Cesarean Section

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Cesarean Section

Cesarean section, a life-saving operation for both fetus and mother, accounts for approximately 20% of deliveries in the United States today. The lower cervical transverse incision for this operation has become the accepted technique, except in cases in which compound presentations require the classic vertical incision in the fundus of the uterus.

The purpose of the operation is to deliver the fetus through the abdomen in instances where vaginal delivery would be either impossible or dangerous to the life or health of the mother and/or fetus.

Physiologic Changes. There are many differences in the physiologic changes between vaginal delivery and cesarean section. Fetuses delivered by ceaseran section may have a higher incidence of respiratory distress syndrome. On the other hand, vaginal delivery with dystocia can produce central nervous system damage. Further discussion involving the physiology of cesarean section is beyond the scope of this text, and the reader is referred to the obstetrical literature for additional information.

Points of Caution. The anesthesia for cesarean section should be selected with care. An epidural regional block is recommended, since this has the least chance of causing fetal depression.

If general anesthesia is to be used, the anesthesiologist should be consulted to ensure proper timing between the infusion of the rapid-acting barbiturates and delivery of the baby in order to minimize any depressing effect on the central nervous system of the fetus. Care should be exercised in dissecting the bladder off the lower uterine segment to prevent laceration of the bladder during the procedure. If, by chance, excessive manual stretching of the transverse incision should lacerate the uterine vessels in the broad ligament, this ligament should be opened. The uterine vessels should then be carefully dissected out and individually ligated to prevent postoperative hematoma and possible damage to the underlying ureter.

Technique

For cesarean section, a Foley catheter is placed in the bladder, and the patient is placed in the dorsal supine position. The abdomen is surgically prepped. The abdomen can be opened through a lower transverse incision or a midline incision.

After opening the abdominal cavity, the vesicouterine fold is identified and opened. Moist packs can be placed in the lateral gutters on each side of the uterus to prevent blood and fluid from draining into the peritoneal cavity.

When the bladder has been dissected down, a small transverse incision is made in the lower uterine segment with a scalpel.

An opening is made in the amniotic sac large enough to admit two fingers.

The fingers are inserted into the uterine cavity.

The incision is stretched laterally.

The appropriate fetal parts are grasped.

Occasionally, obstetrical forceps or the hand is inserted to aid in removal of the fetus.

The fetus is removed.

The cord is doubly clamped and incised. The fetus is immediately suctioned and handed to the pediatrician.

We prefer to deliver the uterus through the incision. The placenta is manually extracted.

A retractor is inserted into the uterine incision. The uterus is manually explored, and any remaining placental membranes are removed under direct vision.

Excess blood in and around the incision is removed by suction.

The first layer of 0 synthetic absorbable suture is placed in the transverse incision as a continuous suture. A second layer of interrupted 0 synthetic absorbable suture is placed in the myometrium.

The serosa of the uterus and the vesicouterine peritoneal fold are closed with continuois 3-0 synthetic absorbable suture.

The parietal peritoneum is closed with continuous 3-0 synthetic absorbable suture.

The rectus muscles are approximated in the midline, and the fascia is closed with interrupted 0 Vicryl suture.

The remaining abdominal wall is closed in layers. The Foley catheter is left in the bladder for 24 hours.