Review of techniques ofLSCSVeerendrakumar C.M MD.,DNBVIMS, Bellary
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.
Caesarean has evolved over centuries. It has meant different things to different people at different times. Dead mother dead baby Dead mother live baby Live mother live baby Healthy mother healthy baby Healthy mother, healthy baby & healthy pelvic floor.
Timing of antibiotic administrationNICE 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.
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.
Skin preparation Shaving results in microscopic nicks and tears of the epidermis Actually increases the risk of skin infection unless done immediately preoperatively. Surgical obstetrics 1992
Betadine sprayBefore shifting to OT abdomen cleansed and betadine spray applied operating area covered with sterile drape Prepackaged adhesive draping
Incision Pfannensteil Joel cohen Midline vertical Supraumbilical in morbidly obese Am J obst gynecol 2000
Abdominal incisionNICE RECOMMENDATIONS The 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
Meticulous attention toplacement of skin incision Allis clamp test Am J Obst Gynecol 1991
Abdominal exposure Tubular plastic retractor with a rolled edge
Uterine incision -CLASSICALLY - several centimetres below the UV fold - just below the UV fold
Uterine incisionNICE RECOMMENDATIONS When 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
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
E R R-for extraction of the head Elevation Rotation Reduction Cho, OBG management 2003
Difficult cranial delivery Thinking ahead is a great boon keep relaxants ready Vaccum/short forceps/vectis Keep asst ready for ‘Passing it up” technique
Delivery of the babyNICE 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]
Delayed cord clamping Suggested benefits of delayed cord clamping include decreased neonatal anaemia; Better systemic and pulmonary perfusion; and better breastfeeding outcomes. Possible harms are polycythaemia, hyperviscosity, hyperbilirubinaemia, trans ient tachypnoea of the newborn and risk of maternal fetal transfusion in rhesus negative women.
Delivery of placentaNICE RECOMMENDATION Oxytocin 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.
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.
EXTERIORISATION OF UTERUS"Misgav Ladach" Cesarean Section
Extra-abdominal versus intra-abdominalrepair 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
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
Uterine closure auto stapler preloaded with dissolving copolymer staples made of polylactic and polyglycolic acid Incises and staples the myometrium in single action No advantage -cochrane review 2006 May be of use in fetal surgery
Closure versus non-closure of theperitoneum 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
NICE RECOMMENDATION Routine 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
NICE RECOMMENDATION Women having a CS should be offered thromboprophylaxis as they are at increased risk of venous thromboembolism.
CAESAR trial european study3000 women recruited 2x2x2 factorial multicentric RCT Single- versus double-layer uterine closure. Closure of the peritoneum Liberal versus restricted use of a subsheath drain.
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.
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.
CORONIS2x2x2x2x2fractional factorial randomisedTRIAL in developing countries 15936 women Blunt versus sharp abdominal entry Exteriorisation of the uterus for repair versus intra- abdominal repair Single versus double layer closure of the uterus Closure versus non-closure of the peritoneum (pelvic and parietal) Chromic catgut versus Polyglactin-910 for uterine repair
ReferencesTHE COCHRANE LIBRARY Cochrane Database of Systematic ReviewsNICE GUIDELINESIssued: November 2011NICE clinical guideline 132