LOWER SEGMENT CAESAREAN SECTION

INDICATIONS. See Section 18.8.

PREOPERATIVE COUNSELLING. Where appropriate, discuss with the patient the advisability of tying her tubes. Her husband, or in some cultures her mother, or preferably both, should consent. The indications are: (1) >2 previous Caesarean sections. (3) Parity >6. (4) Age >35. (5) Medical problems which endanger her life, such as hypertension, diabetes, or heart disease.

PERIOPERATIVE ANTIBIOTICS have been shown to halve the incidence of wound infection after Caesarean section. Most routines are expensive, but here is a cheaper one which is equally effective.

If she is at special risk of infection (membranes ruptured for more than 8 hours, or if you are operating after a failed vacuum or forceps delivery, etc.) give her perioperative chloramphenicol and metronidazole as in Section 2.9. Continue metronidazole for 3 days postoperatively.

If she is a routine case, give her 1 g of metronidazole with the premedication as a rectal suppository or as rectal tablets, and give her another gram 8 hours later.

ASSISTANT. Find yourself a competent assistant. If the head is impacted in her pelvis, ask him to wear two gowns and two pairs of gloves, so that he can disimpact it and then discard the first pair (see below).

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Figure 18.14: CAESAREAN SECTION—ONE. A, catheterizing the patient’s bladder. B, preparing her abdomen. C, draping her and covering her with an abdominal towel. D, incising the skin. E, picking up a fold of peritoneum to feel if there is any gut in it. F, incising her peritoneum. G, enlarging the opening in her peritoneum with scissors.

A MIDWIFE TO RECEIVE THE BABY. Before you begin make sure that there is a midwife ready to receive the baby, with all the equipment that she needs to resuscitate him (19.12).

EQUIPMENT. Use the Caesar set described in Section 4.12. This includes a large round-ended Doyen’s retractor to fit over the bladder and protect it (or use a wide Deaver’s or a Morris retractor), and 6 Green Armytage forceps (use sponge–holders if you don’t have these). You will need ‘1’  chromic catgut for the uterus, 2/0 catgut for the peritoneum of her vesico–uterine pouch, monofilament for her abdominal wall, and two round-bodied Mayo’s needles, a large one for the first layer and a smaller one for the second. A narrow 20 cm steel ruler to measure the true conjugate. The anaesthetist must have a syringe of ergometrine with oxytocin (‘Syntometrine’) or plain ergometrine ready. You and he will both need suckers.

PACKS. Five or six large abdominal packs with tapes. NEVER use single swabs, you can too easily lose them in the peritoneal cavity!

ANAESTHESIA is discussed in detail in Sections 18.2 and in A 6.9 and A 16.6. You have a choice of: (1) Several methods of local anaesthesia (A 6.9). (2) Ketamine (A 8.1). (3) General anaesthesia (A 16.6) for which she must be intubated (A 13.3). (4) Subarachnoid (spinal) anaesthesia is satisfactory, provided you know the method and its complications in detail (A 7.1), you put up a drip and give her 1–2 litres of fluid fast, you tilt her to the left, and you observe the contraindications, which are: shock, severe anaemia, hypertension, and heart disease. An augmented saddle block is the safest form of subarachnoid anaesthesia (see below).

If your anaesthetist is an expert, general anaesthesia with cricoid pressure and tracheal intubation will be best (A 16.5), especially if her circulation is unstable due to an APH, or advanced obstructed labour.

If she is shocked, and you are inexpert, and single- handed, local infiltration (A 6.9) will be the safest.

If she is not shocked, an augmented saddle block (A 7.7) is suitable, particularly if you are single-handed. An ordinary saddle block is inadequate, because it does not extend high enough. You need to combine it with local infiltration of the abdominal wall, as in Primary Anaesthesia Fig. 7-8.

Explain what is going to happen. Put her on to the operating table before you induce her.

