**4. Classification of caesarean section**

Traditionally, caesarean section has been classified as emergency or elective. However, with advanced practice in obstetrics and more complicated deliveries encountered, this definition has become too simplistic, and more detailed categories are needed. Some authors have also suggested that the term "elective caesarean delivery" should probably be eliminated because a caesarean delivery is either "medically/obstetrically indicated" or "on maternal request" and never truly "elective" [8]. Such authors advocate for terms as *scheduled or planned* caesarean delivery in which the decision to perform an indicated caesarean delivery may be made antepartum and *unscheduled or unplanned* caesarean section where decision to perform an indicated caesarean delivery is made as a result of concerns identified after labour has begun. The decision to perform an unscheduled caesarean section may also arise even when labour has not occurred such as in abruption placentae with a live baby and no labour pains or absent foetal movement with abnormal umbilical artery Doppler studies not in labour.

Also distinguishing between prelabour caesarean section (which may be scheduled/elective or emergency/unscheduled) and intrapartum caesarean delivery (which is, by default, emergency) is preferable [14].

Lucas and colleagues [15] developed the classification of caesarean delivery based on urgency approved by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Anaesthetists in the UK after it was developed further into the most consistent method recommended by National Confidential Enquiry into Perioperative Deaths [16].

The initial classification by Lucas et al. [15] was a four-grade classification system including:


#### **Table 1.**

*Classification of caesarean section.*

1.Immediate threat to life of woman or foetus

2.Maternal or foetal compromise which is not immediately life-threatening

3.Needing early delivery but no maternal or foetal compromise

4.At a time to suit the patient and maternity team

Based on this the following classification of caesarean delivery was proposed (**Table 1**) [3].

### **5. Techniques for caesarean section**

Caesarean operation has undergone a number of technical changes as the procedure has evolved. Many different practitioners extol the benefits of various techniques of skin incision, uterine incision, uterine closure, and many other technical aspects of the operation. However, there are relatively few randomised trials to support many of the commonly used practices at caesarean section. As such there is no standard technique for caesarean delivery although there are a few evidencebased recommendations for the surgical technique.

#### **5.1 Abdominal opening**

Abdominal opening is accomplished through either transverse (Pfannenstiel and Joel-Cohen) or vertical skin incisions, each of which has advantages and disadvantages. Incision of about 12–15 cm is usually adequate for access [3, 14]. Historically, a vertical midline skin incision was implemented; however, this scar is cosmetically less acceptable and is associated with higher incidence of postoperative wound discomfort, dehiscence, infection, and hernia formation [3]. It may still be necessary if access is required to the upper uterus or to other abdominal organs. At present, the most frequently used type of skin incision is the Pfannenstiel incision since it is associated with less postoperative pain, greater wound strength and better cosmetic results than the vertical midline incision [17]. The use of scalpel is preferred although there are no randomised trials comparing scalpel to electrocautery which can also be used during caesarean delivery.

**91**

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Opening the subcutaneous tissue layer is achieved bluntly preferred to sharp dissection as blunt dissection has been associated with shorter operative times and less chance of injury to vessels [18]. However, there are no randomised trials comparing techniques for incision and dissection of the subcutaneous tissues at caesarean delivery. There are no randomised trials comparing different techniques of opening the fascia. A small transverse incision is usually made medially with the scalpel and then extended laterally with scissors. Alternatively, the fascial incision can be extended bluntly by inserting the fingers of each hand under the fascia and then

Rectus muscles are separated bluntly in most cases. Avoiding transection of muscles preserves muscle strength. Dissection of the rectus fascia from the rectus sheath and muscles is unnecessary [19] but has not been studied separately in a randomised trial. Opening the peritoneum can be achieved using the fingers bluntly to minimise the risk of inadvertent injury to the bowel, bladder or other organs that may be adherent to the underlying surface [18, 19]. However blunt versus sharp entry into

Opening of the bladder flap may or may not be performed. Some surgeons choose to open the bladder flap if difficult delivery is anticipated such as when the foetal head is deep in the pelvis or when the bladder is attached well above the lower uterine segment after a previous caesarean delivery. In these cases, creation of the bladder flap may help to keep the bladder dome out of the surgical field if the uterine incision extends.

