T and J vertical extensions in low transverse cesarean births

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. 1996 Feb;87(2):238-43.

doi: 10.1016/0029-7844(95)00388-6.

J G Boyle 
¹
, S G Gabbe

Affiliations

Affiliation

• ¹ Division of Maternal-Fetal Medicine, Ohio State University Medical Center, Columbus, USA.

• PMID:

  8559531

• DOI:

  10.1016/0029-7844(95)00388-6

J G Boyle et al.

Obstet Gynecol.

1996 Feb.

. 1996 Feb;87(2):238-43.

doi: 10.1016/0029-7844(95)00388-6.

Authors

J G Boyle 
¹
, S G Gabbe

Affiliation

• ¹ Division of Maternal-Fetal Medicine, Ohio State University Medical Center, Columbus, USA.

• PMID:

  8559531

• DOI:

  10.1016/0029-7844(95)00388-6

Abstract

Objective:

To determine the frequency of T and J extensions in low transverse cesarean births at a regional perinatal center, identify the indications for these incisions, and evaluate the associated complications.

Methods:

We reviewed the medical records of 56 patients delivered between January 1988 and November 1994 by low transverse cesarean birth requiring vertical extension of the incision into-the upper uterine segment. Cases of extension were compared with controls matched for gestational age, presentation, and indication for cesarean delivery. Data collected included demographic information, indications for extension, extension type, estimated blood loss, intraoperative complications, and length of hospital stay. Paired Student t test and McNemar test were used for statistical analysis.

Results:

Vertical extensions were performed in 1.3% (95% confidence interval 0.42-2.26%) of low transverse incisions over a 7-year period. The most common indications were malpresentation (n = 31), poorly developed lower uterine segment (n = 12), and fetal head deeply arrested in the midpelvis (n = 6). Estimated blood loss was greater for patients requiring an extension (990 +/- 310 mL) compared with controls (790 +/- 150 mL), as were differences in preoperative versus postoperative hemoglobin and hematocrit (P < .05). Surgical complications were observed in 28 of 56 (50%) subjects with a uterine extension, including excessive blood loss (n = 20), broad ligament hematomas or extensions (n = 4), cervical lacerations (n = 4), and uterine artery lacerations (n = 4). Patients with vertical extensions also had longer hospital stays (4.6 +/- 1.6 versus 3.8 +/- 1.1 days) (P < .05).

Conclusions:

Low transverse uterine incisions may be inadequate for the safe delivery of a fetus in cases of malpresentation, preterm birth, and poor development of the lower uterine segment. Used to complete these difficult deliveries, T and J extensions are often associated with intraoperative complications and prolonged hospital stays compared with controls.

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Primary Low Transverse C-Section | JOMI

Table of Contents

1. Abstract
2. Case Overview
   1. Background
   2. Focused History of the Patient
   3. Physical Exam
   4. Imaging
   5. Rationale for Treatment
   6. Special Considerations
3. Discussion
4. Postoperative Course
5. Equipment
6. Disclosures
7. Statement of Consent
8. Citations

Abstract

Cesarean sections, often referred to as c-sections, are the most common operation performed for pregnant people across the US. They are viewed as a safe mode of fetal delivery. While there are many indications for planned, non-elective primary cesarean deliveries, there are growing numbers of planned, elective primary c-sections in the US. Vaginal delivery should still be considered in all cases in which an elective c-section is requested. The decision regarding mode of delivery often involves an interdisciplinary discussion between obstetrical, anesthesia, and specialty teams as well as joint decision making between a patient and their provider, taking into consideration their concerns and long-term goals. In this case, an elective primary c-section was performed on a 31-year-old gravida 1 para 0 patient with a term, singleton gestation in the setting of prior lumbar sacral fusion and pelvic fixation surgeries.

Case Overview

Background

Disclaimer – The words “maternal,” “woman,” and “mother” are used in referenced literature. However, we acknowledge the lack of inclusivity these terms impose and have chosen to use pregnant people to also include transgender, non-binary, and gestational or surrogate carrier patients when possible.  

Cesarean sections, or c-sections, are the most common surgery performed for pregnant people across the US.¹ The surgery involves an open abdominal and uterine incision to deliver a neonate. Historically, c-sections were only used in emergent or life-threatening situations; however, there are now expanding indications for the procedure.²  Today, a cesarean delivery is viewed as a safe, and sometimes the recommended, mode of delivery. 

There are both elective and non-elective indications for a planned cesarean delivery. Elective c-sections are performed for many reasons, including history of a prior c-section, multiple gestation pregnancy, fear of labor pain, or patient preference. The list of indications for elective c-sections is expansive, and calculation of the risks and benefits is often multifactorial and personal for each patient. Non-elective indications for a planned c-section, or contraindications to vaginal delivery, include history of a classical uterine incision, prior full-thickness uterine wall surgeries, history of uterine rupture, placenta previa or accreta spectrum, vasa previa, or non-cephalic fetal presentation. ^4, 10 

The risks of c-section include multiple surgical risks in addition to longer recovery time, increased rates of endometritis, blood transfusion, ICU admission, and venous thromboembolism.⁸ The option for vaginal delivery should therefore be considered and further explored in all cases in which a patient is considering an elective primary c-section. Choice of delivery method ultimately depends on careful shared decision making and patient considerations of their long-term goals. 

