the bladder.
Lateral extension  risk laceration major blood
vessels
J or T incision: if need large incision  weaker scar
DISADVANTAGES OF CLASSICAL OPERATION:
More liable to chest infection.
More liable to intestinal distension.
The scar is more liable to rupture (next pregnancy).

26. • HYSTEROTOMY EXPANSION
Blunt (finger) vs sharp (scissors) Extended the
incision
Blunt :
- Fast
- less risk trauma to fetus
- less blood loss, lower drop in Hb and HCT
postpartum
- less risk of unintended extension (RR 0,47;
95%CI 0,28-0,79)

27. BLUNT HYSTEROTOMY EXPANSION

28. FETAL
EXTRACTI-
ON

29. CORD CLAMP
Early Cord Clamping
Delayed Cord Clamping
Milking Cord

30. PLACENTAL EXTRACTION
DRAIN vs NOT DRAIN umbilical cord before placental
extracrion :
Drain  less fetomaternal transfusion
only small trial
GENTLE TRACTION vs MANUAL EXTRACTION :
MANUAL EXTRACTION :
Endometritis post-partum > (RR 1,64 95%CI 1,42-
1,90)
blood loss > (mean difference 94 mL, 95%CI
17-172mL)
blood loss > 1000mL > (RR 1,81 95%CI 1,11-2,28)
lower postpartum Hematocrit
Cavum uteri : wiped with gausge sponge
- remove remaining membrane

32. EXTERIORIZING vs INSITU UTERINE REPAIR
EXTERIORIZING
 improve uterus exposure
 facilitate closure uf hysterotomy
 shorter time
 Post-op nausea & vomiting
 other complication ~

33. UTERINE
EXTERIORIZING

34. CERVICAL CANAL
Routine manual/instrumental Cx
dilatation
- unnecessary both labor or not
laboring
- Hb post-op ~
- fever ~
- wound infection ~

35. SUTURING
Choice of suturing ~ personal preference
Chromic catgut vs delayed absorbable
 not difference in maternal outcome
Chromic, monofilament (monocryl), braided
(vicryl),
LOCKED vs UNLOCKED CLOSURE
LOCKED SUTURE:
scar weakness >
thinner myometrial
bell shaped wall defect
 dehiscence / rupture >
but data are limited

36. PARAMETER LUS CLOSURE
SINGLE DOUBLE
Operative time Less 6’ shorter
Endometritis ~ ~
Wound infection ~ ~
Blood transfusion ~ `
Thick LUS better
Uterine rupture (next
pregnancy)
4,8% 2,9% Not significant
Risk bladder
adhesion
> Need further
study
SINGLE vs DOUBLE LUS CLOSURE
(20 STUDY INCLUDING 15.000 PATIENTS)

37. ABDOMINAL IRRIGATION
 maternal infection : not reduced
 Increased intra-op nausea
 estimated blood loss ~
 operating time >
 hospital stay ~
 return GIT function ~

38. PERITONEUM
CLOSURE vs NON CLOSURE (533 women)
NON CLOSURE :
decreased operating time (± 6’)
on repeat CS
adhesion ~
time incision – delivery ~

39. NON CLOSURE PERITONEUM
 Less time
 Less post operative fever
 Less post operative analgetics
 Less wound infection
 Less of length of hospital stay

40. RECTUS MUSCLES
Reapproximate naturally
Not need suturing
SUTURING :
increased pain (first start moving)
decreased dense adhesion formation

41. FASCIA :
the most wound strength
avoid to much tension since approximation
not strangulation
MIDLINE FASCIAL INCISION :
- simple running technique
- no 1 or 2 delayed absorbable monofilamen
- mass closure, all laye of the abdominal wall
- wide tissue bites (≥ 1 cm)
- short stitch interval (≤ 1 cm)
- non strangulation tension suture
TRANSVERSE INCISION :
- continuous closure
- slow absorbable no 0 or 1 braided suture

43. SUBCUTANEUS TISSUE
Not need irrigation
Closing with interrupted delayed absorbable
if subcutaneous layer ≥ 2 cm
inhibit blood and serum accumulation
WOUND DRAINAGE
routine use  not beneficial
not reduce :
seroma
hematoma
infection
wound disruption

44. SKIN
STAPLE vs SUBCUTICULER SUTURE
STAPLE :
increase infection and separation
shortening operating time (only few
minutes)
post-op discomfort >
cosmetic appearance ~

45. PFANNENSTIEL PELOSI-TYPE JOEL-COHEN MISGAV-LADACH
Incision Pfannenstiel Pfannenstiel Joel-Cohen Joel-Cohen
Sub-cutan tissue Electro cauter Open 3 cm Open 3 cm
Fascia dissection Transverse, sharp Electro-cauter Transverse, blunt
lateral extended
Transverse, sharp
(semi open
scissors)
Rectus musle
dissection
sharp Blunt Blunt Blunt
Peritoneal
opening
Longitudinal,
sharp
Blunt (finger &
all layer
stretched
manually
Blunt (finger &
all layer
stretched
manually
Blunt (finger &
all layer
stretched
manually
Reflected
bladder
inferiorly
(+) (-) (+) (-)
SUMMARY

46. PFANNENSTIEL PELOSI-TYPE JOEL-COHEN MISGAV-
LADACH
Uterine opening Transverse LUS Transverse LUS,
blunt lateral
extended
Transverse LUS,
blunt lateral
extended
Transverse LUS,
blunt lateral
extended
Uterine closing 2 layers,
continuous
Single layer
continuous
locking
Interrupted
sutures
Single layer
locking sutures
(exteriorization)
Peritoneal suturing (+) (-) (-) (-)
Fascia suturing Continuous
/interupted
Continuous non
locking
Continuous non
locking
Continuous non
locking
Sub-cutan layer
suturing
(+) (+) in thick (>2
cm)
(-)
Skin Continuous
/interupted
Staples 2-3 mattres
sutures
Others Placenta
removed
manually
Allis clamp (5’)

47. RECOMMENDATION
Procedure Type of Preocedure Grade
Incision abdominal wall Transverse 2 C
Skin incision Scalpel ~ cauter Personal preference
Open peritoneum Blunt -
Bladder flap No -
Hysterotomy Transverse 2 C
Expansion hysterotomy Blunt 2 B
Placental extraction Spontaneous 1 A
Uterus exteriorization Both acceptable Personal preference
Uterine closure 2 layer (if VBAC in next
pregnancy)
2 C
Closing peritoneum Not closing 2 B
Subcutan tissue closure Closure (if s.c. tissue ≥ 2 cm) 1 A
Skin closure Subcuticular suture 2 C