The indications as to when to do Caesarean section are discussed in Sections 18.1, 18.2, and 18.4, and in M 22.12. Here we are concerned with what kind of Caesarean section you do. One indication which is not accepted, is the need to tie a mother’s Fallopian tubes. There are easier and safer ways of doing this (15.3).
Always do the ordinary lower segment operation unless one of these others is indicated.
CLASSICAL SECTION is indicated if neither a lower segment operation, nor a transverse incision in the upper segment are possible (unusual). This may happen if: (1) The lower half of the patient’s upper segment is very vascular, or inaccessible as the result of adhesions from a previous operation joining her lower segment to her abdominal wall. (2) She has had a previous classical incision, which has healed poorly. (3) She has a very vascular lower segment, with many thick veins on it. This may occur with placenta praevia (Type Four, or Types One or Two if the placenta is anterior), or it may sometimes occur with a normally placed placenta. She will bleed much, if you do a lower segment incision in a uterus like this, so a classical one is better. (4) A poorly developed lower segment which does not allow a transverse incision of adequate length. For some special points concerning Caesarean section in placenta praevia, see Section 18.10. (5) You are very inexperienced indeed. Alternatively, make a transverse incision half-way up her upper segment, and as you gain experience, transfer the incision to her lower segment. (6) As a preliminary to Caesarean hysterectomy.
CAUTION! Don’t let her wish to have her tubes tied favour the decision to do a classical section.
DE LEE SECTION. Do this if her lower segment is likely to tear, because it is thin and distended, or because there is a transverse lie.
EXTRAPERITONEAL SECTION. Do this if the contents of her uterus are infected and antibiotics are scarce.
