- The factors that increase cesarean delivery rate
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* The rates of cesarean delivery practices for breech, fetal distress,
and “other” are similar across all populations examined.
* The rates of cesarean deliveries for previous cesareans and labor dystocias differ markedly
--> Thus, any reductions in the rate in the United States will most likely come about by more selective diagnoses of labor dystocia and a wider acceptance of vaginal birth after a previous cesarean.
A. Transverse scars confined to the lower uterine segment
--> minimal risk of symptomatic scar separation during a subsequent pregnancy
-->this risk does not appear to be affected by the route of delivery, the risk of scar separation is 1.8 % with a trial of labor versus 1.9 % for elective repeat cesarean
--> it appears reasonable to encourage a trial of labor in most women
with a low-transverse scar
--> Women with more than one prior cesarean should not be discouraged from a trial of labor (ACOG 1995b)
--> insignificantly increased risk of rupture in women undergoing labor after two prior cesareans compared with one (Asakura and Myers 1995)
--> three-fold increased risk in women with two prior cesarean incision compared with only one (Kornfield 1996)
--> women with multiple cesarean incisions are at risk for hysterectomy because of abnormal placental adherence. Women with repeat cesarean delivery had a three-fold increase of hysterectomy compared with women undergoing primary cesarean section (Case 1996)
B. Low vertical scar confined to the lower uterine segment ? controversial
--> the risk of scar dehiscence was not different from those3 laboring with a prior low-transverse incision (Rosen 1991, Naef 1995)
C. A uterine incision that has extended into the upper contractile portion of the myomentrium is a contraindication to subsequent labor
--> approximately 12 % incidence of symptomatic and often catastrophic rupture during labor
-->these women are delivered by cesarean upon achievement of fetal pulmonary maturity prior to the onset of labor
2) Indication for Prior Cesarean
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3) Elective Sterilization
- Desire for permanent sterilization in a woman with a prior cesarean is not an indication for a repeat operation
4) Oxytocin and Epidural Analgesia
- No evidence that the use of oxytocin should be modified in a woman laboring with a prior low-transverse incision (ACOG 1995b)
- Less than 10 % of women with scar separation experience pain and bleeding, and fetal heart rate decelerations are the most likely sign of such an event. everal studies attest to the safety of properly conducted
epidural analgesia (Farmer 1991, Flamm 1994)
5) Examining the Scar
- The integrity of the old scar by palpation following successful vaginal delivery
- There is general agreement that surgical correction of a scar dehiscence is necessary only if significant bleeding is encountered.
- Asymptomatic nonbleeding separations do not generally require exploratory
laparotomy and repair
6) Elective Repeat Cesarean Delivery
- Guidelines for timing an elective operation (ACOG 1991)
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- Although maternal death is an infrequent sequel of cesarean birth, morbidity is increased dramatically compared with vaginal delivery
- Major morbidity
Advantages
1) less blood loss
2) easier to repair
3) least likely to rupture with extrusion of the fetus into the abdominal cavity during a subsequent pregnancy
4) does not promote adherence of bowel or omentum to the incisional line
1) Choice of Abdominal Incision
A. Infraumbilical midline vertical incision ? quickest
- Its length should correspond with the estimated fetal size
- Sharp dissection is performed to the level of the anterior rectus sheath
- Expose a strip of fascia in the midline about 2 Cm wide
- Make a small opening and then incise the fascial layer with scissors
- The rectus and the pyramidalis muscles are separated in the midline by sharp and blunt dissection to expose transversalis fascia and peritoneum
- The transversalis fascia and preperitoneal fat are dissecdted carefully to reach the underlying peritoneum
- The peritoneum is incised superiorly to the upper pole of the incision and downward to just above the peritoneal reflection over the bladder
B. The modified Pfannenstiel incision
- The skin and subcutaneous incision is made at the level of the pubic hairline and is extended somewhat beyond the lateral borders of the rectus muscles
- The fascia is incised transversely the full length of the incision
- The superior edges of the fascia are grasped with suitable clamps
and then elevated by the assistant as the operator separates the fascial sheath from the underlying rectus muscles by blunt dissection. The separation is carried near enough to the umbilicus to permit an adequate midline longitudinal incision of the peritoneum.
