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Caesarean Section
Preparation
| 1 |
Review
indications. Check fetal presentation and ensure that
vaginal delivery is not possible. |
| 2 |
Obtain
consent from the patient after explaining the procedure
and the reason for it. |
| 3 |
Check
the patient’s haemoglobin concentration, but do
not wait for the result if there is fetal or maternal
distress or danger. Send the blood sample for type and
screen. If the patient is severely anaemic, plan to give
two units of blood. |
| 4 |
Start
an IV infusion. |
| 5 |
Give
sodium citrate 30 ml 0.3 molar and/or ranitidine 150
mg orally or 50 mg IV to reduce stomach acidity. Sodium
citrate works for 20 minutes only so should be given
immediately before induction of anaesthesia if a general
anaesthetic is given. |
| 6 |
Catheterize
the bladder and keep a catheter in place during the operation. |
| 7 |
If
the baby’s head is deep down into the pelvis, as
in obstructed labour, prepare the vagina for assistance
at caesarean delivery. |
| 8 |
Roll
the patient 15° to her left or place a pillow under
her right hip to decrease supine hypotension syndrome. |
| 9 |
Listen
to the fetal heart rate before beginning surgery. |
Choice of anaesthesia
In cases of extreme urgency, general anaesthesia can be faster
than a spinal and may also be safer if the mother is hypovolaemic
or shocked. In lesser degrees of urgency (delivery within
30 minutes required) a well conducted spinal by an experienced
anaesthetist minimizes the risk to mother and baby. These
issues should be discussed between the surgeon and anaesthetist
(see pages 14–12 to 14–14).
Opening the abdomen and making the bladder flap
The abdomen may be opened by a vertical midline skin incision
or a transverse skin incision. Caesarean section under local
anaesthesia is more difficult to do with the transverse skin
incision. The scar following a transverse incision is stronger.
Vertical midline incision
| 1 |
Make
a 2 to 3 cm vertical incision in the fascia (Figure
11.10). |
|
| 2 |
Hold
the fascial edge with forceps and lengthen the fascial
incision up and down, using scissors. |
| 3 |
Separate
the rectus muscles (abdominal wall muscles) with your
fingers or scissors. |
| 4 |
Use
your fingers to make a hole in the peritoneum near the
umbilicus. Use scissors to lengthen the incision up and
down to see the uterus well. Use scissors to separate
layers. Open the lower part of the peritoneum carefully
to prevent bladder injury. |
Transverse incision
| 1 |
Make
a straight transverse incision in the skin about 3 cm
below the line joining the anterior superior iliac spines.
The incision should measure 16–18 cm in length. |
| 2 |
Deepen
the incision in the midline about 3–4 cm through
the fat down to the rectus sheath. |
| 3 |
Make
a small transverse incision in the rectus sheath. Place
the tip of one blade of a partly open scissors under
the rectus sheath and the other blade over the rectus
sheath and push laterally to cut the sheath. |
| 4 |
Insert
your index finger under the rectus muscle on your side
and ask your assistant to do so on the opposite side.
Pull the muscles sideways to expose the peritoneum. |
| 5 |
Open
the parietal peritoneum as high as possible with your
index finger and enlarge this opening by stretching sideways. |
Making the bladder flap
| 1 |
Place
a bladder retractor over the pubic bone. |
| 2 |
Using
forceps, pick up the loose peritoneum covering the anterior
surface of the lower uterine segment and incise with
scissors. |
| 3 |
Extend
the incision by placing scissors between the uterus and
the loose serosa and cutting about 3 cm on each side
in a transverse fashion. |
| 4 |
Use
two fingers to push the bladder downwards off the lower
uterine segment. Replace the bladder retractor over the
pubic bone and bladder. |
Opening the uterus
| 1 |
Use
a scalpel to make a 3 cm transverse incision in the lower
segment of the uterus, about 1 cm below the level where the
vesico-uterine serosa was incised to bring the bladder down
(Figure 11.11). |
|
| 2 |
Widen
the incision by placing a finger at each edge, and by
pulling up and laterally at the same time. If the lower
uterine segment is thick and narrow, extend the incision
using scissors instead of fingers in a crescent shape
to avoid extension to the uterine vessels. |
Make the uterine incision big enough to deliver the head and
body of the baby without tearing the uterine incision.