Focused History of the Patient

The patient was a 31-year-old, gravida 1 para 0 at 39 weeks 0 day with a singleton gestation who presented for an elective primary c-section in the setting of a history of complex spinal surgeries. She had a BMI of 26.35 and American Society of Anesthesiologists score of 2. Her past medical history included lumbosacral spondylolisthesis and spondylosis, and she underwent a posterior bilateral L4-L5 and L5-S1 decompression, transforaminal lumbar interbody fusion at L5-S1, and instrumented fusion L4 to S1 including pelvic fixation. She later had a re-exploration surgery of her previous lumbar sacral fusion with removal of bilateral iliac pelvic fixation screws. During her prenatal course, the anesthesia team cleared her for neuraxial anesthesia administration, and her neurosurgeon cleared her for both vaginal and cesarean deliveries. After many discussions throughout her prenatal course, the patient elected to proceed with a primary c-section for delivery due to concerns around being able to push effectively in labor and reinjury to her back that would require significant rehabilitation or additional reparative procedures after delivery.

Physical Exam

Our patient was well-appearing, with a gravid abdomen, appropriate size for gestational age. Her neurologic exam had no focal deficits and was without an antalgic gait. She had symmetrical posture with standing, walking, flexion, extension, and lateral rotation. Her BMI was 26.

Imaging

In addition to routine prenatal obstetrical ultrasounds, other imaging modalities are not required in deciding on an elective primary c-section. In patients with complex spinopelvic anatomy, further imaging with plain films and MRI may be useful. In this case, pertinent imaging was reviewed and an x-ray was notable for intact remaining hardware L4-S1, without any abnormal movement on flexion or extension views. The imaging studies were used in aiding the decision made by the anesthesia team regarding the ability to administer spinal anesthesia safely and effectively.

Rationale for Treatment

The goal of a c-section is to deliver a healthy fetus by minimizing poor maternal and neonatal outcomes, including immediate labor complications and long-term risks. In this case, long-term morbidity was heavily considered, with a goal to reduce the risk of further lumbosacral pain and need for further interventions.

Special Considerations

Patients with complex spinal or pelvic histories should seek early consultation with the anesthesia team for discussion of neuraxial anesthesia candidacy, regardless of desired mode of delivery. In these cases, it is worth noting that it is not guaranteed that the neuraxial anesthetic will be successful and, in the case of a c-section, this would be an indication to proceed with general anesthesia during the procedure. In the case of a vaginal trial of labor, this may result in suboptimal pain control during labor.

Discussion

In this case, a primary elective c-section was performed in a patient with a history of complex spinopelvic anatomy. The surgery resulted in the delivery of a healthy newborn without any immediate surgical complications. 

Prior to surgery, decision making involved an interdisciplinary discussion between the patient and the obstetrics, anesthesia, and neurology teams. Ultimately, the patient’s internalized risk of long-term spinopelvic pain or potential additional surgeries outweighed the risks of a cesarean delivery. 

On the day of surgery, the patient was taken to the operating room where her spinal anesthetic was administered and found to be adequate. Perioperative cefazolin was administered. Cefazolin is the first-line choice of prophylactic antibiotics for cesarean delivery, as use of standard alternatives have shown an increased risk of surgical site infections.¹¹ Pneumatic compression boots were placed and activated for venous thromboembolism prophylaxis. A urinary Foley catheter was placed. The patient’s abdomen was prepped and draped in the normal sterile fashion in the dorsal supine position with a left lateral tilt. The lateral tilt is used to relieve pressure from the fetus on the inferior vena cava responsible for blood return to the heart. 

A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia with sharp and blunt dissection. A Pfannenstiel incision is the most common choice for c-section. While newer literature proposes alternative skin incisions may have shorter operative time, disruption of fewer skin layers, and less blood loss,¹² the Pfannenstiel incision is well studied with predictable long-term outcomes, better postoperative healing, and preferred patient aesthetics. ^13, 14 The fascia was then incised in the midline and extended laterally with sharp dissection with Mayo scissors. The superior aspect of the fascial incision was grasped with Kocher clamps, elevated, and the underlying rectus muscle was dissected off with blunt dissection and sharp dissection with Mayo scissors. In a similar manner, the inferior aspect of the fascial incision was grasped with Kocher clamps, elevated, and the underlying rectus muscle dissected off with blunt dissection and sharp dissection with Mayo scissors. The rectus muscles were separated in the midline. The peritoneum was identified and entered bluntly. The peritoneal incision was extended bluntly, maintaining good visualization of the bladder. A bladder blade was inserted. Some surgeons create a bladder flap that brings the bladder further from the hysterotomy incision.

A low transverse incision was made on the uterus. The use of alternative uterine incisions in cases of full-term gestation with a well-developed lower uterine segment is avoided as they are associated with increased risk of uterine rupture in subsequent pregnancies. ¹⁸ Alternative incisions may be necessary in the case of altered anatomy or preterm gestations with a poorly developed lower uterine segment. The uterine incision was then extended bluntly, by stretching in the cephalocaudal direction. The membranes were ruptured sharply with an Allis clamp. The bladder blade was removed. The infant’s head was palpated and brought to the incision. Subsequently, the left rectus muscle was cut with bandage scissors to aid in delivery of the fetal head. In many cases, the rectus muscle is not cut in a c-section; however, evaluation of the anatomic space-limiting factor may lead to extension of the uterine incision and/or cutting of the rectus muscle in order to safely deliver the neonate. The rest of the body followed easily. After one minute of delayed cord clamping, the cord was clamped twice and cut, and the neonate was transferred to the warmer to the awaiting pediatric staff. 

The placenta was expressed intact. The uterus was then exteriorized and cleared of all clot and debris with a lap sponge. The hysterotomy was closed in two layers with 0 Monocryl, first in a running locked layer and then in an imbricating layer. There has been ongoing literature debate on the utility of a single- versus double-layer uterine closure. Some studies show similar rates of estimated blood loss while others argue possible increased risk of future uterine rupture with a single-layer closure.^19, 20, 21 A double-layer is often indicated for adequate hemostasis, as was used for this patient. The patient’s fallopian tubes and ovaries were examined and appeared normal. The uterus was returned to the abdomen. The uterine incision, peritoneal edges, and subfascial planes were inspected and all found to be hemostatic. The fascia was closed with 0 Vicryl suture in a running fashion. The subcutaneous tissues were irrigated, and hemostasis was confirmed. The subcuticular space was closed with a 3-0 plain gut suture in three interrupted sutures. The skin was closed with subcuticular 4-0 Monocryl.  

