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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Not Your Typical Cesarean – International Cesarean Awareness Network

Not Your Typical Cesarean

An Intro to Special Scars by Jessica Tiderman

Most people know at least one person that has had a cesarean. Not many realize that there are a variety of incisions that can be used on the uterus during that cesarean. The most typical incision is a low transverse incision, which is a horizontal cut in the lower portion of the uterus usually called the lower uterine segment (LUS). Due to the lack of shorthand to describe the more unusual uterine incisions such as classical, inverted T, J, upright T or any cesarean incision other than the low transverse incision, I started calling them Special Scars. Without a way to describe these incisions, women weren’t getting the information and support that they needed.

An inverted T incision starts out with a low transverse incision and then the OB makes a vertical incision upward in the center of the uterus. A J incision also starts out with a low transverse incision but the OB makes the vertical incision up along the side of the uterus rather than the center, perhaps because the placenta or the baby was in the way. An upright T incision can happen in two ways; either the OB started with a low vertical incision and then needed more room at the top of the incision or started with a low transverse incision and made a vertical incision down toward and sometimes reaching the cervix. These three incisions are usually used for babies that are severely malpositioned and/or very stuck. The vertical portion of these incisions can range from a few millimeters to several centimeters. These are also usually contained within the LUS, but can extend into the upper uterine segment (UUS).

Classical incisions are vertical incisions and can be placed just about anywhere on the midline (middle) of the uterus but tend to be in the UUS. There is some dispute about the standard placement of a classical incision. They are still commonly used for early preterm cesareans although some doctors have switched to using the low transverse incision for those as well. Finally, low vertical incisions are simply that, a vertical incision on the midline that is contained within the LUS. This is used when the baby is in a transverse lie or if the placenta is in a location where they would typically cut.

Clearly, the Special Scars are a more complicated matter. The cesareans that end up in these incisions tend to take longer due to baby’s position, which leaves the mom more vulnerable to infection or other adverse effects from being open for so long. Moms with these incisions are more likely to have a host of problems that are less likely to occur with low transverse incisions – wound infection, endometritis, septicemia, transfusion, ICU admission, hysterectomy, and maternal death. These incisions can also increase the mother’s length of stay in the hospital. Babies born from these incisions also have increased risks – stillbirth, neonatal death, APGAR less than 7 at 5 minutes, ICU admission.(1)

Emotionally, the moms may suffer from postpartum depression or post-traumatic stress disorder. It is very likely that they were told many times during their stay in the hospital after their cesarean that they would never be able to have a vaginal birth after cesarean (VBAC) after that particular surgery. They likely heard that statement so many times that they believe it. When they find out that it is possible to have a vaginal birth after their Special Scar they may feel shocked, angry, betrayed or any combination of those. Sadly, there is no research about the emotional effects of these incisions on women.

Once the woman decides she wants to have a vaginal birth it can be very difficult to find a care provider who is willing to assist a VBAC after a Special Scar (VBASSC). The search usually requires calling many doctors and/or midwives before locating one that will attend a trial of labor. When a care provider is not initially open to the idea, it is usually best to not even try talking them into it. It is unlikely that you will be the one to change his or her mind. University hospitals tend to be more willing to assist due to their size and staff. Some home birth midwives are willing to attend VBASSCs when not legally restricted from doing so by their state.

Many care providers are unwilling to assist a VBASSC because the risk of rupture is slightly higher than the risk of rupture after a low transverse incision. The generally accepted risk of rupture for low transverse incisions is 0.4-0.9% while the risk of rupture for inverted T, classical and J incisions is 1.9%.(2) Interestingly, low vertical incisions have no more of an increase in the risk of rupture than low transverse incisions. (3) If the cesarean was performed preterm there is a minimal increase in the risk of rupture.(4) As we know from Dr. Sarah Buckley’s writings, if a woman is allowed to labor unhindered her birth much more likely to go as it was designed.

Clearly, there is a need for further studies on these scars, the effects on future pregnancies and the effects on the mother emotionally. The few studies that are available used a relatively small number of subjects. Therefore, without clear evidence of exceptional risk the woman and her partner should be the ones to make the decision whether or not she attempts to have a vaginal birth. Care providers should not be making decisions about VBASSC due to a level of fear or a lack of information. Indeed, if the care provider does have that much fear he or she should excuse themselves from serving the woman and let her find a care provider who is willing to serve her and trust her body to work as it was designed. There are already a number of women who have succeeded in having a VBASSC. To read their stories, for more information about this topic and access to the studies that I have mentioned, please visit http://www.specialscars.org.

(1) Patterson et al. Maternal and Perinatal Morbidity With Cesarean.Obstet Gynecol 2002;100:633-7

(2) Landon et al. Trial of Labor after Prior Cesarean Delivery. N Engl J Med 2004;351:2581-9.

(3) Shipp et al. Intrapartum Uterine Rupture. Obstet Gynecol 1999;94:735-40.

(4) Sciscione et al. Preterm Cesarean Delivery and Uterine Rupture. Obstet Gynecol 2008;111:648-53.

For more information on Special Scars, head over to Special Scars~Special Women and connect with them on Facebook.

Where are incisions made for mammoplasty

Where are incisions made (mammoplasty accesses)?

Periareolar approach

The incision is made along the lower edge of the areola, at the border of pigmented and uncolored skin, which allows the postoperative scar to become almost invisible after a while. Periareolar access can be used to install any type of breast implants (anatomical or round) both under the muscle and under the mammary gland.

