Caesarean section

• Review for indications. Ensure that vaginal delivery is not possible.

• Check for fetal life by listening to the fetal heart rate and examine for fetal presentation.

• Review operative care principles.

• Use local infiltration with lignocaine, ketamine, spinal anaesthesia or general anaesthesia:

- Local anaesthesia is a safe alternative to general, ketamine or spinal anaesthesia when these anaesthetics or persons trained in their use are not available;

- The use of local anaesthesia for caesarean section requires that the provider counsel the woman and reassure her throughout the procedure. The provider should use instruments and handle tissue as gently as possible, keeping in mind that the woman is awake and alert.

Note: In the case of heart failure, use local infiltration anaesthesia with conscious sedation. Avoid spinal anaesthesia.

• Start an IV infusion.

• Determine if a high vertical incision is indicated:

- an inaccessible lower segment due to dense adhesions from previous caesarean sections;

- transverse lie (with baby’s back down) for which a lower uterine segment incision cannot be safely performed;

- fetal malformations (e.g. conjoined twins);

- large fibroids over the lower segment;

- a highly vascular lower segment due to placenta praevia;

- carcinoma of the cervix.

• If the baby’s head is deep down into the pelvis as in obstructed labour, prepare the vagina for assisted caesarean delivery.

• Have the operating table tilted to the left or place a pillow or folded linen under the woman’s right lower back to decrease supine hypotension syndrome.

OPENING THE ABDOMEN

• Make a midline vertical incision below the umbilicus to the pubic hair, through the skin and to the level of the fascia (Fig P-19).

Note: If the caesarean section is peformed under local anaesthesia, make the midline incision that is about 4 cm longer than when general anaesthesia is used. A Pfannenstiel incision should not be used as it takes longer, retraction is poorer and it requires more local anaesthetic.

Figure P-19

 Site of abdominal incision

• Make a 2-3 cm vertical incision in the fascia.

• Hold the fascial edge with forceps and lengthen the incision up and down using scissors.

• Use fingers or scissors to separate the rectus muscles (abdominal wall muscles).

• Use fingers to make an opening in the peritoneum near the umbilicus. Use scissors to lengthen the incision up and down in order to see the entire uterus. Carefully, to prevent bladder injury, use scissors to separate layers and open the lower part of the peritoneum. 

• Place a bladder retractor over the pubic bone. 

• Use forceps to pick up the loose peritoneum covering the anterior surface of the lower uterine segment and incise with scissors. 

• Extend the incision by placing the scissors between the uterus and the loose serosa and cutting about 3 cm on each side in a transverse fashion.

• Use two fingers to push the bladder downwards off of the lower uterine segment. Replace the bladder retractor over the pubic bone and bladder. 

OPENING THE UTERUS

• Use a scalpel to make a 3 cm transverse incision in the lower segment of the uterus. It should be about 1 cm below the level where the vesico-uterine serosa was incised to bring the bladder down.

• Widen the incision by placing a finger at each edge and gently pulling upwards and laterally at the same time (Fig P-20). 

• If the lower uterine segment is thick and narrow, extend the incision in a crescent shape, using scissors instead of fingers to avoid extension of the uterine vessels.

It is important to make the uterine incision big enough to deliver the head and body of the baby without tearing the incision. 

Figure P-20

Enlarging the uterine incision

DELIVERY OF THE BABY AND PLACENTA

• To deliver the baby, place one hand inside the uterine cavity between the uterus and the baby’s head. 

• With the fingers, grasp and flex the head. 

• Gently lift the baby’s head through the incision (Fig P-21), taking care not to extend the incision down towards the cervix.

• With the other hand, gently press on the abdomen over the top of the uterus to help deliver the head. 

• If the baby’s head is deep down in the pelvis or vagina, ask an assistant (wearing high-level disinfected gloves) to reach into the vagina and push the baby’s head up through the vagina. Then lift and deliver the head (Fig P-22).

Figure P-21

Delivering the baby’s head

Figure P-22

 Delivering the deeply engaged head 

• Suction the baby’s mouth and nose when delivered. 

• Deliver the shoulders and body. 

• Give oxytocin 20 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute for 2 hours.

• Clamp and cut the umbilical cord. 

• Hand the baby to the assistant for initial care. 

• Give a single dose of prophylactic antibiotics after the cord is clamped and cut:

- ampicillin 2 g IV;

- OR cefazolin 1 g IV.

• Keep gentle traction on the cord and massage (rub) the uterus through the abdomen.

• Deliver the placenta and membranes.

CLOSING THE UTERINE INCISION

Note: If a Couvelaire uterus (swollen and discolored by blood) is seen at caesarean section, close it in the normal manner and observe.

• Grasp the corners of the uterine incision with clamps. 

• Grasp the bottom edge of the incision with clamps. Make sure it is separate from the bladder. 

• Look carefully for any extensions of the uterine incision. 

• Repair the incision and any extensions with a continuous locking stitch of 0 chromic catgut (or polyglycolic) suture (Fig P-23).

• If there is any further bleeding from the incision site, close with figure-of-eight sutures. There is no need for a routine second layer of sutures in the uterine incision.