PREVENTING THE ACID ASPIRATION SYNDROME. Don’t assume her stomach is empty because she has not taken food for a long time. Labour slows stomach emptying. If she has a general anaesthetic, she is in particular danger from the acid aspiration syndrome (A 16.3). Remove her gastric contents with a stomach tube, give her 30 ml of magnesium trisilicate mixture, or 0.3M sodium citrate within 15 minutes of induction, and then leave a Ryle’s tube down. You cannot give her sodium citrate prophylactically throughout labour. If she is given a general anaesthetic, she must be intubated using cricoid pressure (A 16.5).

If possible, as prophylaxis against acid aspiration, give her ranitidine 50 mg intramuscularly 1 hour before an elective section, or by slow intravenous injection immediately before an emergency section. Or, if you expect to section her, give her 150 mg by mouth at the onset of labour and then every 6 hours.

POSITION. Stand on her right side. Prevent the supine hypotensive syndrome by tilting her about 5\ensuremath{^\circ } to the left (A 16.6). Do this, either by tilting the table, or by putting a pillow or sandbag under her right buttock. Find some way of preventing her slipping off the table. A moderate Trendelenburg position will give you better access to her lower segment, and make delivering the baby’s head easier, if there is a vertex presentation. It will also be an additional safeguard if she vomits.

PREPARATION. Catheterize her in the theatre while she is still awake, and leave the catheter in (A, in Fig. 18-11). You can also do this in the maternity labour unit. At the same time, do a vaginal examination to make sure you do not miss unexpected progress, and thus the opportunity to do a vaginal delivery if this is indicated.

If you have difficulty catheterizing her bladder before operating, raise the baby’s head with your hands. If you fail to pass a rubber catheter on the first occasion, try again after she is anaesthetized, when pushing up his head will be easier. If you have to operate with a full bladder, be very careful as you open her peritoneum. Open it as far cranially as you can, opposite the upper quarter of the incision through her abdominal wall, and empty her bladder with a syringe from her abdomen.

Shave or clip her from her mons pubis to above her umbilicus, and laterally to her iliac crests (optional). Prepare the skin of her lower abdomen (B), drape her with 4 plain towels, and cover these with a towel with a slit in it (C).

LOWER MIDLINE INCISION. Cut through her skin and subcutaneous tissue down to the level of her rectus sheath (D). Extend the incision to within 3 cm of her umbilicus. Try not to carry the incision further down than the upper limit of her pubic hair.

If she has had a previous Caesarean section, see Section 18.10.

Separate her rectus and pyramidalis muscles in the midline as far as her symphysis. If necessary, extend the skin incision further down. A short downwards extension is more effective in improving access than an extension upwards.

Use sharp and blunt dissection to expose her transversalis fascia and her peritoneum. Use two haemostats to pick up peritoneum near the upper end of the incision (E). This is especially important if her labour is obstructed, and her bladder is displaced upwards. Feel the fold of peritoneum you have picked up, to make sure there is no bowel or bladder in it. Make a small opening in it with a scalpel (F), and then open the rest of it with scissors (G), longitudinally from above downwards to just above the reflection of her bladder. If you hold her parietal peritoneum with a light shining through it, you will see a constant small vein running transversely across it. If you avoid this, you will avoid her bladder. If her bladder is high deviate to the side of the midline.

CAUTION! If she has had a previous operation, including a previous Caesarean section, omentum or gut may have stuck to her abdominal wall, so that you can easily cut them. If you cut her gut by mistake, sew it up as in Fig. 9-6. If she has had several previous Caesarean sections, her anatomy will be much distorted by adhesions.

Clamp any active bleeders if they are big, but postpone tying them until later. They usually stop bleeding on their own.

Feel her uterus to find how it is rotated, and identify the presenting part. It is usually rotated to the right, so that her left round ligament is usually more anterior and closer to the midline than the right one. If her uterus is markedly rotated, turn it towards the midline.

Place a large abdominal pack on each side of her uterus, to keep her gut out of the way. Attach artery forceps to the tapes of these packs, to prevent them being lost.

THE CLASSICAL ALTERNATIVE. Consider doing a classical rather than a lower segment section if: (1) her lower segment seems abnormally vascular, or (2) it is abnormally adherent to her anterior abdominal wall. If you decide to do one, see Section 18.12.

