Cesarean Delivery (CD)

by David Harnisch

In the world of medical education the dictum regarding education and experience has long been “See one, do one, teach one.” Certainly this mantra has long been prevalent. Let me now update it for you, because S1D1T1 also needs to be prefaced with “read about it!”

It is quite disconcerting to be approached by a provider with a request to do a CD when even the most rudimentary academic interest has been lacking and thus a huge hole in your knowledge is present. Let's get to work building some structure here.

I. Cat skinning. The first thing you need to understand is that there are many ways to skin a cat. I am going to outline for you here the steps in a basic primary low transverse cesarean delivery (CD). I realize that other people skin their cats differently, but you need to learn a way that works. What follows is a way that works taken from a variety of sources and flavored with my personal experience.

II. Indications (potential)
A. Maternal
1. Obstruction of the birth canal by pelvic masses
2. Invasive carcinoma of the cervix
3. Previous vaginal surgery (fistulas)
4. Cerebral aneurysms or avm’s
5. Connective tissue disorders (e.g. Marfan’s syndrome, Ehlers-Danlos syndrome)
6. Pelvic malformations or pelvic inadequacy
7. Severe hypertension (progressive)
8. Prior cesarean delivery
9. Multiple gestations (e.g. twins with malpresentation, triplets, or greater multiples)
10. Abdominal or Shirodkar cerclage placement
11. Failure to progress (now referred to as arrest of dilation or arrest of descent)
12. Prior uterine surgery or mullerian anomaly
13. Uterine rupture
14. Placenta previa
15. Abruptio placentae
B. Fetal
1. Malpresentation (e.g. fixed transverse lie, compound presentation)
2. Fetal distress/presumed fetal jeopardy (now referred to as “non-reassuring fetal status”)
3. Fetal anomalies (e.g. neural tube defect, conjoined twins)
4. Active genital herpes
5. Fetal macrosomia
6. Fetal thrombocytopenia