When choosing this method, the surgeon has the opportunity to perform additional areola plasty simultaneously with the augmentation.

The disadvantages of periareolar access include the possibility of changing the sensitivity of the nipple. However, in most cases, it recovers completely over time. Another disadvantage is an increase in the possibility of developing mastitis during breastfeeding, retraction and, due to this, a moderate asymmetry of the areola area.

Axillary access

The incision is located in the armpit and runs along the posterior border of the pectoralis major muscle. Installing an implant through such an access does not injure the mammary gland, since its tissues are not affected at all during the operation. In addition, this is the most cosmetic way, in which it is easiest to hide the traces of surgery. Unfortunately, this access may not be used in all cases, but only for clear indications (unexpressed submammary fold, absence of breast ptosis, absence of sharp asymmetry). The limitations of the method include its relative inconvenience when installing anatomical implants and increased requirements for the skill of the surgeon and the equipment of the clinic. With this method, it is quite difficult, despite the use of endoscopic techniques, to control bleeding.

Submammary access

Involves an incision in the natural crease under the breast. In the case when the mammary gland and the submammary fold are clearly formed and there is no need to displace it, the postoperative scar will be almost invisible. Advantages of the method: breast tissue is not affected during mammoplasty, which makes it possible to completely exclude their injury. This method is considered the easiest for the surgeon and the safest for the patient, allowing good control of bleeding.

The only drawback is that this access is not recommended for patients with a “girlish” breast shape.

It is worth remembering 3 more “exotic” types of surgical access for augmentation mammoplasty. Today, they are practically not used due to the increased risk of postoperative complications or unnecessary difficulties during the operation:

• Transareolar approach, in which the incision is made across the areola, bypassing the nipple along the lower edge. This type of access allows you to install drop-shaped and round implants under the pectoral muscle or mammary gland, but if the size of the areola is not large enough, the length of the incision may not be enough. This option is the most traumatic for breast tissue, accompanied by frequent infectious complications and persistent loss of nipple sensitivity. At the same time, the method is characterized by high cosmeticity, since the postoperative suture is invisible on the pigmented skin of the areola.
• Transabdominal access is provided through an incision in the anterior abdominal wall along the bikini line. Mammary gland tissues are not affected during the operation. Such augmentation mammoplasty is performed exclusively during abdominoplasty, as this gives surgeons the opportunity to perform two operations simultaneously through one incision. This is a rather complicated option for breast augmentation, which is often accompanied by various complications due to the need to separate the subcutaneous layers over a large area and difficulties in creating a cavity for the implant.
• Umbilical access is provided by an incision on the upper semicircle of the umbilicus. With such mammoplasty, the surgeon creates a long tunnel in the tissue, through which breast implants are installed. This method is currently not used, because. it can only be used to install implants filled with saline, which are now practically not used.

Soil cut

Soil morphology

Soil morphology is a special branch of soil science, characterized by its own subject and research method. A person in the process of cognition always begins the study of any object by considering its external appearance, sensing it as something different from other objects surrounding it. That is why morphology – the study of form – underlies all natural sciences. Just as medicine begins with human anatomy, and zoology and botany with animal anatomy and plant morphology, so soil science has soil morphology as its starting point. Without knowledge of the morphology of an object, further knowledge of its properties, its relationships with other objects and the environment is impossible. Soil morphology underlies their diagnostics and, consequently, their classification.

Establishment of soil cuts

To study and determine soils in nature, to establish boundaries between different soils, to take samples for analysis, special holes are laid, which are commonly called soil cuts. They are of three types: full (main) cuts, semi-pits (control), pits (surface).

Full or main sections are made in such a way that all soil horizons and partially the upper part of the unchanged or slightly modified parent rock are visible. They are laid in the most typical, characteristic places. Their purpose is a detailed study of the morphological and genetic characteristics of soils with sampling for physicochemical, biological and other analyzes, determination of color, structure, etc. The depth of the main soil sections varies greatly depending on the thickness of the soils and the objectives of the research. Usually, in the practice of field studies and soil mapping, soil sections are laid to a depth of 1.0–2 m.

Full, or main, section

Semi-holes, or control, sections are laid at a shallower depth – from 75 to 125 cm, usually before the beginning of the parent rock. It serves for additional (control) study of the main part of the soil profile – the thickness of soil humus and other horizons, the depth and occurrence of salts, the degree of leaching, podzolization, alkalinity, solonchak, etc.

Half hole, or control, section

Pit, or surface, sections with a depth of less than 75 cm, serve mainly to clarify the soil boundaries identified by full sections and half-pits.

Pit, or surface, cut

Principles of laying a soil cut

At the place chosen for the soil section, a hole is dug 0.8 × 1.5 × 2.0 m in size so that three of its walls are sheer, i.e. vertical, and the fourth with steps. The front “front” wall, which is intended for studying the soil section, should be facing the sun. The soil from the pit must be thrown out on the long sides, but in no case towards the “front” wall, as this leads to its “contamination” and even to the destruction of the upper part of the wall of the soil section. At the same time, the following rule is followed: first, the soil is thrown onto one side of the section, then, when a light-colored, slightly humus horizon begins, onto the other. After the work is completed, the cut is buried, and here the order of work will be different: first, the soil mass from the lower horizons is dumped to the bottom of the cut, then from the upper ones. This causes the least damage to nature.

When the pit is ready, they begin to describe the soil (soil section description form), starting the entry in the field diary with the number of the section, its geographical location, and also the position relative to permanent landmarks (reference).