- The rectus muscles are separated in the midline to expose the underlying peritoneum
- The peritoneum is opened
- Advantage of the transverse skin
2) Uterine Incision
- With thick meconium or infected amnionic fluid, some operators prefer to lay a moistened laparotomy pack in each lateral peritoneal gutter to absorb fluid and blood that escape from the opened uterus
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- The loose vesicouterine serosa is grasped with the forceps. The hemostat tip points to the upper margin of the bladder
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- The loose serosa above the upper margin of the bladder is elevated and incised laterally
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- Dissection of bladder off uterus to expose lower uterine segment
- In general, the separation of bladder should not exceed 5 Cm in depth and usually less
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- The myometrium is being incised carefully to avoid cutting the fetal head
- The uterus is opened through the lower uterine segment about 1 Cm below the upper margin of the peritoneal reflection
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- After entering the uterine cavity, the incision is extended laterally
with either fingers or bandage scissors
3) Delivery of the Infant
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4) Repair of the Uterus
- The upper and lower cut edges and each angle of the uterine incision are examined carefully for bleeding vessels
- The uterine incision is closed with one or two layers of continuous 1-0 absorbable suture. Traditionally, chromic suture was used
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- The initial suture is placed just beyond one angle of the incision.
- A running-lock suture is then carried out, with each suture penetrating the full thickness of the myometrium
- Similar outcomes in the one- versus two-layer closure groups (Chapman 1996)
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- Serosal edges overlying the uterus and bladder in the past have been approximated with a continuous 2-0 chromic catgut suture
- When both visceral and parietal peritoneum were left open ? reduced need for postoperative analgesia and a quicker return of bowel function (Hull & Varner 1991)
5) Abdominal Closure
3) Uterine repair
- One method employs a layer of continuous 1-0 chromic catgut to approximate the inner halves of the incision.
- The outer half of the uterine incision is then closed with similar suture, using either a continuous stitch or figure-of-eight sutures
- The edges of the uterine serosa are approximated with continuous 2-0 chromic catgut
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- The round ligaments close to the uterus are divided and doubly ligated
- The incision in the vesicouterine serosa is extended laterally and upward through the anterior leaf of the broad ligament to reach the incised round ligaments
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- The posterior leaf of the broad ligament adjacent to the uterus is perforated just beneath the fallopian tube, utero-ovarian ligaments and ovarian vessels
- Then, these are doubly clamped close to the uterus
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- The posterior leaf of the broad ligament is divided inferiorly toward
the uterosacral ligaments
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- The bladder is further dissected from the lower uterine sefment by
blunt dissection with pressure directed towards the lower segment and not
bladder. Sharp dissection may be necessary
- The bladder is dissected free for about 2 Cm below the lowest margin
of the cervix to expose the uppermost part of the vagina
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- The ascending uterine artery and veins on either side are identified and near their origin are doubly clamped immediately adjacent to the uterus and divided
- The vascular pedicle is doubly suture ligated
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- The cardinal and uterosacral ligaments and many large vessels the ligaments contain are doubly clamped systematically with Heaney curved clamps and incised and suture ligated
- These steps are repeated until the level of the lateral vaginal fornix is reached
In this way, the descending branches of the uterine vessels are clamped, cut, and ligated
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- Immediately below the level of the cervix, a curved clamp is swung in across the lateral vaginal fornix, and the tissue is incised medially to the clamp
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- Each of the angles of the lateral vaginal fornix are secured to the cardinal and uterosacral ligaments
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- A running-lock stitch is placed through the edge of the vaginal mucosa
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- Reperitonealization of the pelvis