THE De LEE ALTERNATIVE. Consider doing a de Lee incision if: (1) Her lower segment is so thin and distended, that it might tear when you extract the baby. (2) She has a transverse lie with a prolapsed arm, and a live baby. (3) A lower segment fails to form, as may happen with a premature delivery in a primip. To make a de Lee incision, incise her visceral peritoneum transversely, as described below but high on her lower segment. Mobilize her peritoneum and her bladder well down. Find the midline of her uterus. Insert a small transverse suture where the bottom end of your incision is going to be, to prevent it extending downwards behind her bladder. Make a longitudinal incision, two-thirds of it in her lower segment, and one-third in her upper segment.

Later, repair a de Lee incision, with two layers of continuous chromic No. 1 or 2 catgut. Make sure you include her uterine fascia in the second layer, or it will continue to bleed. Repair her peritoneum, and pull it up high, so that the top of the incision is covered. If you incised her upper segment over a long distance, tie her tubes on the same indications as in a classical Caesarean section.

THE ALTERNATIVE OF A TRANSVERSE INCISION IN THE UPPER SEGMENT may be necessary if there is a transverse lie or a contraction (Bandl’s) ring. Check that her uterus is wide enough. Incise her peritoneum over the lower part of its upper segment with a scalpel. Mobilize it away from the incision with scissors, and incise her uterus transversely in the midline. Enlarge the incision to the right and left, by stretching it with your fingers (it is usually too thick to be cut with scissors), and deliver the baby by breech extraction.

Repair the incision in two layers with continuous chromic No. 1 or 2 catgut. Don’t catch the full thickness of her uterine wall in the first layer: it is often too thick. Repair her peritoneum over the incision, preferably with a locking stitch. Tie her tubes.

ORDINARY LOWER SEGMENT CAESAREAN SECTION

If her baby’s head is jammed in her pelvis and needs to be disimpacted from below, ask yourself if a symphysiotomy would not have been better, and remember this next time! Ask your assistant to put his hand into her vagina, and to disimpact it to the site where you are going to make your incision. He must do this before you incise her uterus. If he waits until after you have incised it, the baby’s shoulders may prolapse into the wound, and make delivery difficult. Having done this, ask him to take off his second gown and gloves (see above). Unfortunately, it is difficult to predict that the head needs disimpaction, until after you have opened the uterus.

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Figure 18.15: CAESAREAN SECTION—TWO. H, pick up the peritoneum of the patient’s vesico-uterine pouch with dissecting forceps and cut it. I, put the scissors into the cut, and open them, so as to separate her peritoneum. J, as you reach the edge of her uterus, cut in a more cephalic direction. K, raise the lower fold of peritoneum with her bladder in it. L, put a strong stay suture in her uterus. M, incise her uterus. N, liquor will spurt out. O, put your fingers into the incision and lengthen it.

Pick up the loose peritoneum of her vesico–uterine pouch with dissecting forceps (H). Make a small cut in the peritoneum over her uterus, just below the point where the loose peritoneum becomes firmly attached to the anterior wall of her uterus. This is the abdominal marking of her lower segment. Then put the scissors into the cut, and extend the incision in her peritoneum to left and right, so as to separate it from her uterus underneath (I). As you reach the edges of her uterus, aim the scissors in a more cephalic direction, so that the incision in her peritoneum is curved (J). Aim to leave a bare area about 2 cm wide and 12 cm long. Don’t cut into the muscle of her uterus yet.

Use a swab in a holder, or on your finger, to separate the folds of peritoneum on either side of the incision, pressing on her uterus as you do so. This will help to separate her tissues in the right plane, and avoid tearing her peritoneum, or her bladder.

Raise the lower fold, and her bladder with it for about 3 cm (K).

CAUTION! (1) Take great care to avoid injuring her bladder, especially if this is pulled up high and is oedematous. (2) Don’t raise it more than 5 cm. If her cervix is effaced and dilated, you may enter her vagina by mistake.

