Cesarean Section (C-Section)

by Veronica Gillispie, MD, FACOG

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    00:01 Now we'll talk about Cesarean section.

    00:05 So what is the indication for C-section? It can be fetal intolerance of labor.

    00:09 Meaning a Category 3 tracing.

    00:12 Arrest of dilation or descent in labor.

    00:15 Meaning the cervix doesn't dilate after 2 hours or the baby doesn't descent after 2 hours when they are in the second stage of labor.

    00:22 Malpresentation such as breech.

    00:24 Placental abnormalities such as placenta acreta, increta or percreta.

    00:29 And previous uterine surgeries such as myomectomy.

    00:32 Or if a patient has had more than two C-sections.

    00:36 For C-section techniques, let's first talk about anesthesia.

    00:41 Now this is discussed in more detail in another lecture.

    00:43 But let's briefly talk about it here.

    00:45 So there's three options.

    00:46 Epidural, spinal or general.

    00:48 With epidural, the anesthesia is placed in the epidural space through a catheter allowing for continuous pain relief.

    00:56 Generally used for labor in patients.

    00:59 Spinal is one injection into the subarachnoid space.

    01:02 This last approximately 2 to 4 hours.

    01:04 With general anesthesia we only perform this in an emergency.

    01:12 Next let's talk about the type of skin incisions we can have during a C-section.

    01:16 First is Pfannestiel.

    01:18 That's what is demonstrated here in this picture.

    01:20 With Pfannestiel there is less risk of dehiscence.

    01:24 Cosmetically is preferred.

    01:27 But the downside there's not as much as exposure to the abdomen as when we see a midline incision.

    01:34 With midline you have a faster entry into the abdomen.

    01:37 There's less blood loss.

    01:39 However, the downside is a higher rate of dehiscence.

    01:44 So let's talk about the layers that we go through when we are performing a C-section.

    01:48 First we go through the fascia.

    01:51 After the fascia is opened, we see a rectus abdominal muscles.

    01:55 You can see them displayed here.

    01:57 Those are separated and we identify the peritoneum.

    02:01 Once the peritoneum is entered, then we make it to our uterus.

    02:05 So with our uterine incisions there's a few options there.

    02:10 Low transverse is the most common uterine incision.

    02:13 Because the incision is made in the lower uterine segment, the non-contact top part of the uterus.

    02:18 This is the least likely to rupture.

    02:20 So if a patient have had one C-section, she is a candidate for trial of labor after cesarean.

    02:26 And there is a low risk of rupture.

    02:28 Less than 1%.

    02:30 Low vertical incision is utilize if the fetus is in a presentation such as transverse back down that would not allow delivery through a low transverse incision.

    02:41 Classical incisions are utilized when C-section is performed at an earlier gestation.

    02:46 And the lower uterine segment has not developed or has not thinned out.

    02:51 And then T-incision is an upward extension of the low transverse incision when there's difficulty delivering the baby.

    02:57 Now this incision has a highest risk of rupture during subsequent pregnancies if labor occurs.

    03:03 The only type of uterine incision where we do evocate for a vaginal birth after cesarean or a trial of labor after cesarean is the low transverse incision.

    03:15 Now let's talk about repair of the hysterectomy.

    03:19 Now this is done in one or two layers.

    03:21 And the big part of the repaired of the hysterectomy, the most important part is we need to maintain hemostatsis.

    About the Lecture

    The lecture Cesarean Section (C-Section) by Veronica Gillispie, MD, FACOG is from the course Intrapartum Care.

    Included Quiz Questions

    1. Maintaining hemostasis
    2. Tucking in all the endometrium
    3. Avoiding the uterine serosa
    4. Trying to complete the repair in one layer
    5. Assuring the repair is done with interrupted vertical mattress pattern
    1. Low transverse hysterotomy
    2. Classical hysterotomy
    3. Low vertical incision
    4. T-incision
    5. J-incision
    1. Better cosmetic result
    2. More exposure for delivery of the fetus
    3. Faster operative time
    4. Less blood loss
    5. Higher rate of wound dehiscence
    1. A 34-year-old woman with a history of 1 c-section (low transverse incision) for the arrest of dilation during labor
    2. A 35-year-old woman with a history of 3 prior c-sections at term. The first two sections were due to fetal intolerance during labor, and the third was due to the arrest of the second stage of labor
    3. A 28-year-old woman with a history of 1 prior c-section (classical incision) at 27 weeks for life-threatening fetal abnormality
    4. A 27-year-old woman with a history of fundal fibroid myomectomy
    5. A 31-year-old woman with a history of 1 prior c-section (low vertical incision) for transverse backdown fetal malpresentation

    Author of lecture Cesarean Section (C-Section)

     Veronica Gillispie, MD, FACOG

    Veronica Gillispie, MD, FACOG

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