The Evidence-Based Cesarean Section

Today we go through the steps of cesarean delivery from an evidence basis. We hope this helps everyone from the new interns starting up in just a few weeks to senior residents thinking more about their technique and teaching. The essential article on this from AJOG in 2013 can be found here. However, there have been a number of other articles and talks since, including one regularly given at the ACOG Annual Meeting (check out the 2017 edition by Dr. Strand here), that you all may be aware of and that we encourage you to check out.

One of the more challenging things to relay in the podcast is incisional technique, particularly comparing the traditional Pfannenstiel technique to newer techniques such as Joel-Cohen or Misgav-Ladach. We summarize the differences in those techniques here:

(C) CREOGs Over Coffee (2019)

What’s the difference in these skin incisions?

  • Pfannenstiel: traditionally taught as a curved incision made two finger breadths above the symphysis pubis, with the mid portion of the incision generally within the superior-most aspect of the pubic hair.

  • Joel-Cohen: a straight incision made 3cm below the imaginary line that connects the ASIS on either side. Ultimately this is slightly higher than the Pfannenstiel.

  • Maylard: curved incision made 5-8 cm obove the pubic symphysis. The rectus fascia and muscle are cut transversely, and the inferior epigastric arteries must be ligated.

  • Cherney: using the same skin incision as a Pfannenstiel, but then blunt dissection is used to identify the rectus muscle tendons at their insertion to the public symphysis. They are cut 1-2 cm above their insertion point. On closure, the muscles should be reattached to the anterior rectus sheath, as reattaching to the pubic symphysis may serve as a nidus for osteomyelitis.

Uterovaginal Prolapse

Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!

The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.

One common quiz question are the levels of support. These are:

  • Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

  • Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP. 

  • Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter.  Loss of level 3 support can result in a distal rectocele or perineal descent.  

Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.

Perioperative Care and Optimization for GYN Patients

Today we’re featuring a special guest on the Podcast! Dr. Lauren Stewart is a current PGY-6 in Female Pelvic Medicine and Reconstructive Surgery here at Brown / Women and Infants. Lauren has special interest in perioperative care strategies in GYN, and has published a two-part series on the subject in “Topics in Obstetrics and Gynecology.”

It is a venti episode - a bit longer, but chock full of useful information!

While we can’t share Lauren’s articles directly due to paywall restrictions, you can find them here if your institution has a subscription: Part 1 and Part 2.

At the beginning of this episode, we discuss a number of systems you can utilize for preoperative evaluation of risk for patients, each with their own sets of pros and cons:
American Society of Anesthesiology (ASA) Physical Status Classification
Revised Cardiac Risk Index (RCRI)
American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator

In addition, ACOG does have some publications that can aide with your perioperative management:
-PB 195 - Preventing Infection after GYN Surgery
-CO 750 - Enhanced Recovery After Surgery (ERAS)
-PB 084 - Prevention of DVT/PE

The Caprini score we talk about in the podcast is a common tool for deciding on perioperative mechanical vs. pharmacological DVT prophylaxis, and is the scale recommended in the 2012 CHEST guidelines for VTE prophylaxis in non-orthopedic surgical patients. MD Calc has an excellent appraisal of the evidence as well as an interactive Caprini calculator for your use.

The Caprini score for VTE prevention in surgical patients

For antibiotic prophylaxis, this table from PB 195 is very handy review for CREOGs:

ACOG PB 195 - for further review of evidence, see full text.