Video Clips on DVD
- 16-1
Techniques for Performing Cesarean Section with Discussion of Management of Potential Complications
Cesarean delivery is the most common major surgical procedure performed on women worldwide. The rate of cesarean section continues to rise due to a multitude of causes. As the rate increases, the number of repeat cesarean sections will also increase due to the decreasing rate of vaginal birth after cesarean (VBAC) section. In the United States, the cesarean section rate ranges between 25% to 35%. Most likely this rate will continue to rise due to the changes in patient demographics as well as the changes in obstetrical practice ( Table 16-1 ). Many patients ask for primary elective cesarean section and obstetricians are not being trained to perform operative deliveries, breech deliveries, and vaginal deliveries of multiple gestation. As more and more cesarean sections are performed, we will undoubtedly see an increase in the number of surgical complications such as hemorrhage, infection, and bowel and bladder injuries. These complications are more likely to occur in the presence of one or more of the risk factors listed in Table 16-2 . This chapter reviews the appropriate techniques that should be used when performing an elective or emergency cesarean section, with emphasis placed on how to avoid and manage complications related to this procedure.
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Case 1: Planned Cesarean Section
The patient is a 32-year-old G2P1 who presents at full term (39 weeks). She had a previous cesarean section at 32 weeks for severe pregnancy-induced hypertension. She has had an uncomplicated pregnancy and desires a repeat cesarean section. The cesarean section was performed without complications. The patient experienced a normal postoperative course and is discharged on her third postoperative day.
Technique of Repeat Cesarean Section
The most common incisions used for repeat cesarean section are transverse incisions (Pfannenstiel, Maylard, or Cherney). Vertical incisions are usually used in emergency situations for rapid entry into the abdominal cavity. A Pfannenstiel incision was used in this patient based on the fact that this same incision was used on her previous cesarean section. Once the incision was made, the subcutaneous tissue was opened and bleeding was cauterized with suture ties or electrocautery. The fascial layer was then opened and extended with the scissors or knife. It is then reflected cephalad and posterior. The peritoneum is entered and the gravid uterus is visualized and inspected for any rotation or abnormal anatomy. The visceral peritoneum or bladder flap is taken off the lower uterine segment. The lower uterine segment is incised transversally and extended laterally either bluntly or sharply with scissors. The amniotic sac is ruptured and the fetus is delivered in the vertex presentation. Suctioning of the nasopharynx is performed followed by cord clamping and cutting. The placenta is delivered by gentle traction or manually. The uterus is exteriorized through the anterior abdominal wall, and the uterine cavity is explored for any placental remnants. The lower uterine segment is closed in two layers using absorbable suture. The uterus is repositioned back into the abdominal cavity and the gutters are cleaned and irrigated; and when the sponge and needle count is correct, the abdomen is closed. The fascia is closed with an absorbable suture. The subcutaneous tissue is reapproximated and the skin is closed. (See the DVD for video demonstration of a repeat cesarean section. 
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Case 2: Emergency Cesarean Section
The patient is a 39-year-old G4P3 with two previous cesarean sections and known low-lying placenta (not a complete placenta previa). The patient declined genetic testing and had an uncomplicated prenatal course. The only problem the patient presented with during her pregnancy was a bleeding episode in her early second trimester. This episode was resolved with conservative management. She presented to labor and delivery at 37 weeks having active contractions and some vaginal bleeding with a nonreassuring fetal heart rate tracing. The patient was taken back for an emergency cesarean section. On opening the abdominal cavity through a previous transverse incision it became obvious that the bladder was attached very high on the lower and upper segments of the uterus. The bladder was taken down sharply to minimize the chance of bladder injury. Once the bladder was completely mobilized and the lower uterine segment was exposed, the lower uterine segment was incised and extended manually. The fetus was delivered by footling breech extraction and the placenta was noted to be low lying and was delivered in the usual fashion. The uterus was exteriorized and explored for any placental remnants. At this point it was noted that there was an extreme amount of bleeding and that the uterus was not contracting down as quickly as expected. Appropriate procedures to manage intrapartum hemorrhage during the time of cesarean section were instituted. Anesthesia was instructed to start another large-bore IV and give 20 units of oxytocin (Pitocin) at a rapid rate. Uterine massage was performed. Also, intramyometrial injection of vasoconstricting agents such as oxytocin or Hemabate may also be used at this point (see the DVD for demonstration of appropriate technique for uterine massage and intramyometrial injection of a vasoconstricting agent 
). On examining the lower uterine segment it was obvious that a lateral extension had occurred on the patient’s left side extending very close to the uterine vessels ( Fig. 16-1 ). Multiple sutures were placed to control the bleeding. Once the bleeding was under control there was concern about possible ureteral obstruction secondary to one of the suture ligations. At this point, the safest and most efficient way to ensure ureteral patency or diagnose ureteral compromise was to go to the extraperitoneal portion of the bladder and make a high advertent cystotomy allowing direct visualization of the ureteral orifice. (See Chapter 17 for the technique for opening and closing the bladder.) The anesthesiologist was instructed to give IV indigo carmine and once the bladder was opened, approximately 4 to 6 minutes later it was obvious that there was spillage of dye from both ureteral orifices, thus assuring no ureteral compromise. The bladder was then closed in two layers using an absorbable 3-0 suture. The first layer was through and through with the second layer being an imbricating stitch (see Chapter 17 ). At this time it was noted that the uterus was again becoming boggy even after giving IV and intramyometrial vasoconstricting agents. Anesthesia was instructed to send blood for a coagulation profile and it was decided to perform a B-Lynch suture (see the DVD for video demonstration of how to perform B-Lynch suture 
). On failure of the B-Lynch to control the bleeding, an O’Leary stitch was used to ligate the uterine vessels and another stitch to ligate the utero-ovarian vessels ( Fig. 16-2 ). With failure of the these stitches to control the hemorrhage, a bilateral hypogastric artery ligation was performed (refer to the DVD and figures for techniques of O’Leary stitch and utero-ovarian vessel ligation 
). After all conservative surgical procedures were used in an attempt to control the hemorrhage, the decision was made to perform a cesarean hysterectomy (see Chapter 4 for technique of cesarean hysterectomy).