Put the Doyen’s retractor over her bladder, to protect it for the rest of the operation.

Put a stay suture of 2/0 catgut or monofilament into her lower segment (L), and hold the end of it in a haemostat.

Ask your assistant to hold up the stay-suture. A short, full-thickness central incision minimizes the danger of cutting the baby. If you extend it shallowly on either side, the uterus will tear open in the right direction. So, make a 3 cm horizontal incision through the uterine wall in the midline, just above the stay suture (M). Cut only the centre of her lower segment. This should be 2 cm below the peritoneal reflection, and at least 2 cm above her detached bladder. Put a finger either side of the incision and press as you cut (not shown). This will help you to judge how deeply you are cutting. Deepen it little by little until the membranes bulge into the incision. Cut through them (some operators keep them intact at this stage).

Liquor will spurt out (N). Ask your assistant to suck it away. Insert your closed scissors through the incision, and open them, so as to extend it enough to let you insert both your index fingers. Lengthen the incision by pulling them apart laterally, in the line of the muscle fibres, until it is 10 cm long (O). Her uterus will open naturally, with a curve upwards at each end. If she has had previous Caesarean sections, and her uterus is very fibrotic, you may have to extend the incision with scissors, curving it upwards laterally. Ask your assistant to suck it dry.

Alternatively, and most contributors would say preferably, make a scalpel incision for 2 cm in the midline, without cutting the membranes. Use scissors to cut the uterus, leaving the membranes intact until the incision is complete. Cut in an upward curve from the midline to the left angle of the uterus, and then in a similar curve from the midline to the right angle. If her uterus tears, the tear will then be more likely to run away from the cervix than towards it.

CAUTION! (1) The lower segment varies considerably in thickness. It is thick before labour and becomes thinner during labour, so be careful not to cut the baby. Protect him with a finger between the membranes and her uterine wall as you cut. (2) Don’t make the incision too small, or the uterus will tear as you remove his head. (3) Should you decide to enlarge the incision by cutting, curve it upwards at its ends, so as to avoid the uterine vessels. Also, when you suture it, you will be less likely to suture her ureters.

If she has a scar in her lower segment from a previous Caesarean section, make a shallow cut along it, where you want the rest of it to tear.

If you can feel the baby’s vertex through the uterine wall, the placenta is probably lying in the fundus or posteriorly, so you can expect to deliver him without difficulty.

If you cut the placenta as you cut into the uterus, try to detach it, and deliver him round it. Only cut through it if you have to. He can bleed severely from a cut placenta, so clamp his cord quickly. See also Section 18.10.

If the ends of the incision in the lower segment bleed severely, before he has been delivered, quickly deliver him, and then control bleeding as described below.

If there are large veins over her lower segment, incise it precisely and carefully, and deliver him rapidly. The veins will probably stop bleeding as soon as you have delivered him. If necessary, clamp them and insert further haemostatic sutures.

DELIVERING THE BABY AT CAESAREAN SECTION

Remove the Doyen’s retractor. Put your finger (only) into the uterus under the baby’s head to relieve the vacuum, and make it easier for his head to rise in the incision. Then put your hand outside the lower flap of the incision, and lift his head up. If necessary, apply Wrigley’s forceps (P). If, when you apply them, the incision is not long enough to deliver him without a lateral tear, extend its ends upwards and laterally with scissors, so as to make a U–shaped flap.

Contributors differ in the way they deliver the head. Some think that you should not put the bulk of your hand into the uterus, because it may cause tears. In practice most do, because it is quicker than forceps.

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Figure 18.16: CAESAREAN SECTION—THREE. P, if necessary, apply Wrigley’s forceps. Don’t put your whole hand into the patient’s uterus, the extra bulk of your hand may tear it. Q, place the baby on his mother’s thighs and resuscitate him as in Section 19.12. R, put clamps on the angles of her uterus, and on any major bleeding points. S, remove her placenta by controlled cord traction and fundal pressure, but wait until her uterus is contracting first. T, start suturing just lateral to the ends of the incision. U, closing the second layer. V, closing the peritoneum.

