LOWER SEGMENT CESARIAN SECTION (LSCS)
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:
- 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.
- 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.
- 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.
A lower (uterine) segment Caesarean section (LSCS) is the most commonly used type of Caesarean section used today. It includes a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair than other types of Caesarean sections.
It may be transverse (the usual) or vertical in the following conditions:
- presence of lateral varicosities
- constriction ring to cut through it
- deeply engaged head
- The location of an LSCS is beneficial for the following reasons:
- peritoneum is more loosely attached to the uterus
- contraction is less than in upper part of uterus
- healing is more efficient
- sutures are intact (less problem with suture loosening)
Most bleeding takes place from the angles of the incision, and forceps can be applied to control it. Green Armytage forceps are specifically designed for this purpose.
HOME CARE FOLLOWING LSCS
For six weeks, you should watch for all of the following (fever, vaginal bleeding, and pain), but precautions also should include not placing anything inside the vagina (this means no tampons, douching, or sexual intercourse). Some doctors recommend driving restrictions (meaning don’t drive) from three to four weeks or longer this is also dependant on you car insurance company.
Don’t forget to make a follow-up appointment with the Women’s Health Group. Make the appointment within six weeks after the delivery.
As far as wound care goes, you can take a shower, but don’t rub the incision while showering. Let the water run over it and take a bar of antibacterial soap, make a dollop of suds in your hands and apply it gently to the incision, let the suds sit for a minute, and then rinse them off. Use a clean towel and pat the incision dry, don’t rub it. Taking a bath is acceptable once your bleeding has decreased significantly. For the first couple of weeks, a shower is preferable.
For painkillers, the majority of women can take paracetamol or Ibuprofen. Make sure you take any medicine with food or milk, assuming that there are no contraindications to that. Take medicine regularly for the first couple of days after surgery. Be aware that the Ibuprofen might have gastro-intestinal side effects.
For the six weeks after surgery, use walking as your main source of exercise. Avoid situps or crunches or anything that could weaken or tear the incision.
There is no getting around the fact that a c-section is an operation that requires cutting, and as such, it can be dangerous. Fortunately, with the advent of antibiotics and improvements in surgical techniques, it is a relatively normal procedure that is performed routinely and successfully every day around the world.
Make sure you have plenty of help after the baby is born. You will be sore for quite a while and will need some help getting around.