Primary Low Transverse C-Section

Abstract

Cesarean sections, often referred to as c-sections, are the most common operation performed for pregnant people across the US. They are viewed as a safe mode of fetal delivery. While there are many indications for planned, non-elective primary cesarean deliveries, there are growing numbers of planned, elective primary c-sections in the US. Vaginal delivery should still be considered in all cases in which an elective c-section is requested. The decision regarding mode of delivery often involves an interdisciplinary discussion between obstetrical, anesthesia, and specialty teams as well as joint decision making between a patient and their provider, taking into consideration their concerns and long-term goals. In this case, an elective primary c-section was performed on a 31-year-old gravida 1 para 0 patient with a term, singleton gestation in the setting of prior lumbar sacral fusion and pelvic fixation surgeries.

Case Overview

Background

Disclaimer - The words “maternal,” “woman,” and “mother” are used in referenced literature. However, we acknowledge the lack of inclusivity these terms impose and have chosen to use pregnant people to also include transgender, non-binary, and gestational or surrogate carrier patients when possible. 

Cesarean sections, or c-sections, are the most common surgery performed for pregnant people across the US.¹ The surgery involves an open abdominal and uterine incision to deliver a neonate. Historically, c-sections were only used in emergent or life-threatening situations; however, there are now expanding indications for the procedure.²  Today, a cesarean delivery is viewed as a safe, and sometimes the recommended, mode of delivery. 

There are both elective and non-elective indications for a planned cesarean delivery. Elective c-sections are performed for many reasons, including history of a prior c-section, multiple gestation pregnancy, fear of labor pain, or patient preference. The list of indications for elective c-sections is expansive, and calculation of the risks and benefits is often multifactorial and personal for each patient. Non-elective indications for a planned c-section, or contraindications to vaginal delivery, include history of a classical uterine incision, prior full-thickness uterine wall surgeries, history of uterine rupture, placenta previa or accreta spectrum, vasa previa, or non-cephalic fetal presentation.^4, 10 

The risks of c-section include multiple surgical risks in addition to longer recovery time, increased rates of endometritis, blood transfusion, ICU admission, and venous thromboembolism.⁸ The option for vaginal delivery should therefore be considered and further explored in all cases in which a patient is considering an elective primary c-section. Choice of delivery method ultimately depends on careful shared decision making and patient considerations of their long-term goals. 

Focused History of the Patient

The patient was a 31-year-old, gravida 1 para 0 at 39 weeks 0 day with a singleton gestation who presented for an elective primary c-section in the setting of a history of complex spinal surgeries. She had a BMI of 26.35 and American Society of Anesthesiologists score of 2. Her past medical history included lumbosacral spondylolisthesis and spondylosis, and she underwent a posterior bilateral L4-L5 and L5-S1 decompression, transforaminal lumbar interbody fusion at L5-S1, and instrumented fusion L4 to S1 including pelvic fixation. She later had a re-exploration surgery of her previous lumbar sacral fusion with removal of bilateral iliac pelvic fixation screws. During her prenatal course, the anesthesia team cleared her for neuraxial anesthesia administration, and her neurosurgeon cleared her for both vaginal and cesarean deliveries. After many discussions throughout her prenatal course, the patient elected to proceed with a primary c-section for delivery due to concerns around being able to push effectively in labor and reinjury to her back that would require significant rehabilitation or additional reparative procedures after delivery.

Physical Exam

Our patient was well-appearing, with a gravid abdomen, appropriate size for gestational age. Her neurologic exam had no focal deficits and was without an antalgic gait. She had symmetrical posture with standing, walking, flexion, extension, and lateral rotation. Her BMI was 26.

Imaging

In addition to routine prenatal obstetrical ultrasounds, other imaging modalities are not required in deciding on an elective primary c-section. In patients with complex spinopelvic anatomy, further imaging with plain films and MRI may be useful. In this case, pertinent imaging was reviewed and an x-ray was notable for intact remaining hardware L4-S1, without any abnormal movement on flexion or extension views. The imaging studies were used in aiding the decision made by the anesthesia team regarding the ability to administer spinal anesthesia safely and effectively.

Rationale for Treatment

The goal of a c-section is to deliver a healthy fetus by minimizing poor maternal and neonatal outcomes, including immediate labor complications and long-term risks. In this case, long-term morbidity was heavily considered, with a goal to reduce the risk of further lumbosacral pain and need for further interventions.

Special Considerations

Patients with complex spinal or pelvic histories should seek early consultation with the anesthesia team for discussion of neuraxial anesthesia candidacy, regardless of desired mode of delivery. In these cases, it is worth noting that it is not guaranteed that the neuraxial anesthetic will be successful and, in the case of a c-section, this would be an indication to proceed with general anesthesia during the procedure. In the case of a vaginal trial of labor, this may result in suboptimal pain control during labor.