The uterine incision may be transverse or vertical. The type of incision depends upon several factors, including the position and size of the foetus, location of the placenta, presence of leiomyomas and development of the lower uterine segment. The principal consideration is that the incision must be large enough to allow atraumatic delivery of the foetus. Transverse incision along the lower uterine segment is recommended. Compared with vertical incisions, advantages of the transverse incision include less blood loss, less need for bladder dissection, easier approximation and a lower risk of rupture in subsequent pregnancies [19]. Low vertical and classical incisions may also be performed in certain circumstances. Low vertical incision is performed in the lower uterine segment and appears to be as strong as the low transverse incision [20]. The major disadvantage of the low vertical incision is the possibility of extension cephalad into the uterine fundus or caudally into the bladder, cervix or vagina. It is also difficult to determine that the low vertical incision is truly low, as the separation between lower and upper uterine segments is not easily identifiable clinically. Classical incision is rarely performed at or near term because in subsequent pregnancies it is associated with a higher frequency of uterine dehiscence/rupture than low vertical and low transverse incisions. The generally accepted indications for considering a vertical uterine incision are:

• Poorly developed lower uterine segment in a setting in which more than normal intrauterine manipulation is anticipated (e.g. extremely preterm breech

• Lower uterine segment pathology that precludes a transverse incision (e.g.

presentation, back down transverse lie)

• Densely adherent bladder

• Postmortem delivery

large leiomyoma, anterior placenta praevia or accreta)

*DOI: http://dx.doi.org/10.5772/intechopen.88573*

pulling in a cephalad-caudad direction [17, 18].

**5.2 Hysterotomy/opening the uterus**

the peritoneum has not been compared in a randomised trial.

*Caesarean Section in Low-, Middle- and High-Income Countries DOI: http://dx.doi.org/10.5772/intechopen.88573*

*Recent Advances in Cesarean Delivery*

**Classification Indication**

Grade 1: emergency caesarean section

section

**Table 1.**

Grade 2: urgent caesarean

Grade 3: nonscheduled caesarean section

Grade 4: scheduled, also referred to as elective caesarean section

*Classification of caesarean section.*

1.Immediate threat to life of woman or foetus

*Reproduced from The Global Library of Women's Medicine.*

out of hours)

4.At a time to suit the patient and maternity team

based recommendations for the surgical technique.

which can also be used during caesarean delivery.

proposed (**Table 1**) [3].

**5.1 Abdominal opening**

**5. Techniques for caesarean section**

2.Maternal or foetal compromise which is not immediately life-threatening

(antepartum) or uterine rupture (intrapartum)

intrauterine growth restriction, preeclampsia, etc.

Immediate threat to the life of the woman or the foetus, i.e. placental abruption

No immediate risk to the life of the woman or baby, but delivery should be achieved as soon as possible, e.g. three previous caesarean sections, membranes are ruptured with meconium-stained liquor (antepartum) or non-reassuring cardiotocograph and foetal blood sampling are not possible or contraindicated

Delivery is needed but can fit in with delivery suite workload and allow for fasting/steroid administration and some degree of planning, e.g. preterm

No urgency whatsoever and procedure planned to suit the mother, staff, delivery suite, etc. and carried out at 39 weeks' gestation during the working day (i.e. not

3.Needing early delivery but no maternal or foetal compromise

Based on this the following classification of caesarean delivery was

Caesarean operation has undergone a number of technical changes as the procedure has evolved. Many different practitioners extol the benefits of various techniques of skin incision, uterine incision, uterine closure, and many other technical aspects of the operation. However, there are relatively few randomised trials to support many of the commonly used practices at caesarean section. As such there is no standard technique for caesarean delivery although there are a few evidence-

