Classical Caesarean section

In spite of the long list of rather rare indications in Section 18.8, a classical
Caesarean section is seldom done by experienced obstetricians. We describe it
mainly because it is slightly easier if you are inexperienced. Because rupture of the
uterus is such a danger with subsequent pregnancies, perhaps as early as 28 weeks,
sew up the patient's uterus with particular care, and do all you can to persuade her
to have her tubes tied. Many steps are the same as for a lower segment operation,
so refer to them where necessary.

Fig. 18-14 CLASSICAL CAESAREAN SECTION. A, packing gauze round the

patient's uterus. B, incising her uterus. C, extending the incision downwards. D,
delivering the baby. E, emptying her uterus. F, removing the placenta and
membranes. G, an anchor stitch has been inserted, and the wound is being closed
by an inverting suture, which pierces each wound edge from within outwards. This
buries the peritoneal surface of the wound, and minimizes the formation of
adhesions. After ''Bonney's Gynaecological Surgery', Figs. 331[nd]7. Bailli[gr]ere,
with kind permission.

CLASSICAL CAESAREAN SECTION See elsewhere for the indications (18.8),

the equipment, and anaesthesia (A 16.6).

INCISION. The patient's bladder may be high in her abdomen, so take care not to
injure it. Stand on her right side, and make a right paramedian incision, or a
midline incision skirting her umbilicus, two-thirds of it below and one-third above
her umbilicus. This is best if she has a Bandl's ring or a high bladder.

Look for her round ligaments. Their position will tell you if her uterus is rotated or
not. If it is rotated, centre it.

Put large packs each side of her uterus to keep blood and liquor out of her
peritoneal cavity (A, Fig. 18-14). If you fail to do this blood will run into her upper
abdomen and flanks, and you will have to remove it before you finally close her
peritoneal cavity.

Make a 12 cm vertical midline incision in her uterus (B). The uterus is much
thicker here than in the lower segment. Make it as low down as possible, extending
into her lower segment[md]taking care to avoid her bladder. If necessary, reflect
this downwards (as in K, Fig. 18-12). Deepen the centre of the incision steadily,
being careful not to wound the baby. As soon as you are in her uterine cavity, put
two fingers into the wound and complete it upwards and downwards using scissors
to cut between your fingers (C). If the placenta is in the way, try to displace it
rapidly, rather than cutting through it.
Search for a leg, and deliver the baby as a breech, guiding his head with your other
hand (D). As soon as he is being delivered, ask the anaesthetist to inject
ergometrine with oxytocin (''Syntometrine'), or ergometrine 0.5 mg, intravenously.
Place two artery forceps on the cord, cut it between them, hand him to the midwife,
who should be waiting to receive him, and see that he is resuscitated rapidly. Hold
him by his legs with one finger between them as she does so.

As soon as he is delivered, deliver her retracted uterus through the abdominal

incision, by hooking your index and middle fingers into its cavity, helped, if
necessary, by the fingers of your left hand behind it.

As soon as her uterus has contracted, deliver her placenta and membranes (E).
Remove any shreds of membrane that remain by wiping the inside of her uterus
with a swab (F). If her membranes were not ruptured before the operation, the
appearance of the lower pole of the bag will show you that you have removed them
whole.

If her uterus is slow to contract, as may happen if anaesthesia is too deep, wait for
the ergometrine to act, and if necessary for lighter anaesthesia. Then, if necessary,
remove her placenta manually. Meanwhile wrap her uterus in a hot abdominal
towel, and compress it.

Inspect and feel her uterus to make sure that it is not ruptured. Repair it in layers
with ''1' chromic catgut. For the first layer stitch the decidua and the deep layer of
muscle with a continous suture. For the second one, use the sutures shown in G,
and H, to invert the peritoneal covering.

If a continuous suture is difficult, because her uterine wall is being pulled apart so
that each suture cuts out, place several sutures of interrupted silk 1 cm apart. Ask
your assistant to pull on all but one of them, so as to approximate the edges of the
incision, while you tie the remaining one. The result will be neat and may give a
stronger scar than catgut.

If she has agreed to have her tubes tied, now is the time to do it.

Remove and count the abdominal packs. Mop blood and exudate from her
peritoneal cavity, and close it (9.8). Alternatively, put tension sutures in her
abdominal wall, and leave them in for 10 days. Remove blood clot from her
vagina, as in Section 18.9. As soon she has recovered from the anaesthetic, give
her baby to her.

POSTOPERATIVELY, follow the same regime as for the lower segment operation
(18.9). Explain to her, and to her relatives, that, in her next pregnancy, she must
come into hospital, or into a maternity village at 32 weeks. She should have an
elective section at the 38th week, or earlier, if there is any suspicion of her uterus
rupturing.

Extraperitoneal Caesarean section

This operation dates from the pre-antibiotic era, and the introduction of
metronidazole (2.7) has made it largely unnecessary. But if you don't have
metronidazole, and you have to operate in the presence of sepsis, you may find it
useful. It is one of the more contentious operations in this book and one contributor
doubts its value.

