Friday, May 4, 2012

Cesarean Section , step by step

There are several incisions (cuts) your obstetrician will need to make as part of a C-section. Rest assured that the entire procedure, without complications, lasts a little over half an hour and your body should heal quickly in the weeks that follow.
I prefer to make the horizontal, or "bikini" incision in the lower abdomen. It's called a "Pfannenstiehl" incision, and besides being cosmetically superior to the up-and- down midline incision, it also heals better and hurts less during recovery.

A scalpel is used to make this incision. This is done with a smooth firm pressure of the blade as it moves across and against the skin. The skin is thin and the blade is so sharp that the underlying yellow fat layer almost bursts out. A smaller tract of cutting then takes place in the middle of this fat layer until a shiny, tough, fibrous layer called the fascia is seen below it. The fascia, which lies over the abdominal muscles, also serves as a floor for the fatty layer just cut into. One can push a finger of each hand against this fascia and then rake away the fatty layer to each side, exposing an adequate length of this tough, lower layer. Once again, a scalpel is used to nick an opening in this fascia that's just been exposed. 

The rectus abdominal muscles (the "abs") are two muscles that run up and down from the upper abdomen down to the pubic bone. They are joined together at the midline, so when a pair of scissors is used to cut this fascia, horizontally toward each side, these muscles are easily seen. Where they meet can be easily separated with a gentle pushing away at the midline. They're fairly pliable, and even though they run vertically compared to the horizontal incisions made thus far, they can easily be pulled apart and away to expose the next layer to open.

This next layer is called the peritoneum, a filmy, flimsy layer that is the actual lining of the abdominal cavity (this is why inflammation of this layer, as with a ruptured appendix, is called peritonitis). It is opened very carefully with sharp thin scissors. It is usually such a thin layer that one can see any bowel underneath it. This is a good thing, because cutting bowel is a very bad idea.
Once a small opening is made in the peritoneum, it is actually opened up and down, which is a departure from the direction of all of our openings so far. It, too, is very pliable, and this up-and-down direction poses no difficulty in spreading it open enough to see the lower abdomen with good visibility.

Because the bladder wraps itself under the lowermost portion of this lining, care is taken not to take this peritoneal incision down too far, or the bladder may be accidentally damaged. Usually a retractor called a "bladder blade" is used to pull the lowest part of the opening downward (toward the patient's feet) so as to protect it from the rest of the procedure.
The patient's uterus (womb) is enlarged to a great extent. There's another layer of peritoneum over it, which is actually the floor of the abdomen (we had just opened the layer that was the "roof" portion of the peritoneum surrounding the abdomen). The uterus, actually lying under this floor of the abdomen (called "retroperitoneal"), is therefore covered with peritoneum as well. It's still flimsy and filmy here, too. A small cut is made in it and an excision extended horizontally on either side. Before when I said the bladder wraps itself against the lowermost portion of the abdomen, the other half of the story is that it sits riding up the lowest part of the uterus. Therefore the incision into the peritoneum that covers the lower uterus makes it possible to push the bladder away from the rest of the surgery, once again sparing it injury.

Now with the uterus exposed, the bladder pushed down and away, an incision can be made across this lower portion of the womb. This is when you'll see it.
This round, fleshy and soon-to-be very cute mass which occupies the uterus is a head which can be pushed outward through the uterine incision into the outside world where the pediatrician is waiting to suction the throat and nose. Pulling gently on the head then allows the rest of the delivery.

The umbilical cord is clamped in two places and cut between the two clamps, allowing the pediatrician to attend the infant at the warmer nearby. The placenta is removed by separating it gently from the inside of the uterine wall. By this time everyone can hear the baby crying. The uterus, since it is anchored into the pelvis by ligaments that attach to it near it's bottom, is easily tilted through all of the incisions and laid on the mother's belly. This allows easy access.

The uterine incision is then closed by using a suture designed to melt away in several weeks. This closure stops the bleeding from the edges of the incision. If there is no further bleeding at this reapproximated incision line, the uterus is allowed to fall back into the pelvis. We used to close the peritoneum back up, until recent studies indicated that this isn't necessary, because left open, it will close up on its own, and possibly hazardous, because sewing it together might lead to internal scarring called adhesions. So the layer over the lower uterus is left alone, and the "roof," the peritoneum above, is also left alone. The next structures, the abdominal muscles, usually fall together by themselves, but they can be reminded how they go by gently tying them together at spots along their lengths.

The fascia repair is the most important. The fascia is the main supporting layer of the abdomen. Physicians like to put that together with thicker and more durable suture. The fat layer can be skipped, or it can be, like the abs, "reminded" how it falls together with a few isolated absorbable sutures. The skin, the weakest reapproximation of the whole repair, is gently brought together and stapled, or closed with "invisible" stitches or glue.

In experienced hands, this whole process takes about a half hour unless complications occur. And also in experienced hands, it will be a distant second choice in how to deliver a baby.

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