Now ask your assistant to press on the fundus to assist delivery. He may have to press hard. Do this carefully and gently, without hurrying. Before you deliver the baby’s thorax, aspirate his nose and mouth, if convenient. Then deliver his shoulders and trunk.

CAUTION! Don’t try to suck him out with a big Yankauer sucker: it may injure him. Resuscitate him as in Section 19.12.

ERGOMETRINE OR OXYTOCIN. If she has PIH, or eclampsia, or you are operating under local anaesthesia, some operators avoid ergometrine, and give her 5 units of oxytocin intravenously or intramuscularly. Otherwise, give her ergometrine intravenously as soon as you have delivered his head. Ergometrine occasionally makes a conscious patient sick, and may raise her blood pressure.

THE BABY. Before you clamp his cord, hold him up by his legs with one finger of your left hand between them, so that the midwife who is helping you can suck out his nose and mouth. Lay him head downwards between his mother’s thighs (Q). Ask your assistant to put two clamps on his cord and divide it between them, while you care for her wound, especially the angles, which may bleed. In placenta praevia especially, clamp his cord quickly, because he may bleed from the injured sinuses of the placenta. If necessary, resuscitate him (19.12).

CONTROLLING BLEEDING. If you are a quick operator, apply two Green Armytage clamps, one on the upper flap and one on the lower one, just proximal to the angle (R). They will identify the angle for you and allow you to suture it more accurately.

If you are a slow operator apply several Green Armytage clamps (or sponge-holders) all round the cut edges of her uterus, particularly at the angles. Make sure they don’t grasp the posterior wall of her empty uterus, as it lies on the promontary of her sacrum; you can easily do this by mistake if bleeding has been brisk. The difficulty in applying many clamps is that they will get in your way.

REMOVING THE PLACENTA AFTER CAESAREAN SECTION

When her uterus is contracting firmly, remove her placenta by a combination of controlled cord traction and fundal pressure (S). If necessary, help it to contract by massaging her fundus from inside her peritoneal cavity. Pull gently on the cord, and press her uterus back with your left hand. This should deliver the placenta easily. If it has stuck, removing it manually from inside her uterus may cause severe bleeding.

When the placenta is delivered: (1) Inspect her uterine cavity to make sure it is empty. Wipe it dry with a gauze pack to remove pieces of membrane and clots. (2) Make sure that the placenta is complete. If she has a secondary postpartum haemorrhage, you don’t want to have to re-explore her uterus—see ‘Stop Press’.

CAUTION! Don’t probe her cervix to improve drainage—keep out of her dirty vagina!

SUTURING THE UTERUS AFTER CAESAREAN SECTION

Do this in two layers using thick chromic catgut and a large round-bodied Mayo’s needle. Don’t use non–absorbable sutures, particularly not on the inner wall. Ask your assistant to hold the lower edge of her uterus forwards with the stay suture, while you sew from the angles inwards (T). Start the sutures just beyond the right extremity of the incision, work towards the middle, and then start at the left angle. In this way, you secure the angles first.

Alternatively, put a separate stay suture in the right angle, and start a continuous suture from the left angle.

Sew the first layer as a continous running suture. Ask your assistant to hold the free end of the catgut tightly, while you work towards the other end of the incision. Unless the sutures are tight, it will not stop bleeding.

CAUTION! (1) Start suturing just lateral to the angle. (2) Don’t sew the lower edge above the upper one, because this may advance her bladder up her uterus. (3) Don’t include her bladder in your sutures. If you find you have included it, you will probably be wise to leave a catheter in for a few days, rather than removing the sutures and starting again, which will cause severe bleeding. (4) If you suture too deeply with a large needle at the angles of incision, you may obstruct her ureters. (5) Don’t sew the front and back walls of her uterus together. So, before the first layer of stitches is completed, put two fingers into the uterine cavity, to make sure that its walls are free. If necessary, release the sutures and start again. (6) Don’t stitch her gut to the back of her broad ligament. If you are in any doubt, put your fingers down behind it before you start to stitch the lateral extremities of the incision.

