La lacenta

Best Practice & Research Clinical Obstetrics & Gynaecology Vol. 15, No. 1, pp. 17±47, 2001

doi:10.1053/beog.2000.0147, available online at http://www.idealibrary.com on

2 Techniques for performing caesarean section
Karumpuzha R. Hema*
Sta€ Grade in Obstetrics

MBBS, MRCOG

Richard Johanson*

BSc, MA, MD, MRCOG

Senior Lecturer in Obstetrics North Sta€ordshire Hospital NHS Trust,Stoke on Trent ST4 6QG, UK

In many countries caesarean section has become the mode of delivery in over a quarter of all births. Safety of the mother and cost are the two main areas of concern. Various studies on the techniques of performing a caesarean section have focused on reducing the operating time, blood loss, wound infection and cost. Given the fact that caesarean section is the mostcommonly performed operation in obstetrics, it is important that trainers and trainees are familiar with the basic surgical techniques and that best practice is followed. At the same time surgeons should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV. The skin incision and entry into abdominal cavity is best achieved by the modi®ed Cohen's incision. The lowersegment transverse uterine incision has stood the test of time over a period of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer appears to be acceptable, whenever technically possible. Placental delivery should be by controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers of the peritoneum no longer seems to benecessary. Obliteration of space in the subcutaneous layer, either by suture or by suction, seems to reduce wound disruption. These issues are being considered in the CAESAR randomized controlled trial of surgical techniques currently underway in England. Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the above mentioned steps have been tested in randomizedtrials. Further studies are needed to examine a wide range of questions arising from this review, e.g. best position of the patient, the value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax the uterus in dicult deliveries. Key words: caesarean section; methods; materials; complications; research.

Ever since the wider introduction of caesarean section inthe latter part of the 19th century, the safety of the procedure has improved. Indeed, con®dence in safety1 has increased to the point that, in some countries, nearly a quarter of all deliveries are now being conducted by the abdominal route.2 There is currently widespread debate about the relative merits of abdominal and vaginal delivery3 and this discussion is dealt with in depth in Chapter 9.*Address for correspondence: Clinical Governance Support Oce, North Sta€ordshire Hospital NHS Trust, Ward 58, Maternity Unit, Newcastle Road, Stoke on Trent ST4 6QG, UK. 1521±6934/01/010017‡31 $35.00/00 c * 2001 Harcourt Publishers Ltd.

18 K. R. Hema and R. Johanson

Improved safety is related to the availability of antibiotics and blood transfusion1 and also to advances in anaesthesia, aswell as to improvements in technique. The principal complications are haemorrhage and infection and these, in turn, are related to the complexity of each case. Prolonged labour, prolonged rupture of membranes and increased frequency of vaginal examinations all predispose to infection. Previous caesarean section, placenta praevia and placenta accreta increase the risk of haemorrhage. In general,the risks and complications are greater for emergency than for elective procedures. Generic risks relate to excessive speed and lack of surgical experience in performing the operation. While surgical techniques do vary from surgeon to surgeon, good adherence to basic surgical principles and an awareness of recognized methods of performing caesarean sections will minimize morbidity. Caesarean...