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Cesarean Section: Indications and Technique
Cesarean Section: Indications and Technique PAUL E. LAWLER, JR., M.D. Instructor in Obstetrics and Gynecology, Stritch School of Medicine of Loyola University; Attending Obstetrician and Gynecologist, Little Company of Mary and Lewis ~Memorial Maternity Hospitals; Associate, Department of Obstetrics, Cook County Hospital, Chicago, Illinois
CESAREAN section has become a safer procedure than it was 30 years ago, chiefly because of modern medical advances but also because we act more quickly. Instead of the older practice of allowing the patient to have two days of labor or operating under shock conditions we rely sooner on surgical interference and have the patient in better condition with blood and antibiotics if necessary. Although the maternal mortality in cesarean sections is about one in 500 cases, one must not forget that the patient is still subjected to the hazards of major surgery, such as thrombophlebitis, hernia, embolism, peritonitis, bladder injury or bowel obstruction. Also we must note that abdominal delivery does not guarantee a healthy baby; Hesseltine l has noted that vaginal delivery is safer for the infant than abdominal delivery. There were no maternal deaths in the last 600 eases of cesarean sections 0950-1959) at Lewis Memorial Maternity Hospital, but there was a morbidity incidence of 20 per cent. Complications consisted mostly of wound and bladder infections. It is of interest to note that the use of prophylactic antibiotic therapy did not decrease the incidence of infection. The operative rate at Lewis Memorial was 2.15 per cent of the total number of deliveries. INDICATIONS
Table 1 lists the indications for cesarean section at Lewis Memorial Maternity Hospital during the last ten years in the order of their frequency. Table 2 lists the miscellaneous indications. The chief indication for abdominal delivery is a previous cesarean section and this accounts for nearly 50 per cent of all sections. We schedule these patients for section between one and two weeks before the baby is due. If we are not sure of the due date or the infant's weight, we postpone elective surgery until we are more certain or until the patient
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PAUl.
Table 1.
LAWLER,
.In.
Indications for Cesarean Section at the Lewis Memorial Maternity Hospital (In order of frequency)
J Previous ccsarean Heetioll 2. Cephalopelvic disproportion :~. Placenta previa 4. Miscellaneous I). Abruptio placcnta" 6. Toxemia
Table 2.
E.
7. Prolapsed cord 8. Uterine inertia !l. Fetal distresR 10 TransverRe li .. 11. Diabetes
Miscellaneous Indications for Cesarean Section
Vaginoplasty Myomectomy Dystocia from fibroids Elderly primipara-breech Elderly primipara with fibroid Postmortem Low-lying placenta Primipara-breech with fibroid
Multiple stillborns Paraplegic-perineal infection Previous cerebrovascular accident Constriction ring Cervical cancer Face presentation Ovarian cyst
goes into spontaneous labor. At Cook County Hospital the policy is to allow spontaneous lab or before proceeding with the section. This method prevents the alwaYR preRent risk of electing section hefore the bahy iR large enough to Rurvive. If the patient had a previous e1assie type seetioll or a postoperative infection we do not deliver from below. One can see that it is mandatory to have adequate records of the previous surgery. We do not deliver from below if the patient is hesitant. On the other hand, we allow vaginal delivery in cases of a previous Rection under certain conditiolls. The patient who enters the hospital with the vertex presenting in the pelvis in normal lab or, for example, is a good candidate for vaginal delivery. These patients must have blood available and he watched constantly. Lawler et al,2 reviewed 100 cases from private practice and reported no ruptures of the uterine scars. Technically, repeated section is more difficult than the first section hecause of previous scar tissue, and in many cases because the bladder has been advanced well upward over the fundus. The bladder may be more difficult to visualize and there may be trouble disseeting it from the lower uterine segment. Cephalopelvic disproportion is the second most common indication, occurring in 23 per cent of the cases. Over 90 per cent of the patients in this group had x-ray pelvimetry done to augment the diagnosis. The most common type of pelvic abnormality found was the generally contraeted pelvis, followed in close order by the android and flat varieties. The use of carefully administered intravenous Pitocin has prevented some of our patients from becoming candidates for section or difficult forceps.