The patient tolerated the procedure well and was taken to the recovery room in stable condition. The neonate was taken to the recovery room with the patient.

Postoperative Course

Operative time was approximately 1 hour. Estimated blood loss was 800 ml. The patient was discharged on postoperative day 3 without any postpartum complications.

Equipment

Standard c-section equipment. 

Disclosures

No disclosures.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

1. Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One. 2016 Feb 5;11(2):e0148343. doi:10.1371/journal.pone.0148343.
2. Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol. 2013 Oct;209(4):294-306. doi:10.1016/j.ajog.2013.02.043.
3. Wax JR. Maternal request cesarean versus planned spontaneous vaginal delivery: maternal morbidity and short-term outcomes. Semin Perinatol. 2006 Oct;30(5):247-52. doi:10.1053/j.semperi.2006.07.003.
4. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000 Oct 21;356(9239):1375-83. doi:10.1016/s0140-6736(00)02840-3.
5. Burke C, Skehan M, Stack T, Burke G. Rising caesarean section rates: a cause for concern? BJOG. 2003 Oct;110(10):966. doi:10.1111/j.1471-0528.2003.3026b.x.
6. Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. Maternal outcomes associated with planned vaginal versus planned primary cesarean delivery. Am J Perinatol. 2010 Oct;27(9):675-83. doi:10.1055/s-0030-1249765.
7. Leijonhufvud A, Lundholm C, Cnattingius S, Granath F, Andolf E, Altman D. Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Am J Obstet Gynecol. 2011 Jan;204(1):70.e1-7. doi:10.1016/j.ajog.2010.08.034.
8. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol. 2004 May;103(5 Pt 1):907-12. doi:10.1097/01.AOG.0000124568.71597.ce.
9. ACOG Committee on Practice Bulletins. Clinical management guidelines for obstetrician-gynecologists. Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014 Mar;123(3):693-711. doi:10.1097/01.AOG.0000444441.04111.1d.
10. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. No. 82 June 2007. Management of herpes in pregnancy. Obstet Gynecol. 2007 Jun;109(6):1489-98. doi:10.1097/01.aog.0000263902.31953.3e.
11. Kawakita T, Huang CC, Landy HJ. Choice of prophylactic antibiotics and surgical site infections after cesarean delivery. Obstet Gynecol. 2018 Oct;132(4):948-955. doi:10.1097/AOG.0000000000002863.
12. Hofmeyr GJ, Mathai M, Shah A, Novikova N. Techniques for caesarean section. Cochrane Database Syst Rev. 2008 Jan 23;2008(1):CD004662. doi:10.1002/14651858.CD004662.pub2.
13. Sung S, Mahdy H. Cesarean Section. 2022 Sep 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.
14. Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol. 2013 Oct;209(4):294-306. doi:10.1016/j.ajog.2013.02.043.
15. Kadir RA, Khan A, Wilcock F, Chapman L. Is inferior dissection of the rectus sheath necessary during Pfannenstiel incision for lower segment caesarean section? A randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. 2006 Sep-Oct;128(1-2):262-6. doi:10.1016/j.ejogrb.2006.02.018.
16. Tuuli MG, Odibo AO, Fogertey P, Roehl K, Stamilio D, Macones GA. Utility of the bladder flap at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2012 Apr;119(4):815-21. doi:10.1097/AOG.0b013e31824c0e12.
17. Aslan Cetin B, Aydogan Mathyk B, Barut S, Zindar Y, Seckin KD, Kadirogullari P. Omission of a bladder flap during cesarean birth in primiparous women. Gynecol Obstet Invest. 2018;83(6):564-568. doi:10.1159/000481283.
18. Kan A. Classical cesarean section. Surg J (NY). 2020 Feb 6;6(Suppl 2):S98-S103. doi:10.1055/s-0039-3402072.
19. Vachon-Marceau C, Demers S, Bujold E, et al. Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy. Am J Obstet Gynecol. 2017 Jul;217(1):65.e1-65.e5. doi:10.1016/j.ajog.2017.02.042.
20. Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev. 2014 Jul 22;(7):CD004732. doi:10.1002/14651858.CD004732.pub3.
21. Hegde CV. The never ending debate single-layer versus double-layer closure of the uterine incision at cesarean section. J Obstet Gynaecol India. 2014 Aug;64(4):239-40. doi:10.1007/s13224-014-0573-9.

Cite this article

Stewart TP, Taney JB. Primary low transverse c-section. J Med Insight. 2023;2023(390). doi:10.24296/jomi/390.

incision, sutures, processing, care after surgery

Caesarean section is always performed in the interests of the mother and fetus when a woman cannot give birth through the natural birth canal.

Every year there is an increase in the number of operative delivery in obstetric practice. For example, in the 90s, the number of caesarean sections was 10.2%, and by 2005 – 17.9% ¹ .

Currently, the number of primiparous women over 35 has increased, as well as the number of in vitro fertilization (IVF). The widespread use of modern methods of fetal diagnostics: ultrasound, cardiac monitoring (registration of fetal cardiac activity and contractile activity of the uterus), X-ray pelvimetry (to determine the degree of narrowness of the bones of the female pelvis) – make it possible to better detect pregnancy anomalies and establish indications for caesarean section.

