C-Section Technique Leslie Ablard, M.D. 1. Preoperative Antibiotics W hich of the below is correct? 1. 1gm of Ancef can be given a maximum time of 30.

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C-Section TechniqueLeslie Ablard, M.D.

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Preoperative Antibiotics

• Which of the below is correct?• 1. 1gm of Ancef can be given a maximum time of 30 minutes

before a c-section is performed• 1gm Ancef within 60 minutes, 30 minutes is IDEAL

• 2. A women 220 lbs or greater should receive 2 gms of Ancef• 3. For women with chorioamnionits during labor, amp and gent

is not adequate for preoperative prophylaxis• May consider adding clindamycin

• 4. A procedure longer than 2 hrs should receive additional dose of Ancef• 3 hrs or longer should receive 2nd dose

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Skin Incisions• Which of the following is FALSE?

• 1. Other names for the transverse skin incision are Pfannensteil or Joel-Cohen

• 2. Transverse incision is associated with less postoperative pain, greater wound strength, and better cosmetic results than the vertical midline incision

• 3. Vertical incisions generally allow faster abdominal entry, cause less bleeding and nerve injury, and can be easily extended cephalad if more space is required for access

• 4. Vertical incisions result in improved neonatal and maternal outcomes• While delivery time is shortened (3 vs 4min), most outcomes were not

improved and some worse when compared to transverse

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Skin Incisions

• Minimum length of skin incision for expedient delivery of infant?

• 1. 10cm• 2. 12cm• 3. 15cm• 4. 18cm

• (length of Allis clamp)

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Pick out Allis Clamp

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Subcutaneous Tissue• Enter by either blunt or sharp dissection

• Name the vessels you need to avoid during this?

• Superficial epigastric

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Facial Layer• Incise in the midline and extend laterally

• Pick out the instruments used

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Rectus Muscles• Name rectus muscles

• The musculature of the abdominal wall is composed of 2 muscle groups • 1. flat muscles- external oblique, internal oblique, and the transversus

abdominis• 2. vertical muscles- rectus abdominis and the pyramidalis

• Use Richardson retractors in superior/lateral fashion to assist in incising rectus fascia

• Assist with elevating superior and inferior edges of rectus fascia with Kocher clamps, provide counter-traction, ensure adequate lighting

• Dissect rectus muscles off of the superior and inferior fascia

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Find the Richardson Retractor

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What is the difference above and below the arcuate line?

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Find the Kocher Clamp/Oschner

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Entering the Peritoneum• Which of the following is FALSE• 1. May be performed bluntly to prevent injury to

bowels/bladder• 2. Start as inferior as possible• 3. Rule- don’t cut anything you can’t see through• 4. Separate rectus muscles in the midline before entering

the peritoneum

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• Obtain exposure by using richardson retractors to expose the uterus laterally

• What do you use to obtain exposure inferiorly in the lower uterine segment?

• Bladder Blade

•BONUS- FIND ONE!!!

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Bladder Flap• Pick out instruments used to create the bladder flap

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Hysterotomy

• Name the 3 types of uterine incisions• 1. Low Transverse – Kerr or Monroe-Kerr• 2. Low Vertical- Kronig or De Lee• 3. Classical

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• Low Transverse incision •  Compared with vertical incisions, advantages of the transverse incision include less blood loss, less

need for bladder dissection, easier reapproximation, and a lower risk of rupture in subsequent pregnancies

• Lateral extension is not possible without risking laceration of major blood vessels• A "J" or inverted "T" extension is often required if a larger incision is needed

• This can be problematic because the "J" extension goes into the lateral fundus and the angles of the inverted "T" incision are poorly vascularized, both of which potentially result in a weaker uterine scar

• Low Vertical incision• The low vertical is performed in the lower uterine segment and may be as strong as the low

transverse incision• One study also suggests that there is no increased risk rupture of a low vertical uterine incision

when compared to a low transverse incision• The major disadvantage of the low vertical incision is the possibility of extension cephalad into the

uterine fundus or caudally into the bladder, cervix, or vagina• It is difficult to determine that the low vertical incision is truly low, as the separation between lower

and upper uterine segments is not easily identifiable clinically

• Classical incision• This incision is rarely performed because in subsequent pregnancies it is associated with a higher

frequency of uterine rupture (4 to 9%) compared with low vertical (1 to 7%) and low transverse (0.2 to 1.5%) incisions