If you section a mother in the presence of intrauterine infection, or after a long

labour, she runs the serious risk of multiple peritoneal abscesses or peritonitis.
There is quite a chance that she will die. You can reduce the risk of peritonitis by
excluding the incision in her uterus from her peritoneal cavity. To do this, reflect
her parietal peritoneum from the inside of her abdominal wall, and her visceral
peritoneum from the front of her lower segment, and tie them together. This will
seal off her peritoneal cavity from the incision that you are about to make into her
infected uterus. This takes longer than the standard method, and is not as easy as it
looks, but it is worth trying, if she is badly infected.

-Fig. 18-15 EXTRAPERITONEAL CAESAREAN SECTION. A, a view of the

patient's anterior abdominal wall from inside her abdomen, indicating the
structures to be cut. B, artery forceps attached to her median umbilical ligament. C,
her peritoneum reflected off her anterior abdominal wall. D, her peritoneum is
being reflected off her lower segment. E, her peritoneum tied in a purse string.
Kindly contributed by Hugh Philpott.

EXTRAPERITONEAL CAESAREAN SECTION See also Sections 18.8 and

18.11. Many of the details for the standard lower segment operation apply here
also.

INDICATIONS. Any Caesarean section in which the risk of subsequent peritoneal

infection is great, when you have no adequate antibiotic cover, and especially no
metronidazole. In an obstructed labour the attempt to do an extraperitoneal
Caesarean section may be an impractical addition to an already complicated
situation.

PERIOPERATIVE ANTIBIOTICS. Give what antibiotics you can, as in Section

2.9.

INCISION. Enter the patient's abdomen through a vertical incision from her
umbilicus to her symphysis pubis. Extend this down to her peritoneum, but not
through it.
To reflect her peritoneum, attach a haemostat to the root of her median umbilical
ligament. Pull on this to allow you to mobilize her parietal peritoneum: (1) laterally
towards the walls of her pelvis, and (2) down to the anterolateral aspect of her
lower segment.

CAUTION ! Be sure to mobilize her parietal peritoneum superiorly and laterally

for several centimetres above the lateral extremity of her uterovesical pouch. If you
don't mobilize it extensively the purse string that you are about to make will be too
tight, and may leak.

To enter her peritoneum, define and divide her median umbilical ligament. Extend
the incision in her peritoneum laterally and downwards on each side towards her
lower uterine segment. Cut her lateral umbilical ligaments (obliterated hypogastric
arteries) as you do so, and keep close to the point of firm attachment to her
bladder. Reflect her bladder downwards.

Attach a curved haemostat to her uterovesical pouch in the midline, where it joins
the base of her bladder. Divide her peritoneum between her bladder and her uterus,
and extend your incision laterally to join the incision that you have made on
entering her peritoneal cavity. Ignore the covering of peritoneum attached to the
fundus of her bladder.

Attach artery forceps to the upper incised margin of her uterovesical pouch. Use
this to help you mobilize a flap of peritoneum off her lower segment. Mobilize it as
far as the point of attachment to the upper segment.

Sew the two layers of peritoneum that you have just mobilized with a continuous
suture. Pull it tight to make a bunched-up button of peritoneal tissue. It should look
watertight.

Reflect her bladder off her lower uterine segment, and proceed with a lower
segment operation in the usual way (18.9).

At the end of the operation, close the incision in her uterus, and control bleeding
carefully. If possible, lavage the wound with 2 g of kanamycin or tetracycline
dissolved in 200 ml of warm saline. Don't attempt to remove this. If you use water
only, remove it.

Insert a 26 Ch fenestrated rubber tube extraperitoneally through her abdominal

wall, to lie over the suture line in her lower segment. Introduce a tube drain in her
opposite iliac fossa. This will enable you to irrigate her extraperitoneal space
postoperatively.

Ignore the peritoneum covering the remainder of her bladder, but stitch the remains
of her median umbilical ligament to the back of her rectus abdominis muscle. As
you do so, include as much of the overlying transversalis fascia as you can
conveniently gather together.

Apply intermittent suction drainage through the rubber tube, and irrigate the
antibiotic solution through the tube dressing drain.

If suction drainage is impractical, insert two corrugated drains, one in each iliac
fossa, extraperitoneally, leave them in for 48 hours, and then shorten them 3 cm,
before you finally remove them.

CAUTION ! Don't try to insert intraperitoneal drains. The aim is to try to keep her
peritoneal cavity uninfected.

Fig. 18-16 MEASURING THE TRUE CONJUGATE AT CAESAREAN

SECTION. If you pack a steel ruler in the the Caesar set, and measure a patient's
true conjugate routinely, it will help you to decide if a trial of scar is indicated next
time she goes into labour. If you do it carefully, it will give you an exact
measurement, and will enable you to check the vaginal measurement you made of
her her diagonal conjugate when you examined her in the antenatal clinic (it is 2
cm less).

A, her uterus has been pushed to the right and the ruler placed across her pelvic
cavity. Her bladder has been displaced, partly out of the wound. In reality her
symphysis is covered by the lower end of the wound and by her bladder. B, put
your finger down behind her symphysis on to its posterior surface, bring your
finger and the ruler out together, and see where it comes on the ruler. ''X' is her true
conjugate.