If indications for a caesarean section are determined during pregnancy, then surgery is planned. With a planned caesarean section, the frequency of postoperative complications is 2-3 times less than with an emergency operative caesarean section.

Vaginal disinfection with a solution of chlorhexidine or povidone-iodine is performed before caesarean section for ruptured membranes and in women in childbirth to reduce the risk of postoperative endometritis (inflammation of the inner layer of the uterus) ² .

Povidone iodine

Characteristics and properties of povidone iodine. What is povidone-iodine used for? Instructions for use of the solution, ointment, suppositories Betadine ^® with povidone-iodine.

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Types of incisions for caesarean section

By localization incisions on the uterus for caesarean section are: in the lower segment partly in the body of the uterus

Cesarean section is classified as a complex surgical intervention ¹ . Most often, manipulation is performed in the lower segment of the uterus with a transverse incision due to better healing of the postoperative wound ² in this area.

There are 3 types e steps through the anterior abdominal wall :

• Pfannenstiel incision (transverse incision of the skin and subcutaneous tissue along the suprapubic fold)
• Joel-Cohen incision (transverse incision of the skin and subcutaneous tissue 2.5-3 cm below the line connecting the anterior superior iliac spines bones)
• Inferior median incision (incision along the line between the umbilicus and the pubic bone)

Suturing

After the birth of the child and afterbirth, the uterus, peritoneum, abdominal muscles, and skin are sutured.

Tissue suturing is carried out with absorbable synthetic threads from catgut, vicryl, monocryl and others. Catgut threads dissolve in about 100 days, monocrylic threads in 90-120 days, Vicryl threads will dissolve by 42 days.

Immediately after a caesarean section, cold is applied to the lower abdomen for two hours to reduce bleeding. According to the indications, a woman is prescribed drugs that improve blood flow, painkillers, anticoagulants (prevent the formation of blood clots), oxytocin (improves the contractile function of the uterus), antibiotics. Some time after a caesarean section, unpleasant pain in the lower abdomen will persist. On the 5th day, ultrasound is prescribed to determine the condition of the wound. Staples or sutures from the anterior abdominal wall are removed on the 6-7th day, and on the 8th day the woman is discharged under the supervision of a antenatal clinic doctor at the place of residence.

How to treat healing wounds, see a short video with surgeon Fedor Yanovich Kraskovsky

Algorithm for treating sutures after caesarean section

6 hours after delivery by caesarean section, in order to minimize the risk of wound infection, the dressing is removed ³ .

Stitches after caesarean section are treated daily ¹ .
Processing may include the following steps:

Washing

If washing of the suture area is required, disinfecting solutions can be used: povidone-iodine, potassium permanganate solution, chlorhexidine solution.

Disinfection

At this stage, disinfectants and drying agents are applied: based on iodine, alcohol-containing solutions of brilliant green, fucorcin and others.

Let’s consider the most popular means for decontamination of postoperative sutures.

Applying a dressing

After each treatment of the suture, it is recommended to apply a sterile dressing, which will protect the injured area from external influences.

Povidone-iodine solution (Betadine®)

Povidone-iodine solution ( Betadine ^® ) is a modern broad-spectrum antiseptic. It is used in various areas of modern medicine due to its activity against many microorganisms and a favorable benefit/risk ratio.

Solution Betadine ^® is active against bacteria, viruses, fungal pathogens and protozoa ⁴ . In this disinfectant, the iodine molecule is attached to the carrier – povidone, which made it possible to exclude alcohol from the composition and thereby ensure comfortable use of the drug, without burning sensations, even when applied to fresh wounds and sutures. When treating wounds, the components of the solution Betadine ^® are practically not absorbed into the body ⁸ , which ensures a high safety profile.

Wash with solution Betadine ^® diluted 1:10, and used undiluted for joint lubrication. It is important to note separately that the solution Betadine ^® allows for comfortable use without burning. Yellow-brown staining is easily washed off the skin with plain water.

Instruction

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Based on povidone-iodine, Betadine® ointment is produced, which has a dual effect:

• povidone-iodine disinfects
• macrogol, which is part of the ointment, helps to “pull out” pus when it appears as a result of wound complications

Ointment Betadine ^® can be used under dressings in a thin layer without rubbing into the incision twice a day.

In the treatment of infected wounds under wipes soaked in solution or Betadine Ointment ^® , during the first 5-7 days the area of ​​edema noticeably decreased and the amount of purulent discharge decreased, there was also a decrease in pain ⁵ .

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Solutions of hydrogen peroxide 3% and potassium permanganate

Solution of hydrogen peroxide 3% and solution of potassium permanganate (manganese) belong to the group of oxidizers. Upon contact with an unhealed suture, the active substance decomposes with the release of active oxygen, which causes a disinfecting effect. They are especially effective for suppressing anaerobic infections (clostridia, streptococci, shigella, yersinia, fusobacteria and others), for these microorganisms oxygen is detrimental, since an oxygen-free environment is needed for the normal functioning of these organisms. However, treating a wound with hydrogen peroxide does not guarantee against contracting a wound infection ⁶ , must not be used under occlusive (airtight) dressings ⁴ .

Use of hydrogen peroxide may cause allergic reactions ⁷ .

To prepare a solution of potassium permanganate, several crystals of potassium permanganate are placed in a container with warm water, only freshly prepared agent ⁸ is used. Potassium permanganate is subject to special control and accounting in the Russian Federation, therefore, the sale of this product is limited. Moreover, an undissolved crystal of potassium permanganate can cause skin burns.

Chlorhexidine solution

Chlorhexidine solution ⁹ belongs to the group of antiseptic and disinfectants, active against viruses, bacteria, fungal infections. Use 2-3 times a day with a mandatory exposure of 1-3 minutes. Simultaneous use with iodine is not recommended. It is used with caution during breastfeeding.