• Associated with a higher rate of maternal morbidity• Whether a vertical incision is confined to the lower, noncontractile portion of the myometrium (low

vertical) or extends into the upper contractile portion of the myometrium (classical) is a subjective

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When to do vertical?• Which of the below is NOT correct• 1. Transverse back up• 2. Lower uterine segment pathology that precludes a

transverse incision (eg, large leiomyoma, poorly developed lower uterine segment)

• 3. Densely adherent bladder • 4. Anterior placenta previa or accreta • 5. Postmortem delivery

• - Transverse lie BACK DOWN should undergo VERTICAL incision

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FIND RING FORCEPSBONUS- FIND PENNINTON FORCEPS

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Hysterotomy technique• True or False• Most studies, but not all, have reported a direct

association between a prolonged uterine incision-to-delivery time and lower fetal blood gas pH values and Apgar scores, regardless of the type of anesthesia

•TRUE• The mechanism is thought to be hysterotomy induced increased uterine tone, which

can interfere with uteroplacental blood flow. Thus, careful attention to the duration of this interval by the surgeon is important, especially in a fetus with a nonreassuring fetal heart rate assessment prior to the onset of surgery

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DeliveryWhich of the following is FALSE?• 1. Hysterotomy extensions, particularly those involving the cervix, occur more frequently if the cesarean is

performed after a prolonged second stage of labor

• 2. To deliver a fetus in cephalic presentation, the surgeon inserts his/her hand into the uterine cavity to extend the fetal head and bring it to the level of the uterine incision, from which it can be extracted• Care should be taken to FLEX with fetal head and avoid EXTENSION

• 3. Transabdominal fundal pressure is usually applied by the surgical assistant

• 4. A deeply impacted fetal head can be hard to disengage and deliver. The "push" method involves the operator or an assistant pushing the head back through the vagina and out of the pelvis; the "pull" or "reverse breech" method has the surgeon grasp the fetal legs in the upper uterine segment and extract the fetus by the breech• The pull method appears to have lower maternal and neonatal morbidity than the push method

• 5. In some cases, it is necessary to extend the hysterotomy incision into an inverted 'T" or a "J" shape to deliver the fetus, as a large incision is required.• A set of forceps or a vacuum device should be available in the operating room to assist with flexing the head and

guiding it through the incision if this is difficult, but routine use of these instruments is not recommended since they may increase morbidity

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Breech ManeuversWhich of the following is FALSE?• 1. Use a low transverse hysterotomy incision • 2. The technique of fetal extraction through the hysterotomy

incision is very different to that for for vaginal breech delivery • 3. Forceps should be available for controlling delivery of the

aftercoming head• 4. Care should be taken not to hyperextend or place too much

traction on the cervical spine• 5. Use of a uterine relaxant is suggested when a difficult

delivery is anticipated or encountered

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Find Forceps for Breech Delivery

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Placental Extraction

Which of the following is FALSE1. Drainage of the placenta prior to extraction appears to result in less fetomaternal

transfusion

2. Spontaneous extraction (gentle traction on the cord and use of oxytocin to enhance uterine contractile expulsive efforts) should be performed, instead of manual extraction, because several randomized trials have shown that manual extraction results in more postoperative endometritis and lower postpartum hematocrit

3. Gloves should be changed before removal of the placenta

4. To ensure that all of the placenta has been removed, the uterus is usually explored with one hand holding a sponge to remove any remaining membranes or placental tissue, while the other hand is placed on the fundus to stabilize the uterus. These manipulations further stimulate uterine contraction

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Exteriorize?• Which is TRUE?• 1. The uterus should always be exteriorized• 2. The uterus should never be exteriorized• 3. There is insufficient evidence to conclude

• Exteriorization is associated with lower febrile morbidity and longer hospitalization , but there were no significant differences in other outcomes (eg, blood loss, postoperative change in hematocrit, endometritis, wound complications, analgesia requirements, length of surgery)