Delivery of the fetus and placenta
| 1 |
To
deliver the baby, place one hand inside the uterine cavity
between the uterus and the baby’s head. |
| 2 |
Use
your fingers to grasp and flex the head. |
| 3 |
Gently
lift the baby’s head through the incision, taking
care not to extend the incision down towards the cervix
(Figure 11.12). |
|
| 4 |
With
the other hand, gently press on the abdomen over the
top of the uterus to help deliver the head. |
| 5 |
If
the baby’s head is deep down in the pelvis or vagina,
ask an assistant (wearing sterile gloves) to reach under
the drapes and push the head up through the vagina. (Figure
11.13). |
|
| 6 |
Then
lift and deliver the head. |
| 7 |
Suction
the baby’s mouth and nose when delivered, then
deliver the shoulders and body. |
| 8 |
Give
oxytocin 20 units in 1 L IV fluids (normal saline or
Ringer’s lactate) at 60 drops per minute for 2
hours. |
| 9 |
Clamp
and cut the umbilical cord. |
| 10 |
Hand
the baby to the assistant for initial care. |
| 11 |
Give
a single dose of prophylactic antibiotic after the cord
is clamped. |
| 12 |
If
there is foul-smelling liquor, give antibiotics for therapy
(see pages 4–10 to 4–11). |
| 13 |
Keep gentle traction on the cord and massage (rub) the
uterus through the abdomen. |
| 14 |
Deliver
the placenta and membranes. |
Closing the uterine incision
| 1 |
Grasp
the corners of the uterine incision with clamps. |
| 2 |
Grasp
the bottom edge of the incision with clamps. Make sure
it is separate from the bladder.
|
| 3 |
Look
carefully for any extensions of the uterine incision. |
| 4 |
Repair
the incision and any extensions with a continuous locking
stitch of 0 chromic non absorbable (or polyglycolic)
suture (Figure 11.14). |
|
| 5 |
If
there is any further bleeding from the incision site,
close with figure-of-eight sutures. There is no need
for a routine second layer of sutures in the uterine
incision. |
Closing the abdomen
Look carefully at the uterine incision before closing the abdomen.
Make sure there is no bleeding and that the uterus is firm.
| 1 |
Close
the fascia with a running stitch of 0 chromic non absorbable
(or polyglycolic suture). There is no need to close the peritoneum.
Peritoneal closure is not necessary for its healing. |
| 2 |
If
there are signs of infection, pack the subcutaneous tissue
with gauze and place loose 0 non absorbable (or polyglycolic)
sutures. The skin can be closed with a delayed closure
later after the infection has cleared.
|
| 3 |
If
there are no signs of infection, close the skin with
vertical mattress sutures of 3-0 nylon sutures (or silk)
and apply a sterile dressing. |
| 4 |
Gently
push on the abdomen over the uterus to remove clots from
the uterus and vagina. |
What to do if problems occur
If bleeding is not controlled
| 1 |
Massage
the uterus. |
| 2 |
If
uterus is atonic, continue to infuse oxytocin and give
ergometrine 0.2 mg and prostaglandins, if available (see
page 12–7).
|
| 3 |
Transfuse
as necessary. |
| 4 |
Have
an assistant press fingers over the aorta to reduce the
bleeding until the source of bleeding can be found and
stopped. |
| 5 |
If
bleeding is not controlled, perform uterine artery and
utero-ovarian artery ligation or a hysterectomy. |
Ergometrine is easily destroyed by heat. If logistics are
poor, you may need to give what appears to be a very large
dose – but
beware its use in eclamptic patients as it
raises the blood pressure.
When the baby is breech at caesarean section
| 1 |
Grasp
a foot and deliver it through the incision. |
| 2 |
Complete
the delivery as in a vaginal breech delivery:
| • |
Deliver
the legs and body up to the shoulders, then deliver
the arms. |
| • |
Lay
the body on your left forearm. Insert the middle
finger of your left hand into the baby’s
mouth. Place your right palm on the shoulders of
the baby. Flex (bend) the head using the fingers
of your right hand and deliver it through the incision. |
|
When the baby is transverse (sideways)
| 1 |
If
the back is up (near the top of the uterus), reach into
the uterus and find the baby’s ankles. Grasp the
ankles and pull gently through the incision to deliver
the legs. Complete the delivery as for a breech baby. |
| 2 |
If
the back is down, a high vertical uterine incision may
be necessary to deliver the baby. After making the incision,
reach into the uterus and grasp the feet. Pull them through
the incision and complete the delivery as for a breech
baby. To repair the vertical incision, you will need
several layers of suture (see below). The patient should
not labour with future pregnancies.
|
In placenta previa
| 1 |
If
a low anterior placenta is encountered, incise through
it and deliver the fetus. |
| 2 |
If
the placenta cannot be detached manually after delivery
of the baby, diagnose placenta accreta. This is a common
finding at the site of a previous caesarean scar. Perform
a hysterectomy. |
| 3 |
Women
with placenta previa are at high risk of postpartum haemorrhage.