Abdominal opening is accomplished through either transverse (Pfannenstiel and Joel-Cohen) or vertical skin incisions, each of which has advantages and disadvantages. Incision of about 12–15 cm is usually adequate for access [3, 14]. Historically, a vertical midline skin incision was implemented; however, this scar is cosmetically less acceptable and is associated with higher incidence of postoperative wound discomfort, dehiscence, infection, and hernia formation [3]. It may still be necessary if access is required to the upper uterus or to other abdominal organs. At present, the most frequently used type of skin incision is the Pfannenstiel incision since it is associated with less postoperative pain, greater wound strength and better cosmetic results than the vertical midline incision [17]. The use of scalpel is preferred although there are no randomised trials comparing scalpel to electrocautery

**90**

Opening the subcutaneous tissue layer is achieved bluntly preferred to sharp dissection as blunt dissection has been associated with shorter operative times and less chance of injury to vessels [18]. However, there are no randomised trials comparing techniques for incision and dissection of the subcutaneous tissues at caesarean delivery.

There are no randomised trials comparing different techniques of opening the fascia. A small transverse incision is usually made medially with the scalpel and then extended laterally with scissors. Alternatively, the fascial incision can be extended bluntly by inserting the fingers of each hand under the fascia and then pulling in a cephalad-caudad direction [17, 18].

Rectus muscles are separated bluntly in most cases. Avoiding transection of muscles preserves muscle strength. Dissection of the rectus fascia from the rectus sheath and muscles is unnecessary [19] but has not been studied separately in a randomised trial.

Opening the peritoneum can be achieved using the fingers bluntly to minimise the risk of inadvertent injury to the bowel, bladder or other organs that may be adherent to the underlying surface [18, 19]. However blunt versus sharp entry into the peritoneum has not been compared in a randomised trial.

#### **5.2 Hysterotomy/opening the uterus**

Opening of the bladder flap may or may not be performed. Some surgeons choose to open the bladder flap if difficult delivery is anticipated such as when the foetal head is deep in the pelvis or when the bladder is attached well above the lower uterine segment after a previous caesarean delivery. In these cases, creation of the bladder flap may help to keep the bladder dome out of the surgical field if the uterine incision extends.

The uterine incision may be transverse or vertical. The type of incision depends upon several factors, including the position and size of the foetus, location of the placenta, presence of leiomyomas and development of the lower uterine segment. The principal consideration is that the incision must be large enough to allow atraumatic delivery of the foetus. Transverse incision along the lower uterine segment is recommended. Compared with vertical incisions, advantages of the transverse incision include less blood loss, less need for bladder dissection, easier approximation and a lower risk of rupture in subsequent pregnancies [19]. Low vertical and classical incisions may also be performed in certain circumstances. Low vertical incision is performed in the lower uterine segment and appears to be as strong as the low transverse incision [20]. The major disadvantage of the low vertical incision is the possibility of extension cephalad into the uterine fundus or caudally into the bladder, cervix or vagina. It is also difficult to determine that the low vertical incision is truly low, as the separation between lower and upper uterine segments is not easily identifiable clinically. Classical incision is rarely performed at or near term because in subsequent pregnancies it is associated with a higher frequency of uterine dehiscence/rupture than low vertical and low transverse incisions. The generally accepted indications for considering a vertical uterine incision are:


#### **5.3 Delivery of the baby and placenta**

Extraction of the foetus at caesarean delivery is usually uncomplicated but may be made more difficult by extreme prematurity, a deeply impacted or floating foetal head or an abnormal lie. However, careful attention to the duration of prolonged uterine incision to delivery time is important especially in a foetus with a nonreassuring foetal heart rate assessment prior to the onset of surgery.

