Fig. 23.1
Caesarean section incisions
The Joel-Cohen incision (Fig. 23.1).
Midline Uterine Incision (Classical Caesarean Section)
Less commonly performed.
Higher risk of scar dehiscence and uterine rupture in subsequent pregnancies (1 in 50) [1].
Higher incidence of adhesions.
Greater blood loss.
Indications
Delivery by CS can be performed either as an elective procedure or as an emergency procedure. Some women request a CS but it is important that the patient makes an informed decision only once she has been counselled on all of the risks involved and the potential complications.
Elective CS Indications
Pre-existing maternal medical conditions:
Maternal HIV with a high viral load.
Active primary genital herpes infection at the onset of labour.
Contracted pelvis e.g. from a previous fracture.
Anatomical uterine anomalies.
Obstetric indications:
Previous CSs.
Multiple pregnancy e.g. twins/triplets.
Breech, transverse or oblique presentation of the baby.
Severe pre-eclampsia.
Severe intrauterine growth restriction.
Placenta praevia obstructing vaginal delivery.
Emergency CS Indications
Failure to progress in first stage of labour.
Severe foetal compromise (foetal distress).
Intrapartum CTG abnormalities e.g. decelerations (variable or late) and/or bradycardia.
Antepartum haemorrhage.
Malpresentation of the foetus.
Cord prolapse.
Uterine scar rupture.
Severe pre-eclampsia/Eclampsia.
Classification of Urgency of CS: A Continuum of Risk
This is an evidence-based classification system categorising the urgency of CS. It recognises four categories of urgency in contrast to the traditional classification of emergency and elective CS. Some units use the categories in a colour coded system.
- 1.
Immediate risk to life of mother and/or foetus.
- 2.
Urgent but no immediate risk to mother or foetus.
- 3.
Early delivery required but no urgent risk to mother or foetus.
- 4.
Elective CS at a time convenient for the woman and maternity services.
Anaesthesia for CS
Most elective CSs are performed using a spinal anaesthetic block (SAB).
Emergency CS will be performed using either a SAB or GA depending on the urgency of the CS.
If time allows an emergency CS can be performed using a topped-up epidural if there is already one in place.
Step-by-Step Summary: Caesarean Section
- 1.
Open the abdomen with a Pfannenstiel incision.
- 2.
Open the rectus sheath through the linea alba.
- 3.
Open the visceral peritoneum over the lower uterine segment and gently reflect the bladder by pushing it down.
- 4.
Open the lower segment.
- 5.
Put a hand under the presenting part and deliver the baby through the uterine incision.
- 6.
Deliver the baby and clamp and cut the umbilical cord.
- 7.
Deliver the placenta and membranes.
- 8.
Gently check the uterine cavity manually with a large swab to ensure it is empty.
- 9.
Repair the uterine incision in two layers, checking haemostasis.
- 10.
Grossly check the ovaries are normal and that the uterus has contracted.
- 11.
Check that there is no blood remaining in the paracolic gutters.
- 12.
Close the abdomen in the usual way.
CS Complications
Complications are more common in emergency CSs.
Intraoperative Complications
Haemorrhage greater than 1 l.
Damage to the surrounding visceral organs (most commonly lacerations to the bladder, bowel and ureters).
Rarely emergency hysterectomy.
Post-operative Complications
Infection of the incision site.
VTE.
UTI.
Pulmonary atelectasis.
Scar dehiscence and rupture in future pregnancies.
Post-op Care and Follow-Up
Keep the patient in overnight.
Check on day 1 post CS that the uterus is contracted and lochia is normal.
Follow-up is usually with a GP, unless the case was complex.
Counselling on delivery options in subsequent pregnancies.
CTG monitoring during labour in subsequent pregnancies.
Gynaecology
Core Operations
Where possible, gynaecological surgery is now performed laparoscopically (i.e. using key hole surgery), although, in some cases immediate intervention via laparotomy may be required e.g. massive haemoperitoneum in ectopic pregnancy (see Table 23.1). To perform laparoscopy, the abdomen is insufflated with carbon dioxide, and for many procedures the uterus must be externally anteverted using forceps with sponge inserted through the vagina or a Spackman cannula in the uterine cavity attached to a cervical vulsellum. Gynaecological surgery can also be performed vaginally e.g. prolapse repairs and vaginal hysterectomies. In addition, open surgery is still the method of choice in some scenarios and is performed using a midline or transverse lower abdominal laparotomy incision (Fig. 23.2). In 2005 the FDA approved the use of robotic surgery in the USA for gynaecological surgery. Although not currently in routine practice in the UK its use for gynaecological conditions is likely to grow exponentially.