If there is bleeding at the placental site, under-run
the bleeding sites with chromic non absorbable (or polyglycolic)
sutures. |
| 4 |
Watch
for bleeding in the immediate postpartum period and take
appropriate action. |
The high vertical (“classical”)
incision
| 1 |
Open
the abdomen through a midline incision skirting the umbilicus:
| • |
Approximately
one-third of the incision should be above the umbilicus
and two thirds below |
| • |
Make
the uterine incision in the midline over the fundus
of the uterus |
| • |
The
incision should be approximately 12–15 cm
in length |
| • |
The
lower limit should not extend to the utero-vesical
fold of peritoneum. |
|
| 2 |
Ask
an assistant to apply pressure on the cut edges to control
bleeding.
|
| 3 |
Cut
down to the level of the membranes and then extend the
incision using scissors. |
| 4 |
After
rupturing the membranes, grasp the fetal foot and extract
the fetus. |
| 5 |
Deliver
the placenta and membranes. |
| 6 |
Grasp
the edges of the incision with Allis or Green Armytage
forceps. Close the incision using at least three layers
of suture:
| • |
Close
the first layer closest to the cavity, but avoiding
the decidua, with a continuous 0 chromic non absorbable
(or polyglycolic) suture |
| • |
Close
the second layer of uterine muscle using interrupted
No. 1 chromic non absorbable (or polyglycolic)
sutures |
| • |
Close
the superficial fibres and the serosa using a continuous
0 chromic non absorbable suture (or polyglycolic)
suture with an atraumatic needle |
| • |
Close
the abdomen as for lower segment caesarean section. |
|
Antibiotics
Prophylactic antibiotics in caesarean section decrease post
operative infection. They are given after the cord is clamped.
Recommended doses are:
| :: |
Cefazolin
1 gm IV |
| :: |
Or
Ampicillin
1–2 g IV: one dose only. |
If signs of infection are already present at the time of caesarean
section, give
| :: |
Ampicillin
1–2 g IV 6 hourly |
| :: |
Plus
gentamicin 5 mg/kg/day IV as single daily dose |
| :: |
Plus
metronidazole 500 mg 8 hourly until the patient has been
afebrile for 24–48 hours. |
Tubal sterilization at caesarean section
Tubal
ligation may be performed immediately following caesarean
section if the woman requested the procedure before labour
began.
| :: |
Review
for consent of the patient. |
| :: |
Grasp
the least vascular, middle portion of the tube with a
Babcock or Allis forceps. |
| :: |
Hold
up a loop of tube 2.5 cm in length (Figure
11.15). |
|
| :: |
Crush
the base of the loop with artery forceps and ligate it
with a 0 plain non absorbable suture (Figure
11.16, 11.17). |
|
|
| :: |
Excise
the loop (a segment of 1 cm in length) through the crushed
area (Figure 11.18). |
| :: |
Repeat
the procedure on the other side. |
Postoperative
care after caesarean section
| 1 |
Carefully
watch and record vital signs, bleeding and urine output.
Be prepared to take action if necessary.
|
| 2 |
If
bleeding occurs, massage the uterus to expel blood and
blood clots. Blood clots in the uterus inhibit uterine
contractions.
|
| 3 |
Give:
| • |
Oxytocin
20 units in 1 L IV fluids (normal saline or Ringer’s
lactate) at 60 drops per minute |
| • |
Ergometrine
0.2 mg IM |
| • |
Prostaglandins,
if available. |
| • |
Close
the abdomen as for lower segment caesarean section. |
|
| 4 |
Use
a second IV line to give volume replacement as the above
regime only gives an infusion of 4 ml/min which is inadequate
in a bleeding patient. |
| 5 |
If
there are signs of infection or the woman currently has
fever, give appropriate antimicrobial therapy. |
| 6 |
Give
sufficient analgesic drugs.
|
| 7 |
Give
oral fluids the day after surgery. Provide food when
the patient is drinking fluids well. |
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