In addition, today there is a decrease in the effectiveness of a number of antiseptic preparations having a chlorine-containing molecule ¹¹ .

Care of a maturing scar

After the sutures have dissolved, the wound has healed, scar tissue begins to form. At this stage, to prevent the development of rough scars, it is recommended to use creams and gels based on silicone, hyaluronidase, natural plant components (for example, combined preparations based on onion extract, sodium heparin and allantoin).

Possible complications from incorrect or no handling

On the first day after caesarean section, the temperature may rise to 38°C and the number of leukocytes in the blood may increase ³ .

In the modern medical community, the strategy of “Accelerated recovery after surgery” is actively practiced – the woman in labor is prescribed pain relief, prevention of postoperative blood clots, and early physical activity is recommended.

4-6 hours after the operation, they are allowed to sit up in bed, put their feet on the floor, then walk. This reduces the risk of thrombosis, congestion in the lungs, the formation of adhesions in the abdominal cavity ³ .

However, a woman may experience the following problems with suture healing: Therefore, after the operation, it is not recommended to lift weights.

Formation of a hypertrophic or keloid scar

• If the scar tissue begins to protrude above the skin surface, then most likely a hypertrophic or keloid scar has formed ¹⁰ .
• Keloid scars form not earlier than 3 months after suture, may extend beyond the suture, often accompanied by pain ¹⁰ . Grow indefinitely.
• Hypertrophic scars begin to form in the first month after skin injury, do not extend beyond the suture and grow over the next 6 months. Hypertrophic scars can spontaneously decrease in size.

Infection/suppuration of the wound

Signs of infection are: increasing pain in the suture area, swelling, redness of the skin, the suture may become hot to the touch, pus may be released when pressed. Infection of the wound slows down the healing process and the inflammatory process can spread to the abdominal muscles and abdominal cavity, which can be life threatening.

Therefore, it is important to keep the area of ​​the healing suture clean, treat it with antiseptics in a timely manner, do not touch it with unwashed hands, and wear clean underwear.

As the postoperative wound heals, itching may appear in the area of ​​scar formation. This is the norm when healing any wounds, the main thing is not to accidentally injure the suture and not to remove the suture material on your own.

Frequently Asked Questions

When can I bathe after a caesarean section?

The bandage from the suture after caesarean section is removed after 6 hours, after which it is possible to take a shower daily ³ .

How do you know if a caesarean section is healing properly?

Over time, swelling and soreness should decrease, as well as the amount of sanious discharge in the suture area. There should be no purulent discharge. The skin around the suture becomes normal in color, although the scar itself may remain red for several months.

How can ugly scars after caesarean section be treated?

For the treatment of keloid and hypertrophic scars, doctors prescribe ¹⁰ :

• course intralesional administration of anti-inflammatory hormonal drugs
• exposure to liquid nitrogen once every 3-4 weeks, at least 3 procedures per course
• laser exposure (pulsing laser on dyes or based on carbon dioxide)
• surgical excision

To prevent the formation of scars after the healing of the suture, preparations based on hyaluronidase, plant extracts, and silicone are prescribed.

How long can you not lift weights?

To reduce the load on the abdominal muscles and improve their healing, physical activity is limited to 1.5 months.

Moshkova Elena Mikhailovna

Dermatovenereologist, Head of the CDO for the provision of paid services, St. Petersburg State Budgetary Institution of Healthcare “City Dermatovenerological Dispensary”, St. Petersburg

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References

1. “National guide to obstetrics”. Edited by E.K. Ailamazyan, V.I. Kulakova, V.E. Radzinsky, G.M. Savelyeva, 2015.
2. Clinical guidelines. Singleton birth, delivery by caesarean section, 2021.
3. Clinical guidelines. Singleton birth, delivery by caesarean section, 2020.
4. Instructions for medical use Betadine ^® (solution, ointment), P N015282/03, P N015282/02.
5. breast cancer No. 29 dated 12/23/2010 “The use of the drug Betadine ^® in the treatment of infected wounds.” Authors: V.V. Mikhalsky, A.E. Bogdanov, S.V. Zhilina, A.I. Prvidentsev, A.I. Anikin, A.A. Ulyanina.
6. Hydrogen peroxide, 3% solution, radar.
7. Rational pharmacotherapy of skin diseases and sexually transmitted infections. Edited by A.A. Kubanova, 2007.
8. Potassium permanganate, powder. radar.
9. Chlorhexidine solution, radar.
10. “Federal Clinical Guidelines for the Management of Patients with Keloid and Hypertrophic Scars”, 2015
11. “Prevalence of microbial resistance to chlorhexidine from a systematic review and analysis of regional resistance monitoring.” Authors: Kvashnina D.V., Kovalishena O.V. Fundamental and clinical medicine. 2018;3(1):63-71.

Modern technique of caesarean section in evidence-based medicine Obstetrics and Gynecology academician V.I. Kulakov of the Ministry of Health of Russia, Moscow, Russia

This lecture presents the currently available data of evidence-based medicine for each of the stages of the caesarean section. It has been shown that Joel-Kohen laparotomy, a transverse incision in the lower segment of the uterus with an increase in the incision with the surgeon’s fingers, placenta extraction by traction behind the umbilical cord, suturing the uterine wall in one or two layers with a continuous suture, leaving the parietal and visceral peritoneum unsutured , routine suturing of subcutaneous tissue with a thickness of 2 cm or more without routine drainage of the subcutaneous and subaponeurotic space.

cesarean section

laparotomy

uterine incision and fetal extraction

restoration of the integrity of the uterus and anterior abdominal wall

surgical technique

Caesarean section (CS) is one of the most ancient operations with a long history of development . In the modern world, CS is the most frequent abdominal operation and the trend of its frequency growth continues. For 2007–2008 in developed countries, the highest frequency of CS in Mexico (43.9%), Italy (39.8%), South Korea (35.3%) [1]. In the United States during this period, abdominal delivery was performed in 31.8% of cases. Currently, every fifth pregnant woman is delivered by CS in Russia.