Lower segment Caesarean section

The first steps are to open the mother's abdomen through a lower midline incision,
to reflect the peritoneum off her lower segment, and to reflect her bladder
downwards at the same time.

If you are not careful, you can easily cut her bladder: (1) When you enter her
abdomen. You will be less likely to cut it, if you empty it with a catheter before the
operation starts, leave the catheter in, and then carefully reflect her bladder
downwards, before you open her uterus. (2) If It is stuck by scar tissue to her
abdominal wall or lower segment. (3) Later, if her lower segment tears.

With her bladder well out of the way, you can now open her uterus transversely.
The size of the incision is important, and so is the way you make it. It should be
about 10 cm long, with its ends curving gently upwards (the ''smile' incision). Both
an incision which is too large, and one which is too small can cause serious
bleeding from the uterine arteries. These arise from the internal iliac arteries, pass
through the paracervical fascia close to the ureters, and then climb up the sides of
her uterus.

There are several reasons for severe bleeding: (1) You fail to allow for the fact that
her uterus may be rotated[md]usually to the right. So, before you incise it, check
for rotation by looking at her round ligaments. If you don't allow for rotation, you
may cut her left uterine artery, because your incision is too far to the left. If you
find that the left side of the incision always bleeds excessively, this is probably
what you are doing. (2) She will bleed, if you let her uterus tear in an uncontrolled
way, by pulling the baby out through an incision which is too small. (3) She will
also bleed if you get him partly out, and then try to extend the incision by cutting.
Avoid these mistakes by first cutting a small incision, and then extending it as
described later. Never use a scalpel, or scissors, too far laterally towards the sides
of the uterus!

Deliver the baby, then clamp the edges of the incision, especially its outer angles,
with Green Armytage forceps, which were designed for this purpose. Most
bleeding takes place from the angles of the incision, and these forceps will control
it. Wait for her uterus to contract, remove the placenta, and then close her uterus in
two layers.

Although you are unlikely to cut her ureters, you can easily obstruct them with
misplaced sutures when you close her uterus, especially if there is much bleeding,
and you suture wildly with a large curved needle. So: (1) Put a stay suture into her
lower segment, just below where you are going to make your incision. This will
help you to find it later, when you come to stitch it up. (2) Be sure to suture only
her uterus, and not to suture too deeply downwards towards the vault of her vagina.
Put a finger behind her broad ligament when you stitch the ends of the wound.

Most operators place abdominal packs on either side of the uterus before they
incise it, so as to prevent blood, liquor, and meconium from soiling the peritoneal
cavity. Meconium is irritant, and if it becomes infected peritonitis may follow.
Others rely on mopping it out afterwards.

Normally, it is best not to bring the uterus out of the abdomen when you repair it:
but if there is any problem this may be helpful.

WAMBUE (35 years) had had three previous Caesarean sections, and went into
premature labour one evening. The duty doctor took her to the theatre. Her lower
segment was very vascular, and there were many adhesions from previous
operations. When he incised it, he cut into the placenta (placenta praevia). Section
was otherwise uneventful, her uterine incision was repaired, and all bleeding
carefully controlled. He noted that her bladder was distended, but assumed that the
catheter had come out. When she left the theatre her blood pressure was normal,
and she was given a unit of blood. Her urine was however noticed to be
bloodstained. Fiften minutes later he was summoned urgently to the ward because
she was lying in a pool of blood, with no pulse and a systolic blood pressure of 30
mm Hg. Her uterus was well contracted, she was given ergometrine, and rushed
back to the theatre. She was resuscitated and her abdomen was reopened; there was
no blood in it. She died on the table. At postmortem she had a large tear in her
bladder; the upper edge of her uterine incision had been mistakenly sutured to the
upper edge of her bladder, so that the lower edge of her uterus had been able to
bleed freely into her bladder. The doctor was overcome by grief and felt very
incompetent. LESSONS (1) The anatomy of a patient having her fourth section can
be complicated. (2) Always insert a stay suture in the lower segment of the uterus,
just below where you plan to make your incision, so that you can recognize it later.
This may be difficult after delivery, especially if there are adhesions and the
anatomy is complicated (many obstetricians never insert one). (3) If you find an
abnormally adherent or vascular lower segment, do a classical operation. (4) As so
often, disaster was the result of the combination of risk factors. A lower segment
which has been the site of adherence of a placenta praevia, is apt to bleed
postoperatively. Had she not also had a placenta praevia, she would probably have
escaped with her life, and merely had a vesico-uterine fistula, which could have
been repaired. (5) If you have to try to do your best in 20 expert fields
simultaneously (see the frontispiece), you will, by the standards of 20 experts, not
be as competent as they are, so you will inevitably meet tragedies of this kind, for
which you cannot be blamed. One can but do one's best, and what that is will
depend on who we are. What is reprehensible is not to care, and not to strive to
improve one's standards. (6) A colleague in this condition needs support. Fig. 18-
11 CAESAREAN SECTION[md]ONE. A, catheterizing the patient's bladder. B,
preparing her abdomen. C, draping her and covering her with an abdominal towel.
D, incising the skin. E, picking up a fold of peritoneum to feel if there is any gut in
it. F, incising her peritoneum. G, enlarging the opening in her peritoneum with
scissors.