Cord clamping. Delayed, rather than immediate, cord clamping results in greater neonatal haemoglobin levels and appears to be beneficial for preterm, and some term, infants. However, in asphyxiated baby, the cord should be quickly clamped and cut.

Delivery of the placenta is best achieved with controlled cord traction and aided by oxytocin administration instead of manual delivery which is associated with postoperative endometritis and greater blood loss. To ensure that all of the placenta has been removed, the uterus is usually explored with one hand holding a sponge to remove any remaining membranes or placental tissue, while the other hand is placed on the fundus to stabilise the uterus. These manipulations further stimulate uterine contraction.

#### **5.4 Closure of the uterus**

The uterus may or may not be exteriorized. No approach is superior to the other. Closing the uterus after caesarean section is best performed with a double-layer technique using continuous closure with delayed absorbable synthetic suture incorporating all of the muscle in order to avoid bleeding from the incision edges. Some obstetricians prefer locking the sutures instead of continuous [21]. Recently, Lambert's suture technique for the second layer is being promoted. The bladder peritoneum may or may not reperitonised.

#### **5.5 Closure of the abdomen**

The peritoneal layer may or may not be closed. Nonclosure might allow the enlarged uterus to adhere to the anterior abdominal wall or impede spontaneous closure of the peritoneum, while closure might cause a foreign body reaction to sutures and tissue damage [22]. A systematic review of peritoneal nonclosure and adhesion formation after caesarean delivery found some evidence that nonclosure was associated with greater adhesion formation than closure of the parietal layer or both visceral and parietal layers [23].

Rectus muscles are believed to reapproximate naturally, and suturing them together may cause unnecessary pain when the woman starts to move after surgery [17]. There is no randomised trial that has evaluated rectus muscle closure versus nonclosure.

Fascial closure is a critical aspect of incisional closure as this provides the majority of wound strength during healing. Care should be taken to avoid too much tension when closing the fascia since reapproximation, not strangulation, is the goal. The closure is best achieved with a simple running technique using no 1 or 2 delayed absorbable monofilament suture [22].

The subcutaneous adipose layer is closed with interrupted delayed absorbable sutures if the layer is ≥2 cm. Closure of the dead space seems to inhibit accumulation of serum and blood, which can lead to a wound seroma and subsequent wound breakdown [24]. The point of this layer is to support the skin layer, so Scarpa's fascia should be deliberately included in it [14].

**93**

*Caesarean Section in Low-, Middle- and High-Income Countries*

subcuticular suture, absorbable sutures such as Vicryl may be used.

Reapproximation of the skin may be performed with staples or subcuticular suture. No approach is superior to the other [25] although stables are associated with a doubling of wound complications (infection and wound separation) [26]. Subcuticular stitches have been associated with less immediate postoperative pain and are more cosmetically appealing at 6 weeks than the stapling device [27]. For

Although a life-saving procedure for either the mother or the baby or both, caesarean section comes with a number of complications including but not

1.Infections including endometritis and wound infections. Necrotizing fasciitis

2.Septic pelvic thrombophlebitis including ovarian vein thrombophlebitis and

3.Haemorrhage. The mean blood loss at caesarean is approximately 1000 mL;

4.Urinary tract and blood problems including ileus, urinary tract and bowel

5.Venous thrombosis and embolism whose risk is increased during the postoperative period. Early ambulation and thromboprophylaxis for high-risk mothers

6.Disruption (or opening) of the caesarean laparotomy wound is common, especially in women with risk factors such as obesity, diabetes, history of wound

7.Foetal and neonatal birth risks such as iatrogenic prematurity and birth trauma, transient tachypnea of the newborn, respiratory distress syndrome, etc.

10.Subfertility. Women whose first birth is by caesarean are less likely to have a subsequent pregnancy than women whose first birth is a spontaneous vaginal

11.Scar complications including hysterotomy scar pregnancy, numbness and

13.Abdominal adhesions that may predispose to bowel obstruction, strangulation, infertility and visceral injury during subsequent abdominal operations.