With such a high frequency of CS, this operation should be accompanied by a proven, practically routine technique. At the same time, the data of modern literature indicate a significant variety of approaches to the implementation of individual stages of this operation, not only in different countries, but even in neighboring institutions and, moreover, often within the walls of one maternity hospital.

This diversity indicates the incompleteness of ideas about the advantages and disadvantages of certain methods. To date, there have been certain approaches to the choice of CS technique, but how correct they are can only be assessed from the standpoint of evidence.

The main technical stages of delivery by CS are laparotomy, uterine incision and fetal extraction, restoration of the integrity of the uterus and anterior abdominal wall.

Laparotomy

The following types of laparotomies can be used during CS surgery: lower median, transverse suprapubic according to Pfannenstiel, Joel-Kohen, as well as transmuscular according to Czerny or Maylard. Each laparotomy has its own advantages and disadvantages. When choosing the type of laparotomy, one should rely on the following characteristics: the adequacy of access to the area of ​​surgical intervention, the absence of obstacles to the free cure of the fetus, the possibility of revision of adjacent organs.

Inferomedian incision is a classic laparotomy method that quickly provides good access to the organs of the lower half of the abdominal cavity and small pelvis, as well as the possibility of revision of the organs of the upper half of the abdomen. Compared to the suprapubic Pfannenstiel ventricular surgery, the lower midline laparotomy is a faster method of ventricular surgery. According to S. Timonen et al. (1970) [2], with laparotomy according to Pfannenstiel in 72%, it takes more than 4 minutes to extract the fetus, while with the lower median incision in 56%, it is born earlier. Difficult extraction of the fetus, the duration of which exceeds 8 minutes, occurs in 17% with a suprapubic incision, while with a longitudinal laparotomy it is twice as rare (8%). Therefore, in emergency situations, when an urgent extraction of the fetus is necessary, a lower median incision is usually recommended. At the same time, N. Youssef et al. (1989) [3] on a large number of observations (7216 CS performed over 5 years in 102 perinatal centers, public and private institutions in France) showed that, despite the longer time from the start of the operation to the extraction of the fetus with a Pfannenstiel incision, the condition of the newborn regardless of the type of laparotomy.

Thus, the advantages of the inferomedian laparotomy are the short time from skin incision to the incision on the uterus, wide access and ease of retrieval of the fetus. However, in the postoperative period, there is severe pain, a higher risk of postoperative hernia formation, worse cosmetic than with transverse suprapubic laparotomy. The Pfannenstiel incision prolongs the operation time, is often accompanied by the formation of hematomas, which makes it difficult to remove the fetus.

Currently, in developed countries, a transverse suprapubic incision is more often used, including in obese women (the risk of complications is 12 times lower). The proportion of lower median laparotomy is about 1%. In addition, with the introduction of Joel-Kohen transverse laparotomy into obstetric practice, such a criterion as the speed of entry into the abdominal cavity has lost its relevance [4]. During laparotomy according to Joel-Kohen, a superficial transverse rectilinear incision of the skin of the abdomen is made 2.5–3 cm below the line connecting the anterior superior iliac spines. Along the midline with a scalpel, the incision is deepened until the aponeurosis is exposed, which is incised on the sides of the white line. Then the aponeurosis is dissected to the sides under the subcutaneous fat with slightly open ends of straight scissors. The rectus abdominis muscles are released in a blunt way, opening access to the parietal peritoneum. Muscles and subcutaneous fat are simultaneously bred by bilateral traction. The peritoneum is opened in a blunt way, stretching the fingers in the transverse direction.

This type of laparotomy reduces the time to delivery of the fetus by an average of 3-4 minutes. In addition, the overall duration of the operation, the volume of blood loss, the severity of pain syndrome and the frequency of fever in the postoperative period are reduced [5, 6].

Incision on the uterus

The classic (corporal) incision does not require the formation of a vesicouterine fold flap, provides a wide operating window, is performed quickly and allows for easy removal of the fetus. However, at present, a longitudinal incision of the uterus is rarely used due to the intersection of the pronounced muscular layer of the uterine body and a large number of large vessels, which is accompanied by significant bleeding, and in repeated pregnancies, there is a high frequency of uterine rupture along the scar [4, 7]. The peritoneum covering the body of the uterus is rather tightly attached to the myometrium, so peritonization of the wound is difficult.

The wall of the uterus in the lower segment is thinner, contains fewer muscle fibers and blood vessels, which causes less trauma and reduces blood loss, promotes better wound healing. As a result, the risk of uterine rupture in subsequent pregnancies is reduced. The mobility of the peritoneal cover in the area of ​​the vesicouterine fold creates favorable conditions for subsequent peritonization of the uterine wound.

Regardless of the direction of the incision, the initial stage of the CS operation in the lower segment is its release from the peritoneal cover with the formation of a flap of the vesicouterine fold, which is subsequently used to peritonize the uterine wound. The peritoneum of the vesicouterine fold is grasped with tweezers 2-3 cm above the point of attachment to the bladder and cut with scissors in the transverse direction, almost close to the round ligaments of the uterus. The corners of the incision are directed slightly upward, so that the incision has a crescent shape, with a convexity downwards.