LOWER SEGMENT CAESAREAN SECTION INDICATIONS. See Section 18.8.

PREOPERATIVE COUNSELLING. Where appropriate, discuss with the patient

the advisability of tying her tubes. Her husband, or in some cultures her mother, or
preferably both, should consent. The indications are: (1) [mt]2 previous Caesarean
sections. (3) Parity [mt]6. (4) Age [mt]35. (5) Medical problems which endanger
her life, such as hypertension, diabetes, or heart disease.

PERIOPERATIVE ANTIBIOTICS have been shown to halve the incidence of

wound infection after Caesarean section. Most routines are expensive, but here is a
cheaper one which is equally effective.

If she is at special risk of infection (membranes ruptured for more than 8 hours, or
if you are operating after a failed vacuum or forceps delivery, etc.) give her
perioperative chloramphenicol and metronidazole as in Section 2.9. Continue
metronidazole for 3 days postoperatively.

If she is a routine case, give her 1 g of metronidazole with the premedication as a

rectal suppository or as rectal tablets, and give her another gram 8 hours later.

ASSISTANT. Find yourself a competent assistant. If the head is impacted in her

pelvis, ask him to wear two gowns and two pairs of gloves, so that he can
disimpact it and then discard the first pair (see below).

A MIDWIFE TO RECEIVE THE BABY. Before you begin make sure that there is
a midwife ready to receive the baby, with all the equipment that she needs to
resuscitate him (19.12).

EQUIPMENT. Use the Caesar set described in Section 4.12. This includes a large
round-ended Doyen's retractor to fit over the bladder and protect it (or use a wide
Deaver's or a Morris retractor), and 6 Green Armytage forceps (use sponge-holders
if you don't have these). You will need ''1' chromic catgut for the uterus, 2/0 catgut
for the peritoneum of her vesico[nd]uterine pouch, monofilament for her
abdominal wall, and two round-bodied Mayo's needles, a large one for the first
layer and a smaller one for the second. A narrow 20 cm steel ruler to measure the
true conjugate. The anaesthetist must have a syringe of ergometrine with oxytocin
(''Syntometrine') or plain ergometrine ready. You and he will both need suckers.

PACKS. Five or six large abdominal packs with tapes. NEVER use single swabs,
you can too easily lose them in the peritoneal cavity!

ANAESTHESIA is discussed in detail in Sections 18.2 and in A 6.9 and A 16.6.

You have a choice of: (1) Several methods of local anaesthesia (A 6.9). (2)
Ketamine (A 8.1). (3) General anaesthesia (A 16.6) for which she must be
intubated (A 13.3). (4) Subarachnoid (spinal) anaesthesia is satisfactory, provided
you know the method and its complications in detail (A 7.1), you put up a drip and
give her 1[nd]2 litres of fluid fast, you tilt her to the left, and you observe the
contraindications, which are: shock, severe anaemia, hypertension, and heart
disease. An augmented saddle block is the safest form of subarachnoid anaesthesia
(see below).

If your anaesthetist is an expert, general anaesthesia with cricoid pressure and

tracheal intubation will be best (A 16.5), especially if her circulation is unstable
due to an APH, or advanced obstructed labour.

If she is shocked, and you are inexpert, and single- handed, local infiltration (A
6.9) will be the safest.
If she is not shocked, an augmented saddle block (A 7.7) is suitable, particularly if
you are single-handed. An ordinary saddle block is inadequate, because it does not
extend high enough. You need to combine it with local infiltration of the
abdominal wall, as in Primary Anaesthesia Fig. 7- 8.

Explain what is going to happen. Put her on to the operating table before you
induce her.

PREVENTING THE ACID ASPIRATION SYNDROME. Don't assume her

stomach is empty because she has not taken food for a long time. Labour slows
stomach emptying. If she has a general anaesthetic, she is in particular danger from
the acid aspiration syndrome (A 16.3). Remove her gastric contents with a stomach
tube, give her 30 ml of magnesium trisilicate mixture, or 0.3M sodium citrate
within 15 minutes of induction, and then leave a Ryle's tube down. You cannot
give her sodium citrate prophylactically throughout labour. If she is given a general
anaesthetic, she must be intubated using cricoid pressure (A 16.5).

If possible, as prophylaxis against acid aspiration, give her ranitidine 50 mg

intramuscularly 1 hour before an elective section, or by slow intravenous injection
immediately before an emergency section. Or, if you expect to section her, give her
150 mg by mouth at the onset of labour and then every 6 hours.

POSITION. Stand on her right side. Prevent the supine hypotensive syndrome by
tilting her about 5[de] to the left (A 16.6). Do this, either by tilting the table, or by
putting a pillow or sandbag under her right buttock. Find some way of preventing
her slipping off the table. A moderate Trendelenburg position will give you better
access to her lower segment, and make delivering the baby's head easier, if there is
a vertex presentation. It will also be an additional safeguard if she vomits.