Cesarean Section: Indications and Technique
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Placenta previa was third on the list of indieations and was followed by abruptio placentae. Many patients with the latter may be delivered vaginally by rupturing the membranes and giving Pitocin if the baby is dead and the mother is not in shock. ANESTHESIA AND TECHNIQUE
We believe that local infiltration anesthesia using 0.5 per eent procaine with epinephrine is the safest type, especially for patients in shock, diabeties with their metaholic disturbanees, and for premature deliveries. For repeated seetions we think that spinal bloek is good beeause of the longer time required for them. This anesthesia must not be given by the untrained, who tend to give too great a dose. A 5-mg. injeetion of Nupereaine supplemented if neeessary with general anesthesia is safer than a larger dose with resultant vascular eollapse. A review of our 600 eases showed no differenee in fetal mortality using general and regional methods of anesthesia. In emergency situations when time is important, as in fetal distress or hemorrhage, the skin is quickly prepared with ether and alcohol. When time allows, the skin is soaped for five minutes and then painted with a suitable antiseptic solution. The vast majority of our patients had longitudinal skin incisions. A transverse skin incision takes more time, is unsuitable for local anesthesia and the exposure is not as good. Also the unfortunate wound separation is more difficult to manage with the Pfannenstiel type incision. Under general anesthesia or when speed is paramount, skin towels are not necessary. We train our residents in executing both transverse and vertical incisions into the uterus because the case may warrant one type over the other. For transverse lies and large babies the vertical incision is preferred. Many authors favor this incision for placenta previa but our experience with it has not been favorable. The inexperienced operator can cut into the uterine hlood vessels with the transverse incision or enter the bladder using the vertical approach. Visualization is better if the membranes are not broken until the desired length of lower uterine segment is incised. A trained operator can perform a low cervical cesarean section as fast as the classical type. The latter approach may be used if there are marked varicosities in the lower uterine segment, if the uterus is to be removed, or in the patient who has had a previom; section and whose bladder is situated high up over an undeveloped lower segment. Bladder injuries usually are not trouhlesome if they are recognized and properly drained. A classical section causes greater blood loss, increases morbidity and forecloses the patient's chance of any possible later vaginal delivery. It also increases the chance of uterine rupture before term. During the ten years of this study at Lewis Memorial Hospital there were 18 extra-
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LAWLER, JR.
peritoneal cesarean sections, mostly done for resident teaching. Since the advent of antibiotics we have not had to rely on this type of abdominal delivery. Our review of 600 cases of cesarean section shows that it is a safe procedure but carries with it surgical complications, material cost to the patient and a greater hazard to the infant. Therefore there must be a good indication for subjecting a woman to cesarean section. REFERENCES 1. Hesseltine, H. C. and Freese, U. E.: The Risk to the Fetus in Cesarean Section.
J. Iowa State Med. Soc. 49: 135, 1959. 2. Lawler, Paul, Bulfin, M. J., Lawler, F. C. and Lawler, P. E. Jr.: Vaginal Delivery After Cesarean Section. Am. J. Obst. & Gynec. 72: 252, 1956. 1150 W. 78th Street Chicago 20, Illinois
CESAREAN section has become a safer procedure than it was 30 years ago, chiefly because of modern medical advances but also because we act more quickly. Instead of the older practice of allowing the patient to have two days of labor or operating under shock conditions we rely sooner on surgical interference and have the patient in better condition with blood and antibiotics if necessary. Although the maternal mortality in cesarean sections is about one in 500 cases, one must not forget that the patient is still subjected to the hazards of major surgery, such as thrombophlebitis, hernia, embolism, peritonitis, bladder injury or bowel obstruction. Also we must note that abdominal delivery does not guarantee a healthy baby; Hesseltine l has noted that vaginal delivery is safer for the infant than abdominal delivery. There were no maternal deaths in the last 600 eases of cesarean sections 0950-1959) at Lewis Memorial Maternity Hospital, but there was a morbidity incidence of 20 per cent. Complications consisted mostly of wound and bladder infections. It is of interest to note that the use of prophylactic antibiotic therapy did not decrease the incidence of infection. The operative rate at Lewis Memorial was 2.15 per cent of the total number of deliveries. INDICATIONS
Table 1 lists the indications for cesarean section at Lewis Memorial Maternity Hospital during the last ten years in the order of their frequency. Table 2 lists the miscellaneous indications. The chief indication for abdominal delivery is a previous cesarean section and this accounts for nearly 50 per cent of all sections. We schedule these patients for section between one and two weeks before the baby is due. If we are not sure of the due date or the infant's weight, we postpone elective surgery until we are more certain or until the patient
185
186
PAUl.
Table 1.
LAWLER,
.In.
Indications for Cesarean Section at the Lewis Memorial Maternity Hospital (In order of frequency)
J Previous ccsarean Heetioll 2. Cephalopelvic disproportion :~. Placenta previa 4. Miscellaneous I). Abruptio placcnta" 6. Toxemia
Table 2.
E.