The advantage of a vertical incision in the lower uterine segment is the possibility of extending it upwards towards the body if the original dimensions are not adequate for free delivery of the fetus. At the same time, for a vertical incision in the lower uterine segment, it is necessary to expose the lower segment from the peritoneal cover and bladder down over a large extent. If delivery is difficult, the incision may extend into the vaginal wall and/or bladder. Involvement in a vertical incision of a contracting part of the myometrium of the body of the uterus in a subsequent pregnancy creates a higher risk of rupture than after a transverse incision in the lower segment.

It is possible to use an oblique incision in the lower uterine segment, which provides sufficient space for easy removal of the fetus with a “narrow”, unformed lower segment, as occurs in preterm pregnancy. At the same time, the probability and depth of the spread of the incision into the myometrium of the uterine body is less than with a vertical incision. At the same time, this incision option also has a higher risk of bladder injury, due to the need to mobilize it, and in subsequent pregnancy, careful monitoring is necessary due to an increased risk of uterine rupture.

The transverse section in the lower uterine segment is devoid of most of the above disadvantages. At the same time, it should be borne in mind that the continuation of the transverse incision into the gap (with difficult extraction of the fetus, its large size, etc.) can lead to damage to the vascular bundles of the uterus passing along its lateral surface, which is accompanied by massive blood loss. In addition, there may be difficulties for the birth of the fetus with a high location of the presenting head. Therefore, when determining the level of the transverse incision in the lower segment of the uterus with the head presentation of the fetus, one should first of all strive to ensure that the incision, if possible, falls on the projection area of ​​the largest diameter of the head.

In general, low trauma, less blood loss, favorable conditions for peritonization, low incidence of complications in the postoperative period and scar rupture in subsequent pregnancies determine the current situation, in which a transverse incision in the lower uterine segment is used in most women who are indicated for abdominal delivery. Other variants of cuts (along the back wall, in the bottom) are used extremely rarely or have only historical significance.

For a transverse incision of the uterus, the incision is initially made in the middle of the lower segment by 2-3 cm. From this point on, one of two options for continuing the incision is possible. In the first variant (according to Derfler), the incision is enlarged to 10–12 cm in lateral directions with scissors under the control of the surgeon’s index and middle fingers inserted into the wound [8]. The incision at the corners should be slightly raised upward (semilunar), which corresponds to the course of muscle fibers and allows you to increase access to the uterus for easy delivery of the fetal head without damaging the vascular bundles.

L.A. Gusakov (1939) CS is performed with an incision at the level of the vesicouterine fold without separation and displacement of the bladder. After a transverse incision of the lower segment of the uterus by 2-3 cm, the expansion of her wound is achieved by blunt dilution with the help of index fingers. The technique of blunt tissue dilution is combined with a decrease in blood loss by an average of 43 ml [9].

To reduce the risk of trauma to the fetus and reduce blood loss, it is recommended to make a careful incision in the lower uterine segment in layers without damaging the membranes, which are opened after its complete completion [10]. When using a layered technique, the pressure of the fetal bladder on the lower segment and the edges of the incision helps to reduce blood loss.

Birth of the fetus and afterbirth

In cephalic presentation, the surgeon passes four fingers between the anterior wall of the uterus and the fetal head, placing them below its level. Then the head is somewhat taken up and, bending the fingers, contribute to its eruption into the wound. At this moment, the assistant helps the birth of the head with dosed pressure on the fundus of the uterus through the anterior abdominal wall. After the birth of the head, it is carefully grasped with both hands, placing the palms biparietally, and with the help of gentle traction, the anterior and posterior shoulders of the fetus are alternately released. After removing the shoulder girdle, index fingers are inserted into the armpits and, carefully clasping the body at the level of the chest, contribute to the birth of the fetus. In case of difficult birth of the fetus, one should avoid swinging movements, do not use excessive efforts, but calmly assess the situation, determine the cause of the difficulty, after the elimination of which the birth will take place without difficulty (insufficient degree of incision of the aponeurosis, passage of the shoulders of the fetus perpendicular to the length of the incision, etc. ).

After the fetus is delivered and the umbilical cord is cut, the fetus is handed over to the midwife or pediatrician, and the operation continues with the birth of the placenta. To prevent bleeding, an infusion of oxytocin 10 U is started intravenously in saline solution (500 ml). It is preferable to extract the placenta by traction by the umbilical cord, which is accompanied by less blood loss, a decrease in the fall in hematocrit in the postoperative period, the incidence of endometritis and bed-days compared with those after separation and extraction by hand (Table 1) [11].

Table 1. Comparison of scores after removal of placenta by umbilical cord traction or separation and removal by hand .

Restoration of the integrity of the uterine wall

Before considering the methods and restoration of the integrity of the walls and uterus, it is advisable to discuss the issue of its removal from the abdominal cavity (exteriorization). The available data were analyzed in a systematic review in 2004 [12].

Supporters of uterine suture in the abdominal cavity point to a higher incidence of nausea and vomiting during surgery, pain during hysterectomy, while proponents of removal point to a decrease in the amount of blood loss and the duration of the operation. But the greatest controversy was the risk of an increased likelihood of infectious complications. The Cochrane study found no difference in complication rates, except for a reduction in postoperative fever with uterine exteriorization (Table 2).

Table 2. Restoration of the integrity of the uterus during its exteriorization or in the abdominal cavity.

Thus, at present there is no evidence that the removal or, on the contrary, leaving the uterus in the abdominal cavity during its suturing is more advantageous. The experience of Russian obstetric institutions over the past 15 years shows that the removal of the uterus for suturing it is a safe manipulation that creates favorable conditions for restoring the integrity of the wall.

Scientific development of the suture on the uterus began about 130 years ago (since 1882), when the German doctor Max Senger recommended that the peritoneum be separated from the myometrium first, then, making an incision in the uterus, excise its part in the form of a wedge up to 2 cm wide, the top of which is directed towards the uterine cavity. This type of incision was developed for the subsequent layer-by-layer two-story peritonizing suturing of the uterine wound, thus achieving the most favorable cooptation of its edges.