PREPARATION. Catheterize her in the theatre while she is still awake, and leave
the catheter in (A, in Fig. 18-11). You can also do this in the maternity labour unit.
At the same time, do a vaginal examination to make sure you do not miss
unexpected progress, and thus the opportunity to do a vaginal delivery if this is
indicated.

If you have difficulty catheterizing her bladder before operating, raise the baby's
head with your hands. If you fail to pass a rubber catheter on the first occasion, try
again after she is anaesthetized, when pushing up his head will be easier. If you
have to operate with a full bladder, be very careful as you open her peritoneum.
Open it as far cranially as you can, opposite the upper quarter of the incision
through her abdominal wall, and empty her bladder with a syringe from her
abdomen.
Shave or clip her from her mons pubis to above her umbilicus, and laterally to her
iliac crests (optional). Prepare the skin of her lower abdomen (B), drape her with 4
plain towels, and cover these with a towel with a slit in it (C).

LOWER MIDLINE INCISION. Cut through her skin and subcutaneous tissue
down to the level of her rectus sheath (D). Extend the incision to within 3 cm of
her umbilicus. Try not to carry the incision further down than the upper limit of her
pubic hair.

If she has had a previous Caesarean section, see Section 18.10.

Separate her rectus and pyramidalis muscles in the midline as far as her symphysis.
If necessary, extend the skin incision further down. A short downwards extension
is more effective in improving access than an extension upwards.

Use sharp and blunt dissection to expose her transversalis fascia and her
peritoneum. Use two haemostats to pick up peritoneum near the upper end of the
incision (E). This is especially important if her labour is obstructed, and her
bladder is displaced upwards. Feel the fold of peritoneum you have picked up, to
make sure there is no bowel or bladder in it. Make a small opening in it with a
scalpel (F), and then open the rest of it with scissors (G), longitudinally from above
downwards to just above the reflection of her bladder. If you hold her parietal
peritoneum with a light shining through it, you will see a constant small vein
running transversely across it. If you avoid this, you will avoid her bladder. If her
bladder is high deviate to the side of the midline.

CAUTION ! If she has had a previous operation, including a previous Caesarean

section, omentum or gut may have stuck to her abdominal wall, so that you can
easily cut them. If you cut her gut by mistake, sew it up as in Fig. 9-6. If she has
had several previous Caesarean sections, her anatomy will be much distorted by
adhesions.

Clamp any active bleeders if they are big, but postpone tying them until later. They
usually stop bleeding on their own.

Feel her uterus to find how it is rotated, and identify the presenting part. It is
usually rotated to the right, so that her left round ligament is usually more anterior
and closer to the midline than the right one. If her uterus is markedly rotated, turn
it towards the midline.

Place a large abdominal pack on each side of her uterus, to keep her gut out of the
way. Attach artery forceps to the tapes of these packs, to prevent them being lost.

Fig. 18-12 CAESAREAN SECTION[md]TWO. H, pick up the peritoneum of the

patient's vesico-uterine pouch with dissecting forceps and cut it. I, put the scissors
into the cut, and open them, so as to separate her peritoneum. J, as you reach the
edge of her uterus, cut in a more cephalic direction. K, raise the lower fold of
peritoneum with her bladder in it. L, put a strong stay suture in her uterus. M,
incise her uterus. N, liquor will spurt out. O, put your fingers into the incision and
lengthen it.

THE CLASSICAL ALTERNATIVE. Consider doing a classical rather than a

lower segment section if: (1) her lower segment seems abnormally vascular, or (2)
it is abnormally adherent to her anterior abdominal wall. If you decide to do one,
see Section 18.12.

THE De LEE ALTERNATIVE. Consider doing a de Lee incision if: (1) Her lower
segment is so thin and distended, that it might tear when you extract the baby. (2)
She has a transverse lie with a prolapsed arm, and a live baby. (3) A lower segment
fails to form, as may happen with a premature delivery in a primip.

To make a de Lee incision, incise her visceral peritoneum transversely, as

described below but high on her lower segment. Mobilize her peritoneum and her
bladder well down. Find the midline of her uterus. Insert a small transverse suture
where the bottom end of your incision is going to be, to prevent it extending
downwards behind her bladder. Make a longitudinal incision, two-thirds of it in her
lower segment, and one-third in her upper segment.

Later, repair a de Lee incision, with two layers of continuous chromic No. 1 or 2
catgut. Make sure you include her uterine fascia in the second layer, or it will
continue to bleed. Repair her peritoneum, and pull it up high, so that the top of the
incision is covered. If you incised her upper segment over a long distance, tie her
tubes on the same indications as in a classical Caesarean section.

THE ALTERNATIVE OF A TRANSVERSE INCISION IN THE UPPER

SEGMENT may be necessary if there is a transverse lie or a contraction (Bandl's)
ring. Check that her uterus is wide enough. Incise her peritoneum over the lower
part of its upper segment with a scalpel. Mobilize it away from the incision with
scissors, and incise her uterus transversely in the midline. Enlarge the incision to
the right and left, by stretching it with your fingers (it is usually too thick to be cut
with scissors), and deliver the baby by breech extraction.

