Review of techniques of LSCS

Veerendrakumar C.M MD.,DNB

VIMS, Bellary

James Young Simpson1811-1870

Obstetrics is not one of the exact sciences and in our penury of truth

- we ought to be accurate in our statements,

- generous in our doubts, - tolerant in our convictions.

evolutionBeing Bipedal

Being intelligent

Caesarean has evolved over centuries. It has meant different things to different people at different times.

Dead mother dead babyDead mother live babyLive mother live babyHealthy mother healthy babyHealthy mother, healthy baby & healthy

pelvic floor.

IS C.S. SAFE ?

NO !

….if a C.S is not done, the woman and her baby take the risks

….while if the C.S is done, The doctor takes the risk

‘REDUCE THE QUANTITY IMPROVE THE

QUALITY’

‘8’ hours Vs ‘8’ minutes

easy normal delivery or s. c. s.

O. T.A. Good Boyle’s apparatusB. Multipara monitorC. Suction apparatusD. Defibrillator ‘?’

Decorum of the O.T.

Timing of antibiotic administration

NICE RECOMMENDATION [new 2011]

• Offer women prophylactic antibiotics at CS before skin incision.

• Offer women prophylactic antibiotics at CS to reduce the risk of postoperative infections.

Choose antibiotics effective against endometritis, urinary tract and wound infections, which occur in about 8% of women who have had a CS.

Do not use co-amoxiclav when giving antibiotics before skin incision.

Skin preparationShaving results in microscopic

nicks and tears of the epidermis

Actually increases the risk of skin infection unless done immediately preoperatively.

Surgical obstetrics 1992

Betadine sprayBefore shifting to OT abdomen

cleansed and betadine spray applied

operating area covered with sterile drape

Prepackaged adhesive draping

IncisionPfannensteilJoel cohenMidline verticalSupraumbilical in morbidly obese

Am J obst gynecol

2000

Abdominal entry

Abdominal incision

NICE RECOMMENDATIONSThe transverse incision of choice should be the

Joel Cohen incision (straight skin incision, 3 cm above the symphysis pubis; subsequent tissue layers are opened bluntly and if necessary extended with scissors and not a knife).

It is associated with shorter operating times and reduced postoperative febrile morbidity. A

 

Meticulous attention to placement of skin incision

Allis clamp test

Am J Obst Gynecol 1991

Abdominal exposureTubular plastic

retractor with a rolled edge

UV fold entryBlunt or sharpPrevious surgery- sharp better

Uterine incision

-CLASSICALLY - several centimetres below the UV fold

- just below the UV fold

Uterine incision

NICE RECOMMENDATIONSWhen there is a well formed lower uterine

segment, blunt rather than sharp extension of the uterine incision should be used as it reduces blood loss, incidence of postpartum haemorrhage and the need for transfusion at CS. A

T incision is the weakest and poorest of uterine wound healing

Use J or double J (trap door) incision

Use of intravenous dilute 150 mcg-300 mcg NTG O’grady, operative obstetrics

E R R- for extraction of the head

Elevation Rotation Reduction

Cho, OBG management 2003

Difficult cranial deliveryThinking ahead is a great

boon

keep relaxants ready

Vaccum/short forceps/vectis

Keep asst ready for ‘Passing it up” technique

Delivery of the baby

NICE RECOMMENDATIONS

Forceps should only be used at CS if there is difficulty delivering the babies head. The effect on neonatal morbidity of the routine use of forceps at CS remains uncertain. C

[Either forceps or a vacuum device may be used to deliver the fetal head-Williams]

Delayed cord clampingSuggested benefits of delayed cord clamping

include decreased neonatal anaemia; Better systemic and pulmonary perfusion; and

better breastfeeding outcomes. Possible harms are polycythaemia,

hyperviscosity, hyperbilirubinaemia, transient tachypnoea of the newborn and risk of maternal fetal transfusion in rhesus negative women.

Delivery of placenta

NICE RECOMMENDATIONOxytocin 5 iu by slow intravenous injection

should be used at CS to encourage contraction of the uterus and to decrease blood loss. C

At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of endometritis.

A .

Mechanical dilatation of the cervixThree trials with a total of 735

women(CDSR)

There was insufficient evidence of mechanical dilatation of the cervix at non-labour caesarean section for reducing postoperative morbidity.

EXTERIORISATION OF UTERUS

"Misgav Ladach" Cesarean Section

Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean

Six studies were included, with 1294 women (CDSR)

There is no evidence from this review to

make definitive conclusions about which method of uterine closure offers greater advantages

Uterine closureNICE RECOMMENDATION Intraperitoneal repair of the uterus at CS should be

undertaken. Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection. A

The effectiveness and safety of single layer closure of the uterine incision is uncertain.

Except within a research context the uterine incision should be sutured with two layers.

B

Correct method of uterine closure

Uterine closure auto stapler preloaded with

dissolving copolymer staples made of polylactic and polyglycolic acid

Incises and staples the myometrium in single actionNo advantage -cochrane review 2006

May be of use in fetal surgery

Suction… mop…

GUTTER CLEANING

Routine gutter cleaning with mopTo be avoidedMay result in microscopic

abrasions Adhesions may develop

Forgotten mop with sigmoid injury !!!

Closure versus non-closure of the peritoneum at caesarean section

Fourteen trials, involving 2908 women.(CDSR)

There was improved short-term postoperative outcome if the peritoneum was not closed.

Long-term studies --limited

Examination of adnexa mandatory

NICE RECOMMENDATIONRoutine closure of the subcutanoues tissue space

should not be used, unless the woman has more than 2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.

A

Superficial wound drain should not be used at CS because they do not decrease the incidence of wound infection or wound haematoma.

A

NICE RECOMMENDATIONWomen having a CS should be offered

thromboprophylaxis as they are at increased risk of venous thromboembolism.

CAESAR trial european study3000 women recruited2x2x2 factorial multicentric RCT

Single- versus double-layer uterine closure.

Closure of the peritoneumLiberal versus restricted use of a

subsheath drain.

there is a difference in the duration of surgery(mean difference, 2.4 minutes; 95% CI, 1.3–3.6 minutes),favouring nonclosure. However, the duration of surgery is a poor surrogate for morbidity.

However, there have been suggestions that non closure of the peritoneum may be harmful in the longer term.

Lyell D, Peritoneal closure at primary caesarean delivery and adhesions. Obstet Gynecol 2005;106:275–80.

CORONIS 2x2x2x2x2fractional factorial randomised TRIAL in developing countries 15936 women

Blunt versus sharp abdominal entryExteriorisation of the uterus for repair versus

intra-abdominal repairSingle versus double layer closure of the

uterusClosure versus non-closure of the

peritoneum (pelvic and parietal)Chromic catgut versus Polyglactin-910 for

uterine repair

ReferencesTHE COCHRANE

LIBRARYCochrane Database

of Systematic Reviews

NICE GUIDELINES Issued: November

2011 NICE clinical guideline

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