Table 23.1
Advantages and disadvantages of laparotomy and laparoscopy in gynaecological surgery
Laparotomy | Laparoscopy | ||
|---|---|---|---|
Advantages | Disadvantages | Advantages | Disadvantages |
Immediate access to peritoneum and pelvic organs | Increased risk of infection and haemorrhage | Decreased risk of infection and haemorrhage | Slower access |
Easier to remove larger organs | Longer recovery time | Shorter recovery period | Harder to remove larger organs |
Larger scar | Smaller scars | Increased risks in patients with midline laparotomy scar | |
Fig. 23.2
Common gynaecological scars
It is important to always ask if the patient has had a previous midline laparotomy. Scars can fade and are easily missed on examination: even consultants miss them occasionally. It is therefore important to always ask about previous abdominal surgeries as part of your history. You should think twice before performing a laparoscopy on someone who has had a midline laparotomy as adhesions can form between the bowel and the anterior abdominal wall. Insufflation and instrumentation may result in bowel perforation!
Hysterectomy
A hysterectomy is a surgical procedure performed to remove the uterus and other pelvic organs where applicable. Traditionally, a hysterectomy was performed via laparotomy using an abdominal incision. This technique is still widely used. Newer techniques include vaginal hysterectomy (performed using an incision in the vaginal canal) and laparoscopic vaginal hysterectomy.
Indications
Fibroids.
Abnormal uterine bleeding (AUB) especially heavy (and prolonged) menstrual bleeding (HMB).
Endometriosis.
Adenomyosis.
Endometrial carcinoma.
Uterine prolapse.
Chronic PID.
Where possible, hysterectomy is avoided if medical treatment is appropriate.
Complications
Haemorrhage.
Infection: UTI and other postoperative infections.
Pelvic organ prolapse and/or pelvic organ fistula.
Urinary retention and potentially incontinence.
Renal and ureteral injury.
Death (rare).
Classification
There are many different types of hysterectomy which can be classified. They are defined by the anatomy removed (See Table 23.2).
Table 23.2
Types of hysterectomy
Procedure | Organs removed | Indications | Comments |
|---|---|---|---|
Total abdominal hysterectomy (TAH) | Uterus, cervix | AUB, fibroids | Women with abnormal smears should opt for hysterectomy with cervix removal |
Sub-total hysterectomy | Uterus only | Fibroids | Less risk of damage to urinary and GI systems. Smear tests are still required |
Vaginal hysterectomy (VH) | Uterus, cervix | Uterine prolapse | Uterus accessed and removed through an incision in the upper vaginal canal Shorter recovery time than TAH |
Laparoscopic assisted vaginal hysterectomy (LAVH) ± BSO | Uterus, cervix ± fallopian tubes, ovaries | AUB, prolapse, atypical endometrial hyperplasia | Quicker recovery than with open operation |
TAH and BSO | Uterus, cervix, fallopian tubes, ovaries | Hysterectomy in a peri- or post-menopausal woman; early ovarian cancer | Generally (but not always) performed as an open laparotomy procedure |
Wertheim’s (radical) hysterectomy | Uterus, cervix, parametrium upper 1/3rd of the vagina, pelvic lymph nodes | Cervical carcinoma | Young patients who desire ovarian preservation and retention of a functional vagina are the patients most likely to have this procedure |
Step-by-Step Summary: Total Abdominal Hysterectomy
- 1.
Position the patient in the dorsal supine or lithotomy position.
- 2.
Open the abdomen, usually via a Pfannenstiel incision. A midline vertical incision may also be adopted depending on a variety of factors.
- 3.
Divide pelvic and/or intra-abdominal adhesions if present to mobilise the pelvic organs.
- 4.
Clamp, cut and tie the round ligaments and ovarian pedicles, the uterine vessels and uterosacral ligaments
- 5.
Open the top of the vagina to remove the uterus.
- 6.
Ensure haemostasis within the vaginal vault.
- 7.
Irrigate the pelvis and inspect the bladder and ureters.
- 8.
Close the abdomen as appropriate.
Step-by-Step Summary: Subtotal Abdominal Hysterectomy
- 1.
Position the patient and open the abdomen as above.
- 2.
Clamp, cut and tie the round ligaments and ovarian pedicles, the uterine vessels and the uterosacral ligaments.
- 3.
Cut the body of the uterus from the cervix at the level of the internal os.
- 4.
Remove the uterus.
- 5.
Oversew the cervical stump and cauterise the cervical canal.
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