Repair the incision in two layers with continuous chromic No. 1 or 2 catgut. Don't
catch the full thickness of her uterine wall in the first layer: it is often too thick.
Repair her peritoneum over the incision, preferably with a locking stitch. Tie her
tubes.

ORDINARY LOWER SEGMENT [s7]CAESAREAN SECTION If her baby's

head is jammed in her pelvis and needs to be disimpacted from below, ask yourself
if a symphysiotomy would not have been better, and remember this next time! Ask
your assistant to put his hand into her vagina, and to disimpact it to the site where
you are going to make your incision. He must do this before you incise her uterus.
If he waits until after you have incised it, the baby's shoulders may prolapse into
the wound, and make delivery difficult. Having done this, ask him to take off his
second gown and gloves (see above). Unfortunately, it is difficult to predict that
the head needs disimpaction, until after you have opened the uterus.

Pick up the loose peritoneum of her vesico[nd]uterine pouch with dissecting

forceps (H). Make a small cut in the peritoneum over her uterus, just below the
point where the loose peritoneum becomes firmly attached to the anterior wall of
her uterus. This is the abdominal marking of her lower segment. Then put the
scissors into the cut, and extend the incision in her peritoneum to left and right, so
as to separate it from her uterus underneath (I). As you reach the edges of her
uterus, aim the scissors in a more cephalic direction, so that the incision in her
peritoneum is curved (J). Aim to leave a bare area about 2 cm wide and 12 cm
long. Don't cut into the muscle of her uterus yet.

Use a swab in a holder, or on your finger, to separate the folds of peritoneum on

either side of the incision, pressing on her uterus as you do so. This will help to
separate her tissues in the right plane, and avoid tearing her peritoneum, or her
bladder.

Raise the lower fold, and her bladder with it for about 3 cm (K).

CAUTION ! (1) Take great care to avoid injuring her bladder, especially if this is
pulled up high and is oedematous. (2) Don't raise it more than 5 cm. If her cervix is
effaced and dilated, you may enter her vagina by mistake.

Put the Doyen's retractor over her bladder, to protect it for the rest of the operation.

Put a stay suture of 2/0 catgut or monofilament into her lower segment (L), and
hold the end of it in a haemostat.

Ask your assistant to hold up the stay-suture. A short, full- thickness central
incision minimizes the danger of cutting the baby. If you extend it shallowly on
either side, the uterus will tear open in the right direction. So, make a 3 cm
horizontal incision through the uterine wall in the midline, just above the stay
suture (M). Cut only the centre of her lower segment. This should be 2 cm below
the peritoneal reflection, and at least 2 cm above her detached bladder. Put a finger
either side of the incision and press as you cut (not shown). This will help you to
judge how deeply you are cutting. Deepen it little by little until the membranes
bulge into the incision. Cut through them (some operators keep them intact at this
stage).
Liquor will spurt out (N). Ask your assistant to suck it away. Insert your closed
scissors through the incision, and open them, so as to extend it enough to let you
insert both your index fingers. Lengthen the incision by pulling them apart
laterally, in the line of the muscle fibres, until it is 10 cm long (O). Her uterus will
open naturally, with a curve upwards at each end. If she has had previous
Caesarean sections, and her uterus is very fibrotic, you may have to extend the
incision with scissors, curving it upwards laterally. Ask your assistant to suck it
dry.

Alternatively, and most contributors would say preferably, make a scalpel incision
for 2 cm in the midline, without cutting the membranes. Use scissors to cut the
uterus, leaving the membranes intact until the incision is complete. Cut in an
upward curve from the midline to the left angle of the uterus, and then in a similar
curve from the midline to the right angle. If her uterus tears, the tear will then be
more likely to run away from the cervix than towards it.

CAUTION ! (1) The lower segment varies considerably in thickness. It is thick

before labour and becomes thinner during labour, so be careful not to cut the baby.
Protect him with a finger between the membranes and her uterine wall as you cut.
(2) Don't make the incision too small, or the uterus will tear as you remove his
head. (3) Should you decide to enlarge the incision by cutting, curve it upwards at
its ends, so as to avoid the uterine vessels. Also, when you suture it, you will be
less likely to suture her ureters.

If she has a scar in her lower segment from a previous Caesarean section, make a
shallow cut along it, where you want the rest of it to tear.

If you can feel the baby's vertex through the uterine wall, the placenta is probably
lying in the fundus or posteriorly, so you can expect to deliver him without
difficulty.

If you cut the placenta as you cut into the uterus, try to detach it, and deliver him
round it. Only cut through it if you have to. He can bleed severely from a cut
placenta, so clamp his cord quickly. See also Section 18.10.

If the ends of the incision in the lower segment bleed severely, before he has been
delivered, quickly deliver him, and then control bleeding as described below.

If there are large veins over her lower segment, incise it precisely and carefully,
and deliver him rapidly. The veins will probably stop bleeding as soon as you have
delivered him. If necessary, clamp them and insert further haemostatic sutures.