• Subsequent to this meta-analysis, three additional randomized trials assessing uterine exteriorization versus repair in situ have been published• Taken together, these 9 trials suggest there is no clinically significant difference in outcome

between the two techniques, although exteriorization may be associated with shorter operating time, more nausea, and more pain on the first postoperative day

• Therefore, the surgeon should choose the technique based on individual clinical circumstances and personal preference

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True or False?• Routine manual/instrumental cervical dilatation before

closing the uterus in an elective cesarean delivery is necessary• False- Controlled studies have reported that this practice

does not improve postoperative hemoglobin levels or reduce the incidence of fever or wound infection

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Uterine Closure• Name a suture material appropriate for closing the

uterus- both size and type• For closure of the uterine incision, there are no high quality

data to guide choice of suture material (eg, chromic catgut versus delayed absorbable synthetic [polyglactin 910]) or technique (eg, continuous [locked or nonlocked] versus interrupted)

• The endometrial layer should probably be included in the full thickness myometrial closure

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Find a Needle Driver

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Single or Double Closure?• True or False?• No difference in the rate of maternal infectious morbidity between those who underwent single

versus double layer uterine closure AND• Patients who have a single layer closure may be at increased risk of uterine rupture during the

next pregnancy compared with those who undergo a two-layer closure

• TRUE• One prospective, randomized trial compared single versus double layer closure in 164 women who

had a primary and then repeat cesarean delivery. There were no differences in outcomes; however, the trial lacked adequate power to determine whether a true small difference in rate of uterine rupture existed.

• A case control and a cohort study reported the risk of uterine rupture in pregnancies after single layer closure was increased two- to four-fold compared with pregnancies after a double layer closure.

• A third study did not find a significantly increased risk of rupture after single layer closure but noted the single layer technique was associated with a higher frequency of asymptomatic uterine dehiscence (ie, myometrial defect with intact peritoneum, known as a uterine window) (3.5 vs 0.7% of cases)

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What else should you close?• 1. Peritoneum• 2. Rectus Muscles• 3. Bladder Flap• 4. None of the Above

• NONE OF THE ABOVE• All shown to increase operative time with no proven

evidence on decreasing adhesions, etc• Closing rectus muscles does increase post operative pain

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Fascia• True or False?• Reapproximation, not strangulation, is the goal• Difficulty with hemostasis is usually not a major issue

• TRUE• Optimal technique for closure of these incisions is:

• Use of a simple running technique • Use of #1 or #2 delayed absorbable monofilament suture (eg, polydioxanone [PDS]) for

vertical or #0 Braided (Vicryl) for transverse• Use of mass closure to incorporate all layers of the abdominal wall (except skin) • Taking wide tissue bites (≥1 cm) • Use of a short stitch interval (≤1 cm) • Use of a suture length to wound length ratio of 4 to 1 • Use of non-strangulating tension on the suture

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Subcutaneous Tissue• Which of the following is CORRECT?• 1. Irrigation of the subcutaneous space prevents wound complications

• The value of irrigation before closure of the subcutaneous tissues has not been studied in a randomized trial, and is probably unnecessary in the setting of routine intravenous antibiotic prophylaxis

• 2. A meta-analysis of randomized trials that showed suture closure of the subcutaneous adipose layer at cesarean delivery decreased the risk of subsequent wound disruption by one-third in women with subcutaneous tissue depth ≥1 cm, but not in those <1 cm • 2 cm is the correct answer• Closure of the dead space seems to inhibit accumulation of serum and blood, which can lead to a

wound seroma and subsequent wound breakdown• This occurrence is a major cause of morbidity, can be costly, and lengthens the recovery time

• 3. Routine use of wound drains is not beneficial, even in obese women• Compared to no drain, routine use of drains does not reduce the odds of seroma, hematoma,

infection, or wound disruption• Additionally, restricted use of subrectus sheath drains offers no benefit in maternal infectious

morbidity compared with liberal use

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Skin Closure• Which type of closure is associated with the greatest

wound infection and dehiscence?• 1. Traditional metal staples

• Associated with a doubling of wound complications (infection, separation:13 versus 6 percent)• However, the increased risk of wound separation may have been due to removing staples too early (day 3), rather

than an effect of the staples themselves

• 2. Subcutaneous staples

• 3. Subcutaneous sutures

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• AND THE WINNING TEAM IS???

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Thank you