18.10 Which kind of Caesarean section?

Caesarean section is the commonest emergency procedure in a district hospital. If you are inexperienced it will also be the one which you will be most frightened of doing. In unskilled hands it is often fatal, as the result of: (1) the inhalation of gastric contents, (2) the supine hypotensive syndrome, (3) haemorrhage, or (4) sepsis.

There are several kinds of Caesarean section:

(1) Classical Caesarean section, is done through a vertical incision in the upper segment of the uterus (18.12). It is largely outmoded, but there are some rare occasions when it may be indicated.

(2) A lower segment Caesarean section approaches the uterus through a transverse incision in the peritoneum over the lower segment. It has long been the standard operation because: (a) a scar here ruptures ten times less often than the scar from a classical incision, (b) when it does rupture it does so less dangerously, (c) the incision in the uterus heals better, (d) the danger of spreading infection is reduced, (e) the placenta is less often directly underneath the uterine incision, (f) the gut is less likely to stick to the scar in the uterus, and (g) there are fewer postoperative complications.

But: (a) A lower segment operation needs more skill. (b) It is dangerous if there is intrauterine infection, although less so than a classical one. (c) You may injure the patient’s bladder. (d) Bleeding from the ends of the incision is more difficult to control, especially if there are lateral extension tears, as may happen if the lower segment is thin and distended, or the baby is an awkward position, as in a transverse lie. These tears may bleed severely, and in trying to control bleeding you may tie or cut her ureters. (e) You may find it difficult to extract a distorted presenting part through a lower segment incision, and tear it as you do so. A tear will be dangerous, and the only way to avoid one, once you have begun a lower segment operation, is to extend it as an inverted–T incision. Unfortunately, this does not heal well, and is a very bad incision to have to make. So only make the standard transverse incision if it is safe. It is because of these dangers, that we describe the following three alternatives:

(3) The de Lee incision (18.9) is a vertical incision, two-thirds of which are in the lower segment, and one-third in the upper one. It is thus a cross between the classical upper segment operation, and the ordinary lower segment one. Make a de Lee incision if a lateral tear is likely, as can happen if the lower segment is very thin, or the baby is in an abnormal position, as in a transverse lie.

(4) A transverse incision in the upper segment is occasionally needed if there is a transverse lie, or a contraction ring (Bandl’s ring).

(5) Extraperitoneal Caesarean section (18.13) is indicated if there is established or potential intrauterine infection. It greatly reduces the incidence of peritonitis, especially if you do not have antibiotics, particularly metronidazole.

(6) Caesarean hysterectomy is occasionally necessary for rupture of the uterus (18.17), when you have to remove the uterus (usually subtotally), and the baby (usually dead). It is also occasionally indicated when the lower segment is severely bruised, or major uterine vessels have been torn, or there is is established or potential uterine infection.

If you enter the abdomen through a lower midline incision, you need not decide whether to do a standard or a de Lee operation, until you get inside. But, if you are going to do an extraperitoneal Caesarean section, you will have to decide to do this before you open the abdomen.