Discussion

In this case, a primary elective c-section was performed in a patient with a history of complex spinopelvic anatomy. The surgery resulted in the delivery of a healthy newborn without any immediate surgical complications. 

Prior to surgery, decision making involved an interdisciplinary discussion between the patient and the obstetrics, anesthesia, and neurology teams. Ultimately, the patient’s internalized risk of long-term spinopelvic pain or potential additional surgeries outweighed the risks of a cesarean delivery. 

On the day of surgery, the patient was taken to the operating room where her spinal anesthetic was administered and found to be adequate. Perioperative cefazolin was administered. Cefazolin is the first-line choice of prophylactic antibiotics for cesarean delivery, as use of standard alternatives have shown an increased risk of surgical site infections.¹¹ Pneumatic compression boots were placed and activated for venous thromboembolism prophylaxis. A urinary Foley catheter was placed. The patient’s abdomen was prepped and draped in the normal sterile fashion in the dorsal supine position with a left lateral tilt. The lateral tilt is used to relieve pressure from the fetus on the inferior vena cava responsible for blood return to the heart. 

A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia with sharp and blunt dissection. A Pfannenstiel incision is the most common choice for c-section. While newer literature proposes alternative skin incisions may have shorter operative time, disruption of fewer skin layers, and less blood loss,¹² the Pfannenstiel incision is well studied with predictable long-term outcomes, better postoperative healing, and preferred patient aesthetics.^13, 14 The fascia was then incised in the midline and extended laterally with sharp dissection with Mayo scissors. The superior aspect of the fascial incision was grasped with Kocher clamps, elevated, and the underlying rectus muscle was dissected off with blunt dissection and sharp dissection with Mayo scissors. In a similar manner, the inferior aspect of the fascial incision was grasped with Kocher clamps, elevated, and the underlying rectus muscle dissected off with blunt dissection and sharp dissection with Mayo scissors. The rectus muscles were separated in the midline. The peritoneum was identified and entered bluntly. The peritoneal incision was extended bluntly, maintaining good visualization of the bladder. A bladder blade was inserted. Some surgeons create a bladder flap that brings the bladder further from the hysterotomy incision.

A low transverse incision was made on the uterus. The use of alternative uterine incisions in cases of full-term gestation with a well-developed lower uterine segment is avoided as they are associated with increased risk of uterine rupture in subsequent pregnancies.¹⁸ Alternative incisions may be necessary in the case of altered anatomy or preterm gestations with a poorly developed lower uterine segment. The uterine incision was then extended bluntly, by stretching in the cephalocaudal direction. The membranes were ruptured sharply with an Allis clamp. The bladder blade was removed. The infant’s head was palpated and brought to the incision. Subsequently, the left rectus muscle was cut with bandage scissors to aid in delivery of the fetal head. In many cases, the rectus muscle is not cut in a c-section; however, evaluation of the anatomic space-limiting factor may lead to extension of the uterine incision and/or cutting of the rectus muscle in order to safely deliver the neonate. The rest of the body followed easily. After one minute of delayed cord clamping, the cord was clamped twice and cut, and the neonate was transferred to the warmer to the awaiting pediatric staff. 

The placenta was expressed intact. The uterus was then exteriorized and cleared of all clot and debris with a lap sponge. The hysterotomy was closed in two layers with 0 Monocryl, first in a running locked layer and then in an imbricating layer. There has been ongoing literature debate on the utility of a single- versus double-layer uterine closure. Some studies show similar rates of estimated blood loss while others argue possible increased risk of future uterine rupture with a single-layer closure.^19, 20, 21 A double-layer is often indicated for adequate hemostasis, as was used for this patient. The patient’s fallopian tubes and ovaries were examined and appeared normal. The uterus was returned to the abdomen. The uterine incision, peritoneal edges, and subfascial planes were inspected and all found to be hemostatic. The fascia was closed with 0 Vicryl suture in a running fashion. The subcutaneous tissues were irrigated, and hemostasis was confirmed. The subcuticular space was closed with a 3-0 plain gut suture in three interrupted sutures. The skin was closed with subcuticular 4-0 Monocryl. 

The patient tolerated the procedure well and was taken to the recovery room in stable condition. The neonate was taken to the recovery room with the patient.

Postoperative Course

Operative time was approximately 1 hour. Estimated blood loss was 800 ml. The patient was discharged on postoperative day 3 without any postpartum complications.

Equipment

Standard c-section equipment. 

Disclosures

No disclosures.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.