The principles proposed more than 100 years ago are used in more modern designs of the uterine suture. At present, the evolution of the technique for restoring the integrity of the uterine wall has gone through a number of stages. Separate, continuous, one-, two-, three-layer sutures were used, with and without endometrial puncture. Special complex variants were also proposed, some of which are shown in Fig. 1 and 2. The advantages of separate sutures are better comparison with torn, non-matching wound edges, while with a continuous suture, the technique is simpler, the duration of the operation is reduced, and the amount of suture material is reduced.

Comparison of single-layer and double-layer techniques for suturing the uterine wound shows that the first one is combined with less blood loss, the duration of the operation, and the severity of pain in the postoperative period also decreases (Table 3) [9].

Table 3. Comparison of single-layer and double-layer techniques for suturing a uterine wound.

In this regard, since the late 1990s and early 2000s. The continuous single-layer uterine suture technique has been recommended for closure of the uterine wound in CS in most studies and has been widely adopted throughout the world. An important condition for good healing of the uterine wall and maintaining the necessary strength of the scar is the mandatory restoration of the integrity of the uterine fascia, which is located immediately under the serous membrane.

However, some experts believe that the effectiveness and safety of a single-layer suture remains insufficiently elucidated. Thus, the British Royal College of Obstetricians and Gynecologists recommends using a two-layer technique for restoring the integrity of the uterine wall.

Caution with single layer uterine suture technique based on E. Bujold et al. (2002) [15]. In this study, on a large number of observations (about 2000), it was shown that with a single-layer technique for restoring the integrity of the uterine wall, the probability of uterine rupture during a subsequent pregnancy is 3.95 times higher than double layer.

One of the most discussed issues in modern obstetrics for a long time was the need to suture the peritoneal integument during CS. In 2003, the results of a systematic Cochrane review were obtained, which showed that leaving an unsutured visceral and/or parietal peritoneum does not lead to the development of complications, but is accompanied by a decrease in the duration of surgery, the need for analgesics, morbidity in the postoperative period, postoperative bed-day (Table . 4) [16].

Table 4. Comparison of outcomes for unsutured and sutured parietal and visceral peritoneum during caesarean section.

Thus, the immediate results of non-suturing of the peritoneal integument showed the feasibility of using this approach, although there is still insufficient data on long-term outcomes. Meanwhile, most modern guidelines, including those of the British Royal College of Obstetricians and Gynecologists, have already excluded the suturing of the peritoneal integument during CS from the mandatory stages of this operation.

Restoration of the integrity of the abdominal wall

Suturing of the aponeurosis and rectus abdominis muscles has not been studied in separate studies. Meanwhile, the opinion of experts indicates that the muscles restore anatomical localization in a natural way and their stitching can lead to pain and adhesions. The aponeurosis is recommended to be sutured with a continuous suture without blockage with a slowly absorbable suture material.

To suture or not to suture the subcutaneous tissue? To answer this question, one should refer to the results of a systematic review in 2004 [17]. The results of this review are presented in Table. 5.

Table 5. Comparison of sutured and non-sutured subcutaneous fat during caesarean section.

Thus, suturing the subcutaneous tissue helps to reduce the overall incidence of complications from the wound of the abdominal wall, especially the number of hematomas and seromas. It does not matter which needles were used (RR=2.73, 0.54–13.76). The criterion that determines the need for suturing the subcutaneous tissue is its thickness of 2 cm or more. At the same time, the restoration of the integrity of the abdominal wall is combined with a significant decrease in wound dehiscence (RR=0.66, 95% CI 0.48–0.91) and seroma formation (RR=0.42, 95% CI 0.24–0.75).

Routine drainage of subcutaneous tissue in obese women (body mass index over 30 kg/m2) deserves discussion. As the results presented in Table. 6, routine drainage increases the duration of the operation and presents additional inconvenience to patients, but has no advantages [18].

Table 6. Comparison of outcomes with subcutaneous tissue suturing without and with routine drainage in obese patients.

Currently, there are few works devoted to comparing different options for skin suturing during CS surgery, and the results of studies are often contradictory, much also depends on the woman’s body [19].

When restoring the integrity of the skin, separate sutures are used, a continuous subcutaneous removable or removable suture, staples are applied, and cyanoacrylate glue is also used. At one time, many hopes were associated with the use of staples, but they are inferior to absorbable suture material (Table 7). Brackets reduce the time spent on the seam, but they have a worse cosmetic effect. The effect is also worse when using a non-absorbable suture material (if it is not removed). In general, a cosmetic suture is more convenient for women, although it takes more time to close the skin wound.

Table 7. Comparison of staple and subcutaneous suture for skin resurfacing.

Thus, the Joel-Cohen laparotomy, transverse incision in the lower uterine segment with an increase in the incision with the surgeon’s fingers, removal of the placenta by traction behind the umbilical cord, suturing the uterine wall in one or two layers with a continuous suture, leaving an unsutured parietal and visceral peritoneum, routine suturing of subcutaneous tissue with a thickness of 2 cm or more without routine drainage of the subcutaneous and subaponeurotic space.

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3. Youssef N., Berrafato V., Mida M., Vitse M., Boulanger J.C. Evolution of the parietal incision in cesarean sections, Rev. fr. Gynecol. obstet. 1989;84(10):651-7.
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15. Bujold E., Bujold C., Hamilton E.F., Harel F, Gauthier R.J. The impact of a single-layer or double-layer closure on uterine rupture. Am. J. Obstet. Gynecol. 2002;186(6):1326-1330.
16. Bamigboye A.