7. Prolapsed cord 8. Uterine inertia !l. Fetal distresR 10 TransverRe li .. 11. Diabetes
Miscellaneous Indications for Cesarean Section
Vaginoplasty Myomectomy Dystocia from fibroids Elderly primipara-breech Elderly primipara with fibroid Postmortem Low-lying placenta Primipara-breech with fibroid
Multiple stillborns Paraplegic-perineal infection Previous cerebrovascular accident Constriction ring Cervical cancer Face presentation Ovarian cyst
goes into spontaneous labor. At Cook County Hospital the policy is to allow spontaneous lab or before proceeding with the section. This method prevents the alwaYR preRent risk of electing section hefore the bahy iR large enough to Rurvive. If the patient had a previous e1assie type seetioll or a postoperative infection we do not deliver from below. One can see that it is mandatory to have adequate records of the previous surgery. We do not deliver from below if the patient is hesitant. On the other hand, we allow vaginal delivery in cases of a previous Rection under certain conditiolls. The patient who enters the hospital with the vertex presenting in the pelvis in normal lab or, for example, is a good candidate for vaginal delivery. These patients must have blood available and he watched constantly. Lawler et al,2 reviewed 100 cases from private practice and reported no ruptures of the uterine scars. Technically, repeated section is more difficult than the first section hecause of previous scar tissue, and in many cases because the bladder has been advanced well upward over the fundus. The bladder may be more difficult to visualize and there may be trouble disseeting it from the lower uterine segment. Cephalopelvic disproportion is the second most common indication, occurring in 23 per cent of the cases. Over 90 per cent of the patients in this group had x-ray pelvimetry done to augment the diagnosis. The most common type of pelvic abnormality found was the generally contraeted pelvis, followed in close order by the android and flat varieties. The use of carefully administered intravenous Pitocin has prevented some of our patients from becoming candidates for section or difficult forceps.
Cesarean Section: Indications and Technique
187
Placenta previa was third on the list of indieations and was followed by abruptio placentae. Many patients with the latter may be delivered vaginally by rupturing the membranes and giving Pitocin if the baby is dead and the mother is not in shock. ANESTHESIA AND TECHNIQUE
We believe that local infiltration anesthesia using 0.5 per eent procaine with epinephrine is the safest type, especially for patients in shock, diabeties with their metaholic disturbanees, and for premature deliveries. For repeated seetions we think that spinal bloek is good beeause of the longer time required for them. This anesthesia must not be given by the untrained, who tend to give too great a dose. A 5-mg. injeetion of Nupereaine supplemented if neeessary with general anesthesia is safer than a larger dose with resultant vascular eollapse. A review of our 600 eases showed no differenee in fetal mortality using general and regional methods of anesthesia. In emergency situations when time is important, as in fetal distress or hemorrhage, the skin is quickly prepared with ether and alcohol. When time allows, the skin is soaped for five minutes and then painted with a suitable antiseptic solution. The vast majority of our patients had longitudinal skin incisions. A transverse skin incision takes more time, is unsuitable for local anesthesia and the exposure is not as good. Also the unfortunate wound separation is more difficult to manage with the Pfannenstiel type incision. Under general anesthesia or when speed is paramount, skin towels are not necessary. We train our residents in executing both transverse and vertical incisions into the uterus because the case may warrant one type over the other. For transverse lies and large babies the vertical incision is preferred. Many authors favor this incision for placenta previa but our experience with it has not been favorable. The inexperienced operator can cut into the uterine hlood vessels with the transverse incision or enter the bladder using the vertical approach. Visualization is better if the membranes are not broken until the desired length of lower uterine segment is incised. A trained operator can perform a low cervical cesarean section as fast as the classical type. The latter approach may be used if there are marked varicosities in the lower uterine segment, if the uterus is to be removed, or in the patient who has had a previom; section and whose bladder is situated high up over an undeveloped lower segment. Bladder injuries usually are not trouhlesome if they are recognized and properly drained. A classical section causes greater blood loss, increases morbidity and forecloses the patient's chance of any possible later vaginal delivery. It also increases the chance of uterine rupture before term. During the ten years of this study at Lewis Memorial Hospital there were 18 extra-
188
PAUL
E.
LAWLER, JR.
peritoneal cesarean sections, mostly done for resident teaching. Since the advent of antibiotics we have not had to rely on this type of abdominal delivery. Our review of 600 cases of cesarean section shows that it is a safe procedure but carries with it surgical complications, material cost to the patient and a greater hazard to the infant. Therefore there must be a good indication for subjecting a woman to cesarean section. REFERENCES 1. Hesseltine, H. C. and Freese, U. E.: The Risk to the Fetus in Cesarean Section.
J. Iowa State Med. Soc. 49: 135, 1959. 2. Lawler, Paul, Bulfin, M. J., Lawler, F. C. and Lawler, P. E. Jr.: Vaginal Delivery After Cesarean Section. Am. J. Obst. & Gynec. 72: 252, 1956. 1150 W. 78th Street Chicago 20, Illinois