Figure P-23

 Closing the uterine incision

CLOSING THE ABDOMEN

• Look carefully at the uterine incision before closing the abdomen. Make sure there is no bleeding and the uterus is firm. Use a sponge to remove any clots inside the abdomen.

• Examine carefully for injuries to the bladder and repair any found.

• Close the fascia with continuous 0 chromic catgut (or polyglycolic) suture.

Note: There is no need to close the bladder peritoneum or the abdominal peritoneum.

• If there are signs of infection, pack the subcutaneous tissue with gauze and place loose 0 catgut (or polyglycolic) sutures. Close the skin with a delayed closure after the infection has cleared.

• If there are no signs of infection, close the skin with vertical mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing.

• Gently push on the abdomen over the uterus to remove clots from the uterus and vagina.

PROBLEMS DURING SURGERY

BLEEDING IS NOT CONTROLLED

• Massage the uterus.

• If the uterus is atonic, continue to infuse oxytocin and give ergometrine 0.2 mg IM and prostaglandins, if available. These drugs can be given together or sequentially (Table S-8).

• Transfuse as necessary.

• Have an assistant press fingers over the aorta to reduce the bleeding until the source of bleeding can be found and stopped. 

• If bleeding is not controlled, perform uterine and utero-ovarian artery ligation  or hysterectomy.

BABY IS BREECH

• If the baby is breech, grasp a foot and deliver it through the incision. 

• Complete the delivery as in a vaginal breech delivery:

- Deliver the legs and the body up to the shoulders, then deliver the arms;

- Flex (bend) the head using the Mauriceau Smellie Veit manoeuvre.

BABY IS TRANSVERSE

THE BABY’S BACK IS UP

• If the back is up (near the top of the uterus), reach into the uterus and find the baby’s ankles. 

• Grasp the ankles and pull gently through the incision to deliver the legs and complete the delivery as for a breech baby.

THE BABY’S BACK IS DOWN

• If the back is down, a high vertical uterine incision is the preferred incision.

• After the incision is made, reach into the uterus and find the feet. Pull them through the incision and complete the delivery as for a breech baby. 

• To repair the vertical incision, you will need several layers of suture.

PLACENTA PRAEVIA

• If a low anterior placenta is encountered, incise through it and deliver the fetus.

• After delivery of the baby, if the placenta cannot be detached manually, the diagnosis is placenta accreta, a common finding at the site of a previous caesarean scar. Perform a hysterectomy.

• Women with placenta praevia are at high risk of postpartum haemorrhage. If there is bleeding at the placental site, under-run the bleeding sites with chromic catgut (or polyglycolic) sutures. 

• Watch for bleeding in the immediate postpartum period and take appropriate action.

POST-PROCEDURE CARE

• Review postoperative care principles.

• If bleeding occurs:

- Massage the uterus to expel blood and blood clots. Presence of blood clots will inhibit effective uterine contractions;

- Give oxytocin 20 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute and ergometrine 0.2 mg IM and prostaglandins (Table S-8). These drugs can be given together or sequentially.

• If there are signs of infection or the woman currently has fever, give a combination of antibiotics until she is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- PLUS metronidazole 500 mg IV every 8 hours.

• Give appropriate analgesic drugs.

HIGH VERTICAL (“CLASSICAL”) INCISION

• Open the abdomen through a midline incision skirting the umbilicus. Approximately one-third of the incision should be above the umbilicus and two-thirds below.

• Use a scalpel to make the incision: 

- Check the position of the round ligaments and ensure that the incision is in the midline (the uterus may have twisted to one side); 

- Make the uterine incision in the midline over the fundus of the uterus;

- The incision should be approximately 12-15 cm in length and the lower limit should not extend to the utero-vesical fold of the peritoneum.

• Ask an assistant (wearing high-level disinfected gloves) to apply pressure on the cut edges to control the bleeding. 

• Cut down to the level of the membranes and then extend the incision using scissors.

• After rupturing the membranes, grasp the baby’s foot and deliver the baby.

• Deliver the placenta and membranes.

• Grasp the edges of the incision with Allis or Green Armytage forceps.

• Close the incision using at least three layers of suture:

- Close the first layer closest to the cavity but avoiding the decidua with a continuous 0 chromic catgut (or polyglycolic) suture;

- Close the second layer of uterine muscle using interrupted 1 chromic catgut (or polyglycolic) sutures;

- Close the superficial fibres and the serosa using a continuous 0 chromic catgut (or polyglycolic) suture with an atraumatic needle. 

• Close the abdomen as for lower segment caesarean section (page P-48).

The woman should not labour with future pregnancies. 

TUBAL LIGATION AT CAESAREAN

Tubal ligation can be done immediately following caesarean section if the woman requested the procedure before labour began (during prenatal visits). Adequate counselling and informed decision-making and consent must precede voluntary sterilization procedures; this is often not possible during labour and delivery.

• Review for consent of patient.

• Grasp the least vascular, middle portion of the fallopian tube with a Babcock or Allis forceps.

• Hold up a loop of tube 2.5 cm in length (Fig P-24 A).

• Crush the base of the loop with artery forceps and ligate it with 0 plain catgut suture (Fig P-24 B).

• Excise the loop (a segment 1 cm in length) through the crushed area (Fig P-24).

• Repeat the procedure on the other side.

Figure P-24

 Tubal ligation

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