III. General preparation
A. Consents
1. Risks— to include, but not limited to pain, bleed, scar, infection, damage to bowel/bladder/baby or other internal organs, hysterectomy (1:1000), death (1:10,000), cva, dvt, mi, pe
2. Document consent in the chart
3. Make sure patient and her family are comfortable, aware, and have all their questions answered (time permitting)
4. Call for peds coverage
5. No video cameras in OR
B. Position patient in left lateral tilt
1. Consider one last check of FHT’s to ensure fetal well being (continue the FHR monitoring with the same persistence in close attention as was practiced in the labor room.)
2. Set table height to appropriate position
3. Consider have someone glove up if you think that there might be a need to dislodge the infant from below (i.e. disengage infant from pelvis via vagina)
4. Make sure there’s a vacuum extractor in the room
C. Prep
1. Apply grounding pad, leg strap, foley to drainage
2. Skin prep--shave
D. Drape—patient, light handles
E. Hook up equipment (secure them to operating field so they don’t end up on the floor)
1. Bovie—set to 40-40, blend 1 (more on electrical therapy in another handout)
2. Suction
F. Test anesthetic—allis clamp
G. Incision, skin (here we’ll discuss the Pfannenstiel—a gently upward curving incision often placed in a natural fold of skin and classically located two fingerbreadths(3 cm) above the symphysis, 15 centimeters in length.)
1. Surgical principle #1—incise (cut), don’t whittle
2. Surgical principle #2--Cut at a perpendicular to the skin (90 degrees)
3. Surgical principle #3--Traction, counter-traction
H. Incision through the sub-q layers (knife, bovie, digital dissection) down to the rectus fascia
I. Nick the fascia over each belly of the rectus, then extend these nicks with curved mayo scissors
J. Dissect the rectus muscle off of the fascia by grasping the upper edge of the fascia with two Kocher clamps and using blunt finger dissection. The grasp lower edge and repeat.
1. Note that the midline structures (those between the rectus bellies) are adherent to the rectus fascia and must be carefully dissected off with care not to leave any holes in the fascia (Surgical principle #4—leave the muscle on the fascia.) These midline structures can contain bowel or other important organs, so carefully, carefully with Surgical principle #5—keep the tips up and Surgical principle #6—only cut what you can clearly see and Surgical principle #7—don’t past-point (i.e. watch where your scissor tips are so while you’re cutting suture with the scissor’s belly or hub, you’re not cutting the bowel with the tips at the same time.
2. Remove the midline structures north and south pieces of fascia
K. Split the rectus muscles in the midline between the bellies
L. Open the peritoneum (bluntly or sharply with care) and expose the uterus
M. Place the bladder retractor
N. Check the uterus for scarring (do you have scars holding the uterus in the abdomen or making it adherent to midline or lateral structures)
O. The visceral peritoneum at the vesicouterine fold (bladder-uterus fold) is then elevated and entered sharply transversely. (Making an incision to take down the bladder).
P. Develop the bladder flap digitally (with your finger) then replace the bladder blade protecting the bladder
Q. Make a curvilinear scoring incision in the uterus (smiley face)(1-2 cm above the site of the original upper margin of the bladder.)
1. Surgical principle #8—bladder is south, baby is behind, bleeding (uterine arteries) is lateral
2. Incise gradually through the uterine wall (“baby is behind” the wall!!!!) and enter into the cavity digitally if possible
3. Using digital pressure or a bandage scissors extend the uterine incision laterally and upwards.
R. Remove instruments and elevate the fetal presenting part. Simple fundal pressure by the surgical assistant completes the delivery. Suction the head, check for nuchal cord, and then complete the delivery of the infant. May need to use a vacuum to effect delivery of head. May need to have an assistant provide pressure of the fetal head via the vagina to dislodge the head or push it up high enough to where your abdominal had can effect delivery.
S. Start pitocin (remember postpartum hemorrhage management)
T. Separate placenta from uterus and collect cord gases/cord blood—inspect placenta
U. Inspect and wipe out the uterine cavity
V. Administer your antibiotics (e.g. Ancef 2 gm IV) now if needed.
W. Grasp lateral margins of uterine incision and lower wound margin with T clamps or Pennington’s or other appropriate clamp.
X. May externalize the uterus
Y. Close the uterus with simple running suture in a single layer (may add second imbricating layer or simple figures of 8 as need for hemostasis)
Z. Irrigate behind and around the uterus.
AA. Sponge, lap, and needle counts?
BB. Check wounds for bleeding.
CC. Copious irrigation
DD. Check for hemostasis
EE. Clear gutters of clots and debris
FF. Close fascia
GG. Irrigate
HH. Check for hemostasis
II. Close the sub-q layers (if 2 cm thick or thicker)
JJ. Irrigation
KK. hemostasis
LL. close the skin
MM. dry sterile dressing using foam tape
NN. express clots from uterus
OO. to recovery room
PP. Surgical principle #9—patient movement is controlled and coordinated by anesthesia. Listen to them and help.

Suture Choice
On uterus – 1-vicryl (one oh vicryl) (CTX needle) (or 1-0 chromic)(or 0 or 00 chromic)
(on bladder flap – 3-0 vicryl)
(peritoneum – 3-0 vicryl)
On fascia – 0- vicryl (CT-1 needle)
Sub-q -- 2-0 Plain
Skin -- 4-0 vicryl on Keith needle or stap

by David Harnisch   drharnisch@unmc.edu

Dr. Dave is boarded in FP and OB-GYN, he is a faculty member at UNMC after serving in the military as a physician.

Using Your Residency

Patient prep for emergency CS http://www.horns.freeserve.co.uk/marycronk/cs.htm

History of CS http://www.nlm.nih.gov/exhibition/cesarean/cesarean_1.html

www.ruralmedicaleducation.org