Fig. 18-13 CAESAREAN SECTION[md]THREE. P, if necessary, apply Wrigley's

forceps. Don't put your whole hand into the patient's uterus, the extra bulk of your
hand may tear it. Q, place the baby on his mother's thighs and resuscitate him as in
Section 19.12. R, put clamps on the angles of her uterus, and on any major
bleeding points. S, remove her placenta by controlled cord traction and fundal
pressure, but wait until her uterus is contracting first. T, start suturing just lateral to
the ends of the incision. U, closing the second layer. V, closing the peritoneum.

DELIVERING THE BABY [s7]AT CAESAREAN SECTION Remove the

Doyen's retractor. Put your finger (only) into the uterus under the baby's head to
relieve the vacuum, and make it easier for his head to rise in the incision. Then put
your hand outside the lower flap of the incision, and lift his head up. If necessary,
apply Wrigley's forceps (P). If, when you apply them, the incision is not long
enough to deliver him without a lateral tear, extend its ends upwards and laterally
with scissors, so as to make a U[nd]shaped flap.

Contributors differ in the way they deliver the head. Some think that you should
not put the bulk of your hand into the uterus, because it may cause tears. In
practice most do, because it is quicker than forceps.

Now ask your assistant to press on the fundus to assist delivery. He may have to
press hard. Do this carefully and gently, without hurrying. Before you deliver the
baby's thorax, aspirate his nose and mouth, if convenient. Then deliver his
shoulders and trunk.

CAUTION ! Don't try to suck him out with a big Yankauer sucker: it may injure
him. Resuscitate him as in Section 19.12.

ERGOMETRINE OR OXYTOCIN. If she has PIH, or eclampsia, or you are

operating under local anaesthesia, some operators avoid ergometrine, and give her
5 units of oxytocin intravenously or intramuscularly. Otherwise, give her
ergometrine intravenously as soon as you have delivered his head. Ergometrine
occasionally makes a conscious patient sick, and may raise her blood pressure.

THE BABY. Before you clamp his cord, hold him up by his legs with one finger of
your left hand between them, so that the midwife who is helping you can suck out
his nose and mouth. Lay him head downwards between his mother's thighs (Q).
Ask your assistant to put two clamps on his cord and divide it between them, while
you care for her wound, especially the angles, which may bleed. In placenta
praevia especially, clamp his cord quickly, because he may bleed from the injured
sinuses of the placenta. If necessary, resuscitate him (19.12).

CONTROLLING BLEEDING. If you are a quick operator, apply two Green

Armytage clamps, one on the upper flap and one on the lower one, just proximal to
the angle (R). They will identify the angle for you and allow you to suture it more
accurately.
If you are a slow operator apply several Green Armytage clamps (or sponge-
holders) all round the cut edges of her uterus, particularly at the angles. Make sure
they don't grasp the posterior wall of her empty uterus, as it lies on the promontary
of her sacrum; you can easily do this by mistake if bleeding has been brisk. The
difficulty in applying many clamps is that they will get in your way.

REMOVING THE PLACENTA [s7]AFTER CAESAREAN SECTION When her

uterus is contracting firmly, remove her placenta by a combination of controlled
cord traction and fundal pressure (S). If necessary, help it to contract by massaging
her fundus from inside her peritoneal cavity. Pull gently on the cord, and press her
uterus back with your left hand. This should deliver the placenta easily. If it has
stuck, removing it manually from inside her uterus may cause severe bleeding.

When the placenta is delivered: (1) Inspect her uterine cavity to make sure it is
empty. Wipe it dry with a gauze pack to remove pieces of membrane and clots. (2)
Make sure that the placenta is complete. If she has a secondary postpartum
haemorrhage, you don't want to have to re-explore her uterus[md]see ''Stop Press'.

page 275 CAUTION ! Don't probe her cervix to improve drainage[md]keep out of
her dirty vagina!

SUTURING THE UTERUS [s7]AFTER CAESAREAN SECTION Do this in two

layers using thick chromic catgut and a large round-bodied Mayo's needle. Don't
use non[nd]absorbable sutures, particularly not on the inner wall. Ask your
assistant to hold the lower edge of her uterus forwards with the stay suture, while
you sew from the angles inwards (T). Start the sutures just beyond the right
extremity of the incision, work towards the middle, and then start at the left angle.
In this way, you secure the angles first.

Alternatively, put a separate stay suture in the right angle, and start a continuous
suture from the left angle.

Sew the first layer as a continous running suture. Ask your assistant to hold the
free end of the catgut tightly, while you work towards the other end of the incision.
Unless the sutures are tight, it will not stop bleeding.