COMPLETING THE REPAIR AFTER CAESAREAN SECTION

When the first layer of sutures is completed, make sure again that the ends of the incision are adequately secured. If necessary, put in one or two interrupted sutures, especially if bleeding from the wound continues.

Now start the second layer of continous running sutures (U). Ask your assistant to maintain tension on the stay sutures, so as to show up the edge of her uterus.

Put a large warm pack over her repaired lower segment, and leave it for 2 minutes while you remove the abdominal packs. When you remove it most of the bleeding will have stopped.

Look carefully at your completed sutures. If there is still bleeding, put in some more interrupted or mattress ‘figure of eight’  sutures. Don’t close her peritoneum until you have controlled all bleeding.

When her uterus is no longer bleeding, close the peritoneum of her vesico-uterine pouch with continous sutures of 2/0 catgut (V). Again avoid including her bladder with the lower edge of the peritoneum.

If you are going to tie her tubes (15.4), now is the time to do it. Look for ovarian cysts. If you find one which is >5 cm in diameter, consider ovarian cystectomy (20.7).

CLOSING THE ABDOMEN AFTER CAESAREAN SECTION

Clean all blood and debris from her peritoneal cavity, and especially from her paracolic gutters. They will be much cleaner if you previously inserted abdominal packs (‘lap pads’) beside her uterus. Inspect these by drawing her uterus to the side.

Measure her true conjugate with a steel ruler as in Fig. 18-16. Displace her uterus to the right, and put one end of it on her sacral promontary. Let it rest across her symphysis pubis, and mark the place where it crosses the posterior aspect of her symphysis with your right index finger. Remove the ruler, read off her true conjugate, and record it in her notes and in the summary of labour. It will be invaluable when you come to decide if she should have a trial of scar next time.

Place her greater omentum over her uterus: it will usually reach her bladder. Close her abdomen (9.8). Don’t insert a drain.

Bend up her legs, and press on the fundus to express clot from her uterus and vagina. A uterus full of blood will interfere with retraction and encourage infection; you may later mistake blood in her vagina for a postpartum haemorrhage. Clean out her vagina with a sterile swab on sponge forceps.

As soon as she has recovered from her anaesthetic give her baby to her. This close early contact is important in developing the bond between them. If she has had a local or subarachnoid anaesthetic, she can see him before the operation is over.

POSTOPERATIVE CARE AFTER CAESAREAN SECTION

Estimate her blood loss: it will probably be more than you think. The average loss is 1 litre. Unless you have expert staff, check her vital signs yourself. Check and chart her pulse, temperature, and respiration half-hourly, until she is awake, and then, when her condition is satisfactory hourly for 12 to 24 hours. Continue the intravenous infusion for 24 hours, or until she can take fluids by mouth and bowel sounds are present. Give her 3 litres of fluid in 24 hours (two bottles of 5% dextrose and one of 0.9% saline). Give her pethidine 100 mg up to 4 doses.

If she bled much, arrange for a fast running drip of saline or Ringer’s lactate, and see her yourself in an hour. You will be suprised how often a patient who left the theatre in reasonable condition is now collapsed, because the drip was too slow, or stopped.

CAUTION! Watch for signs of infection: (1) Fever. (2) A large, soft, tender uterus. (3) Tender thickening in her lateral fornices.

If her membranes had been ruptured for more than 24 hours before the operation, or there are other reasons for suspecting infection, continue perioperative antibiotics (2.9) for up to 5 days.

If she has been in obstructed labour and her urine is bloodstained, leave a catheter in her bladder for 5 to 10 days.

If she vomits, or her abdomen becomes distended, start gastric suction.

CAUTION! Before she goes home, make sure that she and her relatives know that she must have future deliveries in hospital—this is ESSENTIAL! She must come regularly for antenatal care. Give her a card which says why Caesarean section was done, and what she should do about her next delivery. Ask her to show this card at the antenatal clinic, when she becomes pregnant again.