Caesarean section incisions

LSCS incisions

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minoo bhagia - Activity on Knol

Indications of LSCS

  • Foetal distress
  • Failed induction
  • Previous caesarean
  • Contracted pelvis or obstructed labour
  • Premature rupture of membranes(PROM)
  • Primi breech
  • Transverse lie
  • Brow presentation
  • Posterior face presentation
  • Severe intrauterine growth reatardation(IUGR)
  • Eclampsia
  • Severe preeclamptic toxaemia(PET)
  • Placenta praevia 3rd degree or 2nd degree
  • Abruptio placentae
  • Cord prolapse etc.
 

Investigations

Routine haemogram, platelet count , BT , CT, Blood Grouping , Blood sugar F,HIV ,HBsAg are usually done before the operation.

Anesthesia

Usually done in spinal anaesthesia , sometimes under GA like in the cases of Eclampsia or Severe PET

Incisions

Vertical subumbilical is commonly not used now a days, Transverse or Pfannensteil is used due to cosmetic reasons and early ambulation.In cancer surgery or pregnancy with myoma and in rural centres in India Vertical is still the method of choice.

 

Pfannensteil versus Misgav-ladach

Pfannensteil is called ” bikini incision” , it is just above the pubis and a curved incision.First skin then subcutaneous tissue is cut with electrocautery. Subcutaneous tissue is separated in midline upto 3cms.Fascia is cut transversely and separated cephalocaudally in the midline with fingers or using cautery or knife.Muscle is separated apart with fingers laterally and is not cut as in Maylard’s incision.Make a hole in the peritoneum with index finger and stretch the whole abdominal wall on each side with the help of assistant.Bladder flap is not made. Transverse hysterotomy incision is made 1cm above the reflection of the bladder peritoneum.Then it is extended usually verticaly or transversely with fingers so as to avoid more bleeding from the angles.Presenting part of the foetus is extracted out with grip of hand and fundal pressure . Sometimes ventouse cup is needed to extract out the foetal head.Sometimes it is deeply impacted in the cavity due to obstructed labour which is very common at periphery in rural areas when delivery is tried by ANM or Dai. They use cerviprime gel and misoprost tablets very frequently,so most of the unbooked cases are brought at midnight  with patient in agony , attendants in distress and ultimately it becomes an Obstetrician distress syndrome.With such an impacted head assistant can push the head from vagina or it can be delivered out as breech which I think is a better choice.After delivering the baby give it to neonatologist or nurse and wait for the placenta to separate.Most of the gynecologists are impatient , they do manual removal of placenta but if one has patience then chances of PPH are less. Tell anaesthetist to give inj methergine and to put oxytocin in the drip which they know but you have to remind them .Uterus is stitched in one layer , continuous locking 0-Chromic catgut or Vicryl-1.If there is bleeding then figure of 8 sutures can be given in second layer.Visceral and parietal peritoneum are not closed but I prefer to close parietal peritoneum ( will be discussing a case in a separate knol ).Rectus fascia is closed with continuous non locking vicryl no-1. Subcutaneous tissue if opened more than 3 cm , then it is better to obliterate the dead space with catgut 3-0 or put a drain. Be sure that there is no bleeding from the muscle before closing the fascia.
Skin is closed with staples or subcutaneous sutures with Prolene or Silk. Mattress sutures are usually applied depending upon the choice of the surgeon.

Misgav-Ladach or Joel-cohen

It is a transverse incision an inch above the site of pfannensteil  incision.Skin and subcutaneous tissue is cut , separated with fingers in the same way.fascia is cut transversely upto skin incision. Rectus muscle are separated in the same way.Peritoneum  is opened and a bladder flap is made.Uterus is closed with interrupted sutures.The procedure reduces the time and bleeding (250 versus 400 ml ) ie with Misgav -Ladach bleeding is less than with the Pfannensteil.Usually knife is used instead of cautery.
 

Midline vertical incision( sub umbilical)

It is still prefered in rural areas as caesarean is usually an emergency operation.All cases are handled by trained or untraind dai or ANM.

Maylard’s incision

It is same as Misgav -Ladach except cutting of the Rectus muscle.In maylard’s muscle is divided.There is no difference in the bleeding during the operation and post operative complications.Keep in mind the inferior epigastric artery.Muscle is usually not sutured afterwards.
 

Churney incision

Churney described a transverse incision that allows excellent surgical exposure to the space of Retzius and the pelvic sidewall. The skin and fascia are cut in a manner similar to a Maylard incision. The rectus muscles are separated to the pubis symphysis and separated from the pyramidalis muscles.

In vertcal insicion chances of haematoma in the abdominal wall are less.Transverse incision can give rise to post operative haemaoma if rectus muscle at the site of inferior epigastric are not tied properly.Vertical incision later on can give rise to hernia in some cases due to dehiscence of the rectus muscle.
Some non absorbable sutures are
 
  • Silk 
  • Cotton 
  • Stainless-steel wire (Flexon) 
  • Nylon (Dermalon, Surgilon) 
  • Polypropylene (Prolene, Novafil)
  • Braided synthetics (Dacron, Tevdek)

Cutting of Rectus Fascia


Separating the Muscle

Opening of Peritoneum
Stretching full thickness of abdominal wall
Delivery of head
Delivery of head with Ventouse application
Breech delivery
Closure of rectus fascia
Closure of skin


Complications during operation

uterine atony , bladder injury especially in 2 previous scars.

Post operative complications

Infection like endomyometritis , wound infection or dehiscence , thromboembolic complications ,abdominal wall haematoma , breast engorgement and urinary tract infections are very common.
Good antibiotics and proper autoclaving and  proper fumigation of the operation theatre can prevent the complication.
Early ambulation and  breast feeding is adviced to the patient.If staples or subcutaneous sutures are applied then the woman can go as early as 48 hrs.
Spinal headache can be treated with lot of fluids, pain killers and the rest.
Tubectomy is done with the consent of the patient after two sections if the condition of newborn is fine ,having good apgar score.
Follow up is done after 8 days to see the stitches or to remove the stitches if non absorbable material is used.
Lochia must be checked.
Contraception is adviced after 4 to 6 weeks. 
 

 

Please visit The Collaborative Book on Obstetrics and Gynecology

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