CAUTION ! (1) Start suturing just lateral to the angle. (2) Don't sew the lower
edge above the upper one, because this may advance her bladder up her uterus. (3)
Don't include her bladder in your sutures. If you find you have included it, you will
probably be wise to leave a catheter in for a few days, rather than removing the
sutures and starting again, which will cause severe bleeding. (4) If you suture too
deeply with a large needle at the angles of incision, you may obstruct her ureters.
(5) Don't sew the front and back walls of her uterus together. So, before the first
layer of stitches is completed, put two fingers into the uterine cavity, to make sure
that its walls are free. If necessary, release the sutures and start again. (6) Don't
stitch her gut to the back of her broad ligament. If you are in any doubt, put your
fingers down behind it before you start to stitch the lateral extremities of the
incision.

COMPLETING THE REPAIR [s7]AFTER CAESAREAN SECTION When the

first layer of sutures is completed, make sure again that the ends of the incision are
adequately secured. If necessary, put in one or two interrupted sutures, especially if
bleeding from the wound continues..

Now start the second layer of continous running sutures (U). Ask your assistant to
maintain tension on the stay sutures, so as to show up the edge of her uterus.

Put a large warm pack over her repaired lower segment, and leave it for 2 minutes
while you remove the abdominal packs. When you remove it most of the bleeding
will have stopped.

Look carefully at your completed sutures. If there is still bleeding, put in some
more interrupted or mattress ''figure of eight' sutures. Don't close her peritoneum
until you have controlled all bleeding.

When her uterus is no longer bleeding, close the peritoneum of her vesico-uterine
pouch with continous sutures of 2/0 catgut (V). Again avoid including her bladder
with the lower edge of the peritoneum.

If you are going to tie her tubes (15.4), now is the time to do it. Look for ovarian
cysts. If you find one which is [mt]5 cm in diameter, consider ovarian cystectomy
(20.7).

CLOSING THE ABDOMEN [s7]AFTER CAESAREAN SECTION

Clean all blood and debris from her peritoneal cavity, and especially from her
paracolic gutters. They will be much cleaner if you previously inserted abdominal
packs (''lap pads') beside her uterus. Inspect these by drawing her uterus to the side.

Measure her true conjugate with a steel ruler as in Fig. 18-16. Displace her uterus
to the right, and put one end of it on her sacral promontary. Let it rest across her
symphysis pubis, and mark the place where it crosses the posterior aspect of her
symphysis with your right index finger. Remove the ruler, read off her true
conjugate, and record it in her notes and in the summary of labour. It will be
invaluable when you come to decide if she should have a trial of scar next time.

Place her greater omentum over her uterus: it will usually reach her bladder. Close
her abdomen (9.8). Don't insert a drain.

Bend up her legs, and press on the fundus to express clot from her uterus and
vagina. A uterus full of blood will interfere with retraction and encourage
infection; you may later mistake blood in her vagina for a postpartum
haemorrhage. Clean out her vagina with a sterile swab on sponge forceps.

As soon as she has recovered from her anaesthetic give her baby to her. This close
early contact is important in developing the bond between them. If she has had a
local or subarachnoid anaesthetic, she can see him before the operation is over.

POSTOPERATIVE CARE [s7]AFTER CAESAREAN SECTION Estimate her

blood loss: it will probably be more than you think. The average loss is 1 litre.
Unless you have expert staff, check her vital signs yourself. Check and chart her
pulse, temperature, and respiration half-hourly, until she is awake, and then, when
her condition is satisfactory hourly for 12 to 24 hours. Continue the intravenous
infusion for 24 hours, or until she can take fluids by mouth and bowel sounds are
present. Give her 3 litres of fluid in 24 hours (two bottles of 5% dextrose and one
of 0.9% saline). Give her pethidine 100 mg up to 4 doses.

If she bled much, arrange for a fast running drip of saline or Ringer's lactate, and
see her yourself in an hour. You will be suprised how often a patient who left the
theatre in reasonable condition is now collapsed, because the drip was too slow, or
stopped.

CAUTION ! Watch for signs of infection: (1) Fever. (2) A large, soft, tender
uterus. (3) Tender thickening in her lateral fornices.

If her membranes had been ruptured for more than 24 hours before the operation,
or there are other reasons for suspecting infection, continue perioperative
antibiotics (2.9) for up to 5 days.

If she has been in obstructed labour and her urine is bloodstained, leave a catheter
in her bladder for 5 to 10 days.

If she vomits, or her abdomen becomes distended, start gastric suction.

CAUTION ! Before she goes home, make sure that she and her relatives know that
she must have future deliveries in hospital[md]this is ESSENTIAL! She must
come regularly for antenatal care. Give her a card which says why Caesarean
section was done, and what she should do about her next delivery. Ask her to show
this card at the antenatal clinic, when she becomes pregnant again.

Fig. 18-13a CAESAREAN SECTION IN AFRICA IN 1879, as described by

Robert Felkin. The mother was liberally supplied wih banana wine, which was also
used to wash the operator's hands and her abdomen. A single rapid lower midline
incision opened her abdominal wall and her uterus. Bleeding points were
cauterized with a hot iron. After delivery her abdomen was closed with seven thin
iron spikes. The baby was put to her breast 2 hours later. Both mother and baby did
well. Felkin RW, ''Notes on Labour in Central Africa'. Edinburgh Medical Journal
1884;29:922. As reported in Medicine Digest 1985;11:17[nd]19.