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INTRODUCTION

KEY QUESTIONS

  • What are the most common indications for cesarean delivery?

  • What preoperative steps should be performed before cesarean delivery?

  • What are the key steps involved in cesarean delivery?

  • What evidence-based steps can reduce the risk of postoperative complications?

CASE 60-1

Ms. Jones is a 33-y.o. G3P2002 who presents in labor at 39 weeks gestation. Her history is notable for two previous vaginal deliveries. She is managed expectantly, and at 6 cm develops recurrent variable and then late decelerations, with a progressive loss of FHR variability. The decision is made to proceed with an emergent cesarean delivery.

Cesarean delivery is the most common surgical procedure performed in the United States, with nearly 1.3 million cases performed each year.1 The rate of cesarean sections (C-sections) has steadily increased over the past several decades, reaching a peak of 32.9% in 2009. The incidence has since slightly declined, with 32.0% of all deliveries performed via C-section in 2015.1 Trends in the rate of cesarean delivery are affected by both the primary cesarean delivery rate as well as the rate of vaginal birth after cesarean (VBAC). This chapter will review the common indications for cesarean delivery, the risks and benefits pertinent to informed consent for cesarean delivery, and the key steps involved in the procedure as well as evidence-based steps for preventing postcesarean complications.

ANATOMY

Appropriate knowledge of the anterior abdominal wall is necessary to perform cesarean delivery. The layers encountered when making a low-transverse abdominal wall incision include the following:

  • Skin

  • Subcutaneous tissue, including the superficial fatty layer of Camper's fascia and the deeper, membranous Scarpa's fascia

  • The thicker rectus fascia created by the aponeurosis of the external and internal obliques and the transversus abdominis muscles

  • The midline muscles of the anterior abdominal wall: the rectus abdominis and the pyramidalis

The dermal fibers of the skin are arranged transversely, creating Langer's lines. Transverse incisions, such as the Pfannenstiel incision, are parallel to these lines and result in less tension and better cosmetic results than vertical midline incisions.

At the level of a low-transverse incision, the fascia entirely overlies the rectus muscles. Above the arcuate line, which is located halfway between the umbilicus and the pubic crest, this fascia splits and envelops the rectus abdominis muscles.

The blood supply to the anterior abdominal wall includes the superficial epigastric vessels. These vessels may be encountered surgically in the subcutaneous tissue as they course diagonally from the femoral artery toward the umbilicus. Also of surgical relevance are the inferior epigastric vessels, which arise from the external iliac arteries and course lateral to and then posterior to the rectus abdominis muscles. These vessels may be encountered lateral to the rectus muscle belly during transection of the rectus muscles in a Maylard incision.

The T10 dermatome is at the level of the umbilicus, ...

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