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.