*DOI: http://dx.doi.org/10.5772/intechopen.88573*

**6. Complications of caesarean section**

is rare but can occur after caesarean section.

however, estimates of blood loss are not very reliable.

are recommended to decrease the risk of thromboembolism.

deep septic pelvic thrombophlebitis.

disruption, vertical incision, etc.

9.Abnormal placentation in subsequent pregnancy.

12.Uterine rupture in a subsequent pregnancy.

8.Maternal mortality.

incisional endometriosis.

delivery.

limited to [28]:

injuries.

*Recent Advances in Cesarean Delivery*

clamped and cut.

uterine contraction.

**5.4 Closure of the uterus**

**5.5 Closure of the abdomen**

peritoneum may or may not reperitonised.

both visceral and parietal layers [23].

delayed absorbable monofilament suture [22].

should be deliberately included in it [14].

versus nonclosure.

**5.3 Delivery of the baby and placenta**

Extraction of the foetus at caesarean delivery is usually uncomplicated but may be made more difficult by extreme prematurity, a deeply impacted or floating foetal head or an abnormal lie. However, careful attention to the duration of prolonged uterine incision to delivery time is important especially in a foetus with a non-

Delivery of the placenta is best achieved with controlled cord traction and aided by oxytocin administration instead of manual delivery which is associated with postoperative endometritis and greater blood loss. To ensure that all of the placenta has been removed, the uterus is usually explored with one hand holding a sponge to remove any remaining membranes or placental tissue, while the other hand is placed on the fundus to stabilise the uterus. These manipulations further stimulate

The uterus may or may not be exteriorized. No approach is superior to the other. Closing the uterus after caesarean section is best performed with a double-layer technique using continuous closure with delayed absorbable synthetic suture incorporating all of the muscle in order to avoid bleeding from the incision edges. Some obstetricians prefer locking the sutures instead of continuous [21]. Recently, Lambert's suture technique for the second layer is being promoted. The bladder

The peritoneal layer may or may not be closed. Nonclosure might allow the enlarged uterus to adhere to the anterior abdominal wall or impede spontaneous closure of the peritoneum, while closure might cause a foreign body reaction to sutures and tissue damage [22]. A systematic review of peritoneal nonclosure and adhesion formation after caesarean delivery found some evidence that nonclosure was associated with greater adhesion formation than closure of the parietal layer or

Rectus muscles are believed to reapproximate naturally, and suturing them together may cause unnecessary pain when the woman starts to move after

surgery [17]. There is no randomised trial that has evaluated rectus muscle closure

The subcutaneous adipose layer is closed with interrupted delayed absorbable sutures if the layer is ≥2 cm. Closure of the dead space seems to inhibit accumulation of serum and blood, which can lead to a wound seroma and subsequent wound breakdown [24]. The point of this layer is to support the skin layer, so Scarpa's fascia

Fascial closure is a critical aspect of incisional closure as this provides the majority of wound strength during healing. Care should be taken to avoid too much tension when closing the fascia since reapproximation, not strangulation, is the goal. The closure is best achieved with a simple running technique using no 1 or 2

Cord clamping. Delayed, rather than immediate, cord clamping results in greater neonatal haemoglobin levels and appears to be beneficial for preterm, and some term, infants. However, in asphyxiated baby, the cord should be quickly

reassuring foetal heart rate assessment prior to the onset of surgery.

**92**

Reapproximation of the skin may be performed with staples or subcuticular suture. No approach is superior to the other [25] although stables are associated with a doubling of wound complications (infection and wound separation) [26]. Subcuticular stitches have been associated with less immediate postoperative pain and are more cosmetically appealing at 6 weeks than the stapling device [27]. For subcuticular suture, absorbable sutures such as Vicryl may be used.
